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ايمان غانم.د Gluteal region .Extends from the iliac crest above to the gluteal fold below The superficial fascia is thick dense and fatty, the deep fascia is thick It continuous below with the fascia lata,. Sacrotuberous ligament: It is a strong band passes upwards from the medial side of the ischial tuberosity to the margins of the sacrum and coccyx and to both posterior iliac spines. Sacrospinous ligament: This is a thick triangular band it passes from the the ischial spine to the margin of coccyx and last piece of the sacrum deep to the sacrotuberous ligament. These two ligaments share together to conver greater and lesser Sciatic notcges into foramina The greater sciatic foramen:. Transmits Structures which enter the gluteal region from the pelvis which include 1-Superior gluteal vessels and nerves. 2-the piriformis muscle 3-.inferior gluteal vessels and nerves 4-sciatic nerve, 5-the posterior cutanous of the thigh 6-pudendal nerve 7—nerve to quadrates femoris The lesser sciatic foramen:, transmits structures between the gluteal region and the perineum these include; the internal pudendal vessels, pudendal nerve and nerve to obturator internus muscle. Muscles of the gluteal region: The muscles of the gluteal region can be divided into two groups: Superficial group – a group of large muscles that abduct and extend the femur. It includes the gluteus maximus, gluteus medius, gluteus minimus and tensor fascia lata. Deep lateral rotators – A group of smaller muscles, that mainly act to laterally rotate the femur. It includes the quadratus femoris, piriformis, gemellus superior, gemellus inferior and obturator internus and obturator externus. . Names of m. origin insertion Tensor Fascia Lata anterior iliac crest, attaching to the anterior superior iliac spine a.Area behind the posterior gluteal line b.back of sacrum and coccyx c.back of sacrotuberous lig. Area between middle and inferior gluteal line iliotibial tract, Gluteus maximus Gluteus minimus Gluteus medius a.3/4 inserted into ilio-tibial tract b.1/4to gluteal tuberosity Front of greater trochanter Area bounded by iliac Greater crest,posterior and trochanter middle gluteal lines Action. Gl. Maximus is main extensor at hip joint assist in raising from sitting position and a powerful muscle on climbing Gl. Medius and minimus and tensor fasia lata are abductors and medial rotation of thigh at hip Nerve supply Inferior gluteal nerve (L5 S1 S2): it is a branch from the sacral plexus enter the gluteal region with the posterior cutanous nerve of the thigh inferior to the piriformis m. supply gluteus maximus m. Superior gluteal nerve (L4 L5 S1): it is a branch from the sacral plexus enters the gluteal region above the piriformis m. divided into numbers of branches supply the glueus medius , minimus and tensor fasciae lata m. Gluteal vessels Include: Inferior gluteal artery: it is a branch of the internal iliac artery emerges from the pelvis below piriformis muscle accompany the inferior gluteal nerve supply the gluteus maximus and gives branches to the back of the thigh, it also give a slender companion artery to the sciatic nerve. The inferior gluteal artery anastomosed with the medial circumflex artery. Superior gluteal artery: arise from the internal iliac artery accompany the superior gluteal nerve, it enters the gluteal region above the piriformis muscle. It follows the superior gluteal nerve supply the gluteus medius, minimus and the hip joint. In addition gluteal region has the following small and short muscles which are located deeply Names of m. Origin Piriformis Inferior gemellus Middle three peices Upper border of of the front of sacrum greater trochanter and trochanteric fossa Pelvic surface of trochanteric fossa just obtur. Membrane inferior to insertion of piriformis Both insertion Ischial spine and together with that of upper border of obturator internus m. ischial tuberosity into trochanteric fossa Quadrates femoris Ischial tuberosity Guadrate tubercle Obturator externus Outer surface obtur. Membrane of trochanteric fossa Obturator internus Superior gemellus insertion All these short muscles are lateral rotaters of the thigh at the hip joint. N. supply 1)-sup.gemellus+obtu. Intr.by nerve to obtu. Int.2)inferior gemellus+ quadrates femoris by nerve to quadratus femoris 3)piriformis by branches from S1andS2. 4) obtu. Exter. By obturater nerve The back of the thigh lec5 The muscles of the back of the thigh are the hamstring muscles which are extensors of the hip joint and flexors of the knee joint, all arise from the ischial tuberosity except the short head of the biceps m. and all are inserted in the bones of the leg. These muscles include: biceps femoris, semitendinosus and semimembranosus. All supplied by the sciatic nerve. Names of m. origin Biceps femoris insertion a-long head has common origin with semitendinossus from ischial tuberosity b-short head from linea aspira semitendinosus has common origin with long head of biceps from ischial tuberosity semimembranousus from ischial tuberosity By common tendone to the head of fibula Ischial part of from ischial tuberosity adductor magnus Adductor tubercle of femor Upper part of medial sureface of tibia Posteromedial part of medial condyle of tibia Action hamstring muscles are extensors of the hip joint and flexors of the knee joint. In addition both semiten.and semimem.act as medial rotaters of leg when knee joint semiflexed.biceps femoris act as lateral rotater of leg when knee joint semiflexed. Sciatic nerve (L4 L5 S1 S2 S3): it is the thickest nerve in the body arise from the sacral plexus, pass inferior to the piriformis m through the greater sciatic foramen, deep to the gluteus maximus m. in the upper part of its course it descends over: 1- ischial wall of the acetabulum. 2- Obturator internus m. and the 2 gemelli ms. 3 -Quadratus femoris m. It leaves the buttock by passing deep to the long head of the biceps femoris, it supply the hamstring ms from the tibial side of the nerve except the short head of biceps muscle receive its nerve supply from the common peroneal side, it also gives articular branch to the hip joint. the sciatic nerve then descends on the posterior surface of the adductor magnus m. at the lower third of the thigh it divided into medial branch (tibial nerve) and lateral branch (common peroneal nerve). The popliteal fossa It is a diamond shaped space ( depression) lies behind the knee, the lower 1/3 of the femur and the upper part of the tibia. The superficial fascia of the fossa contain little fat, while the deep fascia is thin and strong Bounderies: superolaterally --------- biceps femoris m. superomedially--------- semimembranosus and semitendinosus ms. inferolaterally -------- lateral head of the gastrocnemius m. Inferomedially …………. Medial head of the gastrocnemius m. The anterior wall ( floor) : from above downward is the popliteal surface of the femur, popliteus m the posterior capsule of the knee joint and oblique popliteal ligament The posterior wall ( roof) is the skin and deep fascia of the fossa. Contents of the fossa These include: 1- The popliteal vessels. The popliteal art. is most anteriorly , it gives 5 genicular branches in the fossa and bifurcates at lower border of popliteus m. into anterior and posterior tibial arteries 2- Branches of the sciatic nerve the tibial and common peroneal nerves. 3- Popliteal lymph nodes. 4- Posterior cutaneous nerve of the thigh. The popliteal artery These are the direct continuation of the femoral art. enter the fossa through the adductor hiatus. They lie anterior to the tibial nerve,. it lies aganist the posterior part of the capsule of the knee joint, then it lies posterior to popliteus muscle in the upper part of the leg.The popliteal artery ends at the lower border of the popliteus muscle by dividing into anterior and posterior tibial arteries. Branches of popliteal artery: 1- muscular branches to the hamstring ms. And to the muscles of the calf. 2- Articular branches these are the lateral and medial superior and inferior genicular and middle genicular arteries to the knee joint correspond to the genicular branches from the tibial and common peroneal nerves. they anastomosed with the branches from the lateral circumflex femoral, descending genicular arteries, and the recurrent branches of the anterior tibial artery. The popliteal vein: formed by the union of the anterior tibial, the posterior tibial and the peroneal veins at the lower border of the popliteus muscle, it lies superficial to the artery and between it and the tibial nerve. it receive tributaries correspond to the branches of the popliteal artery and the lesser saphenous vein. it become the femoral vein at the adductor hiatus. Tibial nerve (L4 L5 S1 S2 S3). It is the largest of the two terminal branches of the sciatic nerve, it begins above the popliteal fossa descends vertically in the fossa, Lying first on the lateral side of the popliteal artery then posterior to it and finally medial to it. it pass between the two heads of the gastrocnemius muscle and under the soleus muscle. It supply the muscles of the back of the thigh and leg, the sole of the foot, the skin of the lateral and lower half of the back of the leg and sole of the foot. Branches in the popliteal fossa: 1-- Articular branches, it gives superomedial, inferomedial and middle genicular branches to the knee joint, accompanied the corresponding branches from the popliteal artery 2-Muscular branches to the muscles of the back of the thigh and to the gastrocnemius, plantaris, soleus and popliteus ms. 3-sural nerve: it is a cutaneous branch descend in the groove between the two heads of the gastrocnemius m. it pierce the deep fascia about the middle of the back of the leg, supply the skin of the lower posterior part of the leg and the skin of the lateral side of the dorsum of the foot. It accompany the small saphenous vein. Common peroneal nerve (L4 L5 S1 S2) It is smaller than tibial nerve follow the tendon of biceps femoris m. along the upper lateral border of the popliteal fossa to the back of the head of the fibula, then curves forwards along the neck of the fibula deep to the peroneus longus m. here it divides into deep and superficial branches. Branches in the popliteal fossa: 1- cutaneous branches, these include the peroneal communicating branch which arise in the upper part of the popliteal fossa descend on the posterolateral side of the calf , it supply the proximal 2/3 of the posterolateral part of the leg. Lateral cutanous nerve of the calf arise on the lateral head of the gastrocnemius m. supply the lateral side of the leg. 2- articular branches, these include: the superior and the inferior lateral genicular branches they are small branches accompany the corresponding arteries. Recurrent genicular branch arise where the common peroneal nerve divides into superficial and deep branches, it ascends to the knee joint. 3- muscular branch to the short head of the biceps femoris m. arise high up in the fossa. Hip joint: it is a synovial joint of ball and socket type, the joint formed between the head of the femur and the acetabulum, the articular surface of which is horseshoe shaped and is deficient inferiorly at the acetabular notch. The cavity of the acetabulum is deepened by the presence of a fibrocartilaginous rim called the acetabular labrum, the labrum is connected across the acetabular notch by the transverse acetabular ligament. The strength and stability of the joint depend on : 1- depth of the acetabulum which increased by the labrum acetabulae. 2- The strong ligaments and muscles surrounding the joint. The fibrous capsule which surrounds the joint attached to the margin of the acetabulum and transverse ligament proximally. Distally attached to the intertrochantric line and greater trochanter anteriorly and intertrochantric crest posteriorly. The fibrous capsule is lined by the synovial membrane. Ligaments of the joint: 1- iliofemoral ligament is a strong ligament lie in the front of the joint. it is inverted Y shaped.it prevents hyperextens of the hip joint. 2- Pubofemoral ligament it is triangular ligament lie in the lower anterior part of the capsule.) it limits abduction) 3- Ischiofemoral ligament it is lie posteriorlyl.) limit extension) 4- The transverse acetabular ligament it converts the notch into a tunnel through which the blood vessels and nerves enter the joint. 5-Ligaments of the head of the femur it is attached to the pit on the head of the femur and by its base to the transverse acetabular ligament. Blood supply of the joint 1- branch from lateral and medial circumflex femoral artery. 2- Acetabular branches of the obturator. 3- Branches of the superior and inferior gluteal artery. Nerves of the joint 1- nerve to quadratus femoris. 2- The femoral nerve through nerve to rectus femoris. 3- Anterior division of the obturator nerve. Movement at hip joint: 1- flexion which is very free it produced mainly by iliopsoas, assisted by rectus femoris and sartorius. 2-Extension (restricted by the iliofemoral ligament.(it produced mainly by glut. Maximus m. assited by hamstring m. 3- Abduction (restricted by the pubofemoral ligament.) it produced mainly glut. Medius and minimus assited by Sartorius and tensor fascia latae. 4- Adduction is (restricted by the lateral portion of the iliofemoral ligament). it produced mainly by 3 adductor m. assisted by pectineus and gracilis 5- Medial rotation (tightens the ischiofemorall ligament). it produced mainly by glut. Medius and minimus assited by tensor fascia latae. 6-Lateral rotation is( limited by the pubofemoral ligament and the lateral part of the iliofemoral ligament.) it produced mainly by deep glut. M.