GLUTEAL REGION

ANAT 203

DR Akafa T.A MBBS(ABU),FMCFM, MPH.

Dept of Human Anatomy
Federal Uni Wukari
+2348038836419
drakafa@yahoo.com
 OBJECTIVES
• Basic Introduction
• Superficial & Deep Fascia

• Muscles of the gluteal region

• Innervations of the gluteal region

• Blood supply & Lymphatic drainage

• Clinical/Radiological Anatomy
• Conclusion : Questions & Answers
 Student Activity
• Analyze the Surface Anatomy & Fascial of
the Gluteal region
• Discuss the arrangement of the muscles of
the gluteal region & give their actions,
blood supplies,lymphatic drainage and
nerve supply.
• Enumerate the structures deep to gluteus
maximus muscle.

• Articulate the clinical consequences of the gluteal

muscle disorders.
 Basic Introduction of the Buttocks
•The gluteal region is an anatomical area located
posteriorly to the pelvic girdle, at the proximal end
of the femur.
•The muscles in this region move the lower limb at
the hip joint.
•The muscles of the gluteal region can be broadly
divided into two groups: Refer to Slide 13
1. Superficial abductors & extenders
2. Deep lateral rotators
 The Gluteal Region
• It is the region behind the pelvis, extending from
the iliac crest superiorly to the gluteal fold (fold of
the buttock) inferiorly
• Gluteal fold indicates the lower border of the
gluteus maximus muscle (gluteal sulcus/crease is a
skin crease for the hip joint)
• A deep midline groove, the natal (intergluteal) cleft
separates the buttocks from each other.
The image in Slide 7 below shows Natal cleft, Buttock
Gluteal crease & Gluteal fold.
 Superficial Fascia
• Thick, dense, well developed, laden with large
quantities of fat (specially in women) that:
• Gives the characteristic convexity to the buttock
• Forms a thick cushion over the ischial tuberosity
The skin and the fat of the gluteal region is:
Drain into the lateral group of the superficial Inguinal
lymph nodes
Supplied by perforating branches of the superior and
inferior gluteal arteries
Superficial Lyphatic drainage
 Deep Fascia
• Is continuation of the fascia lata (deep fascia of
the thigh)
• At the lower border of the gluteus maximus, fascia
lata splits to enclose the muscle
• Above the gluteus maximus, the deep fascia
continues as one layer covering the gluteus medius
& gets attached to iliac crest
• Laterally the fascia merges with the iliotibial tract
The gluteal region Mx can be broadly
divided into 2 groups:
Superficial abductors & Deep lateral rotators
extenders
• – group of large muscles that • – group of smaller muscles that
abduct and extend the femur. mainly act to laterally rotate the
femur. Includes the
• Includes the
1 quadratus femoris,
1 gluteus maximus,
2 piriformis,
2 gluteus medius,
3 gemellus superior,
3 gluteus minimus and
4 gemellus inferior and
4 tensor fascia lata.
5 obturator internus.
 The Superficial Muscles
• The superficial muscles in the gluteal region
consist of the three glutei and the tensor fascia
lata. They mainly act to abduct and extend the
lower limb at the hip joint.
1. Gluteus Maximus
• The gluteus maximus is the largest of the gluteal
muscles. It is also the most superficial, producing
the shape & prominence of the buttocks.
• Attachments: Originates from the gluteal
(posterior) surface of the ilium, sacrum & coccyx.
GLUTEUS MAXIMUS
 Gluteus Maximus Gmax Contd
• The fibres slope across the buttock at a 45
degree angle and 75% of its fibers insert onto
the iliotibial tract/band while the deep 25% into
gluteal tuberosity of the femur .
• Paralysis of Gmax leads to inability to raise the
trunk from stooping or sitting positions
• Actions: It is the main extensor of the thigh, and
assists with lateral rotation. However, it is only
used when force is required, such as running or
climbing.
• Innervation: Inferior gluteal nerve.
 Gluteus Medius Gmed
• The gluteus medius muscle is fan-shaped and lies
between to the gluteus maximus and the minimus.
It is similar in shape and function to the gluteus
minimus.
• Attachments: Originates from the gluteal surface of
the ilium and inserts into the lateral surface of the
greater trochanter.
• Actions: Abduction and medial rotation of the
lower limb. It stabilises the pelvis during
locomotion, preventing ‘dropping’ of the pelvis on
the contralateral side.
• Innervation: Superior gluteal nerve.
 Gluteus Minimus Gmin
• The gluteus minimus is the deepest & smallest of the
superficial gluteal muscles.
• It is similar in shape and function to the gluteus
medius.
• Attachments: Originates from the ilium and
converges to form a tendon, inserting to the anterior
side of the greater trochanter.
• Actions: Abduction and medial rotation of the lower
limb. It stabilises the pelvis during locomotion,
preventing ‘dropping’ of the pelvis on the
contralateral side.
• Innervation: Superior gluteal nerve.
 Tensor Fascia Lata
• Tensor fasciae lata is a small superficial muscle
which lies towards the anterior edge of the iliac
crest. It functions to tighten the fascia lata, and so
abducts and medially rotates the lower limb.
• Attachments: Originates from the anterior iliac
crest, attaching to the anterior superior iliac spine
(ASIS). It inserts into the iliotibial tract, which itself
attaches to the lateral condyle of the tibia.
• Actions: Assists the gluteus medius and minimus in
abduction and medial rotation of the lower limb. It
also plays a supportive role in the gait cycle.
• Innervation: Superior gluteal nerve.
 Blood supply
• The arterial supply to
these muscles is mostly
via the superior and
inferior gluteal arteries
– branches of the
internal iliac artery.

• Venous drainage follows

the arterial supply.
 Damage of Superior Gluteal Nerve
• The superior gluteal nerve innervates the Gmed &
the Gmin. These muscles have an important role
in stabilising the pelvis during locomotion.
• In the standing position, the Gmin & Gmed
contract when the contralateral leg is raised,
preventing the pelvis from dropping on that side.
• If the superior gluteal nerve is damaged, the
previously described muscles are paralysed – and
the pelvis becomes unsteady.
• A characteristic finding of gluteal muscle weakness
is the Trendelenburg sign.
 Clinical & Applied Anatomy Ctd
• The Trendelenburg sign is produced when the
patient is asked to stand unassisted on each leg in
turn.
• In a positive sign, pelvic drop will occur on the
unsupported leg. Pelvic drop can be recognised by
observing the level of the iliac crests on both sides.
• For example, if the left gluteal muscles are weak,
the right side of the pelvis will drop when the
patient stands on their left leg (and the right leg is
unsupported)
 TRENDELENBURG TEST
• Is the practical way to assesses whether the hip
abductors (particularly gluteus medius) are
functioning normally
• Observe patient from behind, ask him/her to
stand on one foot and then the other

Negative test: Pelvis ‘tilts up’ on contralateral side

Positive test: Pelvis ‘sags’ on contralateral side

ARRANGEMENT OF MUSCLES

GMax GMed

GMin

Piri

GS
OI
GI
QF
MUSCLES OF GLUTEAL REGION
MUSCLE NERVE SUPPLY
1 Gluteus maximus Inferior gluteal N
2 Gluteus medius Superior gluteal N
3 Gluteus minimus Superior gluteal N
4 Pyriformis N. to pyriformis
5 Obturator externus Obturator N
6 Obturator internus N. to obturator internus
7 Gamellus superior N. to obturator internus
8 Gamellus inferior N. To qudratus femoris

9 Quadratus femoris N. To qudratus femoris

MUSCLES OF GLUTEAL REGION ACTION
MUSCLE ACTION
Extension of thigh
Lat. Rotation of thigh
1 Gluteus maximus
Supports the extended knee

2 Gluteus medius Abduction of thigh

Med. Rotation of thigh
3 Gluteus minimus Maintain balance of the body when
the opposite foot is off the ground

4 Pyriformis
5 Obturator externus
6 Obturator internus
Lat. Rotation of thigh
7 Gamellus superior
8 Gamellus inferior
 STRUCTURES DEEP TO GLUTEUS
MAXIMUS
• MUSCLES

• VESSELS

• NERVES

• BONES AND JOINTS

• LIGAMENTS

• BURSAE
 MUSCLES DEEP TO GLUTEUS MAXIMUS

1. Gluteus medius
2. Gluteus minimus 1
3. Reflected head of rectus 2
femoris 4
4. Pyriformis
5. Gemillus superuir
6. Obturator internus 8
7. Gamellus inferior GM
8. Quadratus femoris
9. Obturator externus
10. Origin of hamstrings
11. Attachment of pubic fibres
of adductor magnus
 VESSELS DEEP TO GLUTEUS MAXIMUS

• Superior gluteal
• Inferior gluteal
• Internal pudendal
• Ascending br. Of med. Circumflex
femoral
• Trochanteric anastomosis
• Cruciate anastomosis
• First perforating
 NERVES DEEP TO GLUTEUS MAXIMUS
1. Superior gluteal
2. Inferior gluteal
3. Sciatic
4. Post. Cut. N of thigh
5. N. to quadratus femoris
3
6. Pudendal N
7. N to obturator internus 4

8. Perforating cut. nerves

3
 BONES AND JOINTS DEEP TO GLUTEUS
MAXIMUS
• Ilium
• Ischium with ischial
tuberosity
• Upper end of femor
with greater
trochanter
• Sacrum and coccyx
• Hip joint
• Sacro-iliac joint
 LIGAMENTS AND BURSAE DEEP TO
GLUTEUS MAXIMUS
• LIGAMENTS
– Sacrotuberous
– Sacrospinus
– Ischiofemoral

• BURSAE
– Trochanteric bursa of
gluteus maximus
– Bursa over the ischial
tuberosity
– Bursa b/w the gluteus
maximus and vastus
lateralis
 The Deep Muscles
• The deep gluteal muscles are a set of smaller
muscles, located underneath the Gmin.

• The general action of these muscles is to laterally

rotate the lower limb.

• They also stabilise the hip joint by ‘pulling’ the

femoral head into the acetabulum of the pelvis.
 Piriformis
• The piriformis muscle is a key landmark in the
gluteal region. It is the most superior of the deep
muscles.
• Attachments: Originates from the anterior surface
of the sacrum. The fibres travel inferiorly and
laterally through the greater sciatic foramen to
insert onto the greater trochanter of the femur.

• Actions: Lateral rotation and abduction.

• Innervation: Nerve to piriformis.

 Obturator Internus
• The obturator internus forms the lateral walls of
the pelvic cavity. In some texts, the obturator
internus and the gemelli muscles are considered as
one muscle – the triceps coxae.

• Attachments: Originates from the pubis and

ischium at the obturator foramen. It travels
through the lesser sciatic foramen, and attaches to
the greater trochanter of the femur.
• Actions: Lateral rotation and abduction.
• Innervation: Nerve to obturator internus.
 The Gemelli – Superior & Inferior
The gemelli are two narrow and triangular muscles.
They are separated by the obturator internus tendon.
Attachments: The superior gemellus muscle
originates from the ischial spine, the inferior from the
ischial tuberosity. They both attach to the greater
trochanter of the femur.
Actions: Lateral rotation and abduction.
Innervation: The superior gemellus muscle is
innervated by the nerve to obturator internus, the
inferior gemellus is innervated by the nerve to
quadratus femoris.
 Quadratus Femoris
• The quadratus femoris is a flat, square-shaped
muscle.
• It is the most inferior of the deep gluteal muscles,
located below the gemelli and obturator internus.
• Attachments: Originates from the lateral aspect of
the ischial tuberosity and attaches to the quadrate
tuberosity on the intertrochanteric crest.
• Actions: Lateral rotation.
• Innervation: Nerve to quadratus femoris.
 Clinical Relevance: Landmark of the Gluteal
Region
• The piriformis is an important anatomical
landmark in the gluteal region.
• As the muscle travels through the greater sciatic
foramen, it effectively divides the gluteal region
into an inferior and superior part.
• This division determines the name of the vessels
and nerves that supply the area.
• The superior gluteal nerve and vessels emerge into
the gluteal region superiorly to the piriformis (and
vice versa for the inferior gluteal nerve).
 Clinical Landmark of the Gluteal
Region
• In addition, the piriformis can be used to locate the
sciatic nerve (a major peripheral nerve of the lower
limb).
• The sciatic nerve enters the gluteal region directly
inferior to the piriformis, and is visible as a flat
band, approximately 2cm wide.
 Safe Area for Intramuscular Injection
Intramuscular injection enables a large amount of a
drug to be introduced at once but absorbed
gradually.

The injection site must be carefully selected to avoid

injury to the underlying large vessels and nerves.

Outer upper quadrant of the buttock is the safe area

for intramuscular injection to avoid injury to the
underlying sciatic nerve
 POST INJECTION PARALYSIS (PIP)
• Prevalent in children in Uganda due quinine
injection in the lower buttock.
• Can also happen in hip operations especially in the
posterior approach to the hip.
• Symptoms: Inability to flex hip,+/- inability to
dorsiflex, loss of sensation & proprioception in the
leg.
• Signs: Weakness in the hamstrings and +/- all
muscles in the leg.
• Reduced sensation in the leg. The foot could also
be in equinus position.
Problems for a positive Trendelenburg
• Fracture neck of femur

• Dislocation of hip joint

• Coxa Vara

• Nonfunctioning gluteus medius and minimus due

to: Neurological damage (L4 – 5 disc herniation)

• Any disease affecting muscles (myopathy)

 PIRIFORMIS SYNDROME
• Also known as “The fat wallet syndrome”. More
common in women of childbearing age.
• Occurs when the sciatic nerve is compressed or
irritated by the piriformis muscle.
• Characterized by tingling & numbness in the buttocks
& along the path of the sciatic nerve descending down
the lower thigh & into the leg.
• Pain is increased with activity, prolonged sitting or
walking. May also have lower back pain
Diag: Pain in the area of the sciatic notch.
Physical tests can be done to stretch the irritated
piriformis
 POLIOMYELITIS
• The gluteus medius and minimus muscles may be
paralyzed when poliomyelitis involves the lower
lumbar and sacral segments of the spinal cord.

• They are supplied by the superior gluteal nerve

(L4 and 5 and S1).

• Paralysis of these muscles seriously interferes with

the ability of the patient to tilt the pelvis when
walking.
 TROCHANTERIC BURSITIS
• Most common bursitis around the hip . This
problem is more common in females and middle-
aged to older patients.
The problem may be isolated or associated with
other disorders.
• Symptoms include pain in the region of the greater
trochanter.
• Clinically there is tenderness exercerbated at
extremes of adduction & internal rotation
 Conclusion

ANY QUESTIONS

Teach Me Gross Anatomy

THE END