Download GLUTEAL REGION

GLUTEAL REGION
LEARNING OBJECTIVES
At the end of lecture the student should be able:
 To know about the location of gluteal region
 To know about bones and ligaments of gluteal region
 To know about different structures entering and leaving gluteal region
 To know about muscles, vessels and nerves of gluteal region
 To know about certain clinical correlates regarding gluteal region
EXTENT
• Upwards: to the iliac crest of the hip bone
• Forwards: to the level of the anterior superior iliac spines.
• Posteriorly: limited by the gluteal crease, coinciding with the undersurface of
the buttock
Buttock - the rounded, fat-filled elevation which forms only part of the gluteal region
FASCIA OF THE GLUTEAL REGION
Superficial fascia is
• A little thicker and tougher than other areas of the
body
• Especially thick in females
• Impregnated with fat.
• Responsible for prominence of buttocks
Deep fascia
• Continuous with fascia lata of thigh
• Splits to enclose the gluteus maximus
• Attached as a single layer to iliac crest above
THE CUTANEOUS NERVES IN THE GLUTEAL REGION
Upper medial quadrant
• dorsal rami of lumbar nerves (L1,2,3)
• dorsal rami of sacral nerves (S1,2,3)
Upper lateral quadrant
• lateral branch of subcostal nerve (T12)
• lateral branch of Iliohypogastric nerves(L1)
Lower medial quadrant
• posterior femoral cutaneous nerve of thigh (S2,3)
Lower lateral quadrant
• Lateral femoral cutaneous nerve(L2)
BONES OF GLUTEAL REGION
•
Parts of following bone are present in gluteal region
– back of hip bone
– upper end of femur
– Back of sacrum
– Hip joint is the main joint in gluteal region formed
between acetabulum of hip bone and head of femur
LIGAMENTS OF GLUTEAL REGION
Sactotuberous ligament
• From back of sacrum to ischial tuberosity
Sacrospinous ligament
• From back of sacrum to spine of ischium
The convert the greater and lesser sciatic notches into
foramina of same name
FORAMINA OF GLUTEAL REGION
Greater sciatic foramen
Structures leaving pelvis entering gluteal region are:
• Piriformis muscle
Structures passing above piriformis
• Superior gluteal vessels and nerve
Structures passing below the piriformis
• sciatic nerve
• Posterior cutaneous nerve of thigh
• Inferior gluteal vessels and nerves
• Nerve to obturator and quadratus femoris
• Pudendal nerve
• Internal pudendal vessels
Lesser sciatic foramen
Entrance into perineum from gluteal region
Structures passing through it:
• Tendon of obturator internus
• Internal pudendal vessels
• Pudendal nerve
• Nerve to obturator internus
MUSCLES OF GLUTEAL REGION
• Gluteus maximus
• Gluteus medius
• Gluteus minimus
• Tensor fascia lata
• Piriformis
• Obturator internus
• Gemellus superior
• Gemellus inferior
• Quadratus femoris
Gluteus maximus
Largest muscle in the body
Origin
• Outer surface of ilium, sacrum, coccyx
Insertion
• Iliotibial tract and gluteal tuberosity of femur
Action
• Extensor and lateral rotator of hip
• extensor of knee through iliotibial tract
Three bursa are related
Between tendon of insertion and greater trochanter
Between tendon of insertion and vastus lateralis
Bursa overlying ischial tuberosity
Gluteus medius
Origin
• Outer surface of ilium
Insertion
• Lateral surface of greater trochanter of femur
Gluteus minimus
Origin
• Outer surface of ilium
Insertion
• Anterior surface of greater trochanter of femur
Actions of gluteus medius and minimus
• Abductors of hip
•
During walking, when opposite foot is off the ground, tilt
opposite side of pelvis upward, support pelvis during walking
Tensor fascia lata
• Can be seen on the lateral side of gluteal region
Origin
• Iliac crest
Insertion
• Iliotibial tract
Action
• Assists gluteus maximus in extension of knee
Piriformis
Passes through greater sciatic foramen
Origin in the pelvis
• Anterior surface of sacrum
Insertion in gluteal region
• Ant surface of greater trochanter
Nerve supply
• S1 S2
Origin of
• Gemellus superior from spine of ischium
• Obturator internus from Inner surface of obturator membrane
• Gemellus inferior from Ischial tuberosity
Insertion of
• above 3 muscles is on upper border of greater trochanter
• quadtratus femoris arise from ischial tuberosity inserted at
quadrate tubercle of femur
All of the following muscles of gluteal region are LATERAL
ROTATOR of hip
Piriformis
Obturator internus
Superior Gamellus
Inferior Gamellus
Quadratus femoris
NERVE SUPPLY OF GLUTEAL MUSCLES
• Superior gluteal nerve
– Gluteus medius
– Gluteus minimus
– Tensor fascia lata
• Inferior gluteal nerve to gluteus maximus
• Nerve to obturator internus
– Obturator internus
– Superior Gamellus
• Nerve to quadratus femoris
– Quadratus femoris
– Inferior Gemellus
NEUROVASCULATURE OF GLUTEAL REGION
• The PIRIFORMIS muscle separates the greater sciatic foramen into superior and
inferior parts
• The branches of nerves and vessels come into the gluteal region either through
the superior part or the inferior part
VESSELS OF THE GLUTEAL REGION
There are three VESSELS i.e. arteries and veins coming into the gluteal region through
the greater sciatic foramen:
 Inferior gluteal
 Superior gluteal
 Internal pudendal
These vessels are branches and tributaries of the internal iliac
artery and vein respectively, which lie inside the pelvis
Superior gluteal vessels
• Artery is a Branch of internal iliac artery
• Vein is a tributary of internal iliac vein
• Passes through greater sciatic foramen above piriformis
• Runs between gluteus medius and minimus
Inferior gluteal vessels
• Artery is branch of internal iliac artery
• vein is a tributary of internal iliac vein
• Pass through greater sciatic foramen below piriformis
• Run between gluteus maximus and medius
Internal pudendal vessels
• Very short course in gluteal region
•
Enters through greater sciatic foramen
•
Leave through lesser sciatic foramen and enter perineum
Trochanteric anastomosis:
• Main source of blood supply to head of femur
• Lie near trochanteric fossa
• Arteries taking part are:
– Superior gluteal(descending branch)
– Medial circumflex femoral(ascending branch)
– Lateral circumflex femoral(ascending branch )
– Inferior gluteal
Cruciate anastomosis:
• Lie at the level of middle of lesser trochanter of femur
• Arteries taking part are:
– Medial circumflex femoral(transverse branch)
– Lateral circumflex femoral(transverse branch )
– Inferior gluteal(descending branch)
– First perforating (ascending)
NERVES OF THE GLUTEAL REGION
• Branches of the lumbosacral plexus
• Enter gluteal region from pelvis through greater sciatic foramen
Passing above the piriformis
• Superior gluteal
Passing below piriformis
• Inferior gluteal
• Sciatic
• Posterior femoral cutaneous
• Pudendal
• Nerve to quadratus femoris
• Nerve to obturator internus
Superior gluteal nerve
• Branch of sacral plexus
• Enter gluteal region above piriformis
• Runs between gluteus medius and minimus
Muscles innervated:
• Gluteus medius
• Gluteus minimus
• Tensor fascia lata
Inferior gluteal nerve
• Branch of sacral plexus
• Enter gluteal region below piriformis
• Runs between gluteus maximus and medius
Muscle innervated
• Gluteus maximus
Sciatic nerve
• Largest nerve of body
• Branch of sacral plexus
• Consists of tibial and common peroneal nerve bound together
• Enters gluteal region below piriformis
•
Leaves gluteal region by passing beneath the long head of bicep femoris ,enters in
posterior compartment of thigh
Relations of sciatic nerve
Anterior relation
– root of ischial spine
– Superior Gemellus
– Obturator internus
– Inferior Gemellus
– Quadratus femoris
– Back of adductor magnus
Posterior relation
– Posterior cutaneous nerve of thigh
– Gluteus maximus
Posterior cutaneous nerve of thigh
• Branch of sacral plexus
• Enters gluteal region below piriformis
Relations
• Anterior: sciatic nerve
• Posterior: deep fascia
Branches of posterior cutaneous nerve of thigh
• Lower medial quadrant of gluteal area
• Perineal branches to skin of back of scrotum/labium majus
• Cutaneous supply to back of thigh and popliteal fossa
Pudendal nerve and nerve to obturator internus
• Branches of sacral plexus
• Short course in gluteal region
• Enter through greater sciatic foramen
• Leave gluteal region through lesser sciatic foramen
• Crosse ischial spine
• Pudendal nerve supplies perineum
• Nerve to obturator internus
– obturator internus
– superior Gemellus
Nerve to quadratus femoris
• Branch of sacral plexus
• Enters gluteal region below piriformis
Muscles innervated
– Quadratus femoris
– Inferior Gemellus
CLINICAL CORRELATES
Gluteal maximus bursitis
• Also known as trochanteric bursitis
• Inflammation of bursa
• Friction or trauma to bursa
• Common in athletes
• Extremely painful
WEAKNESS OF GLUTEUS MEDIUS AND MINIMUS
Causes
• Inferior gluteal nerve damage
• Intrinsic weakness of muscle
Symptoms
• Inability to lift pelvis while walking
• Waddling gait
Trendelenburg test (hip)
• Test for pathology of hip joint
• Drooping of pelvis on one side when ipsilateral foot is lifted off the ground
• May be present in other conditions:
• Pain (e.g. due to osteoarthritis)
• Short femoral neck
• Medial migration of femoral head
• Neuropathy
SCIATIC NERVE AND INTRAMUSCULAR INJECTION
• Intramuscualr injections are usually given in gluteus maximus
• Sciatic nerve passes midway between greater trochanter and ischial tuberosity
• To avoid injury to sciatic nerve, injection should be given in upper outer
quadrant
GLUTEAL ABCESS
• Wrong techniques and bad practices while giving
intragluteal injections can lead to gluteal abscess
PIRIFORMIS SYNDROME
• certain leg positions pull the piriformis up against the sciatic nerve causing
buttock pain & radiating leg pain