LOWER LIMB

Lower limb : Upper limb

FEMORAL TRIANGLE AND ADDUCTOR CANAL
 Femoral triangle
Triangular depression on the front of the upper one-third of the thigh
Boundaries
Laterally – medial border of sartorius
Medially – medial border of adductor longus
Base – formed by the inguinal ligament
Apex – formed by the overlapping of medial and lateral boundaries
Roof – formed by the skin, superficial fascia with its contents and fascia lata
Floor – formed by the adductor longus, pectineus, psoas major and iliacus
Roof:
• Skin
• Superficial fascia: Made up of connective tissue
fibers, blood vessels, nerves and lymphatics.
In the upper part of the thigh near the inguinal region
the superficial fascia consists of two layers:
• Superficial fatty layer
• Deep membranous layer
This membranous layer is attached to the deep fascia
(fascia lata) along a horizontal line which extends
from the pubic tubercle laterally for about 8 cm,
which corresponds to the flexion crease of the hip
joint called Holden’s line.
Nerves of front of the thigh are:
Cutaneous nerves:
• Lateral femoral cutaneous nerve
• Intermediate femoral cutaneous nerve
• Medial femoral cutaneous nerve
• Ilio-inguinal nerve
• Femoral branch of genital-femoral nerve
• Saphenous nerve
• Anterior division of obturator nerve
Femoral nerve
Lateral cutaneous nerve of the thigh: (L2,3)
 Branch of lumbar plexus
 Root value: dorsal division of ventral rami of
L2,3.
 Emerges beneath the fascia iliaca in the iliac
fossa lateral to psoas major muscle
 Passes beneath inguinal ligament to enter the
thigh
Branches:
 Anterior branch - supplies the anterolateral
aspect of thigh and contributes to patellar
plexus
 Posterior branch - supplies skin of gluteal
region and postero lateral aspect of thigh.
Lateral cutaneous nerve of the thigh: (L2,3)
Clinical anatomy:
 Meralgia parasthetica: The lateral cutaneous nerve of the thigh sometime gets
compressed as it passes through the inguinal ligament, causing pain and altered
sensation in the upper lateral aspect of the thigh – Meralgic paraesthetica.
 This condition is treated surgically by releasing the nerve from inguinal ligament
Intermediate cutaneous nerve of the thigh:
 Branch of anterior division of femoral nerve
 Pierces the fascia lata 8 cms below inguinal ligament
 Consist of medial and lateral branches
 Lateral branch pierces the sartorius muscle
Areas supplied
 Supplies the front of thigh
 Gives a branch to patellar plexus
Medial cutaneous nerve of the thigh:
 Branch of the anterior division of femoral nerve
 Accompanies the femoral artery on its lateral side and
then crosses medially
Areas supplied:
 Skin on the medial aspect of thigh and the upper part
of leg
 Gives a branch to the patellar plexus and subsartorial
plexus
Femoral branch of genito femoral nerve (L1)
 Derived from lumbar plexus (L1,2)
 Enters the thigh along the lateral compartment of femoral sheath
 Crosses in front of femoral artery from lateral to medial side and becomes cutaneous
Areas supplied:
 Area of skin below the middle of inguinal ligament
Ilio-inguinal nerve:
 Derived from lumbar plexus (L1)
 Collateral branch of ilio-hypogastric nerve
 Pierces the internal oblique muscle and enters the inguinal canal in the middle.
 Traverses the inguinal canal, emerges out through the superficial inguinal ring
Area supplied:
 Skin of upper medial part of thigh
 Upper part of scrotum (anterior 1/3) in males and mons pubis and labia majora in
females
Cutaneous arteries and veins in the
front of the thigh….
Great saphenous vein
 Longest vein in the body
 Thick walled with numerous valves
 Represents the pre-axial vein of the lower limb
 Formed on the dorsum of the foot by the union of the
medial end of the dorsal venous arch and medial
marginal vein
Course
 Ascend in front of the medial malleolus, then along the
medial margin of leg
 Lies behind the knee
 Ascend in the thigh along the medial aspect
 Finally pierces the cribriform fascia at the saphenous
opening to drain into femoral vein
Tributaries
• Posterior arch vein
• Anterior leg vein
• Anterolateral vein
• Posteromedial vein
• Superficial epigastric vein
• Superficial circumflex iliac vein
• Superficial external pudendal vein
• Deep external pudendal vein
Clinical anatomy
In coronary by-pass a segment of great saphenous vein is
used for aorto-coronary grafting to by-pass an
coronary obstruction, since its wall is thicker
compared to other veins
Varicose veins - dilated tortuous veins of lower limb
Cause of varicose veins:
 Due to valve incompetency in the deep vein or in
perforators results in pooling of blood in superficial veins
 Thrombosis of deep veins
Deep fascia of the thigh or Fascia lata
It is very strong and envelops the thigh like a
sleeve
It shows two modifications:
• Iliotibial tract
• Saphenous opening
Iliotibial tract
Formed by the thickening of the fascia lata
on the lateral aspect of the thigh
Attachments:
 Inferiorly it is attached to the anterior
surface of lateral condyle of the tibia.
 Superiorly at the level of greater trochanter
it splits to receive the insertion of
gluteus maximus and tensor fascia latae
- The superficial lamina is attached to
the tubercle of the iliac crest and deep
lamina is attached to the capsule of
hip joint.
Saphenous opening (fossa ovalis)
• It is a gap in the fascia lata, situated 4 cm below
and lateral to the pubic tubercle (supero-lateral to
the pubic tubercle is the superficial inguinal ring)
• Its vertical length is about 3-4 cm
• It is formed between the superficial and deep layer of
the fascia lata
 It is covered by the cribriform (sieve like) fascia
which is pierced by great saphenous vein, superficial
branches of femoral artery and lymphatics
• Femoral hernia becomes subcutaneous at this point
Fascia lata encloses the entire thigh like a sleeve.
Three intermuscular septae (lateral, medial, posterior) pass from the inner aspect of the
deep fascia to the linea aspera of the femur and divide the thigh into:
• Anterior or extensor compartment
• Posterior or flexor compartment
• Medial or adductor compartment
Contents
• Femoral artery and its branches
• Femoral vein and its tributaries
• Femoral nerve and its branches
• Femoral branch of genitofemoral N
• Deep inguinal group of lymph nodes
• Femoral sheath
Femoral triangle
Femoral sheath
 Funnel shaped facial prolongation around the
proximal part of femoral vessels
 Femoral nerve is outside the sheath
 Extends for about 3-4 cm below the inguinal
ligament
 Beyond which it blends with the tunica
adventitia of femoral vessels
 Anterior wall of the sheath is formed by fascia
transversalis
 Posterior wall is formed by fascia iliaca
 Sheath is rudimentary in the new born due to
foetal position of flexion
 Extends below the inguinal ligament when the
extension of thigh becomes habitual
Femoral sheath…..
 Antero-posterior septae divide the sheath into 3 compartments
 Lateral compartment contains the femoral artery
 Intermediate compartment contains the femoral vein
 Medial compartment is called the femoral canal
Femoral canal
 1.25 cm long and 1.25 cm broad at its base
 Base contains an oval shaped opening - femoral ring
 Femoral ring is closed by condensation of extra-peritoneal tissue: femoral septum
 This septum is pierced by lymph vessels, connecting deep inguinal with external
iliac lymph nodes
 Peritoneal depression called, femoral fossa lies above the septum
Femoral ring boundaries
 In front – inguinal ligament
 Behind – pectineus with its facial covering
 Medially – base of lacunar ligament
 Laterally – femoral vein separated by medial interfacial septum
Femoral ring…..
 Is a potential weak point in the abdominal wall
 Wider in females, because of greater width of pelvis and smaller size of
femoral vessels. Hence femoral hernia is more common in females than males
 The omentum or intestinal loops may herniate through the femoral ring
Coverings of complete Femoral hernia from within outwards
 Peritoneum of the hernial sac
 Femoral septum: extra-peritoneal tissue
 Anterior wall of femoral sheath
 Cribriform fascia
 Superficial fascia and skin
Strangulated femoral hernia:
• Treated surgically by cutting the lacunar ligament
• But while cutting the lacunar ligament one should remember the possibility of
abnormal obturator artery (in 30% of cases) which is related to the base of the
lacunar ligament, which forms the medial boundary of the femoral ring
• Normally the obturator artery is branch of internal iliac artery, rarely it is replaced by
the pubic branch of inferior epigastric artery
Femoral canal
 Acts as potential dead space for the expansion of
femoral vein during high venous return
 Contains a lymph node – lymph node of Cloquet
or Rosenmuller, which drains the lymph from the
glans penis or clitoris
Structures piercing the femoral sheath…..
 Laterally – femoral branch of genitofemoral nerve
 Medially – great saphenous vein
 In front – superficial epigastric, superficial external pudendal, superficial
circumflex iliac branches of femoral artery
 FEMORAL ARTERY
 Continuation of external iliac artery
 Enters the femoral triangle at the mid-inguinal
point
 Passes down and medially, leaves the femoral
triangle through the apex of the femoral triangle
beneath the sartorius
 Traverses the adductor canal to enter the popliteal
fossa as popliteal artery through the fifth osseo-
aponeurotic opening in the adductor magnus
 The proximal 3-4 cm of the artery along with the
femoral vein is enclosed in femoral sheath
 The artery can be marked on the surface by a line
connecting the adductor tubercle to the mid-
inguinal point (with the thigh abducted and
laterally rotated), upper two third of the line
corresponds to the artery
 Pulsation of the artery can be felt just below the
inguinal ligament
Relations of the femoral artery
Anterior:
• Skin
• Superficial fascia
• Superficial inguinal lymph nodes
• Superficial circumflex iliac vein
• Fascia lata
• Anterior wall of femoral sheath
• Femoral branch of genito-femoral nerve before
piercing the femoral sheath
• Close to the apex the artery is crossed from lateral to
medial side by medial femoral cutaneous nerve
Relations of the femoral artery…..
Posterior:
 The artery lies on psoas tendon – separates the artery
from the capsule of the hip joint
 The artery is separated from the psoas by the femoral
sheath and nerve to pectineus
 Pectineus – separated from the femoral artery by the
profunda femoris vessels
 Adductor longus – separated from the artery by the
femoral vein
Lateral
• Femoral nerve and its branches
Medial
• Femoral vein
Branches
Superficial branches:
 Superficial epigastric
artery
 Superficial circumflex
iliac artery
 Superficial external
pudendal artery
Deep branches:
 Deep external (Profunda femoris artery)

pudendal artery
 Muscular branches
 Profunda femoris
artery
Branch in the adductor
canal:
 Descending genicular
artery
Branches of femoral artery
1. Superficial epigastric artery
• Pierces the femoral sheath and cribriform fascia
• Runs upward across the inguinal ligament towards the
umbilicus
• Supplies the anterior abdominal wall below the
umbilicus
2. Superficial circumflex iliac artery
 Pierces the femoral sheath and fascia lata lateral to
saphenous opening
 Runs towards the anterior superior iliac spine below the
inguinal ligament
 Takes part in the formation of spinous anastomosis
Spinous anastomoses is formed by branches of:
 Superficial circumflex iliac artery
 Deep circumflex iliac artery
 Deep branch of superior gluteal artery
 Ascending branch of lateral circumflex iliac artery
3. Superficial external pudendal artery
• Pierces the femoral sheath and cribriform fascia
• Passes medially in front of spermatic cord or round
ligament of uterus
• Supply the skin of scrotum or labium majus
4. Deep external pudendal artery
 Pierces the fascia lata more medially
 Passes behind the spermatic cord or round ligament of
uterus
 Supply the scrotum or labium majus
5. Muscular branches
• Supply the adjoining muscles
6. Profunda femoris artery
 Largest branch of femoral artery
 Supplies the extensor, adductor and
flexor muscles
 Arises from the lateral side of the femoral
artery 3.5 cm below the inguinal ligament
 Spirals medially behind the femoral
vessels
 Leaves the femoral triangle between the
pectineus and adductor longus
 Descends between adductor longus and
adductor brevis, then adductor longus and
adductor magnus
 Finally piercers the adductor magnus as
4th perforating artery
Branches
a. Lateral circumflex femoral artery
b. Medial circumflex femoral artery
c. 4 perforating branches
Profunda femoris artery…..
a. Lateral circumflex femoral artery
• Passes between the two division of
femoral nerve, sartorius and rectus
femoris
Divides into: ascending, descending and
transverse branches
Ascending branch takes part in spinous
anastomoses, also forms an arterial ring
to provide retinacular arteries to supply
the head and neck of femur
Transverse branch takes part in the
formation of cruciate anastomoses
Importance of retinacular artery
• These branches are torn off in the fracture
of neck of femur, thus resulting in
avascular necrosis of head of femur as the
artery cannot reach the head of femur
• In such cases the medial circumflex
femoral artery which supplies the head
becomes the chief arterial source to the
head of femur
Profunda femoris artery…..
Lateral circumflex femoral
artery…..

Cruciate anastomosis is formed by

branches of:
 Transverse branch of medial
circumflex femoral artery
 Transverse branch of lateral
circumflex femoral artery
 Ascending branch of first
perforating artery
 Descending branch of inferior
gluteal artery
Descending branch
• Runs behind the rectus femoris
and along the anterior border of
vastus lateralis
• Takes part in the anastomoses
around the knee by joining with
superior lateral genicular branch
of popliteal artery
b. Medial circumflex femoral artery
• Winds round the medial side of the femoral shaft
• Passes successively between the psoas major and
pectineus, adductor brevis and obturator externus,
quadratus fenoris and upper border of adductor magnus
Finally divides into: transverse and ascending branches
Transverse branch – takes part in cruciate anastomosis
Ascending branch:
• Passes in front of the quadratus femoris towards the
tronchantric fossa
• Takes part in the formation of trochanteric anastomosis
Acetabular branch - Arises from the medial circumflex femoral
artery at the upper border of adductor brevis
• Enters the hip joint between the acetabular notch and
transverse acetabular ligament, along with obturator artery
• Supplies the acetabular fat and the head of femur through
the ligament of the head of femur
Medial circumflex femoral artery….

Trochanteric anastomosis formed by:

 Deep branch of superior gluteal artery
 Often by the descending branch of inferior gluteal
artery
 Ascending branch of lateral circumflex femoral
artery
 Ascending branch of medial circumflex femoral
artery
c. Perforating arteries
• 4 in number, last one being the continuation of
profunda femoris artery
• Perforating branches pierces the adductor magnus
and lateral intermuscular spetum
• Supply the adductor and hamstring muscles
 1st perforating A arises along the upper border of
adductor brevis
 2nd perforating A arises in front of adductor
brevis and provides a nutrient branch to femur
 3rd perforating A arises along the lower border of
adductor brevis
Perforating arteries anastomoses with each other
1st perforating artery takes part in cruciate
anastomoses
Last perforating artery anastomoses with popliteal
artery
 It is always preferred to ligate the femoral
artery proximal to the origin of profunda
femoris artery, so that collateral circulation is
established between the branches of profunda
femoris and internal and external iliac arteries
• Occlusion of the artery due to thrombus can result
in gangrene of lower limb
• In cases of narrowing of proximal part of femoral
artery (above the origin of profunda femoris)
circulation to lower limb is maintained through
cruciate and trochanteric anastomosis.
• Femoral artery can be compressed against the
superior ramus of pubis, psoas tendon and head of
femur to obtain haemostasis of lower limb
• Artery is prone to laceration since it is
superficially placed
• Femoral artery aneurysm: localized
enlargement of femoral artery due to weakness
in the arterial wall
• Since the femoral artery is quite superficial it is
preferred artery for injecting dye to perform
angiography, coronary angiography and
angioplasty.
Femoral vein
 From the adductor canal the vein enters the femoral
triangle through the apex
 Here the vein lies behind the artery
 As the vein ascends it shifts from lateral to medial
side of the artery
 Continues above as external iliac vein behind the
inguinal ligament
In the femoral triangle it receives:
• Profunda femoris vein
• Great saphenous vein
• Muscular tributaries
Clinical anatomy
 Femoral vein is preferred site for intravenous infusions
in infants and children, and in patients with peripheral
circulatory failure
 Catheterization of femoral vein is done to obtain blood
sample from the right atrium or right ventricle or to
record the pressure from right heart.
 Route to right ventricle: femoral vein – external iliac
vein – common iliac vein – inferior vena cava – right
atrium – right ventricle
Nerves of front of the thigh are:
Cutaneous nerves:
• Lateral femoral cutaneous nerve
• Intermediate femoral cutaneous nerve
• Medial femoral cutaneous nerve
• Ilio-inguinal nerve
• Femoral branch of genital-femoral nerve
• Saphenous nerve
• Anterior division of obturator nerve
Femoral nerve
Femoral nerve:
 Largest branch of lumbar plexus
Root value: dorsal division of ventral rami of L2,3,4
Course
 Appears in the iliac fossa under the fascia iliaca
 Passes in the muscular gutter between the psoas major
and iliacus muscle
 Enters the femoral triangle behind the inguinal
ligament lying lateral and outside the femoral sheath
 Around one inch below the inguinal ligament the nerve
splits into anterior and posterior divisions
 The splitting of the nerve looks like “cauda equina”
 The two divisions are separated by the lateral
circumflex femoral artery
Branches
From trunk:
 Muscular: iliacus, pectineus
 Vascular branches
Note: Nerve to pectineus passes behind femoral sheath
and supply lateral part of muscle
From Anterior division:
Cutaneous:
 Intermediate femoral cutaneous nerve
 Medial femoral cutaneous nerve
Muscular: Sartorius muscle
From Posterior division:
Cutaneous:
 Saphenous nerve
Muscular:
 Quadriceps muscles: (Rectus femoris,
Vastus medials, Vastus intermedius,
Vastus lateralis)
Note:
 Nerve to rectus femoris also gives
articular branch to hip joint
 Nerve to V. medialis and V. lateralis
give twig to knee joint
 Nerve to V. intermedius also supply
articularis genu muscle
Clinical anatomy
 Femoral nerve may be compressed between psoas major and iliacus in cases of
an abscess in psoas muscle .
 Injury to the nerve results in atrophy of extensors of knee (quadriceps).
 Femoral nerve block is achieved by injecting anaesthetic agent at a point one
finger breadth lateral to pulsation of femoral artery
 Penetrating wounds may injure the femoral nerve, which will result in paralysis of
quadriceps femoris and loss of sensation on the anterior and medial aspects of the
thigh
Adductor canal or Sub-sartorial canal or Hunter’s canal
• Inter-muscular tunnel situated on the medial side of the middle 1/3 of the thigh
• Extends from the apex of the femoral triangle to the hiatus magnus
Boundaries
Anterolaterally: vastus medialis
Posteriorly or floor: adductor longus above and adductor magnus below
Medially or roof: formed by fibrous septa extending from anterolateral wall to the floor,
which is overlapped by sartorius muscle
Beneath the sartorius is the sub-sartorial plexus, which is formed by:
• Medial cutaneous nerve of the thigh, saphenous nerve, anterior division of obturator
nerve
Adductor canal or Sub-sartorial canal or Hunter’s canal
Contents: femoral artery, descending genicular branch of femoral artery, femoral
vein, saphenous nerve, nerve to vastus medialis, occasionally anterior and
posterior divisions of obturator nerve
Clinical correlation
For popliteal aneurysm the femoral artery is ligated in the adductor canal. This
procedure was first performed by famous surgeon, Dr. John Hunter, hence the name,
Hunter’s canal
After ligation of femoral artery in the adductor canal, the collateral circulation is
established through arterial anastomosis around the knee joint
Popliteal aneurysm at present treated by stent-graft placement
Medial (adductor) compartment of the
thigh
Its counterpart in the arm has degenerated
phylogenetically, and is represented by the
coracobrachialis. Since the action of
adduction is carried out by strong muscles
pectoralis major and latissimus dorsi, which
connect the arm to the trunk
Contents of the adductor compartment:
Muscles: (adductor longus, adductor
brevis, adductor magnus), gracilis,
pectineus Vessel: obturator artery and
branches of profunda femoris artery and
obturator nerve
Obturator nerve: Chief nerve of the adductor compartment
• It is a branch from the lumbar plexus
• Root value is ventral division of ventral rami of L2,3,4
Course:
• From its origin it runs downwards along the medial border of psoas major muscle
• In relation to obturator canal it divides into anterior and posterior divisions
• Anterior division is separated from the posterior division (gives a branch to
obturator externus) by few fibers of obturator externus muscle
• Apart from supplying the muscles it also supplies the hip and knee joint, vascular
branch to femoral artery and cutaneous branch supplies the skin on the medial side
of the thigh via sub-sartorial plexus
Accessory obturator nerve
• Present in 30% subjects
• Branch from lumbar plexus (L3,4)
• It runs down to cross the superior ramus of pubis behind the pectineus, and soon
divides into three branches: branch to pectineus, articular branch to hip joint and
communicating branch to anterior division of obturator nerve
Gracilis is also called as custodies virginitatis (custodian of virginity)
Obturator artery
• Branch of anterior division of internal iliac, accompanies the obturator nerve
• Divides into anterior and posterior branches at the obturator foramen
• Both branches supply muscles of adductor compartment
• The posterior branch gives an acetabular branch to supply the fat in the acetabular
fossa and sends a twig to the head of femur along the ligament of the head of the
femur
Gluteal region
Extends from the iliac crest above to the
gluteal fold below; natal cleft and mid-
dorsal line medially to the imaginary
line joining the anterior superior iliac
spine to the anterior edge of the greater
trochanter
Features:
 Buttock
 Gluteal fold
 Natal cleft/inter-gluteal cleft
 Ischial tuberosity
 Posterior superior iliac spine
 Tip of greater trochanter
 Iliac crest
Superficial fascia with its contents
Deep fascia
Ligaments – sacro-spinous and sacro-tuberous
These ligaments convert the greater and lesser
sciatic notches into greater and lesser sciatic
foramina; the two important exits from the
pelvis
Greater sciatic foramen
 Considered as the “door of the gluteal
region”
 Through which all arteries and nerves enter the
gluteal region from the pelvis
Structures passing through the greater sciatic
foramen:
Piriformis
 Almost completely fills the foramen
 Key muscle of the gluteal region
 All the nerves and vessels entering the gluteal
region pass either above or below this muscle
Structures passing through the greater sciatic foramen……….
Structures passing above the piriformis:
1. Superior gluteal nerve
2. Superior gluteal vessels
Structures passing through the greater
sciatic foramen……….
Structures passing below the piriformis:
1. Inferior gluteal nerve and vessels
2. Sciatic nerve
3. Posterior cutaneous nerve of the
thigh
4. Nerve to quadratus femoris
5. Pudendal nerve
6. Internal pudendal vessels
7. Nerve to obturator internus
Lesser sciatic foramen:
• Through which pudendal nerve and internal
pudendal vessels enter the pudendal canal
• Also transmits tendon of obturator internus and
nerve to obturator internus
Sacro-tuberous ligament – degenerated part of the
long head of biceps femoris
Muscles of the gluteal region:
 Gluteus maximus – inferior gluteal nerve - chief extensor of the hip, assists in
getting up from sitting position
 Gluteus medius – superior gluteal nerve – abductor of the hip, prevents the
sagging of pelvis on the unsupported side, anterior fibers act as medial rotators of
the hip
 Gluteus minimus - superior gluteal nerve - abductor of the hip, prevents the
sagging of pelvis on the unsupported side, anterior fibres act as medial rotators of
the hip
Muscles of the gluteal region …….
Trendelenberg’s sign
• In positive Trendelenburg sign or paralysis of the gluteus medius and minimus
muscle of one side
• Patient lurch to the unsupported side with each step – lurching gait
(Trendelenburg gait)
• If the muscles are paralyzed on both sides, leads to waddling gait.
Muscles of the gluteal region……
 Tensor fascia lata - superior gluteal nerve – abducts the hip, through the ilio-tibial
tract maintains the extended position of the knee joint
 Piriformis – ventral rami of S1, S2 – act as lateral rotator of hip joint
 Obturator internus - nerve to obturator internus - lateral rotator of hip joint
 Superior gamellus – nerve to obturator internus - lateral rotator of hip joint
 Inferior gamellus – nerve to quadratus femoris - lateral rotator of hip joint
 Quadratus femoris - nerve to quadratus femoris - lateral rotator of hip joint
 Obturator externus – posterior div. of obturator nerve - lateral rotator of hip joint
Arteries of the gluteal region:
• Superior gluteal artery – from posterior division of internal iliac
• Inferior gluteal artery - from anterior division of internal iliac
• Internal pudendal artery - from anterior division of internal iliac
Superior gluteal artery:
 Branch of the posterior division of
internal iliac artery
 Enters the gluteal region through the
greater sciatic foramen above the
piriformis along with superior gluteal
nerve
 Here it divides into superficial and
deep branches
 Superficial branch passes between
the gluteus medius and maximus to
supply both muscles
 Deep branch passes laterally between
the gluteus medius and minimus, later
divides into upper and lower branches
 Upper branch takes part in the
formation of spinus anastomoses close
to anterior superior iliac spine
 Lower branch takes part in the
formation of trochantratic
anastomoses
Inferior gluteal artery:
• Branch of anterior division of internal iliac artery
• Enters the gluteal region through the greater sciatic foramen below the piriformis
along with inferior gluteal nerve
Here it divides into three branches:
Muscular branches to adjacent muscles
Anastomotic branches – takes part in cruciate and trochanteric anastomoses
Arteria nervi ischiadic or artery accompanying sciatic nerve:
 Accompanies and supplies sciatic nerve
 It is the remnant of axis artery of the lower limb
Internal pudendal artery
 Branch of anterior division of internal iliac artery
 Makes a brief appearance in the gluteal region below the piriformis
 Crosses the tip of the dorsal surface of the ischial spine accompanied by two venae
comitantes
 Here it is related laterally to nerve to obturator internus and medially to pudendal
nerve
 The vessel then curves forwards through the lesser sciatic foramen, to enter the
pudendal canal with the pudendal nerve to supply the structures of the perineum
To control the haemorrhage in the perineum, the internal pudendal artery may be
compressed against the ischial spine
Nerves of the gluteal region
 Superior gluteal nerve – L4,L5.S1
 Inferior gluteal nerve – L5,S1,S2
 Sciatic nerve – L4,L5,S1,S2,S3
 Posterior cutaneous nerve of the thigh – S1,S2,S3
 Nerve to quadratus femoris – L4,L5,S1
 Pudendal nerve – S2,S3,S4
 Nerve to obturator internus – L5,S1,S2
 Perforating cutaneous nerve – S2,S3
Nerves of the gluteal region:
Superior gluteal nerve (dorsal division of ventral rami of
L4,L5,S1):
 Arises from the sacral plexus in the pelvis
 Enters the gluteal region through the greater sciatic foramen
above the piriformis
 Accompanies the superior gluteal vessels, runs between the
gluteus medius and minimus
 Supplies the gluteus medium, gluteus minimus and
tensor fascia lata
 Also provides an articular twig to the hip joint
Inferior gluteal nerve (dorsal division of ventral rami of
L5,S1,S2):
 Arises from the sacral plexus in the pelvis
 Enters the gluteal region through the greater sciatic
foramen below the piriformis
 Accompanies the inferior gluteal vessels and posterior
cutaneous nerve of the thigh
 Here it curves upwards to supply the gluteus maximus
from its deep surface
Sciatic nerve:
 It is the widest nerve of the body, about 2cm broad
 Consists of tibial (ventral division of ventral rami of
L4,L5,S1,S2,S3) and common peroneal (dorsal
division of ventral rami of L4,L5,S1,S2) components
 Enters the gluteal region through the greater sciatic
foramen below the piriformis
 Most lateral structure emerging through the greater
sciatic foramen below the piriformis
 Descends beneath the gluteus maximus midway between
the ischial tuberosity and the greater trochanter
Sciatic nerve……
In the gluteal region it rests on:
 Dorsal surface of the body of ischium separated by nerve
to quadratus femoris
 Tricipital tendon (Gemellus superior, obturator internus,
gemellus inferior)
 Quadratus femoris
 Adductor magnus
 At the back of the thigh the nerve is crossed superficially
by the long head of biceps femoris
 Close to the upper angle of the popliteal fossa it divides
into tibial and common peroneal nerve
 In case of higher division of sciatic nerve into tibial and
common peroneal, the common peroneal nerve enters
the gluteal region by piercing or passing above the
piriformis
 The tibial nerve in such case will pass below the
piriformis
Branches:
Muscular branches – supply long head of biceps femoris,
semitendinosus, semimembranosus and hamstring part
adductor magnus
All muscular branches arise from the medial side of the
nerve
Articular branches to the hip joint
Clinical correlation
Sciatic nerve may be injured by:
• Penetrating wounds
• Posterior dislocation of the hip joint
• Fracture/dislocation of the hip joint
When the injury is complete:
 All the muscles below the knee are paralysed associated
with foot drop
 All cutaneous sensations below the knee are lost except
the area supplied by the saphenous nerve
Sciatic nerve is uncovered in the angle between the lower
border of gluteus maximus and long head of biceps
femoris
 Temporary compression of sciatic nerve against
femur at the lower border of the gluteus maximus leads
to sleeping foot
 When a person sits on the hard edge of the chair for a
long time cause paresthesia in the lower limb
Nerve to quadratus femoris (ventral division of ventral rami of
L4,L5,S1)
• Emerges below the piriformis beneath the sciatic nerve
• The nerve rests on the ischium, descends deep to the tendon
of obturator internus and the two gemelli
• Supplies inferior gemellus and quadratus femoris from
the deep surface
• Gives an articular branch to hip joint
Nerve to obturator internus (ventral division of ventral rami of L5,S1,S2)
 Emerges through the greater sciatic foramen below the piriformis
 Rests on the dorsal surface of the ischial spine
 Makes a short visit in the gluteal region
 Passes forward through the lesser sciatic foramen deep to the fascia covering the
obturator internus and supplies that muscle
 On its way gives a twig to gemellus superior
Pudendal nerve (ventral division of ventral rami of S2,S3,S4)
 Passes below the piriformis through the greater sciatic foramen
 Crosses just medial to the ischial spine around the sacrospinous ligament
 Winds forward through the lesser sciatic foramen to enter the pudendal
canal/Alcock’s canal
 Supplies the perineum
Posterior cutaneous nerve of the thigh (S1,S2,S3)
 Conveys dorsal branches of S1, S2; and ventral
branches of S2,S3
 Appears below the piriformis superficial or medial to
the sciatic nerve
 It descends in the back of the thigh beneath the fascia
lata and superficial to the long head of biceps femoris
 On reaching the popliteal fossa it pierces the roof and
accompanies the small saphenous vein
 Extends up to the middle of the calf, where it
communicates with the sural nerve
Posterior cutaneous nerve of the thigh (S1,S2,S3)……
Branches
Gluteal branches –
• 3-4 in number, curl around the lower border of gluteus
maximus
• Supply the skin of the lower and lateral part of gluteal
region
Perineal branch –
• Supplies the posterior part of scrotum or labium majus
Perforating branch –
• Pierce the fascia lata and supply the skin of the back of
the thigh, popliteal fossa and upper part of the back of
the leg
Clinical correlation
 The segmental origin of posterior cutaneous nerve of the
thigh and pelvic splanchnic nerves (S2,S3,S4), which
supply the derivatives of the cloaca are almost identical
 Hence, pain from the diseases pelvic organs are
occasionally referred to the skin along the posterior
cutaneous nerve of the thigh
Perforating cutaneous nerve (dorsal division of ventral
rami of S2,S3)
Pierces the lower part of sacrotuberous ligament
Winds round the lower border of gluteus maximus to supply
the skin of the posteroinferior quadrant of the gluteal
region
Clinical correlation:
Intramuscular injection in gluteal region
 If given randomly it may damage the sciatic nerve
 It is safe only when given in the upper lateral quadrant of the gluteal region
 Or above the line extending from PSIS to the upper border of greater trochanter,
which corresponds to the upper border of the gluteus maximus
Clinical correlation……
Sciatic nerve block
 The nerve is blocked by injecting an anesthetic agent a few centimeters below the
midpoint of the line joining the PSIS and upper border of the greater trochanter
Piriformis syndrome
 Characterized by pain in buttock due to compression of the sciatic nerve by the
piriformis
 Commonly occurs in sports that require excessive use of gluteal muscles:
e.g. - Ice skaters, cyclists……..
 Causing hypertrophy or spasm of piriformis
 BACK OF THE THIGH
• It is also called Hamstring compartment
• It is incompletely separated from the medial
compartment, because adductor magnus
shares both the compartments
• The skin of this compartment is mainly
supplied by posterior cutaneous nerve of the
thigh
• This compartment contains 3 muscles: biceps
femoris, semitendinosus, semimembranosus
• These muscles are supplied by branches from
the sciatic nerve
Characteristic features of hamstring muscles:
• They should take origin from the ischial tuberosity
• They should be inserted to one of the bone of the leg
• They should be supplied by tibial component of sciatic
nerve
• They should act as flexors of the knee and extensors of the
hip
Hamstring muscles are
• Semitendinosus
• Semimembranosus
• Long head of biceps femoris
• Hamstring or ischial head of adductor magnus
 Hip joint
 Multi-axial ball and socket variety of synovial joint
Bones forming the joint
Head of the femur and acetabulum of the hip bone
• Head of the femur forms more than half of a sphere
• Head of the femur is covered by hyaline cartilage
except at the fovea capitis
• Articular cartilage is thick at the center and thin at
the periphery
Hip joint…..
Acetabulum has a horseshoe shaped lunate surface, acetabular notch and acetabular
fossa
• Only lunate surface is articular and is covered by articular cartilage
• The acetabular margin gives attachment to fibro-cartilagenous rim – the acetabular
labrum, which deepens the socket
• Acetabular notch gives attachment to transverse acetabular ligament and base of
the ligament of the head of the femur
Hip joint is unique in having a high degree of both stability and mobility
Stability of the joint depends on:
 Depth of the acetabulum
 Tension of ligaments
 Strength of surrounding muscles
 Length and obliquity of the neck of the femur – neck shaft angle
In adults - 120°
In children - 160°
 The wide range of mobility depends upon the neck of femur which is narrower than
the equatorial diameter of the head
Ligaments of the joint
o Fibrous capsule
o Ilio-femoral ligament
o Pubo-femoral ligament
o Ischio-femoral ligament
o Ligament of the head of the femur
o Acetabular labrum
o Transverse acetabular ligament
Capsular ligament or Fibrous capsule
• Dense and strong fibrous sac which encloses the joint
Attachments
On the hip bone:
• 5-6mm beyond the acetabular margin to the hip bone
• Acetabular labrum including the transverse acetabular ligament
On the femur:
• In front - to the intertrochanteric line
• Behind - 1cm medial to the intertrochanteric crest
Capsular ligament or Fibrous capsule…..
 Antero-superiorly the capsule is thick and firmly attached, since this part is
subjected to maximum tension in standing posture
 Infero-medial part of the capsule is weakest, in hyper-abduction the femoral
head may be dislocated from its socket after tearing the capsule
Capsule is made up of two types of fibres:
• Outer longitudinal fibres
• Inner circular fibres
Longitudinal fibres are maximum antero-superiorly where they form the retinacula
along the neck
• These retinaculae carry the blood vessels to supply the head and neck
In intra-capsular fracture of the neck the blood vessels may be interrupted, which may
delay the union of the fracture
Synovial membrane lines the:
• Fibrous capsule
• Intracapsular portion of the neck of the femur
• Both surfaces of acetabular labrum
• Transverse acetabular ligament
• Acetabular pad of fat
• Also invests the ligament of the head of femur
Sometimes anteriorly the synovial membrane comes out between the pubo-femoral and
illio-femoral ligament and acts as a bursa for the tendon of psoas major muscle
Ilio-femoral ligament (Y-shaped ligament of Bigelow)
• One of the strongest ligament of the body
• It resists the trunk falling backwards in standing posture
• Triangular in shape
• Apex is attached to the lower half of the anterior inferior iliac spine
• Base is attached to the intertrochanteric line
• Upper and lower fibres form thick, strong bands, while the middle fibres are thin
and weak
• Usually pierced by ascending branch of lateral circumflex femoral artery
Pubo-femoral ligament
• Supports the joint infero-medially
• Triangular in shape
• Superiorly attached to the iliopubic eminence, obturator crest and obturator
membrane
• Inferiorly merges with the capsular ligament and lower band of iliofemoral
ligament
Ischio-femoral ligament
• Comparatively weak ligament, covers the joint posteriorly
• Above it is attached to the ischium, postero-inferior to the acetabulum
• Below the fibres spiral behind the neck of the femur to be attached into the greater
trochanter deep to the iliofemoral ligament
Ligament of the head of the femur (round ligament or ligamentum teres)
 Flat, triangular ligament
 Apex is attached to fovea capitis
 Base is attached to the transverse acetabular ligament and margins of acetabular
notch
 This ligament may be very thin, or even absent
 It transmits acetabular branches of medial circumflex femoral and obturator
arteries to the head of the femur
Hip joint opened: Lateral view
Acetabular labrum (Cotyloid ligament)
 Fibro-cartilagenous rim attached to the acetabular margin
 Triangular in cross-section
 The labrum not only deepens the acetabulum but also grasps the head of femur
lightly to hold it in position
Transverse ligament of the acetabulum
• It is part of acetabular labrum, but has no cartilage cells
• It bridges the acetabular notch, there by converting the notch into foramen
• The foramen transmits acetabular vessels and nerves to the hip joint
• Blends with the base of the ligament of the head of the femur
Relations of the joint
Anterior
• Lateral part of pectineus
• Iliacus and straight head of rectus femoris
• Trunk of the femoral nerve in the ilio-psoas groove
• Femoral artery in front of psoas tendon
• Femoral vein in front of pectineus
Relations of the joint…..
Posterior
 Quadratus femoris covering obturator externus and ascending branch of medial
circumflex femoral artery
 Obturator internus with two gemelli separate the sciatic nerve from the nerve to
quadratus femoris
 Piriformis
Relations of the joint…..
Superior
• Reflected head of rectus femoris covered by gluteus minimus
Inferior
• Lateral fibres of pectineus and obturator externus
Bursae around the hip joint
Subgluteal bursae
Six in number
Four occur under gluteus maximus:
• Between gluteus maximus and smooth area of ilium, lying between the posterior
gluteal line and iliac crest
• Between gluteus maximus and outer surface of greater trochanter (trochanteric
bursa)
• Between gluteus maximus and ischial tuberosity (ischial bursa)
• Between tendon of gluteus maximus and vastus lateralis (gluteofemoral bursa)
One each under gluteus medius and minimus
Subpsoas bursa
• Found between iliopectineal eminence and the psoas tendon
• In 10% of individuals it communicates with the synovial cavity of the hip joint
through a gap in the thin part of the capsule between the iliofemoral and
pubofemoral ligaments

Weaver’s bottom
• Inflammation of subgluteal bursa between the gluteus maximus and ischial
tuberosity
• Common in people whose profession requires long periods of sitting. e.g., weavers
Blood supply
• Obturator vessels
• Medial circumflex femoral vessels
• Lateral circumflex femoral vessels
• Superior gluteal vessels
• Inferior gluteal vessels
Retinacular branches arising from the
arterial circle formed by the medial
and lateral circumflex femoral arteries
supply the intracapsular neck and
greater part of the head of the femur
Small part of the head near the fovea
capitis is supplied by acetabular
branches of the obturator and medial
circumflex femoral arteries
Nerve supply
It is according to Hilton’s law
Supplied by:
• Femoral nerve via nerve to rectus femoris
• Branch from anterior division of obturator nerve
• Branch from accessory obturator nerve if present
• Branch from nerve to quadratus femoris
• Branch from superior gluteal nerve
• Branch from inferior gluteal nerve
• A twig from sciatic nerve
Four consecutive spinal segments (L2,L3,L4,L5) control the movements of the hip joint
as under:
L2 and L3 regulate flexion, adduction and medial rotation
L4 and L5 regulate extension, abduction and lateral rotation
Movements:
Hip joint is a multiaxial joint permits following movements
• Flexion and extension – occur around transverse axis
• Abduction and adduction – occur around antero-posterior axis
• Medial rotation and lateral rotation – occur around vertical axis
• Circumduction [combination of all movements]
Range of movements
Flexion is – 110°-120°
• Limited by contact of the thigh with the abdomen
Extension - 15°, beyond which the iliofemoral ligament becomes taut
Medial rotation - 25°
Lateral rotation - 60°
Abduction - 50°, beyond which pubofemoral ligament becomes taut
Adduction is limited by contact with the opposite thigh
Muscles producing movements
Flexion – iliacus, psoas major, also by pectineus, rectus femoris and sartorius
Extension – gluteus maximus and hamstrings
Adduction – adductor longus, brevis, magnus
Abduction – gluteus medius and minimus
Medial rotation – anterior fibres of gluteus medius and minimus, tensor fasciae latae
Lateral rotation – two obturators, two gemelli, quadratus femoris and piriformis
Clinical correlation
Dislocation of the hip joint
1. Congenital dislocation
• More common than any other
joint
Occurs due to:
• Joint capsule is loose at birth
• Hypoplasia of femoral head
and acetabulum:
- In this condition the
head of the femur slips upwards
into the gluteal region due
to the developmental deficiency of
upper margin of acetabulum
Clinically it presents:
- Inability of the new born to
abduct the thigh
- Affected limb is shorter in length
and externally rotated
- Lurching gait with positive
Trendelenburg’s sign
Dislocation of the hip joint…..
2. Acquired dislocation
• Less common since the joint is very strong and stable
• However, may occur during an automobile accident
• Since, in driving position the femoral head is covered posteriorly by the joint
capsule and not by the bone
Dislocation of hip may be:
 Posterior – most common, sciatic nerve may be injured
 Anterior – less common
 Central- least common
Perthes disease (pseudocoxalgia)
• Characterized by destruction and flattening of the head of the femur with an
increased joint space
• Visualized in the radiograph
Hip joint: Antero-posterior radiograph
Coxa vara and coxa valga
• Normal neck shaft angle is about 120° in
adults and 160° in children
Coxa vara: Reduced neck shaft angle as in
fracture of the neck of the femur, Perthes
disease
Coxa valga: Increased neck shaft angle as in
congenital dislocation of the hip joint

Osteoarthritis
• Disease of old age
• Characterized by growth of osteophytes at
the articular ends, which make the
movements limited, grating and painful
Fracture of the neck of the femur
But usually referred as fractured hip
Common in individuals of more than 60 years of age, especially females
• Can be intra-capsular or extra-capsular
Intra-capsular fracture is further divided into:
• Subcapital [near the head] – more common
• Cervical [in the middle]
• Basal [near the trochanters] – least common
The fracture may damage the retinacular vessels, causing avascular necrosis of the head

Trochanteric fracture
• Inter-trochanteric
• Per-trochanteric – along the trochanter
• Sub-trochanteric
Produced by severe violent injuries
The diagnosis of fracture of the neck or trochanteric fracture is confirmed in the X-rays
by observing the following lines:
Shenton’s line
• Represented by a continuous curve formed by the upper border of the obturator
foramen and margin of the neck of the femur
• The curve is disrupted in fracture of the neck of the femur or dislocation at the hip
The diagnosis of fracture of the neck or trochanteric fracture is confirmed in the X-rays
by observing the following lines:
Schoemaker’s line
• Straight line extending from the tip of the greater trochanter to the anterior superior
iliac spine and upwards to the umbilicus
• If the greater trochanter is elevated [as in fracture of the neck], the line passes
below the umbilicus
Nelaton’s line
 Line joining the anterior superior iliac spine and the most prominent point of
ischial tuberosity
 It crosses the tip of the greater trochanter
Clinical significance
• In cases of dislocation of hip joint or fracture of the neck of the femur the greater
trochanter is felt above the Nelaton’s line
STUDY WELL