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Home , Foramen, Ilium (bone), Pudendal nerve

Gluteal region and the Back of the

Lecture 17

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{وَﻣَﻦْ ﻳَﺘَﻮَﻛﻞْ ﻋَﻠَﻰ اﻟﻠﻪِ ﻓَﻬُﻮَ ﺣَﺴْﺒُﻪُ} ھﺬا اﻟﻌﻤﻞ ﻻ ﯾﻐﻨﻲ ﻋﻦ اﻟﻤﺼﺪر اﻷﺳﺎﺳﻲ ﻟﻠﻤﺬاﻛﺮة Objectives

● Contents of gluteal region: ● Groups of Glutei muscles and small muscles (Lateral Rotators). ● & vessels. ● Foramina and structures passing through them as: 1-Greater Sciatic . 2-Lesser Sciatic Foramen. ● Back of thigh : Hamstring muscles.

● Text in BLUE was found only in the boys’ slides ● Text in PINK was found only in the girls’ slides ● Text in RED is considered important ● Text in GREY is considered extra notes Contents of gluteal region

A. GLUTEI - - -

B. GROUP OF SMALL MUSCLES Muscles (Lateral Rotators) (8 muscles) - Piriformis - Obturator internus - Superior gemellus - Inferior gemellus - Quadratus femoris Contents of gluteal region

- Sciatic - Superior gluteal nerve - Nerves - Posterior cutaneous nerve of (7 nerves) thigh. (all from ) - Nerve to obturator internus - Nerve to quadratus femoris -

- Superior gluteal - Inferior gluteal - Internal pudendal vessels Vessels (all from internal iliac vessels) Greater sciatic foramen

● Greater sciatic notch of is transformed into foramen by Greater sciatic foramen Sacrotuberous Lesser sciatic foramen & sacrospinous ligaments. ● Structures passing through Greater sciatic foramen: - . Above piriformis: - Superior gluteal nerves & vessels. Below piriformis: - Inferior gluteal nerves & vessels. - . - Posterior cutaneous nerve of thigh. - Nerve to quadratus femoris. - Nerve to obturator internus. Pass through - Pudendal nerve both greater and lesser - Internal pudendal vessels. foramen. Lesser sciatic foramen

Lesser sciatic notch of is transformed into foramen by Sacrotuberous & sacrospinous ligaments.

● Structures passing through Lesser sciatic foramen: - Tendon of obturator internus. - Nerve to obturator internus. - Pudendal nerve. - Internal pudendal vessels.

Pass through both greater sciatic and lesser foramen: ● Nerve to obturator internus. ● pudendal nerve. ● internal pudendal vessels. Glutei muscles

Name of the muscle Gluteus minimus Gluteus medius

Origin Anterior part of the gluteal Middle part of the gluteal surface of surface of ilium

Insertion Anterior surface of greater Lateral surface of greater trochanter trochanter

Nerve supply Superior gluteal nerve

Abduction and medial rotation of hip joint. Normally they prevent lateral tilt of the Action by contraction ABDUCTORS of opposite side, on raising the other limb from ground. if the pelvis. tilts this is mean positive Trendlenburge's sign. Glutei muscles

Action of gluteus minimus and medius

Right pelvic tilt as is the right picture means : paralysis of abductor of the OPPOSITE side -the left side of the pelvis is elevated higher than the right side- ﯾﻌﻧﻲ اﻟﭘﻠﻔس اذا ﻣﺎل ﻣن ﺟﮭﺗﮫ اﻟﯾﺳﺎر ﯾﻌﻧﻲ اﻟﻌﺿﻠﺔ ﺑﺟﮭﺔ اﻟﯾﻣﯾن ﻓﯾﮭﺎ ﻣﺷﻛﻠﺔ ﻻﻧﮭﺎ ﻣﺎﺷدت ﻛوﯾس واﻟﻌﻛس Insertions Glutei muscles

Gluteus maximus

Posterior part of the gluteal surface of ilium origin The main origin: Back of , and back of .

1- main insertion : insertion 2- other insertion : gluteal tuberosity of the femur

Nerve supply Inferior gluteal nerve

Extension and lateral rotation of the hip joint. Action Through its attachment to iliotibial tract, it stabilize the femur on tibia during standing. Small muscles (lateral rotators)

Obturator internus

Inner surface of the side wall of the pelvis origin

Into the medial surface of the greater insertion trochanter

Nerve to obturator internus Nerve supply

Lateral rotation of the hip joint & Control Action movement of the hip joint. Small muscles (lateral rotators)

Superior & inferior Gemelli

Superior gemellus Inferior gemellus

Upper part of lesser Lower border of lesser Superior gemellus origin sciatic notch sciatic notch

Upper & lower parts into tendon of obturator insertion internus

Nerve Nerve to to quadratus supply* internus femoris Inferior gemellus

Lateral rotation of hip Lateral rotation of hip Action joint & control joint & control movement of hip joint movement of hip joint

ﻛل وﺣده ﻣﻧﮭم ﯾﻐذﯾﮭﺎ اﻟﻧﯾرڤ اﻟﻠﻲ ﯾﻐذي اﻟﻣﺳل اﻟﻠﻲ ﺗﺣﺗﮭﺎ* Small muscles (lateral rotators)

Piriformis

origin Pelvic surface of middle 3 sacral vertebrae

It passes through GSF* to be inserted into insertion the upper border of the greater trochanter

Nerve supply Anterior rami of S1, S2

Lateral rotation of hip joint & control Action movement of hip joint.

*Greater sciatic foramen -almost all small muscles in the gluteal region make an insertion in greater trochanter Except, Quadratus femoris. Small muscles (lateral rotators)

Quadratus femoris

origin Lateral border of the .

Quadrate tubercle & intertrochanteric insertion crest.

Nerve supply Nerve to quadratus femoris

1. Lateral rotation of the hip joint. Action 2. Control movement of the hip joint. Nerves

Course Branches

Passes through GSF (greater 1. Muscular to gluteus sciatic foramen), above medius, minimus & Superior piriformis, then between tensor fasciae lata gluteal gluteus medius & minimus 2. Articular to hip joint

Passes through GSF, below Muscular to gluteus Inferior piriformis, then deep to maximus gluteal gluteus maximus.

Passes through GSF, below 1. Muscular to quadratus To piriformis femoris & inferior quadratus gemellus femoris 2. Articular to hip joint Only in girls slides Nerves

Course Branches

Passes through GSF, below Cutaneous branches to: piriformis, then descends - Gluteal region

Posterior deep to deep . - Back of in males cutaneous (labium majus) in females - Back of thigh & upper part of back of leg.

Passes through GSF, below ● No branches in gluteal piriformis, then superficial to: region - ● Divides into tibial & - Superior gemellus common peroneal Sciatic - Tendon of obturator nerves, in the middle of Internus back of thigh - Inferior gemellus - Quadratus femoris - Adductor magnus. Posterior compartment of the thigh Contents

Hamstring muscles: • Biceps femoris. Muscles • Semitendinosus. • Semimembranosus. • Ischial part of adductor magnus.

Blood Branches of the profunda supply femoris artery

Nerve Sciatic nerve supply Hamstring muscles

Biceps Femoris

● The long head from the ischial tuberosity. origin ● The short head from the linea aspera . insertion Mainly into the head of the fibula

● The long head is supplied by the tibial part of Nerve sciatic; supply ● The short head is supplied by the common peroneal part of the sciatic.

● Flexion of knee. Action ● Lateral rotation of flexed leg. ● Long head: extends hip.

Lateral Medial Hamstring muscles

SEMITENDINOSUS

origin Ischial tuberosity

Upper part of the medial surface of the shaft of the insertion tibia (SGS) *SGS (semitendinosus / gracialis / sartorius):Three muscles that have the same insertions.

Nerve Tibial portion of the sciatic. supply

● Flexes and medially rotates the leg at the knee Action joint; ● Extends the thigh at the hip joint. Hamstring muscles

SEMIMEMBRANOSUS

origin Ischial tuberosity.

● Posterior surface of the medial condyle of the tibia. insertion ● It forms the oblique popliteal ligament, which reinforces the capsule on the back of the knee joint.

Nerve Tibial portion of the sciatic nerve. supply

● Flexes and medially rotates the leg at the knee joint; Action ● Extends the thigh at the hip. Hamstring muscles

Adductor magnus (hamstring part)

origin Ischial ramus and ischial tuberosity

Adductor tubercle of the medial insertion condyle of the femur

Nerve The tibial portion of the sciatic supply

Extends the thigh at the hip joint Action *it doesn't reach the tibia or fibula so it can't move the knee joint.

The adductor magnus has 2 parts: adductor part and hamstring part. The 2 parts have different origin, insertion, action and nerve supply. They are also in different compartments of the thigh Only in girls slides Blood supply

Blood supply

•The four perforating branches of the profunda femoris artery (deep artery of thigh) provide a rich blood supply to this compartment. (perforating= to pierce or to make a hole)

•The profunda femoris drains the greater part of the blood from the compartment.

perforating branches shown in green Nerve supply

Nerve supply

•The sciatic nerve, a branch of the sacral plexus (L4 and L5; S1, S2,and S3), leaves the gluteal region as it descends in the midline of the thigh.

sciatic nerve

It is overlapped the adjacent margins of the posteriorly by biceps femoris and semimembranosus muscles

It lies on the posterior aspect of the adductor magnus.

Sciatic nerve shown in green In the lower

note : common peroneal third of the it ends by dividing into the , also known as and common peroneal nerves. common fibular nerve thigh MCQs (1) How many vessels are supplying the gluteal region? A- 2 B- 3 (4) If someone comes to ER with injury in his C- 4 , Which one of these nerves may be affected? (2) Which one of the following muscles abduct A- Superior gemellus & medially rotates the hip in the gluteal B- Sciatic nerve region? C- Tibial portion of the sciatic nerve A- Gluteus medius & minimus B- Gluteus medius & maximus C- Gluteus maximus & minimus (5) Gluteal region consists of glutei and group of small muscles, Which one of the following isn’t a (3 )Sciatic nerve passes through GSF, ______glutei muscle? piriformis? A- Gluteus maximus A- below B- Gluteus minimus B- above C- Quadratus femoris C- beside SAQ

A patient came to the clinic complaining from difficulty of extending his thigh at the hip joint:

(1) List the muscles responsible for this action:

(2) Name The nerve responsible of these muscles:

(3) Name the muscles that are responsible of lateral rotation of hip joint? Answers Answers (SAQ) (MCQs) (1) Semimembranosus 1-B Semitendinosus Long head : biceps femoris 2-A Adductor magnus (hamstring part) (2) Tibial portion of sciatic nerve 3-A (3) Gluteus maximus 4-C quadratus femoris piriformis obturator internus. 5-C Superior & inferior gamelli Team Members Lamia Abdullah Alkuwaiz (Team Leader) Faisal Fahad Alsaif (Team Leader) Rawan Mohammad Alharbi Abdulaziz Al dukhayel Abeer Alabduljabbar Afnan Abdulaziz Almustafa Maha Barakah Fahad Alfaiz Abdulmajeed Ahad Algrain Majd Khalid AlBarrak Akram Alfandi Alwardi Alanoud Almansour Norah Alharbi Saad Aloqile Abdulrahman Alageel Albandari Alshaye Nouf Alotaibi Saleh Almoaiqel Rayyan Almousa AlFhadah abdullah alsaleem Noura Mohammed Alothaim Abdulaziz Alabdulkareem Sultan Alfuhaid Arwa Alzahrani Rahaf Turki Alshammari Abdullah Almeaither Ali Alammari Dana Abdulaziz Alrasheed Reham Alhalabi Yazeed Aldossari Fahad alshughaithry Dimah Khalid Alaraifi Rinad Musaed Alghoraiby Muath Alhumood Fayez Ghiyath Ghada Alhaidari Sara Alsultan Abdulrahman Almotairi Aldarsouni Ghada Almuhanna Shahad Alzahrani Mohammed Alquwayfili Ghaida Alsanad Wafa Alotaibi Abdulelah Aldossari Hadeel Khalid Awartani Wejdan Fahad Albadrani Abdulrahman Alduhayyim Abduljabbar Al-yamani Haifa Alessa Wjdan AlShamry Hamdan Aldossari Sultan Al-nasser Khulood Alwehabi Abdullah Alqarni Majed Aljohani Layan Hassan Alwatban Mohammed Alomar Zeyad Al-khenaizan Lojain Azizalrahman Abdulrahman Aldawood Mohammed Nouri Lujain Tariq AlZaid Saud Alghufaily Abdulaziz Al-drgam Hassan Aloraini Fahad Aldhowaihy Khalid Almutairi Omar alyabis