THE LOWER LIMB: HIP

JOINT & THE GLUTEAL

REGION
ARACELI G. DIZON, MD, DPPS, FPSAI
DEPARTMENT OF HUMAN ANATOMY: SECTION OF GROSS ANATOMY
 OBJECTIVES
• Identify the basic anatomy of the Lower Limb.
• Identify the surface markers & organization of the Lowe Limb.
• Identify the Bones, Ligaments of the Hip joint & the Gluteal region.
• Discuss the Gluteal region, its Muscles, Blood supply, Innervation &
their actions.
• Discuss conditions associated with the Hip joint & the Gluteal
region.
 INTRODUCTION
• The primary functions of the Lower Limbs:
1. To support the weight of the body.
2. To provide a stable foundation during standing, walking, & running.
• The Lower Limbs have become specialized for locomotion.
• Composed mainly of the Hip bones ( Pelvic bones), Femur, Tibia, Fibula, Ankle
and Foot bones and their Muscles.
• The two (2) Hip bones articulate posteriorly with the Trunk at the Sacroiliac joints
& anteriorly with each other at the Symphysis pubis.
• The Lower Limbs are very stable & can bear the weight of the body.
ORGANIZATION OF THE LOWER
LIMB
 ORGANIZATION OF THE LOWER LIMB
• The Lower Limbs are divided into
the following:
1. Gluteal region
2. Thigh
3. Knee
4. Leg
5. Ankle
6. Foot
 ORGANIZATION OF THE LOWER LIMB
• Thigh & the Leg are
compartmentalized.
• Each compartment is separated from
the other by fascial covering.
• Each compartment having its own
muscles that perform group
functions.
• Each compartment having also its
own distinct nerve & blood supply.
 FUNCTIONS OF THE LOWER LIMB
• SUPPORTS THE BODY WEIGHT
- The Ligaments at the Hip & Knee joints facilitate locking
of these joints therefore reducing the amount of
muscular energy required to maintain a standing
position.
• FOR LOCOMOTION.
- To move the body through space.
- This involves integration of movements at all joints of
the Lower Limb to place the Foot on the ground &
move the body over it.
 SURFACE ANATOMY OF THE LOWER
LIMB
• GLUTEAL REGION/ POSTERIOR PELVIS
- Iliac Crest (red arrow)
- Gluteus maximus
1. Cheeks
- Natal/Intergluteal Cleft (green arrow)
1. Vertical midline; “Crack”
- Gluteal folds
1. Bottom of the Cheek (blue arrow)
“Prominence”
 SURFACE ANATOMY OF THE LOWER
• ANTERIOR THIGH & LEG
LIMB
- Femoral triangle
A. Boundaries
1. Sartorius (lateral)
2. Adductor longus (medial)
3. Inguinal ligament (superior)
B. Contents: Femoral vessels, nerve,
& LNs
- Patella
- Condyles of Femur
 SURFACE ANATOMY OF THE LOWER
LIMB
• POSTERIOR LEG
- Popliteal Fossa
A. Diamond-shape fossa behind the Knee
B. Boundaries
1. Biceps femoris (superior-lateral)
2. Semitendinosus & Semimembranosus
(superior-medial)
3. Gastrocnemius heads(inferior)
C. Contents: Popliteal artery & vein
- Calcaneal (Achilles) tendon
HIP JOINT
 ARTICULATION OF THE HIP JOINT

• The Hip joint is the articulation

between the hemispherical head of
the Femur & the cup-shaped
Acetabulum of the Hip bone.

• The articular surface of the

Acetabulum is horseshoe shaped & is
deficient inferiorly at the Acetabular
notch.
 ARTICULATION OF THE HIP JOINT
• The cavity of the Acetabulum is
deepened by the presence of a
fibrocartilaginous rim called the
ACETABULAR LABRUM.
• The Labrum bridges across the
Acetabular notch & is here called the
TRANSVERSE ACETABULAR
LIGAMENT.
• The articular surfaces are covered with
HYALINE CARTILAGE.
 TYPE OF JOINT

• The Hip joint is a

Synovial Ball-and
-Socket joint.
• Allows backward,
forward, sideways,
& rotating
movements.
 CAPSULE OF THE HIP JOINT

• The Capsule encloses the joint

& is attached to the Acetabular
Labrum medially.

• Laterally, it is attached to the

Intertrochanteric line of the
Femur in front & halfway along
the posterior aspect of the
neck of the bone behind.
 CAPSULE OF THE HIP JOINT
• At its attachment to the Intertrochanteric line in
front, some of its fibers, accompanied by blood
vessels, are reflected upward along the neck as
bands called RETINACULA.
• These blood vessels supply the head & neck of
the Femur.
• INTERTROCHANTERIC LINE - a ridge on the
Femur which is located on the anterior aspect
of the junction of the Femoral neck & shaft.
 LIGAMENTS OF THE HIP JOINT
• ILIOFEMORAL LIGAMENT (red shade)
• - A strong, inverted Y-shaped ligament.
- Found on the anterior surface of the Hip joint.
- Its base is attached to the Anterior Inferior
Iliac Spine above; below, the two limbs of
the Y are attached to the upper & lower
parts of the Intertrochanteric line of the Femur.
- This strong ligament prevents overextension
during standing.
 LIGAMENTS OF THE HIP JOINT
• PUBOFEMORAL LIGAMENT (green shade)
- It a triangular ligament.
- Its base is attached to the Superior
ramus of the Pubis.
- Its apex is attached below to the lower part
of the Intertrochanteric line of the Femur.
- This ligament limits extension &
abduction.
 LIGAMENTS OF THE HIP JOINT
• ISCHIOFEMORAL LIGAMENT (yellow
shade)
- A spiral shaped ligament
- It is attached to the body of the Ischium
near the Acetabular margin.
- The fibers pass upward & laterally
& are attached to the Greater
trochanter.
- This ligament limits extension.
 LIGAMENTS OF THE HIP JOINT
• LIGAMENT OF THE HEAD OF THE FEMUR
(blue shade)
- It is a flat & triangular ligament.
- It is attached by its apex to the pit on the
head of the Femur (FOVEA CAPITIS) & by its
base to the Transverse ligament & the
margins of the Acetabular notch.
- It lies within the joint & is ensheathed by
Synovial membrane.
 LIGAMENTS OF THE HIP JOINT

• TRANSVERSE ACETABULAR
LIGAMENT
- It is formed by the Acetabular
Labrum as it bridges the
Acetabular notch.
- It converts the notch into a tunnel
through which the blood vessels &
nerves enter the joint.
 SYNOVIAL MEMBRANE OF THE HIP
JOINT
• Lines the Capsule & is attached to the margins
of the articular surfaces.
• Covers the portion of the Neck of the Femur that
lies within the joint capsule.
• Ensheathed the Ligament of the Head of the
Femur & covers the pad of fat contained in the
Acetabular fossa.
• Pouch of synovial membrane frequently
protrudes through a gap in the anterior wall of
the capsule, between the Pubofemoral &
Iliofemoral ligaments, & forms the PSOAS
BURSA beneath the Psoas tendon.
 BLOOD SUPPLY OF THE HIP JOINT
• Arterial supply to the Hip is mainly
from the following:
1. Obturator artery
2. Medial & Lateral Circumflex arteries
3. Branches of the Femoral artery
4. Superior & Inferior Gluteal arteries

• Branches of these arteries form an

anastomotic network around the joint.
 NERVE SUPPLY OF THE HIP JOINT

• Femoral nerve (anterior)

• Obturator nerve (anterior)
• Sciatic nerve (posterior)
• Nerve to the Quadratus
femoris muscle (posterior)
MOVEMENTS OF THE HIP JOINT
 MOVEMENTS OF THE HIP JOINT
• FLEXION
- Performed by the Iliopsoas,
Rectus femoris, Sartorius & by
the Adductor muscles.
• EXTENSION
- A backward movement of the
flexed thigh.
- Performed by the Gluteus maximus
& the Hamstring muscles.
 MOVEMENTS OF THE HIP JOINT
• ABDUCTION
- Performed by the Gluteus medius
& minimus
- Assisted by the Sartorius, Tensor
fasciae latae, & Piriformis.

• ADDUCTION
- Performed by the Adductor longus
& brevis & the adductor fibers of the
Adductor magnus.
- Assisted by the Pectineus & the
Gracilis.
 MOVEMENTS OF THE HIP JOINT
• LATERAL ROTATION
- Performed by the Piriformis, Obturator internus &
externus, Superior & Inferior Gemelli, & Quadratus
Femoris, assisted by the Gluteus maximus.
• MEDIAL ROTATION
- Performed by the anterior fibers of the Gluteus
medius & minimus & the Tensor fasciae latae.
• CIRCUMDUCTION
- It is a combination of the previous movements.
THE GLUTEAL REGION
 SURFACE ANATOMY OF THE GLUTEAL
REGION
• ILIAC CREST: At the level of L4 (red arrow)
• INTERGLUTEAL CLEFT (blue arrow):
- A. k. a. Natal cleft
- Groove between the buttocks that runs from
just below the Sacrum to the Perineum.
- It forms the visible border between the
external rounded protrusions of the Gluteal
Maximus muscles.
 SURFACE ANATOMY OF THE GLUTEAL
REGION
• GLUTEAL FOLD
- A prominent fold on the back of the upper
Thigh that marks the upper limit of the Thigh
from the lower limit of the buttock.
• GLUTEAL SULCUS
- A fold of the buttock or horizontal Gluteal
crease.
- It is an area of the body, described by a
horizontal crease formed by the inferior
aspect of the buttocks & the posterior
upper Thigh.
 THE GLUTEAL REGION
• A. k. a. the BUTTOCKS
• Bounded:
- Superiorly: the Iliac crest
- Inferiorly: the fold of the buttock

• Largely made up of the Gluteal

muscles & a thick layer of Superficial
fascia.
 THE SKIN OF THE BUTTOCKS

• The Cutaneous nerves are derived from Posterior &

Anterior Rami of Spinal nerves:
- The Upper Medial Quadrant (UMQ) is supplied by
the Posterior Rami of the upper three Lumbar
nerves & the upper three Sacral nerves.
- The Upper Lateral Quadrant (ULQ) is supplied by
the lateral branches of the Iliohypogastric (L1) &
12th Thoracic nerves (anterior rami).
 THE SKIN OF THE BUTTOCKS
- The Lower Lateral Quadrant (LLQ) is
supplied by branches from the
Lateral Cutaneous nerve of the Thigh
(L2 & 3, Anterior rami).
• - The Lower Medial Quadrant (LMQ) is
• supplied by branches from the Posterior
Cutaneous nerve of the Thigh (S1, S2, &
S3, Anterior rami).
 THE SKIN OF THE BUTTOCKS

• The skin over the Coccyx in the

floor of the cleft between the
buttocks is supplied by small
branches of the Lower Sacral &
Coccygeal nerves.

• The LYMPH VESSELS drain into the

LATERAL GROUP OF THE
SUPERFICIAL INGUINAL LNs.
LYMPHATIC
DRAINAGE
OF THE
LOWER
LIMB
FASCIA OF THE BUTTOCK
 FASCIA OF THE BUTTOCK

• SUPERFICIAL FASCIA of the

Buttocks
- Thick, especially in women
- Impregnated with large
quantities of Fats.
- Contributes to the
prominence of the buttock.
 FASCIA OF THE BUTTOCK
• DEEP FASCIA of the buttocks
- Continuous below with the deep
fascia, or FASCIA LATA, of the Thigh.
- In the gluteal region, it splits to
enclose the Gluteus maximus muscle.
- Above the Gluteus maximus, it
continues as a single layer that covers
• the outer surface of the Gluteus
• medius & is attached to the Iliac crest.
 FASCIA OF THE BUTTOCK
• DEEP FASCIA of the Buttock
- On the lateral surface of the Thigh, the
fascia is thickened to form a strong, wide
band, the ILIOTIBIAL TRACT.
- The Iliotibial tract is attached above to the
TUBERCLE OF THE ILIAC CREST & below to
the LATERAL CONDYLE OF THE TIBIA.
- The iliotibial tract forms a sheath for the
Tensor fasciae latae muscle & receives the
greater part of the insertion of the Gluteus
maximus.
BONES OF THE GLUTEAL REGION
 BONES OF THE GLUTEAL REGION

• HIP BONE

• FEMUR
HIP BONE
 HIP BONE

• The ILIUM,
ISCHIUM, & PUBIS
form the hip bone.

• They meet one

another at the
ACETABULUM.
 HIP BONE
SACROILIAC
JOINT
• The Hip bones articulate with the
Sacrum at the SACROILIAC JOINTS &
form the anterolateral walls of the
Pelvis.

• They also articulate with one another

anteriorly at the SYMPHYSIS PUBIS.

SYMPHYSIS
PUBIS
 ILIUM
• This is the upper flattened part of ILIAC
the bone, possesses the ILIAC CREST
CREST. PSIS
ASIS

• Iliac crest can be felt through the

skin along its entire length & it ends
in front at the ANTERIOR
SUPERIOR ILIAC SPINE (ASIS) &
behind at the POSTERIOR
SUPERIOR ILIAC SPINE.
 ILIUM
• The ILIAC TUBERCLE lies about 2 in. (5 cm)
behind the ANTERIOR SUPERIOR SPINE.
• Below the Anterior Superior Iliac Spine is a
prominence, the ANTERIOR INFERIOR ILIAC
SPINE; a similar prominence, the POSTERIOR
INFERIOR ILIAC SPINE , is located below the
posterior superior iliac spine.
• Above & behind the Acetabulum, the Ilium
possesses a large notch, the GREATER
SCIATIC NOTCH (red arrow).
 ISCHIUM
• It is an L shaped, possessing an
upper thicker part, the BODY, & a
lower thinner part, the RAMUS.

• ISCHIAL SPINE (red arrow) projects

from the posterior border of the
Ischium & intervenes between the
GREATER & LESSER SCIATIC
NOTCHES.
 ISCHIUM
• The ISCHIAL TUBEROSITY (red
arrow) forms the posterior aspect of
the lower part of the body of the
Ischium.
• The Greater & Lesser Sciatic
Notches are converted into
GREATER & LESSER SCIATIC
FORAMINA by the presence of the
SACROSPINOUS &
SACROTUBEROUS LIGAMENTS.
 PUBIS
• It can be divided into:
1. BODY
2. SUPERIOR RAMUS
3. INFERIOR RAMUS

• The bodies of the two (2) Pubic

bones articulate with each other in
the midline anteriorly at the
SYMPHYSIS PUBIS (red arrow).
 PUBIS
• The Superior ramus joins the Ilium &
Ischium at the ACETABULUM.
• The Inferior ramus joins the Ischial
ramus below the OBTURATOR
FORAMEN.
• The Obturator foramen in life is filled
in by the OBTURATOR MEMBRANE .
• The PUBIC CREST forms the upper
border of the body of the Pubis, & it
ends laterally as the PUBIC
TUBERCLE.
 ACETABULUM
• A deep depression on
the outer surface of the
Hip bone.

• It articulates with the

almost spherical head
of the Femur to form
the Hip joint.
 ACETABULUM
• The inferior margin of the
Acetabulum is deficient & is
marked by the ACETABULAR
NOTCH.
• The articular surface of the
ACETABULAR
Acetabulum is limited to a FOSSA
horseshoe-shaped area & is
covered with Hyaline cartilage.
• Its floor is nonarticular & is
called the ACETABULAR FOSSA. ACETABULAR NOTCH
 HIP BONE

• In the anatomic position, the front of the

Symphysis pubis & the Anterior Superior
Iliac Spines lie in the same vertical plane.
• The pelvic surface of the Symphysis pubis
faces upward & backward & the anterior
surface of the Sacrum is directed forward
& downward.
• The important muscles & ligaments
attached to the outer surface of the Hip
bone.
THE FEMUR
 FEMUR
HIP JOINT

• Articulates above with the

Acetabulum to form the
HIP JOINT & below with
the Tibia & the Patella to
form the KNEE JOINT.
• Upper end of the Femur
has a HEAD, a NECK, &
GREATER & LESSER
TROCHANTERS. KNEE
JOINT
 FEMUR
• The head forms about 2/3 of a sphere &
articulates with the Acetabulum of the
FOVEA CAPITIS
Hip bone to form the Hip joint.
• In the center of the head is a small
depression, the FOVEA CAPITIS, for
the attachment of the ligament of the
head of the Femur .
• Part of the blood supply to the head of
the Femur from the OBTURATOR
ARTERY is conveyed along this
ligament & enters the bone at the
Fovea.
 FEMUR

• The NECK connects the Head to the

Shaft, passes downward, backward,
& laterally & makes an angle of
about 125° (slightly less in the
female) with the long axis of the
Shaft.

• The size of this angle can be altered

by disease.
 FEMUR
• The GREATER & LESSER
TROCHANTERS are large eminences
at the junction of the neck & the shaft.

• Connecting the two trochanters are

the INTERTROCHANTERIC LINE
anteriorly, where the ILIOFEMORAL
LIGAMENT is attached, & a prominent
INTERTROCHANTERIC CREST
posteriorly, on which is the
QUADRATE TUBERCLE. POSTERIOR VIEW OF PROXIMAL END OF THE FEMUR
 FEMUR
• SHAFT of Femur is smooth & rounded on
its anterior surface but posteriorly has a
ridge, the LINEA ASPERA (red arrow),
where muscles & Intermuscular septa are
attached.
• Margins of the Linea aspera diverge
above & below. The medial margin
continues below as the MEDIAL
SUPRACONDYLAR RIDGE to the
ADDUCTOR TUBERCLE on the MEDIAL
CONDYLE.
 FEMUR
• Its lateral margin becomes continuous
below with the LATERAL
SUPRACONDYLAR RIDGE.
• On the posterior surface of the shaft
below the Greater trochanter is the
GLUTEAL TUBEROSITY for the
attachment of the GLUTEUS MAXIMUS
MUSCLE.
• Shaft becomes broader toward its distal
end & forms a flat, triangular area on its
posterior surface called the POPLITEAL
SURFACE.
 FEMUR
• The lower (distal) end of the has a
LATERAL & MEDIAL CONDYLES,
separated posteriorly by the
INTERCONDYLAR NOTCH/FOSSA.
• The anterior surfaces of the Condyles are
joined by an articular surface for the
PATELLA.
• The two Condyles take part in the
formation of the knee joint.
• Above the Condyles are the MEDIAL &
LATERAL EPICONDYLES.
• The Adductor tubercle is continuous with
the Medial epicondyle. POSTERIOR VIEW ANTERIOR VIEW
LIGAMENTS OF THE GLUTEAL
REGION
 LIGAMENTS OF THE GLUTEAL REGION
• The two important ligaments in the
gluteal region are the following:
1. SACROTUBEROUS LIGAMENT
(pink shade)
2. SACROSPINOUS LIGAMENT
(green shade)
• Function: To stabilize the Sacrum &
prevent its rotation at the Sacroiliac
joint by the weight of the Vertebral
column.
 SACROTUBEROUS LIGAMENT

• Connects the back of the

Sacrum to the Ischial
tuberosity.

POSTERIOR VIEW
 SACROSPINOUS LIGAMENT

• Connects the back of the

Sacrum to the Spine of the
Ischium.
FORAMINA OF THE GLUTEAL
REGION
 FORAMINA OF THE GLUTEAL REGION
• The two important foramina in
the gluteal region are the
following:
1. Greater Sciatic Foramen
(red arrow)
2. Lesser Sciatic Foramen
(purple arrow)
 GREATER SCIATIC FORAMEN

• Formed by the GREATER SCIATIC

NOTCH of the Hip bone & the
SACROTUBEROUS &
SACROSPINOUS LIGAMENTS.

• It provides an exit from the Pelvis

into the Gluteal region.
 CONTENTS OF THE GREATER SCIATIC
FORAMEN
• The following structures exit the foramen:
- Piriformis
- Sciatic Nerve
- Posterior Cutaneous Nerve of the Thigh
- Superior & Inferior Gluteal Nerves
- Nerves to the Obturator Internus &
Quadratus Femoris
- Pudendal nerve
- Superior & Inferior Gluteal Arteries &
Veins
- Internal Pudendal Artery & Vein
 LESSER SCIATIC FORAMEN
• It is formed by the LESSER SCIATIC
NOTCH of the Hip bone & the
SACROTUBEROUS & SACROSPINOUS
LIGAMENTS.
• It provides an entrance into the Perineum
from the Gluteal region.
• Its presence enables nerves & blood
vessels that have left the pelvis through
the Greater Sciatic Foramen above the
pelvic floor to enter the perineum below
the pelvic floor.
 CONTENTS OF THE LESSER SCIATIC
FORAMEN
• The following structures pass through
the foramen:
- Tendon of Obturator Internus
muscle
- Nerve to Obturator Internus
muscle
- Pudendal Nerve
- Internal Pudendal Artery & Vein
- Inferior Gluteal vessels
MUSCLES OF THE GLUTEAL
REGION
 MUSCLES OF THE GLUTEAL REGION
• They are situated at the
posterior Pelvis.
• The functions of which are the
following:
- Extend the thigh
- Rotate the thigh
- Abduct the thigh
 MUSCLES OF THE GLUTEAL REGION
• The muscles of the gluteal region include
the following:
- Gluteus maximus muscle
- Gluteus medius muscle
- Gluteus minimus muscle
- Tensor fasciae latae muscle
- Piriformis muscle
- Obturator internus muscle
- Superior & Inferior Gemelli muscles
- Quadratus Femoris muscle
 GLUTEUS MAXIMUS
• ORIGIN: Outer surface of Ilium,
Sacrum, Coccyx, Sacrotuberous
ligament
• INSERTION: Iliotibial tract & Gluteal
tuberosity of the Femur
• NERVE SUPPLY: Inferior Gluteal nerve
• ACTION: Extends & laterally rotates
hip joint; through the Iliotibial
tract, it extends the knee joint.
 GLUTEUS MEDIUS
• ORIGIN: Outer surface of Ilium
• INSERTION: Lateral surface of Greater
Trochanter of the Femur
• NERVE SUPPLY: Superior Gluteal
nerve
• ACTION:Abducts thigh at hip joint; tilts
Pelvis when walking to permit
opposite Leg to clear the ground.
 GLUTEUS MINIMUS
• ORIGIN: Outer surface of the Ilium
• INSERTION:Anterior surface of the
Greater Trochanter of the Femur
• NERVE SUPPLY: Superior Gluteal
nerve
• ACTION: Abducts thigh at Hip joint;
tilts Pelvis when walking to
permit opposite leg to clear the
ground.
 TENSOR FASCIA LATAE

• ORIGIN: Iliac crest

• INSERTION: Iliotibial tract
• NERVE SUPPLY: Superior
Gluteal nerve
• ACTION: Assists Gluteus
maximus in extending the
knee joint.
 QUADRATUS FEMORIS
• ORIGIN: Inner surface of
Obturator membrane
• INSERTION: Upper border of
the Greater Trochanter of
the Femur
• NERVE SUPPLY: Sacral plexus
• ACTION: Lateral rotator of the
Thigh at Hip joint
 PIRIFORMIS
• ORIGIN: Anterior surface of the
Sacrum
• INSERTION: Upper border of the
Greater Trochanter of the
Femur
• NERVE SUPPLY: 1st & 2nd Sacral
nerves
• ACTION: Lateral rotator of Thigh
at the Hip joint
 OBTURATOR INTERNUS
• ORIGIN: Inner surface of
Obturator membrane
• INSERTION: Upper border of the
Greater Trochanter of the
Femur
• NERVE SUPPLY: Sacral plexus
• ACTION: Lateral rotator of the
Thigh at Hip joint
 SUPERIOR GEMELLUS

• ORIGIN: Spine of Ischium

• INSERTION: Upper border of the
Greater Trochanter of the
Femur
• NERVE SUPPLY: Sacral plexus
• ACTION: Lateral rotator of the
Thigh at Hip joint
 INFERIOR GEMELLUS

• ORIGIN: Ischial Tuberosity

• INSERTION: Upper border of
Greater Trochanter of the
Femur
• NERVE SUPPLY: Sacral plexus
• ACTION: Lateral rotator of the
Thigh at the Hip joint
NERVE SUPPLY OF THE GLUTEAL
REGION
 NERVE SUPPLY OF THE GLUTEAL REGION

• Posterior Cutaneous Nerve of the

Thigh
• Superior & Inferior Gluteal Nerve
• Nerve to the Quadratus Femoris
• Pudendal Nerve
• Nerve to the Obturator Internus
 SCIATIC NERVE

• A branch of the Sacral

plexus (L4 & 5; S1, S2, & S3)

• It emerges from the Pelvis

through the lower part of
the Greater Sciatic Foramen.
 SCIATIC NERVE
• The largest nerve in the body & consists of
the TIBIAL & COMMON PERONEAL NERVES
bound together with fascia.
• Appears below the Piriformis muscle.
• It curves downward & laterally, lying
successively on the root of the Ischial spine,
the Superior Gemellus, the Obturator
Internus, the Inferior Gemellus, & the
Quadratus Femoris to reach the back of the
Adductor Magnus muscle.
 SCIATIC NERVE
• Related posteriorly to the Posterior
Cutaneous Nerve of the Thigh & the
Gluteus maximus.

• Leaves the buttock region by

passing deep to the long head of
the Biceps Femoris to enter the
back of the Thigh.
 SCIATIC NERVE

• Occasionally, the Common

Peroneal Nerve leaves the Sciatic
Nerve high in the Pelvis & appears
in the gluteal region by passing
above or through the Piriformis
muscle.

• Usually gives NO BRANCHES in

the Gluteal region.
 POSTERIOR CUTANEOUS NERVE TO
THE THIGH
• A branch of the Sacral plexus
• It enters the gluteal region through the
lower part of the Greater Sciatic Foramen
below the Piriformis muscle .
• It passes downward on the posterior
surface of the Sciatic nerve & runs down
the back of the Thigh beneath the deep
fascia.
• Innervates the skin in the Popliteal fossa.
 POSTERIOR CUTANEOUS NERVE TO THE
THIGH
• BRANCHES
1. Gluteal branches to the Skin over
the Lower Medial quadrant (LMQ) of
the Buttock.
2. Perineal branch to the Skin of the
back of the Scrotum or Labium majus
3. Cutaneous branches to the back of
the Thigh & the upper part of the Leg.
 SUPERIOR GLUTEAL NERVE

• Branch of the Sacral plexus

• Leaves the Pelvis through the
upper part of the Greater Sciatic
Foramen above the Piriformis.
• It runs forward between the Gluteus
medius & minimus.
• Supplies both, & ends by supplying
the Tensor Fasciae Latae.
 INFERIOR GLUTEAL NERVE

• Branch of the Sacral plexus

• Leaves the Pelvis through the
lower part of the Greater
Sciatic Foramen below the
Piriformis.
• It supplies the Gluteus
maximus muscle.
 NERVE TO THE QUADRATUS FEMORIS
• Branch of the Sacral plexus,
the nerve to the Quadratus
femoris leaves the Pelvis
through the lower part of the
Greater Sciatic Foramen.

• It ends by supplying the

Quadratus femoris & the
Inferior Gemellus.
 PUDENDAL NERVE: THE NERVE TO THE
OBTURATOR INTERNUS
• Branches of the Sacral plexus, the Pudendal nerve, &
nerve to the Obturator Internus leave the Pelvis
through the lower part of the Greater Sciatic Foramen,
below the Piriformis.
• They cross the Ischial spine with the Internal
Pudendal artery & immediately re-enter the Pelvis
through the Lesser Sciatic Foramen; they then lie in
the Ischiorectal fossa.
• Supplies structures in the Perineum.
• Nerve to the Obturator Internus supplies the Obturator
Internus muscle on its pelvic surface.
BLOOD SUPPLY TO THE GLUTEAL
REGION
 ARTERIES OF THE GLUTEAL REGION

• SUPERIOR GLUTEAL ARTERY

(green arrow)
• INFERIOR GLUTEAL ARTERY
(purple arrow)
• THE TROCHANTERIC
ANASTOMOSIS
• THE CRUCIATE ANASTOMOSIS
 SUPERIOR GLUTEAL ARTERY

• Branch from the Internal Iliac

artery.
• Enters the gluteal region
through the upper part of the
Greater Sciatic Foramen
above the Piriformis.
• Divides into branches that are
distributed throughout the
Gluteal region.
 INFERIOR GLUTEAL ARTERY

• Branch of the Internal Iliac artery.

• Enters the gluteal region through
the lower part of the Greater Sciatic
Foramen, below the Piriformis.

• Divides into numerous branches

that are distributed throughout the
Gluteal region.
 THE TROCHANTERIC ANASTOMOSIS

• Provides the main blood supply to the

Head of the Femur.
• Nutrient arteries pass along the Femoral
neck beneath the capsule.
• The following arteries take part in the
anastomosis:
- Superior & Inferior Gluteal arteries
- Medial & Lateral Femoral Circumflex
arteries
 THE CRUCIATE ANASTOMOSIS
• Situated at the level of the Lesser Trochanter of the
Femur (yellow circle)
- Together with the Trochanteric anastomosis, it
provides a connection between the Internal
iliac & the Femoral arteries.
• The following arteries take part in the anastomosis:
- Inferior Gluteal artery
- Medial & Lateral Femoral Circumflex arteries
- First Perforating artery, a branch of the
Profunda artery
 VENOUS DRAINAGE OF THE GLUTEAL
REGION
• The GLUTEAL VEINS accompany
the arteries
- It drain into the INTERNAL ILIAC
VEIN.

• They can return the blood from the

lower limb even when the Femoral
vein is ligated.
CLINICAL APPLICATION
 FRACTURE OF THE PELVIC BONE
• Two common ways of fracturing
the Pelvic bones:
1. Direct trauma to the Pelvic
bones (from a vehicular
accident).
2. Forces transmitted from
the lower limb ( A heavy
fall on the feet.
 FRACTURE AT THE SACROILIAC JOINT
• Often occur at the weaker points of
the bones. These are the Pubic
rami, the Acetabulum or in the
region of the Sacroiliac joint.
• A common complication of pelvic
fractures is soft tissue injury.
- Bladder & urethra are at high risk
of damage.
 PUBIC RAMI FRACTURE
• Observed on X-rays in elderly
patients who are investigated after
simple low energy falls from standing
height.
• If this is the only injury a patient has
sustained, these Fractures are
usually treated without surgery.
• Healing can be expected within 6 - 8
wks & patients are encouraged to
fully weight bear straightaway.
 HIP DISLOCATION
• Disruption of the joint between the Femur &
Pelvis.
• Occurs when the ball–shaped head of the
Femur comes out of the cup–shaped
Acetabulum of the Pelvis.
• Symptoms typically include pain & an
inability to move the Hip.
• Complications: Avascular necrosis of the
Hip
• Symptoms: Hip pain, trouble moving the
Hip.
 TYPES OF HIP DISLOCATION

• TYPE I: With or without minor fracture

• TYPE II: With single large fracture of the
posterior Acetabular rim.
• TYPE III: With a comminuted fracture of the
posterior rim of the Acetabulum with or
without a major fragment.
• TYPE IV: With fracture of the Acetabular rim
& floor
• TYPE V: With fracture of the Femoral head
 TRAUMATIC HIP DISLOCATION

• When the Ball of the hip joint is

pushed out of the socket.

• This injury most commonly

occurs during an auto collision
or a high-impact fall, workplace
or sports injury, especially those
that also result in a broken leg
or pelvis.
 ARTHRITIS OF THE HIP JOINT
• Osteoarthritis (OA), the most common
disease of the hip joint in the adult,
causes pain, stiffness, & deformity.
• The pain may be in the hip joint itself or
referred to the knee (Obturator nerve
supplies both joints).
• Stiffness is caused by the pain & reflex
spasm of the surrounding muscles.
• Deformity is flexion, adduction, &
external rotation & is produced initially by
muscle spasm & later by muscle
contracture.
 CONGENITAL HIP DISLOCATION (CHD)
• A. k. a. CONGENITAL ACETABULAR
DYSPLASIA DEVELOPMENTAL
DYSPLASIA OF THE HIP
• Condition where the ‘Ball & Socket'
joint of the hips doesn't properly
form in babies & young children.
• A Complete or partial displacement
of the Femoral head out of the
Acetabulum.
 CONGENITAL HIP DISLOCATION (CHD)

• Occurs when a child is born with

an UNSTABLE HIP.
• Caused by abnormal formation of
the hip joint during their early
stages of fetal development.
• The cause of CHD is UNKNOWN
in many cases.
 CONGENITAL HIP DISLOCATION (CHD)

• Contributing factors:
- Low levels of Amniotic Fluid (AF) in
the Uterus.
- Breech presentation
- A family history of the condition
• According to American Family
Physician, one out of every 1,000
infants is born with a dislocated hip.
 CONGENITAL HIP DISLOCATION (CHD)

• The ball-and-socket joint in the child’s hip may sometimes dislocate.

• The joint may sometimes completely dislocate.
• The physical signs needed for the diagnosis are age-related.
• In the newborns, the tests for instability are the most sensitive.
• This instability worsens as your child grows.
CONGENITAL HIP DISLOCATION (CHD)
 CONGENITAL HIP DISLOCATION (CHD)
• Management:
- PAVLIK HARNESS
for 6 weeks.
• By maintaining the Ortalani
positive hip.
• It prevents hip extension &
adduction & permits flexion &
abduction
 ACQUIRED HIP DISLOCATION

• Acquired dislocations of the hip joint are relatively uncommon,

owing to the strength and stability of the joint.
• They usually occur as a result of trauma, but it can occur as a
complication following Total Hip Replacement or Hemiarthroplasty.
• Two (2) types: Anterior
• Posterior
 ACQUIRED HIP DISLOCATION
POSTERIOR DISLOCATION ANTERIOR DISLOCATIN
• 90% of the acquired type of dislocation • Anterior dislocation is RARE
• Femoral head is forced posteriorly, & tears through • Occurs as a consequence of
the inferior & posterior part of the joint capsule,
where it is at its weakest.
traumatic extension, abduction &
lateral rotation.
• Affected limb becomes shortened & medially
rotated. • The femoral head is displaced
• Sciatic nerve runs posteriorly to the hip joint, & is at anteriorly & (usually) inferiorly in
risk of injury (occurs in 10-20% of cases). This is relation to the acetabulum.
often associated with anterior femoral head and
posterior wall fractures
• .
 FEMORAL NECK FRACTURE
• This type of break occurs in the
femur about 1 or 2 inches from
where the Head of the bone
meets the socket.

• Fracture may cut off the blood

circulation to the ball of the hip
by tearing the blood vessels.
 INTRAMUSCULAR (IM) INJECTION SITE
• IM injections are administered in five
potential sites:
1. Deltoid (commonly used for adult
vaccinations)
2. Dorsogluteal
3. Ventrogluteal
4. Rectus femoris
5. Vastus lateralis
INTRAMUSCULAR INJECTION AT THE
GLUTEAL REGION
 REFERENCES
• Gray, H. (2020). Gray’s Anatomy. Medina University Press International.

• Snell, R. S. (2012). Clinical Anatomy By Regions. Lippincott Williams &

Wilkins.

• Harris Le, Lipscorn PR, Hodgson JR.H. Early diagnosis of congenital

dysplasia and congenital dislocation of the hip. Value of the abduction
test. J Am Med Assoc. 1960 May 21;173:229–233.
END OF
LECTURE
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