Thigh Region PDF

THIGH REGION BY GM MUWANGA The lower limb lower limb consists of the following components:  thigh  leg  foot lower limb is connected to the trunk by pelvic girdle bones (i.e., hip bones) The thigh Fascial compartments of the thigh superficial fascia is deep...

THIGH REGION BY GM MUWANGA The lower limb lower limb consists of the following components:  thigh  leg  foot lower limb is connected to the trunk by pelvic girdle bones (i.e., hip bones) The thigh Fascial compartments of the thigh superficial fascia is deep to the skin superficial fascia contains:  fat  superficial vessels, cutaneous nerves, & superficial lymphatics Deep fascia of thigh is also calledfascia lata & surrounds all thigh muscles like an elastic sleeve is a dense CT layer between the superficial layer & the muscles separates groups of muscles from each other Thigh muscle compartments An anterosuperior view of a transverse section through the thigh. Note superficial & deep fascia. Superficial fascia (subcutaneous tissue) has been invaded by fat & appears as a fatty layer. The deep fascia is the whitish membrane which has sent septa up to the bone, thus dividing muscles into various compartments (A, P & M). Also note some veins & nerves that run outside the deep fascia, and some that run within the deep fascia. Thigh muscle compartments Fascia lata (contn.) fascia lata sends 3 intermuscular septa:  lateral intermuscular septum  medial intermuscular septum  posterior intermuscular septum septa attach to thelinea aspera of the femur Thigh muscle compartments An anterosuperior view of a transverse section through the thigh. Note superficial & deep fascia. Superficial fascia (subcutaneous tissue) has been invaded by fat & appears as a fatty layer. The deep fascia is the whitish membrane which has sent septa up to the bone, thus dividing muscles into various compartments (A, P & M). Also note some veins & nerves that run outside the deep fascia, and some that run within the deep fascia. Fascia lata (contn.) septa thus divides the thigh into 3 muscle compartments:  anterior compartment  medial compartment  posterior compartment Muscle compartments muscles of anterior compartment:  are all innervated by the femoral nerve  act to extend knee joint & flex the hip Fascia lata (contn.) medial oradductor compartment includes muscles that adduct the thigh muscles are innervated by the obturator, femoral, & deep femoral nerves Fascia lata (contn.) posterior compartment contains muscles:  which extend the hip  that are involved in flexing the knee muscles innervated by the sciatic nerve Iliotibial tract fascia lata condenses & thickens laterally to form a broad band of fibers band called theiliotibial tract Iliotibial tract (contn.) tract extends from theiliac tubercle to thelateral condyle of the tibia tract receives insertions of the tensor fasciae latae & part of the gluteus maximus muscles Iliotibial tract Iliotibial tract Saphenous hiatus also known as fossa ovalis or saphenous opening is an opening in the fascia lata opening filled with loose connective tissue called thecribriform fascia Saphenous hiatus (contn.) great saphenous vein pierces the cribriform fascia to drain into the femoral vein superficial branches of femoral artery & lymphatics also transmitted through saphenous opening Saphenous opening * Note saphenous * opening Some clinical aspect Iliotibial tract syndrome is common in runners and presents as lateral knee pain, often in the midrange of flexion, between 20 and 70 degrees of knee flexion. The iliotibial tract, often referred to as “iliotibial band” by clinicians, rubs across the lateral femoral condyle, and this pain also may be associated with more proximal pain from greater trochanteric bursitis. liotibial Tract Friction Syndrome: As knee flexes and extends, iliotibial tract glides back and forth over lateral femoral epicondyle, causing friction. Femoral triangle is a fascial space in the superioanterior one-third of the thigh Femoral triangle (contn.) is bounded:  medially by the medial margin of the adductor longus muscle  laterally by the medial margin of thesartorius muscle  superiorly by theinguinal ligament Boundaries of femoral triangle Boundaries & floor of femoral triangle Femoral triangle (contn.) floor consists of the adductor longus, pectineus, psoas tendon & iliacus roof of the triangle is formed by the fascia lata Floor of femoral triangle Femoral triangle (contn.) when the hip joint is actively flexed, the femoral triangle appears as a depression inferior to the inguinal ligament Femora triangle (contn.) from lateral to medial , contents of the femoral triangle are:  femoral nerve  femoral artery & its branches  femoral vein & tributaries other contents = fat & lymphatics Femoral triangle (contn.) saphenous opening is located in the upper part of the triangle transversalis fascia &psoas fascia fuse &evaginate to form thefemoral sheath below the inguinal ligament Note origin & composition of femoral sheath. Femoral sheath (contn.) sheath encloses:  femoral artery  femoral vein  femoral canal femoral nerve lies outside sheath on its lateral aspect Compartments within the femoral sheath. Proximal end (abdominal opening) of the femoral canal is the femoral ring. Femoral sheath (contn.) sheath divided into 3 compartments:  lateral compartment contains the femoral artery  intermediate compartment contains the femoral vein  medial compartment contains deep lymph nodes Compartments of retro-inguinal space & structures traversing them to enter femoral triangle Femoral sheath (contn.) medial compartment is called the femoral canal opens into the abdominal cavity superiorly at the femoral ring femoral canal contains deep inguinal lymph nodes (glands of Cloquet ) Femoral sheath (contn.) femoral canal is also the site at which a loop of the gut can herniate through (femoral hernia ) femoral hernia can become strangulated & can lead to gangrene of stangulated part Femoral hernia – surface view. Early stage. Anterior (extensor) compartment contains the following muscles:  sartorius  quadriceps femoris  psoas major  Iliacus Anterior (extensor) compartment (contn.) each of these muscles is innervated by the femoral nerve Sartorius Origin: anterior superior iliac spine Insertion: medial surface of the tibia Sartorius (contn.) Action:  abducts thigh at hip joint & laterally rotates the thigh  also flexes the knee joint muscle is the longest one in the body Sartorius Action (contn.)  muscle also responsible for our being able to place our leg in a “cross-leg ” position Innervation: femoral nerve Quadriceps femoris consists of 4 heads, hence the name quadriceps  rectus femoris  vastus lateralis  vastus medialis  vastus intermedius Quadriceps femoris Quadriceps femoris (contn.) (a) Rectus femoris Origin: the anterior inferior iliac spine; upper lip of the acetabulum (b) Vastus medialis Origin: the medial lip of the linea aspera Quadriceps femoris (contn.) (c) Vastus lateralis Origin: lateral lip of the linea aspera (d) Vastus intermedius Origin: lateral & anterior surfaces of the femur Quadriceps femoris: rectus femoris Quadriceps femoris: most of rectus femoris has been removed Quadriceps femoris: v. intermedius v. lateralis v. medialis Quadriceps femoris (contn.) Insertion: all the 4 parts of quadriceps insert into the patella &, from here, to the tubercle of the tibia  patella is thus a sesamoid bone in the tendon of quadriceps femoris Quadriceps femoris (contn.) Action:  extension & stabilization of knee joint  rectus femoris also a weak flexor of the hip joint Innervation: femoral nerve Psoas major Origin: transverse processes of lumbar vertebrae Insertion: lesser trochanter of femur along with iliacus muscle via the iliopsoas tendon Psoas major (contn.) Action:  in the lower limb it to flexes the hip joint  in trunk, flexes & laterally bends the lumbar vertebral column Innervation: femoral nerve Iliacus (contn.) Origin: iliac fossa, iliac crest as well as the ala of the sacrum Insertion: lesser trochanter of femur with psoas major muscle via the iliopsoas tendon Iliacus (contn.) Action: has the same action as the psoas major muscle Innervation: femoral nerve Tensor fasciae latae muscle does not belong to anterior compartment however, it assists muscles of this compartment in:  extending knee joint  flexing hip joint Tensor fasciae latae (contn.) Origin:  anterior iliac crest outer lip  anterior border of ilium  outer surface of anterior superior iliac spine Tensor fasciae latae Insertion: between the two layers of the iliotibial band, about one-third of the way down Tensor fasciae latae (contn.) Action:  tenses fascia lata  i.e., the iliotibial tract moves forward in extension & backward in flexion butis tense in both positions  flexes hip joint Tensor fasciae latae (contn.) Action (contn.):  abducts & medially rotates thigh  stabilizes knee joint in extension Innervation: superior gluteal nerve Nerves of the anterior compartment is innervated by femoral nerve which has:  muscular branches  anterior & lateral femoral cutaneous branches  a saphenous nerve branch Note muscular branches of femoral nerve Note anterior & lateral femoral cutaneous nerves Note branches of lateral cutaneous nerve Note course of lateral cutaneous nerve and territory of skin it is responsible for Some clinical aspect lateral femoral cutaneous nerve enters the thigh just inferior to the inguinal ligament an underwear which has a tight-fitting waist- band may compress the nerve at this point  Some clinical aspect (contn.) compression of the nerve results in paraesthesia (altered sensation). This includes:  feeling of pin pricks  having burning sensation  feeling sharp pain Saphenous nerve: travels along with great saphenous vein continues anterior to medial malleolus at the ankle joint here it supplies articular branches to ankle joint Note saphenous nerve & muscular branches of femoral Nerve. Here saphenous nerve & nerve to vastus medialis are running within the adductor canal (opened by removal of sartorius muscle). Course of saphenous nerve in the thigh & leg.  * Note point where saphenous nerve pierces deep fascia to reach superficial fascia & hence skin Course of saphenous nerve in the leg. Note that now it is superficial (together with great saphenous vein), running superficial to fascia of leg Saphenous nerve (contn.) nerve innervates skin along medial side of the leg & foot innervation extends as far anteriorly as the head of the first metatarsal Territory of skin innervated by saphenous nerve Adductor canal extends:  superiorly to the apex of the femoral triangle  inferiorly to the adductor hiatus Femoral triangle, adductor canal & adductor hiatus. Adductor canal (contn.): contains:  femoral artery & vein  saphenous nerve  nerve to the vastus medialis  lymphatics Adductor canal: note femoral vessels running in canal Adductor canal (contn.) adductor hiatus is the location where femoral vessels pass to reach the popliteal fossa adductor hiatus is an opening in the tendon of the adductor magnus muscle Adductor magnus – adductor & hamstring parts: note adductor hiatus Note adductor hiatus Adductor hiatus: note femoral vessels running thru hiatus to become popliteal vessels. Medial (adductor) compartment muscles arise mainly from the external surfaces of pubic rami main action is to adduct the thigh & hence are generally referred to as adductor group of muscles Adductor compartment muscles Medial (adductor) compartment (contn.) muscles are: (i) Gracilis (ii) Pectineus (iii) Adductor longus (iv) Adductor brevis (v) Adductor magnus (vi) Obturator externus Medial (adductor) compartment (contn.) all adductor muscles except pectineus are innervated by the obturator nerve pectineus is supplied by thefemoral nerve Gracilis long, slender & thin muscle located superficially on medial aspect of the thigh Origin: body & inferior ramus of pubis Insertion: tendon crosses the knee joint to insert on the upper part of the shaft of tibia Pes anserinus this insertion is part of thepes anserinus (=duck’s foot ] it is a common tendon of insertion for 3 muscles (s artorius,g racilis & s emitendinosus) pnemonic = “g irl between two s urgeons”  Pes anserinus Note components of pes anserinus Pes anserinus (contn.) a bursa is associated with pes anserinus it is called theanserine bursa Pes anserinus: note the anserine bursa Gracilis (contn.) Action: it adducts the thigh & assists flexing the knee joint may participate in flexion of the hip joint & medial rotation of the thigh Innervation: obturator nerve Gracilis muscle Pectineus a short, flat & quadrangular muscle forms the medial part of the floor of the femoral triangle Origin: pubic pecten Insertion: pectineal line of femur Pectineus Pectineus (contn.) Action:  adducts the thigh & rotates it medially  also assists flexion of the hip joint Pectineus (contn.) Innervation:  femoral nerve may also be supplied by a branch of the obturator nerve (accessory obturator nerve) when present (i.e., in about 9% of cases) Adductor longus a triangular muscle that forms the medial boundary of the femoral triangle Origin: body & superior ramus of pubis Insertion: middle one-third of thelinea aspera of femur Adductor longus (contn.) Action:  adducts the thigh & rotates it medially  also assists in flexion of the hip joint Innervation: obturator nerve Adductor longus Adductor brevis lies deep to pectineus & adductor longus muscles Origin: body & inferior ramus of pubis Insertion: lower two-thirds of pectineal line & proximal part of linea aspera of femur Adductor brevis (contn.) Action:  adducts the thigh  may assist medial rotation of thigh & flexion of hip joint to a lesser degree Innervation: obturator nerve Adductor brevis – adductor longus has Superficial group of adductors Adductor magnus largest muscle of the adductor group triangular in shape formed by a combination of two muscles with differing innervation Adductor magnus (contn.) the two components are:  (a) the adductor part  (b) the hamstring part Adductor magnus (contn.) Origin:  adductor part – from the inferior ramus of pubis, & ramus of ischium  hamstring part – from ischial tuberosity Adductor magnus (contn.) Insertion:  adductor part – gluteal tuberosity, linea aspera & supracondylar line of femur  hamstring part – adductor tubercle of the medial epicondyle of femur (by a rounded tendon) Adductor magnus – anterior view: note the hamstring component* * Adductor magnus – posterior view: note * origin of the hamstring component* from the ischial tuberosity in common with other hamstring muscles Adductor magnus (contn.) Action:  adductor part is a powerful adductor of the thigh  also assists in medial rotation of the thigh & flexion of the hip joint  hamstring part extends the hip joint & also rotates thigh medially Adductor magnus (contn.) Innervation:  adductor part – obturator nerve  hamstring part – tibial division of the sciatic nerve Obturator externus lies deep to the origins of the adductor group of muscles a relatively small, triangular muscle Origin: external aspect of the margins of obturator foramen & obturator membrane Obturator externus Obturator externus & adductor magnus – anterior view Obturator externus (contn.) Insertion: tendon of insertion crosses the back of the neck of femur & posterior capsule of thehip joint  then inserts on thetrochanteric fossa of the femur Obturator externus (contn.) Insertion (contn.)  synovial membrane of the hip joint descends below the edge of the posterior fibrous capsule  acts as a bursa separating the tendon from the neck of femur Obturator externus (contn.) Action: it is a lateral rotator of the thigh may help to steady the head of femur in the acetabulum Innervation: obturator nerve Posterior compartment of the thigh muscles in this compartmentflex the knee joint &extend the hip joint muscles are:  Semitendinosus  Semimembranosus  Biceps femoris Posterior compartment muscles (hamstring muscles) Posterior compartment of the thigh (contn.) muscles collectively referred to as the “hamstring muscles ” have a common origin from the ischial tuberosity Hamstring muscles- note common origin from ischial tuberosity Posterior compartment of the thigh (contn.) muscles innervated bytibial division of the sciatic nerve biceps femoris has an additional origin from the femur  this part of the muscle is supplied by thecommon fibular (peroneal ) nerve Hamstring muscles (contn.) because of their attachment, they act on both the hip & knee joints ischiocondylar part of the adductor magnus muscle also belongs to this group of muscles Semitendinosus muscle is tendinous in about half of its length is a fusiform muscle having a long tendon Semitendinosus (contn.) Origin: ischial tuberosity Insertion: medial surface of superior part of tibia [part of pes anserinus ] Semitendinosus (contn.) Action:  extends the hip joint & flexes the knee joint  may rotate the flexed leg medially Innervation: tibial nerve Semimembranosus a broad muscle located deep to the semitendinosus Origin: ischial tuberosity Insertion: posterior part of medial condyle of tibia Semimembranosus (contn.) Action:  extends the hip & flexes the knee joint  may rotate the flexed leg medially Innervation: tibial nerve Biceps femoris has 2 heads – a long and short head Origin: (a) long head – ischial tuberosity (b) short head – linea aspera & supracondylar line of femur Insertion: lateral head of fibula (by a heavy rounded tendon ) Hamstring muscles – note heads of origin of biceps muscle. Part long head of biceps has been removed. Biceps femoris (contn.) Action:  it flexes the knee joint & rotates the leg laterally  long head extends the hip joint Biceps femoris (contn.) Innervation:  long head – tibial nerve  short head – common fibular (peroneal ) nerve Hamstring muscles & sciatic nerve Assignment – read about hamstring injuries, e.g.,  pulled hamstring [muscle pull]  hamstring strain, etc.