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Clinical Human Anatomy November 30, 2005 Writer: Shannon Tew Dr. Mark W.

Niedfeldt

THE THIGH I. BONY ANATOMY

A. FEMUR - is the longest, strongest, and heaviest bone in the body. A person’s height is roughly four
times the length of his/her femur. It is quite difficult to fracture, and is only usually broken as a result of major trauma. It can be divided into proximal, shaft (body), and distal portions i. Proximal femur consists of the head, neck, and greater and lesser trochanters. The head is smooth and forms two-thirds of a sphere. It articulates with the acetabulum. This ball and socket joint is less mobile than that of the shoulder, but it is also considerably stronger. The neck connects the head and body of the femur. A broad intertrochanteric line runs from the greater trochanter to the spiral line on the posterior aspect of the femur. The intertrochanteric crest unites the two trochanters posteriorly. It is also the attachment for the quadratus femoris. The greater trochanter is at the junction of the neck and body and is the attatchment for many of the gluteal muscles (such as the piriformis, obturator internus, gemelli, gluteus minimus, and gluteus medius). The lesser trochanter projects from the posteromedial surface of the femur at the inferior end of the intertrochanteric crest. Stress fractures usually occur at the neck, when they do occur. ii.Shaft of the femur is narrowest at its midpoint. It is smooth except for a rough ridge of bone in the middle of the posterior surface, called the linea aspera, which is the origin of a number of the thigh muscles. The linea aspera diverges inferiorly to form the medial and lateral supracondylar lines. iii.Distal femur is broadened for articulation with the tibia. The medial and lateral condyles project posteriorly and are separated by an intercondylar notch. The anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) attach at the intercondylar notch. The medial condyle has a larger radius than the lateral condyle, this is why when you extend your knee, your foot externally rotates. Superior to the medial and lateral condyles are prominences called epicondyles, this is where the medial collateral ligament (MCL) and lateral collateral ligament (LCL) attach. The epicondyles can be palpated for tenderness to determine if either of these ligaments have been torn (a common injury among football players). The adductor tubercle is a small prominence on the superior surface of the medial condyle. II. FASCIA

A. FASCIA LATA - like an elastic stocking - invests the muscles of the thigh like an elastic stocking –
surrounds the leg and runs all the way down. The compression of the muscles improves their effectiveness and prevents them from bulging when they contract. The fascia lata is attached superiorly to the proximal part of the lower limb at the inguinal ligament, iliac crest, sacrum, coccyx, sacrotuberous ligament, ischial tuberosity, and the pubis.

B. ILIOTIBIAL TRACT (IT Band) - extremely strong portion of the fascia lata which runs from the
tubercle of the iliac crest to the lateral condyle of the tibia. It receives tendinous reinforcements from the tensor fascia lata and the gluteus maximus muscles. It is an important structure for posture because a number of muscles attach here and help maintain stability in the hips. Specifically, it keeps the other thigh muscles aligned as the gluteus maximus flexes. Clinically, the iliotibial tract is commonly injured in runners. Over use can lead to inflammation of the tissue or a bursa beneath the iliotibial tract and is called IT band friction syndrome.

C. SAPHENOUS OPENING - of the fascia lata is a gap just inferior to the inguinal ligament where the
great saphenous vein passes through to join the femoral vein. The saphenous vein is the longest vein in the body. It ascends from the dorsal arch of the foot and runs anterior to the medial malleolus (the

“round” bone on the medial side of your ankle). Posterior to it is the nerve that could be severed if not careful. This is a good place for venous access if the arm is unavailable. The saphenous vein is also used for coronary artery bypass and is used in IV access. The small saphenous vein travels up the lateral aspect of the leg until it perforates the popliteal fascia and becomes the popliteal vein.

D. THREE INTERMUSCULAR SEPTA (487) Within the thigh are intermuscular septa that separate
groups of muscles. All of the septa arise from fascia lata and attach to the linea aspera. The lateral septum is the strongest, while the other two are weak. Foot drop occurs when nerves within this area are compressed; this is known as compartment syndrome. III. MUSCLES A. ANTERIOR HIP 1. ILIOPSOAS - Most powerful flexor of the thigh at the hip (not knee) joint. It also helps to flex the pelvis on the trunk, as in raising from the supine position to the sitting position. It is made up of the psoas major and the iliacus muscle, and has a common insertion on the lesser trochanter. The psoas major originates from the T12 to the L5 vertebrae and runs along the medial boarder of the iliacus. It is innervated by the ventral rami of L1, L2, and L3. The iliacus originates from the iliac fossa, iliac crest, iliolumbar ligament, anterior sacroiliac ligament, and the ala of the sacrum and is innervated by the femoral nerve. 2. TENSOR FASCIA LATA - lies on the lateral side of the thigh. As its name implies, it tightens the fascia lata, thereby enabling the thigh muscles to act with increased power. It also tightens the iliotibial tract enabling the gluteus maximus muscle to keep the knee joint in the extended position. Its origin is the anterior superior iliac spine (ASIS), and its insertion is the iliotibial tract. The superior gluteal nerve innervates it (same as gluteus medius). 3. OBTURATOR EXTERNUS - is a deep, powerful lateral (external) rotator of the thigh and a weak adductor. It stabilizes the head of the femur in the acetabulum. Its origin is the obturator foramen and membrane, and its insertion is the trochanteric fossa. It is innervated by the obturator nerve.

B. ANTERIOR THIGH– the main function of all these muscles is to extend at the knee. The femoral nerve innervates them all. 1. SARTORIUS - is the longest muscle in the body and is the most superficial of the thigh (it is often called the tailor’s muscle because tailors often crossed their legs and developed prominent sartorius muscles). It runs laterally to medially from the anterior superior iliac spine (ASIS) to the superior part of the medial tibia. It flexes the thigh at the hip when the leg is straight, and abducts and rotates the thigh laterally when sitting crossed legged. It also flexes the leg and rotates it medially. It illustrates that muscles have different functions when the body is in different positions. (It is one of three muscles that insert as part of the pes anserinus, gracilis and semitendinosis being the other two—see below).

2. QUADRICEPS FEMORIS (Plate 474) - is made up of four muscles (rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius) which are very important for extending the leg at the knee. It is needed to step up stairs. They have a common tendon which contains a sesamoid bone (round, or oval bones that develop in certain tendons), the patella. The common tendon inserts into the tibial tuberosity. The tendon is divided up into the quadriceps tendon (superior to the patella), the medial and lateral retinaculum (medial and lateral to the patella), and the patellar ligament (inferior to the patella). a. rectus femoris is the most superficial of the four muscles and the easiest to see (central). It is a 2-joint muscle which crosses both the hip and the knee joint. Muscles that cross two joints can have functions at both joints, therefore this muscle can flex at the hip and extend at the knee. It originates from the anterior superior iliac spine and the posterosuperior surface of rim of acetabulum and inserts in quadriceps tendon. b. vastus lateralis originates from the greater trochanter and the lateral lip of the linea aspera and inserts in the lateral patellar retinaculum. It is the largest and most lateral of the group. Additionally, the vastus lateralis controls the mechanics of the knee joint.

c. vastus medialis originates from the intertrochanteric line and the linea aspera and inserts on the medial patellar retinaculum. It is a large muscle in the shape of a teardrop; the fibers run angularly, some are almost parallel to the ground. This is the muscle to improve when you want to decrease cracking by improving patellar tracking. Strengthening this muscle pulls the patella medially – back to where it belongs (see below). d. Vastus intermedius is deep and originates from the anterior and lateral surfaces of the body of the femur and distally fuses with the vastus lateralis and medialis. Specific actions include extension in the knee joint and stepping up. All four of these muscles come down, form a common tendon and insert into a common insertion at the tibial tuberosity. Jumping athletes (volleyball, basketball players) commonly have patellar tendinitis, which is an inflammation in the tendons medial and lateral to the patella. The lateral and medial patellar retinacula are what keep the patella in place and tracking as it moves along with the femur. Patellar femoral pain syndrome is anterior knee pain, which can be seen in active or overweight patients and is caused by problems with the patella incorrectly tracking with the femur. This is referred to as Vasus Medialis Obliquis (VMO). Generally, the lateral retinaculum is tighter than the medial retinaculum, and as a result the kneecap tends to be pulled in a lateral direction in a dislocating injury. Strengthening of the vastus medialis can help alleviate this problem. C. MEDIAL THIGH – all are adductor muscles, however, the muscles in this area having origin in the pubis will also flex the thigh. So, many will have the action of crossing your legs which requires both adduction and flexion. All of the medial thigh muscles are innervated by the obturator nerve except for the pectineus and one portion of the adductor magnus. 1. GRACILIS -the most superficial and weakest adductor of the thigh. It crosses the hip and the knee joint and is therefore a 2 joint muscle with 2 different actions. It adducts and flexes the thigh and flexes the leg, and it is a very weak medial (internal) rotator when the knee is flexed. It originates from the body and inferior ramus of the pubis, and inserts in the superior part of the medial tibia in the same area as the sartorius and semitendinosis (pes anserinus). 2. PECTINEUS - is the only medial thigh muscle innervated by the femoral nerve. It adducts and flexes the thigh (crossing legs). It originates from the pectineal line of the pubis, lies between the iliopsoas and the adductor longus, and inserts on the pectineal line of the femur. There are 2 landmarks associated with the pectineus muscle: The medial circumflex artery runs between it and the iliopsoas, and the deep femoral artery lies between it and the adductor longus (medial rotation was also mentioned as an action). 3. ADDUCTOR LONGUS - adducts and flexes the thigh as well as rotating it medially. It originates from the body of the pubis and inserts on the middle third of the linea aspera. Clinically, this muscle is the one usually being referred to when someone “pulls their groin muscle”. It can be ruptured next to origin, which can cause lot of bruising and go into medical aspect of leg and scrotum. Also, the deep pain of a pulled adductor longus may radiate up to the inguinal area and give the impression of a hernia. Soccer and hockey players often have chronic pain associated with the adductor longus, and some may even have the muscle lengthened to alleviate pain. This muscle is located on the inside of the thigh and has a musculotendinous junction. 4. ADDUCTOR BREVIS - is mainly an adductor, but also does some flexion and lateral rotation. It originates from the inferior ramus of the pubis and inserts on the distal pectineal line and proximal linea aspera. 5. ADDUCTOR MAGNUS - as its name implies it is the largest and strongest adductor. It has two main parts, the adductor and hamstring. a. adductor - adducts and flexes the thigh. It originates from the inferior ramus of the pubis and the ramus of the ischium, and inserts on the gluteal tuberosity and the linea aspera. It is innervated by the obturator nerve (like most muscles of the medial thigh). b. hamstring - an extensor (behaves like a hamstring muscle) and medial rotator of the thigh. It originates from the ischial tuberosity (again like a hamstring muscles) and inserts on the adductor tubercle of the femur. It is innervated by the tibial portion of the sciatic nerve. 6. ADDUCTOR HIATUS - is at the junction of the adductor canal and the popliteal fossa. It is a hiatus in the aponeurotic attachment of the adductor magnus to the supracondylar line. The femoral vessels pass through this opening, and become the popliteal vessels.

D. POSTERIOR THIGH - is made up of three muscles which are commonly referred to as hamstrings. The major action of these muscles is to flex the leg and extend the thigh (they’re two joint muscles). All are innervated by the sciatic nerve, and all have a common origin at the ischial tuberosity (“the part that you are sitting on right now”) except the short head of the biceps. In the gym, leg curls will be done to work the hamstrings. 1. SEMITENDINOSIS - is a 2 joint muscle which also medially rotates the thigh. It inserts on the superior part of the medial tibia, therefore, it has a common insertion with the sartorius, and gracilis muscles (the tendons of these three muscles collectively comprise the pes anserinus (crow’s feet). Clinically, there can be inflammation of the anserine bursa deep to where these three muscles insert. This (and other bursa) help to smooth areas that have friction and prevent pain. The semitendinosis is innervated by the tibial portion of the sciatic nerve. ***Contents of the Pes Ancerine (important): Sartorius, Gracilis, SemiTendinosus Inflammation of the bursa sac (bursitis) can cause knee pain where the joint looks okay. 2. SEMIMEMBRANOSIS - is also a medial rotator of the thigh. It inserts on the posterior medial condyle of the femur, and is innervated by the tibial portion of the sciatic nerve. 3. BICEPS FEMORIS - has two heads with a common insertion on the lateral head of the fibula which is split by the lateral collateral ligament. Tears are most common at the muscle-tendon junction. Tears at the ischial tuberosity will take a very long time to heal. a. long head - is a 2 joint muscle which also laterally rotates the leg when it is flexed. It is an important landmark because the sciatic nerve runs between it and the adductor magnus muscle. It is innervated by the tibial portion of the sciatic nerve. b. short head - is a 1 joint muscle which only acts at the knee joint. Its origin is the lateral lip of the linea aspera and the supracondylar ridge and is innervated by the peroneal (fibular) portion of the sciatic nerve (the only muscle of the posterior thigh that is not innervated by the tibial portion of the sciatic nerve). Hamstring Injuries: Common athletic injury. You can have an injury low where you can tear tendon from bone or at musculotendonous junction (weak point) or at the muscle belly. Tears in the higher portion (closer to ischial tuberosity) have poorer prognosis. It is difficult to determine how long athletes with these injuries must avoid activity.

4. POPLITEAL FOSSA - is a diamond-shaped hole behind the knee. Its borders are the biceps femoris
superolaterally, the semimembranosis and semitendinosis superomedially, the lateral head of the gastrocnemius inferolaterally, and the medial head of the gastrocnemius inferomedially. The contents are the popliteal vessels (remember the femoral vessels become the popliteal vessels after the travel through the adductor hiatus), the tibial and common peroneal nerves (both off of the sciatic nerve), the small saphenous vein, the popliteal lymph nodes, fat and bursa sac. Note that the common peroneal nerve runs very superficially and can commonly be injured; in a fracture, this is one nerve you have to be specifically concerned about. The bursa sac is also commonly ruptured and can cause swelling and inflammation (bursitis) behind the knee; this is called a baker’s cyst. When this happens the knee hurts and is tender distal to the knee and over the medial aspect of the tibia. Athletes have gotten overzealous icing this area. A division 1 football player from Michigan State who was predicted to play in NFL decided to go to bed with an ice pack on and woke up with foot drop and it didn’t come back. Damage to common peroneal nerve prevented him from playing pro. The ice pack over the lateral asect of the knee damaged the common peroneal nerve, which functions in foot extension. This is why it is important to give parameters for everything (including icing).

IV. FEMORAL TRIANGLE --a depression inferior to the inguinal ligament when the hip is flexed. Area where femoral pulse is checked

A. BOUNDARIES - Its boarders are the inguinal ligament superiorly, the medial border of the adductor longus medially, and the medial boarder of the sartorius laterally. The base of the triangle is the inguinal ligament, the floor is made up of the adductor longus, pectineus, and iliopsoas and the roof is the fascia lata. B. CONTENTS - include the femoral nerve, femoral artery, femoral vein (lateral to medial), inguinal lymph nodes, and the femoral sheath. 1. FEMORAL ARTERY - is the main arterial supply to the lower extremity. It bisects the femoral triangle to the adductor canal. Clinically, it is important to know that the femoral nerve lies lateral to the femoral artery and the femoral artery lies lateral to the femoral vein when a venous line is needed in the leg. So if you draw blood, check pulse at the triangle, for femoral artery and poke medial. The femoral artery gives off 4 major branches in the femoral triangle including the profunda femoris artery (Deep artery of the thigh). The profunda femoris artery is the chief artery of the thigh. It supplies the adductor magnus and the hamstring muscles. The medial circumflex is a branch off the profunda femoris artery. It supplies the head and neck of the femur and lies between the iliopsoas and pectineus muscles. The lateral circumflex also branches off the profunda femoris artery. It supplies the lateral thigh muscles and the head of the femur and it lies deep to the sartorius and the rectus femoris muscles. 2. FEMORAL VEIN - receives the profunda femoris and saphenous veins within the femoral triangle. As it runs posterior to the inguinal canal it becomes the external iliac vein. 3. INGUINAL LYMPH NODES - drain the lower limb, perineum, anterior abdominal wall, and the gluteal region, therefore, it is an important area to palpate in patients with an infection. 4. FEMORAL NERVE - is the largest branch of the lumbar plexus. It is located lateral to the femoral vessels and outside of the femoral sheath. It innervates the anterior thigh muscles. The saphenous nerve is a cutaneous branch off the femoral nerve which accompanies the femoral artery in the adductor canal. 5. FEMORAL SHEATH - surrounds the femoral vessels and forms the femoral canal. It does not include the femoral nerve (hint!), and is pierced by the great saphenous vein. V. ADDUCTOR CANAL is a fascial tunnel in the thigh which begins where the sartorius muscle crosses the adductor longus muscle and ends at the adductor hiatus. The canal contains the femoral artery and vein and the saphenous nerve. A. BOUNDARIES - include the vastus medialis laterally, the adductor longus and adductor magnus posteromedially, and the sartorius anteriorly. B. CONTENTS - include the femoral artery and vein which exit the canal through the adductor hiatus and become the popliteal vessels. The saphenous nerve does not exit the adductor hiatus but rather between the sartorius and gracilis muscles. It the runs with the saphenous vein to supply the medial leg. VI. VEINS A. GREAT SAPHENOUS - longest vein in the body. This is the vein they use for coronary bypass. It travels from the dorsal venous arch of the foot medially and travels up the leg and thigh through the saphenous opening in the deep fascia of the thigh to the femoral vein. It receives many tributaries from the small saphenous. Clinically important due to its use in coronary bypass surgery. B. Small saphenous vein is posterior to the lateral malleolus and travels up to the popliteal fascia and drains into the popliteal vein.

Dr. Niedfeldt then showed us some movies of athletes getting injured (looked very painful). He discussed two of them in particular, but none of this will be on the test. One was an ankle dislocation in a probaseball player. He caught his cleat while sliding and disrupted his ATF, CF, deep deltoid, and ant tib-fib. So he basically completely dislocated his ankle without fracturing any bone (rare). The second case was of a lower extremity injury in a pro-football player. His left knee was struck by a teammate. He had loss of sensation in his foot and no dorsalis pedis pulse (very bad). This ended up being a left knee dislocation with popliteal artery injury, acute compartment syndrome, and MCL, LCL, ACL, PCL tear. This was a very bad injury, and he ended up with a loss of sensation in the plantar region after almost having his leg amputated.