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FEmALE REPRoduCTivE sysTEm
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Intramural
Isthmus of part of Uterine
uterine tube uterine tube cavity Uterine tube
LP SM
Fig. 77.29 The uterine tube (ampulla) with the mucosal lining thrown into
extensive folds that fill the lumen. The superficial epithelium includes both
secretory and ciliated cells, covering a lamina propria (LP). Smooth
Ampulla of uterine tube Vaginal speculum Spill of muscle (SM) occupies the wall of the tube. (Courtesy of Mr Peter Helliwell
contrast into and the late Dr Joseph Mathew, Department of Histopathology, Royal
peritoneal Cornwall Hospitals Trust, UK.)
cavity
Fig. 77.27 A digitally subtracted hysterosalpingogram. Radiopaque
contrast is introduced via a catheter inserted through the cervical os; the Innervation
catheter is introduced using a vaginal speculum. The contrast fills the
triangular uterine cavity. The lumina of the narrow intramural and isthmic The uterine tube is innervated by autonomic fibres that are distributed
parts of the uterine tubes may be traced inferolaterally from the superior
mainly with the ovarian and uterine arteries. Most of the tube has a dual
angles as they expand into the wider ampullae. Some contrast media has
sympathetic and parasympathetic supply (see Table 77.2). Preganglionic
escaped into the pelvic cavity from the abdominal ostia. (Courtesy of Dr
parasympathetic fibres are derived from the vagus for the lateral half of
Julia Hillier, Chelsea and Westminster Hospital, London.)
the tube, and pelvic splanchnic nerves for the medial half. Preganglionic
sympathetic supply is derived from neurones in the intermediolateral
column of the tenth thoracic to the second lumbar spinal segments;
Broad ligament Round ligament Origin of left uterine Uterus
postganglionic sympathetic fibres are most likely derived from the supe-
tube from uterus
rior hypogastric plexus, via the superior hypogastric and hypogastric
nerves (see Fig 77.5) (Chen et al 2014). Visceral afferent fibres travel
with the sympathetic nerves and enter the cord through corresponding
dorsal roots; they may also travel with parasympathetic fibres. The am-
pullary submucosa contains modified Pacinian corpuscles.
Microstructure
The walls of the uterine tubes show typical visceral mucosal, muscular
and serosal layers (Fig. 77.29). The mucosa is thrown into longitudinal
folds, which are most pronounced distally at the infundibulum and
decrease to shallow bulges in the intrauterine (intramural) portion. The
mucosa is lined by a single-layered, tall, columnar epithelium, which
contains mainly ciliated cells and secretory (peg) cells (so called because
they project into the lumen further than their ciliated neighbours), and
occasional intraepithelial lymphocytes. In the tube, ciliated cells pre-
dominate distally and secretory cells proximally. Their activities vary
with the stage in the menstrual cycle and with age. Secretory cells are
most active around the time of ovulation. Their secretions include
nutrients for the gametes and aid capacitation of the spermatozoa. Cili-
ated cells increase in height and develop more cilia in the oestrogenic
first half of the menstrual cycle. Their cilia waft the oocyte from the
Uterine tube Ovary Fimbriated end of uterine tube
open-ended infundibulum towards the uterus in fluids secreted by the
Fig. 77.28 A laparoscopic view of the origin of the uterine tube from the peg cells. The epithelium regresses in height towards the end of the cycle
uterus.
and postmenopausally, when ciliated cells are reduced in number.
The lamina propria provides vascular connective tissue support and
abundant lymphatic drainage vessels. The smooth muscle of the mus-
Veins cularis is arranged as an inner circular, or spiral, layer and an outer,
Venous drainage is similar to the arterial supply. The venous drainage thinner, longitudinal layer. Together, their contractile activity produces
of the lateral two-thirds of the uterine tube is via the pampiniform peristaltic movements of the tube, which assist propulsion of the
plexus to the ovarian veins, which open into the inferior vena cava on gametes and the fertilized ovum. The uterine tubes are covered exter-
the right side and the renal vein on the left side. The medial two-thirds nally by a highly vascular serosa.
of the tube drain via the uterine plexus to the internal iliac vein.
Lymphatic drainage OVARIES
Lymph drainage is via ovarian vessels to the para-aortic nodes and
uterine vessels to the internal iliac chain. It is possible for lymph to In the adult, non-pregnant state, the ovaries lie on each side of the
reach the inguinal nodes via the round ligament (see Table 77.1). uterus close to the lateral pelvic wall, suspended in the pelvic cavity by | 1,796 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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a double fold of peritoneum, the mesovarium, which is attached to the inferior extremity points downwards towards the pelvic floor. The ante-
upper limit of the posterior aspect of the broad uterine ligament. They rior border faces the posterior leaf of the broad ligament and contains
are dull white in colour and consist of dense fibrous tissue, in which the mesovarium. The posterior border is free and faces the peritoneum,
ova are embedded. Before regular ovulation begins, they have a smooth which overlies the upper part of the internal iliac artery and vein, and
surface but, thereafter, their surfaces are distorted by scarring that the ureter. On the right side, superior and lateral to the ovary, are the
follows the degeneration of successive corpora lutea (Speroff and Fritz ileocaecal junction, caecum and appendix. On the left side, the sigmoid
2004) (Fig. 77.30). Their average dimensions are 4 × 2 × 3 cm in repro- colon passes over the superior pole of the ovary and joins the rectum,
ductively mature women; they more than double their size during which lies between the medial surfaces of both ovaries. The meso-
pregnancy. In the neonate, their dimensions are 1.3 × 0.6 × 0.4 cm. Prior salpinx lies below the uterine tube. The ovarian ligament is inferior and
to the first menstrual period (menarche), the ovaries are about one- medial. The mesovarium and ovary lie inferiorly at its fimbrial end. The
third of the normal reproductive adult size; they gradually increase in round ligament is anterior to the tube. The superior and posterior sur-
size with body growth (Sforza et al 1993, Badouraki et al 2008) and faces of the tube lie free in the peritoneal cavity.
decrease significantly after the menopause. In embryonic and early fetal life, the ovaries are situated in the
The lateral surface of the ovary contacts parietal peritoneum in the lumbar region near the kidneys. They gradually descend along the
ovarian fossa. Behind the ovarian fossa are retroperitoneal structures, gubernaculum, stopping at the lesser pelvis. The relationship between
including the ureter, internal iliac vessels, obturator vessels and nerve, the location of the ovaries and surface landmarks is important in order
and the origin of the uterine artery (Fig. 77.31). The medial surface to enable shielding of the ovaries from exposure to radiation during
faces the uterus and uterine vessels in the broad ligament, and the radiological procedures. In girls, the ovaries lie at or below the iliac
peritoneal recess here is termed the ovarian bursa. Above the superior crest, just medial to the anterior superior iliac spine, and above the
extremity are the fimbria and distal section of the uterine tube. The pubic symphysis at all ages (Bardo et al 2009). Accessory ovarian tissue
may occur in the mesovarium or along the course of the gubernacula;
rarely, the ovaries may descend along the whole course of the guber-
Recto-uterine Uterus Origin of Ovary held up by laparoscopic nacula and are found in the labia majora. During pregnancy, the ovaries
pouch uterine tube instrument to demonstrate the
are lifted high in the pelvis; by 14 weeks of gestation, they become
irregular surface of the ovary
partly abdominal structures, and by the third trimester, they are totally
abdominal structures and lie vertically behind and lateral to the parous
uterus.
Peritoneal and ligamentous supports
of the ovary
The peritoneal and ligamentous supports of the ovary consist of the
infundibulopelvic and ovarian ligaments and the mesovarium.
Infundibulopelvic (suspensory) ligament
The suspensory or infundibulopelvic ligament of the ovary is a perito-
neal fold attached to the upper part of the lateral surface of the ovary,
which contain the ovarian vessels and nerves (see Fig. 77.18). On the
right side, the infundibulopelvic ligament is attached to a fold of peri-
toneum that is posterior and inferior to the caecum and appendix. On
the left side, the peritoneal attachment is higher than on the right, and
is lateral to the junction of the descending and sigmoid colons. As it
joins the peritoneum covering psoas major, the suspensory ligament of
the ovary passes superiorly over the external iliac vessels, genitofemoral
nerve and ureter.
Sigmoid loop in Small bowel in Fimbrial end of
Ovarian ligament (ligament of the ovary)
posterior pelvis posterior pelvis uterine tube
The ovarian ligament (ligament of the ovary) attaches the uterine (infer-
Fig. 77.30 A laparoscopic view of the right ovary, showing its distorted
omedial) extremity of the ovary to the lateral angle of the uterus, pos-
surface.
teroinferior to the uterine tube (see Fig. 77.22). It lies in the posterior
leaf of the broad ligament and contains some smooth muscle cells. It
is continuous with the medial border of the round ligament. Both liga-
Obturator Obturator External External
artery nerve iliac vein iliac artery ments are remnants of the gubernaculum.
Mesovarium
The mesovarium is a short peritoneal fold that attaches the ovary to the
back of the broad ligament. It carries blood vessels and nerves to the
ovarian hilum. The uterine tube arches over the ovary and ascends in
relation to its mesovarian border, then curves over its tubal end and
passes down on its posterior, free, border and medial surface.
Vascular supply and lymphatic drainage
Arteries
The ovarian arteries are branches of the abdominal aorta and originate
below the renal arteries. Each descends behind the peritoneum and, at
the brim of the pelvis, crosses the external iliac artery and vein to enter
the true pelvic cavity. Here, the artery turns medially in the ovarian
suspensory ligament and splits into a branch to the mesovarium that
supplies the ovary, and a branch that continues into the uterine broad
ligament, below the uterine tube, and supplies the tube. There are vari-
ations in the site of the division to the ovary and tube (see Fig. 77.21).
On each side, a branch passes lateral to the uterus to unite with the
uterine artery. Other branches accompany the round ligaments through
Sigmoid colon Obliterated internal Internal iliac Bifurcation of the inguinal canal to the skin of the labium majus and the inguinal
iliac artery artery common iliac artery region. Early in intrauterine life, the ovaries flank the vertebral column
Fig. 77.31 The broad ligament dissected and pelvic lymph nodes inferior to the kidneys, and so the ovarian arteries are relatively short;
removed to reveal the structures of the right-hand pelvic side wall. they gradually lengthen as the ovaries descend into the pelvis. | 1,797 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Early primary Late primary Secondary Tertiary (Graafian follicle) Fig. 77.32 The microstructure
follicle follicle (antral) follicle of the ovary and follicles at
Ovarian surface Primordial Atretic Tunica Ruptured follicle various stages in their cyclical
(germinal) epithelium follicles follicle albuginea development and the formation
of corpora lutea and albicantes.
Note that, in the human ovary,
developing follicles are rarely
Oocyte at ovulation
seen.
Active corpus luteum
Peritoneum Hilum Cortex Medulla
Regressing corpus luteum
Ovarian vessels Corpus albicans
Veins hilum. It contains the ovarian follicles at various stages of development,
and corpora lutea and their degenerative remnants, depending on age
The ovarian veins emerge from the ovary as a plexus (pampiniform
or stage of the menstrual cycle. The follicles and the structures derived
plexus) in the mesovarium and suspensory ligament (see Fig. 77.3A).
from them are embedded in a dense stroma composed of a meshwork
Two veins emerge from the plexus and ascend with the ovarian artery;
of thin collagen fibres and fusiform fibroblast-like cells, arranged in
they usually merge into a single vessel before entering either the inferior
characteristic whorls. Stromal cells differ from fibroblasts in general
vena cava on the right side, or the renal vein on the left side.
connective tissue in that they contain lipid droplets, which accumulate
Lymphatic drainage in pregnancy. Stromal cells give rise to the thecal layers of maturing
The main lymphatic drainage of the ovaries is along vessels that follow ovarian follicles.
the ovarian veins to para-aortic nodes situated near the origin of the
renal arteries (see Table 77.1). Drainage may also occur via pelvic nodes ovarian follicles
into lower para-aortic nodes and, rarely, may follow the round ligament Primordial follicles
to the inguinal nodes. The development of ovarian follicles can be divided into different stages
(Fig. 77.32). At birth, the ovarian cortex contains a superficial zone of
Innervation primordial follicles. These consist of primary oocytes 25 µm in diam-
eter, each surrounded by a single layer of flat follicular cells. The oocyte
The ovarian innervation is derived from autonomic plexuses (see Table nuclei are slightly eccentric and have a characteristically prominent
77.2). The upper part of the ovarian plexus is formed from branches of nucleolus. They contain the diploid number of chromosomes (dupli-
the renal and aortic plexuses, and the lower part is reinforced from the cated as sister chromatids), arrested at the diplotene stage of meiotic
superior and inferior hypogastric plexuses. These plexuses consist of prophase since 16–20 weeks of fetal life (Speroff and Fritz 2004) (Fig.
postganglionic sympathetic fibres, preganglionic parasympathetic fibres 77.33). Many follicles degenerate either during prepubertal (including
from the sacral outflow, and visceral afferent fibres (Lee et al 1973). The prenatal) life, or through atresia at some stage after beginning the
efferent preganglionic sympathetic fibres are derived from the tenth and process of cyclical maturation during the child-bearing period. Their
eleventh thoracic spinal segments. remnants are visible as atretic follicles, the remains of which accumulate
throughout the period of reproductive life. After puberty, cohorts of up
Microstructure to 20 primordial follicles become activated in each menstrual cycle
(fewer are activated with advancing age). Their development takes a
number of cycles. Of the follicles activated in each cohort, usually only
In young females, the surface of the ovary is covered by a single layer
one follicle from one or other ovary becomes dominant, reaches matu-
of cuboidal epithelium, which contains some flatter cells. It appears
rity and releases its oocyte at ovulation.
dull white, in contrast to the shiny, smooth peritoneal mesothelial
Abnormal, non-growing follicles with indistinct germinal vesicle
covering of the mesovarium, with which it is continuous. A white line
membranes and absent nucleoli are sometimes found in prepubertal
around the anterior mesovarian border usually marks the transition
ovaries and, occasionally, in pubertal ovaries, but are not found in adult
between peritoneum and ovarian epithelium. The surface epithelium is
ovaries (Anderson et al 2014).
also termed the germinal epithelium, but this is a misnomer because it
is not the source of germ cells. Immediately beneath the epithelium,
there is a tough collagenous coat, the tunica albuginea. The ovarian Primary follicles
tissue it surrounds is divisible into a cortex, containing the ovarian fol- Primary follicles develop from primordial follicles. The first sign is a
licles, and a medulla, which receives the ovarian vessels and nerves at change in the follicle cells from flattened to cuboidal, followed by their
the hilum. proliferation to give rise to a multilayered follicle consisting of granu-
losa cells surrounded by a thick basal lamina (Fig. 77.34). Stromal cells
Ovarian cortex
immediately surrounding the follicle begin to differentiate into spindle-
Before puberty, the cortex forms 35%, the medulla 20% and interstitial shaped cells, which constitute the theca folliculi that will become the
cells up to 45% of the volume of the ovary. After puberty, the cortex theca interna. They are later surrounded by a more fibrous layer, the
forms the major part of the ovary, enclosing the medulla, except at the theca externa. At the same time, the oocyte increases in size and secretes | 1,798 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
upper genital tract
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TTEE
PP
pp AA
SS GGCC TTII
Fig. 77.33 Ovarian cortex with primordial (p) and early primary (P) follicles Fig. 77.35 An antral (secondary) follicle, showing the layers of the
within the stroma (S); stimulated primary follicles have cuboidal cells developing follicle wall. Granulosa cells (GC) enclose the antrum (A), filled
forming their wall. A large oocyte nucleus is visible in the plane of section with liquor folliculi, and surround the oocyte (not seen in the plane of
of most of the follicles (arrow). (Courtesy of Mr Peter Helliwell and the late section) within an eccentric cellular mass (right). The outer theca interna
Dr Joseph Mathew, Department of Histopathology, Royal Cornwall (TI) is a highly vascular layer that develops steroid secretory activity and
Hospitals Trust, UK.) is enclosed by the outermost theca externa (TE). (Courtesy of Mr Peter
Helliwell and the late Dr Joseph Mathew, Department of Histopathology,
Royal Cornwall Hospitals Trust, UK.)
Fig. 77.36 A low-power
view of a section of a
human ovary,
containing a corpus
luteum (C). (Courtesy of
Mr Peter Helliwell and
the late Dr Joseph
NN Mathew, Department of
Histopathology, Royal
Cornwall Hospitals
Trust, UK.)
FF
C
Fig. 77.34 A high-magnification micrograph of a primary follicle in a
human ovarian cortex. The pale oocyte, with its eccentric nucleus (N), is
separated from the follicle (F) by the zona pellucida (arrow). Cells of the cells synthesize oestrogens (primarily oestradiol). Follicular develop-
follicle wall are in the early stages of proliferation to form a multilayered,
ment is stimulated by follicle-stimulating hormone (FSH).
late primary follicle. (Courtesy of Mr Peter Helliwell and the late Dr Joseph
Mathew, Department of Histopathology, Royal Cornwall Hospitals Trust,
Tertiary (Graafian) follicle
UK.)
Although a number of follicles may progress to the secondary stage by
about the first week of a menstrual cycle, usually only one tertiary fol-
licle develops; the remainder become atretic. The surviving follicle
a thick layer of extracellular proteoglycan-rich material – the zona pel- increases considerably in size as the antrum takes up fluid from the
lucida – between its plasma membrane and the surrounding granulosa surrounding tissues and expands to a diameter of 2 cm. The term Graa-
cells of the early follicle; this is important for the process of fertilization. fian follicle is often used to describe this mature follicular stage. The
The granulosa cells in contact with the zona pellucida send cytoplasmic oocyte and a surrounding ring of tightly adherent cells, the corona
processes radially inwards; these contact and communicate with oocyte radiata, breaks away from the follicle wall and floats freely in the fol-
microvilli at gap junctions (Motta et al 2003). The follicular cells – in licular fluid. The primary oocyte, which has remained in the first meiotic
particular, the granulosa cells – continue to proliferate and so the thick- prophase (see Fig. 1.16) since fetal life, completes its first meiotic divi-
ness of the late primary follicle wall increases. sion to produce the almost equally large secondary oocyte and a small
first polar body with very little cytoplasm. The secondary haploid
Secondary (antral) follicles oocyte immediately begins its second meiotic division, but when it
Secondary (antral) follicles develop from primary follicles. The number reaches metaphase, the process is arrested until fertilization has
of granulosa cells continues to increase. Cavities begin to form between occurred. The follicle moves to the superficial cortex, causing the surface
them and are filled with a clear fluid (liquor folliculi) containing of the ovary to bulge. The tissues at the point of contact (the stigma)
hyaluronate, growth factors, and steroid hormones secreted by the with the tough tunica albuginea and ovarian surface epithelium are
granulosa cells. The follicle is now about 200 µm in diameter and eroded until the follicle ruptures and its contents are released into the
usually lies deep in the cortex. The cavities coalesce to form one large, peritoneal cavity for capture by the fimbria of the uterine tube. The
fluid-filled space – the antrum – which is surrounded by a thin, uniform oocyte at ovulation is still surrounded by its zona pellucida and corona
layer of granulosa cells, except at one pole of the follicle where a thick- radiata of granulosa cells. If fertilization does not occur, it begins to
ened granulosa layer envelops the eccentrically placed oocyte, to form degenerate after 24–48 hours.
the cumulus oophorus. The oocyte has now reached its maximum size
of about 80 µm and the inner and outer thecae are clearly differentiated Corpus luteum
(Fig. 77.35). As follicles mature, the theca interna becomes more prom- After ovulation, the remainder of the follicle becomes the corpus
inent and its cells more rounded and typical of steroid-secreting endo- luteum (Fig. 77.36). The walls of the empty follicle collapse and fold.
crine cells. They produce androstenedione, from which the granulosa The granulosa cells increase in size and synthesize a cytoplasmic | 1,799 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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carotenoid pigment (lutein), giving them a yellowish colour (hence, levels of oestrogen, which is produced by the ovary and which acts
corpus luteum). These large (30–50 µm) granulosa lutein cells form through receptors present on both the stromal and the epithelial cells.
most of the corpus luteum. The basal lamina surrounding the follicle The glands become tortuous and their lining epithelial cells become tall
breaks down, and numerous smaller theca lutein cells infiltrate the columnar in nature (Speroff and Fritz 2004).
folds of the cellular mass, accompanied by capillaries and connective
tissue. Extravasated blood from thecal capillaries accumulates in the
centre as a small clot, but this rapidly resolves and is replaced by con- SECRETORY PHASE
nective tissue. All lutein cells have a cytoplasm filled with abundant
smooth endoplasmic reticulum, characteristic of steroid-synthesizing The secretory phase coincides with the luteal phase of the ovarian cycle.
endocrine cells. Granulosa lutein cells secrete progesterone and oestra- The endometrial changes are driven by progesterone and oestrogen,
diol (from aromatization of androstenedione synthesized by theca secreted by the corpus luteum. Steroid receptors in the endometrium
lutein cells). The two cell types also respond differently to circulating activate a programme of new gene expression that produces, in the fol-
gonadotropins: theca lutein cells respond to luteinizing hormone (LH) lowing 7 days, a highly regulated sequence of differentiative events,
and granulose lutein cells respond to FSH. Theca lutein cells express presumably required to prepare the tissue for blastocyst implantation.
receptors for human chorionic gonadotrophin (hCG). If the oocyte is Part of the response is direct, but there is evidence that some of the
not fertilized, the corpus luteum (of menstruation) functions for effects may be mediated through growth factors (Speroff and Fritz
12–14 days after ovulation, then atrophies. The lutein cells undergo 2004). The first morphological effects of progesterone are evident
fatty degeneration, autolysis, removal by macrophages and gradual 24–36 hours after ovulation (which occurs approximately 14 days
replacement with fibrous tissue. Eventually, after 2 months, a small, before the next menstrual flow). In the early secretory phase, glycogen
whitish, scar-like corpus albicans is all that remains. masses accumulate in the basal cytoplasm of the epithelial cells lining
If fertilization does occur, implantation of the blastocyst into the the glands, where they are often associated with lipid. Giant mitochon-
uterine endometrium usually begins 7 days later and the embryonic dria appear and are associated with semi-rough endoplasmic reticulum.
trophoblast then starts to produce hCG. The chorionic gonadotrophin There is an obvious increased polarization of the gland cells: nuclei are
stimulates the corpus luteum of menstruation to grow, and it becomes displaced towards the centre of the cells, and Golgi apparatus and secre-
a corpus luteum of pregnancy. It normally increases in size from 10 mm tory vesicles accumulate in the supranuclear cytoplasm. The nuclear
in diameter to 25 mm at 8 weeks of gestation and can be seen clearly channel system is prominent and nuclei enlarge. Nascent secretory
on ultrasound. It secretes progesterone, oestrogen and relaxin, and func- products may be detected immunohistochemically within the cells.
tions throughout pregnancy, although it gradually regresses as its endo- Progestational effects on the stroma (known as the decidual reaction)
crine functions are largely replaced by the placenta after 8 weeks’ are also evident in the early secretory phase. Nuclear enlargement occurs
gestation. Its diameter is reduced by the end of pregnancy to 1 cm. In and the packing density of the resident stromal cells increases, due, in
the next few months, it degenerates, like the corpus luteum of men- part, to the increase in volume of gland lumina and onset of secretory
struation, to form a corpus albicans. activity in the epithelial compartment.
By the mid-secretory phase, the endometrium may be up to 6 mm
Ovarian medulla
deep. The basal epithelial glycogen mass is progressively transferred to
The medulla is highly vascular. It contains numerous veins and spiral the apical cytoplasm, and nuclei return to the cell bases. The Golgi
arteries that enter the hilum from the mesovarium and lie within a loose apparatus becomes dilated and products, including glycogen, mucin
connective tissue stroma. Small numbers of cells (hilus cells) with and other glycoproteins, are released from the glandular epithelium
characteristics similar to interstitial (Leydig) cells in the testis are found into the lumen by a combination of apocrine and exocrine mecha-
in the medulla at the hilum; they may be a source of androgens. nisms; this activity reaches a maximum 6 days after ovulation. These
secretory changes are considerably less pronounced in the basal gland
Menopause
cells and the luminal epithelium than in the glandular cell population
At the menopause, ovulation ceases and various microscopic changes
of the stratum functionalis. There is a notable stromal oedema and a
ensue within the ovarian tissues. The stroma becomes denser, the tunica
corresponding decrease in the density of collagen fibrils. At the same
albuginea thickens and the ovarian surface epithelium thins. However,
time, the endoplasmic reticulum and Golgi apparatus become more
many follicles persist within the cortex.
prominent; there is evidence for collagen synthesis and degradation,
presumably reflecting ongoing matrix remodelling.
In the late secretory phase, glandular secretory activity declines.
MENSTRUAL CYCLE
Decidual differentiation occurs in the superficial stromal cells that sur-
round blood vessels; this transformation includes nuclear rounding and
The onset of menstruation (menarche) occurs between the tenth and an increased cytoplasmic volume, reflecting an increase in and dilation
seventeenth years of life, with a peak between 12 and 14 years. The of the rough endoplasmic reticulum and Golgi systems, and cytoplas-
uterus, ovaries and vagina undergo changes during the menstrual cycle, mic accumulation of lipid droplets and glycogen. The cells begin to
which normally lasts approximately 28 days. A follicle begins a period produce basal lamina components, including laminin and type IV
of development in the ovary during the first days of the cycle, and collagen.
matures and ruptures mid-cycle (approximately day 14 of a 28-day Ultrasound is frequently used in the clinical evaluation of the
cycle) to release a secondary oocyte. The wall of the follicle is then endometrium. In the early secretory phase, the endometrium is identi-
transformed into the corpus luteum, which secretes progesterone (luteal fied as a thin echogenic line, a consequence of specular reflection from
phase). About 10 days after ovulation, the corpus luteum begins to the interface between opposing surfaces of endometrium. During the
regress, then ceases to function and is replaced by fibrous tissue. The late proliferative phase, the endometrium appears as a triple layer: a
breakdown of the endometrium that follows this cessation of function central echogenic line (due to the apposed endometrial surfaces), sur-
is due to the reducing levels of progesterone and oestrogen as the corpus rounded by a thicker hypoechoic functional layer, and bounded by an
luteum degenerates. outer echogenic basal layer. During the secretory phase, the functional
The changes that occur in the endometrium during the menstrual layer surrounding the echogenic line becomes more hyperechoic as a
cycle may be divided into three phases: proliferative, secretory and result of the increased mucus and glycogen within the glands and the
menstrual (Fig. 77.37). increased number of interfaces caused by the development of tortuous
spiral arteries (Fig. 77.38).
PROLIFERATIVE PHASE
MENSTRUAL PHASE
In the early proliferative phase, even before the menstrual flow ceases,
the epithelium from the persisting basal parts of the uterine glands Prior to menstruation, three layers can be recognized in the endometrium:
grows over the surface of the endometrium, which has been denuded the strata compactum, spongiosum and basale. In the stratum compac-
by menstruation. Re-epithelialization is complete 5–6 days after the tum, which is next to the free surface, the necks of the glands are only
start of menstruation. Initially, the tissue is only 1–2 mm thick and is slightly expanded and the stromal cells show a distinct decidual reac-
lined by low cuboidal epithelium. The glands are straight and narrow, tion. In the stratum spongiosum, the uterine glands are tortuous,
and their lining cells are short columnar. The apical cell surface contains dilated and, ultimately, only separated from one another by a small
microvilli; some cells are ciliated. The stroma is dense and contains amount of interglandular tissue. The stratum basalis, next to the uterine
small numbers of lymphocytes. During days 10–12 of the proliferative muscle, is thin and contains the tips of the uterine glands embedded
phase, the endometrium thickens. Cells divide in response to rising in an unaltered stroma. | 1,800 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
menstrual cycle
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RETPAHC
Ovary
Primordial follicles Developing follicles Ovulation Corpus luteum Corpus albicans
Endometrium
2 4 6 8 10 12 14 16 18 20 22 24 26 28
Menstrual Proliferative Early secretory Mid-secretory Late secretory
(days 1–3) (days 4–13) (days 14–18) (days 19–23) (days 24–28)
Fig. 77.37 Stages in the menstrual cycle with concomitant changes in the endometrium. Note that developing antral follicles are selected from cohorts
of follicles recruited in earlier cycles. The ten lower panels are histological sections of endometrium at the cycle times indicated (low magnification on top
and high magnification below in each case).
endometrium often diminishes in thickness. Blood escapes from the
superficial vessels of the endometrium, forming small haematomata
beneath the surface epithelium (see below). The stratum functionalis,
next to the free surface, is shed piecemeal, leaving mainly the stratum
basalis, adjacent to the uterine muscle; 65–75% of the thickness of the
endometrium may be shed. Blood and necrotic endometrium then
begin to appear in the uterine lumen, to be discharged from the uterus
through the vagina as the menstrual flow, which usually lasts 3–6 days.
The amount of tissue lost is variable, but usually the stratum compac-
tum and most of the spongiosum are desquamated.
VASCULAR CHANGES WITHIN THE UTERUS DURING
THE MENSTRUAL CYCLE
The vascular bed of the endometrium undergoes significant changes
during the menstrual cycle. The arteries to the endometrium arise from
a myometrial plexus and consist of short, straight vessels to the basal
portion of the endometrium, and more muscular spiral arteries to its
Fig. 77.38 Transvaginal ultrasound of the uterus, showing the triple-
superficial two-thirds. The venous drainage, consisting of narrow per-
layered endometrium. The central echogenic line is produced by the
pendicular vessels that anastomose by cross-branches, is common to
interface of the opposing surfaces of the endometrium. The functional
both the superficial and the basal layers of the endometrium. The capil-
layer of the endometrium surrounding the echogenic line is hypoechoic on
lary bed consists of an endothelium with a basal lamina that is discon-
the left, in keeping with late proliferative phase, but is becoming more
tinuous in the proliferative phase, but becomes more distinct by the
hyperechoic on the right, indicating the early secretory phase.
mid-secretory phase. Pericytes are present, some of which resemble
smooth muscle cells, and these are sometimes enclosed within the basal
The two upper strata are often grouped together as the functional lamina. The pericytes make contact with the endothelial cells by means
layer, stratum functionalis, of the endometrium; the lower (basal) layer of cytoplasmic extensions that project through the basal lamina.
is called the stratum basalis. As regression of the corpus luteum occurs, Enlargement of the pericytes starts in the early secretory phase, and
those parts of the stroma showing a decidual reaction, together with leads to a conspicuous cuff of cells in the mid- and late secretory phases.
the glandular epithelium, undergo degenerative changes and the The arterial supply to the basal part of the endometrium remains | 1,801 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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unchanged during the menstrual cycle. However, the spiral arteries to However, a number of growth factors, e.g. insulin-like growth factor-1
the superficial strata lengthen disproportionately. They become increas- (IGF-1), have been identified, which interact with oestrogen in promot-
ingly coiled and their tips approach the uterine epithelium more closely. ing uterine growth. The myometrium thins with advancing gestation
This leads to a slowing of the circulation in the superficial strata with from 2–3 cm thick in early pregnancy to 1–2 cm at term.
some vasodilation. Immediately before the menstrual flow, these vessels The upper third of the cervix (isthmus) is gradually taken up into
begin to constrict intermittently, causing stasis of the blood and anaemia the uterine body during the second month to form the ‘lower segment’
of the superficial strata. During the periods of relaxation of the vessels, (Fig. 77.40). The isthmus hypertrophies like the uterine body during
blood escapes from the devitalized capillaries and veins, causing the the first trimester and triples in length to about 3 cm. From the second
menstrual blood loss. The breakdown of the endometrium is a conse- trimester, the wall of the isthmus and that of the body are the same
quence of the reducing levels of progesterone and oestrogen as the thickness and their junction is no longer visible externally. This condi-
corpus luteum degenerates. tion persists until the middle of the third trimester, when the lower
uterine segment thins considerably to less than 1 cm in thickness. The
thicker myometrium above this transition is the main contractile
PREGNANCY AND PARTURITION
portion of the uterus that will generate the expulsive forces during
labour; the thin lower uterine segment, which begins just below the
During pregnancy, many morphological changes occur in the female vesico-uterine pouch and is thought to correspond to the level of the
reproductive system and associated abdominal structures. The uterus anatomical internal os, is more compliant and allows for the descent
enlarges to accommodate the developing fetus and placenta, and of the fetus in late pregnancy and during labour. As the lower uterine
various alterations take place in the pelvic walls, floor and contents that segment is thinner and less vascular than the upper uterus, it is the
allow for this expansion, and which anticipate parturition. At the end preferred site of incision during a caesarean section. In addition,
of gestation, dramatic changes occur that facilitate the passage of the because it is less contractile, there is a lower risk of uterine rupture in
baby through the birth canal and, subsequently, allow the pelvic organs subsequent pregnancies, compared with an incision made in the body
to return to the non-pregnant state (involution). of the uterus during a ‘classic’ caesarean section.
On average, human gestation is approximately 280 days (or The growing uterus generally emerges from the pelvis by the twelfth
40 weeks) from the date of the last menstrual period (LMP) (Ch. 14). week of pregnancy and can be palpated on the maternal abdomen just
However, as the menstrual history can often be inaccurate due to cycle above the pubic symphysis. By the twentieth week of pregnancy, the
irregularity or inaccurate recollection, an accurate gestational age can uterine fundus is at the level of the umbilicus and reaches the xiphister-
be calculated by ultrasound measurement of the fetal crown–rump num by 36 weeks. After 24 weeks of gestation, the distance between the
length in the first trimester (Fig. 77.39). A discrepancy of more than pubic symphysis and the uterine fundus generally corresponds to the
5–7 days from the LMP-estimated age is usually cause to revise the number of gestational weeks and is often used in clinical care as a
estimated date of confinement. For women presenting after the first screening method to detect a pregnancy that is measuring suspiciously
trimester, gestational dating can be based on other sonographically larger or smaller than expected. If there is more than a 2 cm discrepancy,
obtained fetal biometric measurements, such as the fetal biparietal a more accurate, sonographic assessment of fetal size and amniotic fluid
diameter, head circumference and femur length, although precision volume is indicated.
gradually decreases later in pregnancy (see Fig. 14.4). The increased
accuracy of gestational dating using sonographic fetal biometry rather Cervix and pregnancy
than menstrual history alone has significantly reduced the number of
pregnancies requiring induction of labour for post-term women.
During pregnancy, the uterine cervix is a relatively rigid, fibromuscular
structure that retains the developing fetus within the uterus. The rigidity
UTERUS IN PREGNANCY of the cervix appears to be related to the orientation of its collagen fibres
within a regular connective tissue matrix. The cervix gradually softens
and shortens in the weeks preceding labour. During active labour,
The function of the uterus in pregnancy is to retain the developing fetus
the cervix dilates to allow the fetus to descend through the birth canal.
and to provide a protected environment until a stage at which the fetus
The exact processes that allow softening, effacement and dilation of the
is capable of surviving ex utero. The uterus must grow, facilitate delivery
cervix are unclear, but are believed to include remodelling of the con-
of the fetus and then involute.
nective tissue matrix, probably mediated by an increase in the activity
The uterus grows dramatically during pregnancy, increasing in
of enzymes such as matrix metalloproteinase 1, a reduction in collagen
weight from about 50 g at the beginning of pregnancy to up to 1 kg at
concentration, a significant increase in the water content in the cervix,
term. Most of the weight gain is the result of increased vascularity and
an infiltration of macrophages and neutrophils, and an increased level
fluid retention in the myometrium. The increased growth of the uterine
of apoptosis.
wall is driven by a combination of mechanical stretching and endocrine
Transvaginal ultrasound examination allows for a robust evaluation
input. The mechanical load that increasing gestation imposes on the
of the cervix during pregnancy. Cervical length, dilation of the internal
uterine wall induces hypertrophy of uterine smooth muscle cells and is
os and bulging of the membranes into the canal can all be assessed
the major stimulus that increases smooth muscle mass. Some hyperpla-
(Fig. 77.41). Detection of a shortened cervical length in mid-gestation
sia occurs early on in pregnancy, mainly from the growth of the media
using transvaginal ultrasound is a strong risk factor for premature deliv-
of the myometrial arteries and veins. The myometrium is relatively
ery and has been used clinically to identify women at high risk of
unresponsive to additional endocrine stimulation during most of preg-
preterm delivery in order to plan appropriate management (Fonseca
nancy, a relative quiescence that is, in part, attributed to progesterone.
et al 2007, Hassan et al 2011, Owen et al 2009). Emerging sonographic
and MRI technologies are being used to investigate both the biome-
chanical properties and the microstructure of the cervix in pregnancy
and promise to shed light on the poorly understood mechanisms
involved in both normal and pathological cervical shortening in human
pregnancy (Feltovich et al 2012, House et al 2013).
Relations of the uterus in pregnancy
With uterine expansion, the ovaries and uterine tubes are displaced
upwards and laterally. The round ligaments become hypertrophied and
their course from the cornual regions of the uterus down to the internal
inguinal ring becomes more vertical. The broad ligament tends to open
out to accommodate the massive increase in the sizes of the uterine and
ovarian vessels. The uterine veins, in particular, can reach about 1 cm
in diameter and they appear to act as a significant reservoir for blood
during uterine contractions. Lymphatics and nerves expand their terri-
tories (the significance of this increased innervation is not clear because
paraplegic women are able to labour normally, albeit painlessly). Later
Fig. 77.39 Transabdominal ultrasound at 12 weeks, showing in pregnancy, the increase in intra-abdominal pressure produced by the
measurement of the crown–rump length to calculate the gestational age. gravid uterus may produce eversion of the umbilicus. On the skin over | 1,802 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Body
Isthmus
Cervix
Anatomical internal os
Histological internal os
External os
Non-gravid First trimester First trimester (late)
Anatomical internal os
Histological internal os
External os
Second trimester Third trimester
Fig. 77.40 A frontal view of the uterus, showing the location and extent of the body, isthmus and cervix in the non-gravid and gravid uterus at different
stages in gestation. The isthmus forms the lower uterine segment with advancing gestation.
Fetal head Internal os External os
A
Endocervical canal
Fetal head Internal os
C
B Fig. 77.41 Transvaginal ultrasound at 36 weeks. A, Measurement of cervical length.
B, Posterior placenta praevia 18.5 mm from the internal os. C, A placenta completely
Lower border of placenta covering the internal cervical os, consistent with a complete placenta praevia. | 1,803 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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the abdomen, a combination of stretching and hormonal changes may Twin 1 Lumbar spine
produce stretch marks (striae gravidarum). In multiparous patients,
diastasis (diverification) of right and left rectus abdominis may occur
to accommodate the enlarging uterine fundus further. In the supine
position, the gravid uterus can cause aortocaval compression, leading
to reduced venous return to the heart and decreased cardiac output. In
some women, this can lead to symptomatic hypotension and symptoms
of nausea and faintness. These symptoms are minimized if the woman
lies on her left side, thereby deviating the gravid uterus and reducing
compression of the inferior vena cava.
The jejunum, ileum and transverse colon tend to be displaced
upwards by the enlarging uterus, whereas the caecum and appendix are
displaced to the right, and the sigmoid colon posteriorly and to the left.
Upward and lateral displacement of the appendix in later pregnancy
can cause difficulties in the diagnosis of appendicitis. The ureters are
pushed laterally by the enlarging uterus and, in late pregnancy, can be
compressed at the level of the pelvic brim, resulting in hydronephrosis
and loin pain. However, mild ureteric dilation is normal in pregnancy,
and is caused by progesterone-induced relaxation of smooth muscle in
the ureteric walls. The axis of the uterus is often dextrorotated by the
presence of the sigmoid colon; this rotation must be considered when
performing a hysterotomy at the time of caesarean section to avoid
injuring the large uterine vessels located bilaterally.
PELVIC CHANGES IN PREGNANCY
The presence of a pregnant uterus results in a change in the centre of
gravity of the body, especially in late pregnancy. In order to compensate
for this, the mother tends to straighten her cervical and thoracic spine,
and throw her shoulders back, resulting in a compensatory lumbar
lordosis. There is also a softening of the pubic symphysis and sacroiliac Twin 2 Bladder
joints, caused by production of relaxin and other pregnancy hormones,
Placenta praevia – low-lying placenta
leading to mild pelvic instability that may result in a waddling gait. covering internal cervical os
Softening also produces an increase in pelvic diameter, which is of
Fig. 77.42 A sagittal T2-weighted scan of a twin pregnancy with a
benefit during the time of labour. Significant joint relaxation may lead
placenta praevia overlying the internal cervical os.
to pubic symphysis diastasis, which, in severe cases, may produce debili-
tating pain during walking.
Advances in three-dimensional ultrasound imaging permit the real-
time visualization of the anatomical relationships and adaptations of
the pelvic floor in pregnancy. They also enable detection of pelvic floor
injury that might lead to symptomatic postpartum pelvic floor prolapse
(Dietz and Lanzarone 2005, Shek et al 2012).
PLACENTAL DEVELOPMENT
Placental attachment to the uterus occurs at the point where the blasto-
cyst becomes embedded, and is determined by a multitude of molecular
signalling pathways. In early pregnancy, the placental disc occupies a
large proportion of the uterine cavity and will often appear to be situ-
ated near the internal os. In the majority of cases, growth and stretching
of the uterus will usually draw the placenta upwards, away from the
cervix, by the end of pregnancy.
In about 1% of pregnancies, the position of the placenta will remain
over, or in close proximity to, the internal cervical os at the end of
pregnancy (see Fig. 77.41B; Fig. 77.42). This condition is called pla-
centa praevia and can be associated with vaginal bleeding during preg-
nancy and labour. If the placenta covers the internal os, or the lower
edge is less than 1–2 cm from the internal os, delivery by caesarean
section is generally indicated.
Normal trophoblastic development includes the remodelling of
Fig. 77.43 Doppler examination of the maternal and fetal circulation in
maternal spiral arterioles to allow for low-resistance flow into the inter-
pregnancy. A pulsed Doppler showing normal waveforms in the umbilical
villous space. Thus, the uteroplacental vasculature is a low-resistance, arteries at 28 weeks.
high-capacitance system. Antenatal ultrasound Doppler velocimetry can
be used during pregnancy to evaluate the resistance to flow in both the
uterine and the umbilical arteries, and may be helpful in the manage-
ment of high-risk pregnancies (Fig. 77.43). LABOUR
Abnormally invasive placentation can occur when trophoblastic
tissue invades through the decidua basalis and reaches the myometrium; The onset of labour is defined as the combination of regular uterine
this can lead to a morbidly adherent placenta and significant maternal contractions that are of sufficient intensity to produce progressive
morbidity. This condition, placenta accreta, occurs in approximately 3 effacement and dilation of the cervix. The process of labour is described
per 1000 births. When the trophoblastic tissue invades the myometrium, in three main stages.
it is referred to as placenta increta; if the placental tissue reaches the
uterine serosa, it is called a placenta percreta. In extreme cases, a pla- First stage
centa percreta can also invade into the maternal bladder mucosa. These The first stage of labour is the period during which the cervix progres-
conditions often require a hysterectomy. Prior uterine surgery, especially sively dilates until the fetus is able to descend into the birth canal and
multiple prior caesarean sections, is the most significant risk factor there is no longer any cervix palpable on vaginal examination. There is
(Fig. 77.44). little change in the uterine volume because myometrial contractions are | 1,804 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Fig. 77.44 A gross photograph taken at the time of caesarean section in
a patient with a placenta accreta. Note the hypervascularity caused by
Fig. 77.45 The fetal surface of a recently delivered placenta. The spiral
the placental tissue invading into, and almost through, the myometrial
umbilical vessels in the umbilical cord and their radiating branches are
layer of the lower uterine segment, which is still covered with its serosal
seen through the transparent amnion. The maternal surface is exposed in
layer.
the lower and right corner of the figure. Note the fringes of amnion and
chorion, the majority of which have been cut away near the placental
margin.
isometric, and so there is minimal shortening of the muscle fibres.
Progress is determined by the equilibrium between forces generated by
myometrial contractions, especially from the fundus, and the resistance
(range 10–40 mm), and a surface area of approximately 30,000 mm2.
of the cervix.
It is thickest at its centre (the original embryonic pole), and rapidly
thins towards its periphery, where it continues as the chorion laeve.
second stage
The size of the placenta correlates well with the birth weight of the
The second stage of labour begins once the cervix is fully dilated, and
neonate.
ends with the delivery of the fetus. Cervical resistance is lost and myo-
Macroscopically, the fetal or inner surface, covered by amnion, is
metrial activity results in isometric contractions that aid descent of the
smooth, shiny and transparent, so that the mottled appearance of the
fetus in the birth canal. The head of the fetus usually enters the pelvis
subjacent chorion, to which it is closely applied, can be seen. The
with the occiput facing laterally. As the head descends further, the
umbilical cord is usually attached near the centre of the fetal surface,
occiput contacts the gutter-shaped pelvic floor formed by levator ani
and branches of the umbilical vessels radiate out under the amnion
and this promotes flexion and rotation of the occiput to the anterior
from this point; the veins are deeper and larger than the arteries. The
position. With further descent, the occiput escapes under the pubic
maternal surface of the placenta is finely granular and mapped into
symphysis and the head is born by extension. At this point, the head
some 15–30 lobes by a series of fissures or grooves. The placental lobes,
of the fetus regains its normal relationship with its shoulders, and slight
which are often somewhat loosely termed cotyledons, correspond, in
rotation (or restitution) of the head is seen. Further external rotation
large measure, to the major branches of the umbilical vessels. The
occurs as the leading shoulder is directed medially by the maternal
grooves correspond to the bases of incomplete placental septa, which
pelvic floor. The body of the fetus is now born by lateral flexion as one
become increasingly prominent from the third month onwards. They
shoulder slips underneath the symphysis and the posterior shoulder is
extend from the maternal aspect of the intervillous space (the basal
drawn over the frenulum.
plate) towards the chorionic plate (see Fig. 9.5) but do not quite reach
it. The septa are complex structures composed of components of the
Third stage
cytotrophoblastic shell and residual syncytium, together with mater-
The third stage of labour is the time from delivery of the fetus until nally derived material, including decidual cells, occasional blood vessels
delivery of the placenta. Prior to separation of the placenta, a large and gland remnants, collagenous and fibrinoid extracellular matrix,
proportion of the mother’s cardiac output passes through the uterine and, in the later months of pregnancy, foci of degeneration.
circulation. After separation in the third stage of labour, maternal exsan- In multiple pregnancies, the number of placentas is determined by
guination is only prevented by marked uterine contraction; the criss- the zygosity; for example, in twin gestations, dizygotic pregnancies will
crossing myometrial fibres act as a tourniquet, restricting blood flow to always have two placentas (dichorionic). Monozygotic pregnancies
the area that was the placental site. This process is usually expedited usually have a single placenta (monochorionic), but about one-third
clinically by the administration of oxytocic drugs in an attempt to limit will have two placentas; the number is determined by the timing of
maternal blood loss. Any condition that predisposes to poor uterine splitting of the embryonic mass (see Ch. 8 and Fig. 8.9). If the split
contraction, such as retained placental tissue, will increase the likeli- occurs within 3 days of fertilization, each fetus will have its own pla-
hood of postpartum haemorrhage. centa and amniotic sac (dichorionic diamniotic); splitting after the
third day following fertilization results in a monochorionic diamniotic
Placenta after delivery pregnancy (two amniotic sacs) and vascular communication within the
two placental circulations (Fig. 77.46); splitting after the ninth day
results in a single placenta and single amniotic sac (monochorionic
Separation of the placenta from the uterine wall takes place along the
monoamniotic); and splitting after the twelfth day results in conjoined
plane of the stratum spongiosum and extends beyond the placental
twins.
area, detaching the villous placenta, with associated fibrinoid matrix
and small amounts of decidua basalis; the chorio-amnion, together
Placental variations
with a superficial layer of the fused decidua capsularis; and the decidua
parietalis. When the placenta and membranes have been expelled, a
thin layer of stratum spongiosum is left lining the uterus; it soon The umbilical cord is usually attached near the centre of the placenta,
degenerates and is cast off in the early part of the puerperium. A new although it can occasionally insert more laterally and closer to the
epithelial lining is regenerated from the remaining stratum basalis. The placental margin; this condition is known as a battledore placenta
expelled placenta is a flattened discoid mass with an approximately (Fig. 77.47). Occasionally, the cord fails to reach the placenta itself and
circular or oval outline (Fig. 77.45). It has an average volume of ends in the membranes as a velamentous insertion. When insertion of
500 ml (range 200–950 ml), a weight of 470 g (range 200–800 g), a the cord is velamentous, the larger branches of the umbilical vessels
diameter of 185 mm (range 150–200 mm), a thickness of 23 mm traverse the membranes before they reach and ramify on the placenta | 1,805 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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(Fig. 77.48). They travel unprotected through the membranes to the
placenta, and this puts the fetus at risk because compression or tearing
of the vessels can disrupt blood flow to and from the fetus. This can be
particularly problematic when the vessels present themselves across the
cervical os, a condition called vaso praevia. An accessory (succenturiate)
placental lobe is occasionally present, connected to the main organ by
membranes and blood vessels. If it is inadvertently retained in utero after
delivery of the main placental mass, it can cause postpartum haemor-
rhage or infection. Other variations include placenta membranacea, in
which villous stems and their branches persist over the whole chorion;
and placenta circumvallata, where the placental margin is undercut by
a deep groove caused by an abnormally central insertion of the mem-
branes (Fig. 77.49).
Bonus e-book tables
Fig. 77.46 A vascular cast from a monochorionic diamniotic Table 77.1 Lymphatic drainage of the female genitalia.
twin pregnancy, showing vascular communications between both
placentas. (Courtesy of Dr Ling Wee, University College London Table 77.2 Innervation of the female genitalia.
Hospital.)
Insertion of umbilical cord into
chorio-amniotic menbrane
Insertion of umbilical
Chorionic plate
cord into placenta
Unprotected fetal
Umbilical cord vessels
Fig. 77.47 A battledore placenta showing the marginal insertion of the Fig. 77.48 Velamentous insertion of the umbilical cord, showing the cord
umbilical cord into the placenta. (Courtesy of Dr Michael Ashworth, inserting into the chorioamniotic membranes rather than the placental
Consultant Histopathologist, Great Ormond Street Hospital for Children, disc. (Courtesy of Dr Michael Ashworth, Consultant Histopathologist,
London.) Great Ormond Street Hospital for Children, London.)
Disc margin with no Circumvallate insertion of Disc margin with no Layer of fibrin at Membrane
membrane attachment membranes membrane attachment site of attachment attachment
A B
Fig. 77.49 Placenta circumvallata. A, The fetal surface and a thick ring of membranes on the fetal surface of the placenta. B, A section through the
placenta, showing that the membranes insert central to the edge of the placental disc. (Courtesy of Dr Michael Ashworth, Consultant Histopathologist,
Great Ormond Street Hospital for Children, London.) | 1,806 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Key references
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different from the male. Aust NZ J Surg 61:380–4. House M, McCabe R, Socrate S 2013 Using imaging-based, three-dimensional
Badouraki M, Christoforidis A, Economou I et al 2008 Sonographic assess- models of the cervix and uterus for studies of cervical changes during
ment of uterine and ovarian development in normal girls aged 1 to 12 pregnancy. Clin Anat 26:97–104.
years. J Clin Ultrasound 36:539–44. Kimberley N, Hutson JM, Southwell BR et al 2012 Vaginal agenesis, the
Bardo DM, Black M, Schenk K et al 2009 Location of the ovaries in girls hymen, and associated anomalies. J Pediatr Adolesc Gynecol 25:54–8.
from newborn to 18 years of age: reconsidering ovarian shielding. Lee JF, Maurer VM, Block GE 1973 Anatomic relations of pelvic autonomic
Pediatr Radiol 39:253–9. nerves to pelvic operations. Arch Surg 107:324–8.
Bill AH, Hall DG, Johnson RJ 1975 Position of rectal fistula in relation to Leung AK, Robson WL 1992 Labial fusion and urinary tract infection. Child
the hymen in 46 girls with imperforate anus. J Pediatr Surg 10:361–5. Nephrol Urol 12:62–4.
Chen C, Huang L, Liu P et al 2014 Neurovascular quantitative study of the Minto C, Hollings N, Hall-Craggs M et al 2001 Magnetic resonance imaging
uterosacral ligament related to nerve-sparing radical hysterectomy. Eur in the assessment of complex Müllerian anomalies. Br J Obstet Gynaecol
J Obstet Gynecol Reprod Biol 172:74–9. 108:791–7.
Corton MM 2012 Anatomy. In: Hoffman B, Schorge JO, Schaffer JI et al (eds) An article that provides a detailed discussion of the formation and MRI
Williams Gynecology, 2nd ed. New York: McGraw Hill. appearance of congenital anomalies of the uterus and Fallopian tubes.
A chapter that provides a comprehensive review of pelvic organs, blood Motta PM, Nottola SA, Familiari G et al 2003 Morphodynamics of the
vessels, lymphatics and nerve supply and supports of the pelvic organs. follicular-luteal complex during early ovarian development and repro-
Delancey JO 2011 Surgical anatomy of the female pelvis. In: Rock JA, Jones ductive life. Int Rev Cytol 223:177–288.
HW (eds) Te Linde’s Operative Gynecology, 10th ed. Philadelphia: Lip- An account that reviews the morphological and functional aspects of the
pincott, Williams & Wilkins. ovarian follicle, corpus luteum and germ cells using light microscopy,
A chapter that provides a detailed review of the supports of the vagina and electron microscopy and numerous drawings.
the pelvic organs. Owen J, Hankins G, Iams JD et al 2009 Multicenter randomized trial of
Dietz HP, Lanzarone V 2005 Levator trauma after vaginal delivery. Obstet cerclage for preterm birth prevention in high-risk women with short-
Gynecol 106:707–12. ened midtrimester cervical length. Am J Obstet Gynecol 201:375.
A landmark study that prospectively identified levator trauma after vaginal Salardi S, Orsini LF, Cacciari E et al 1985 Pelvic ultrasonography in pre-
delivery using non-invasive three-dimensional ultrasound. menarcheal girls: relation to puberty and sex hormone concentrations.
Arch Dis Child 60:120–5.
Feltovich H, Hall TJ, Berghella V 2012 Beyond cervical length: emerging
technologies for assessing the pregnant cervix. Am J Obstet Gynecol Sforza C, Ferrario VF, De Pol A et al 1993 Morphometric study of the human
207:345–54. ovary during compartmentalization. Anat Rec 236:626–34.
A review article that describes emerging imaging technologies for visualizing Shek KL, Kruger J, Dietz HP 2012 The effect of pregnancy on hiatal dimen-
structural and architectural changes in the cervix in normal and abnormal sions and urethral mobility: an observational study. Int Urogynecol J
pregnancies. 23:1561–7.
A study that demonstrates the anatomical changes that occur in the pelvic
Fonseca EB, Celik E, Parra M et al 2007 Fetal Medicine Foundation Second
floor at the urethral hiatus during pregnancy.
Trimester Screening Group. Progesterone and the risk of preterm birth
among women with a short cervix. N Engl J Med 357:462–9. Shoja MM, Sharma A, Mirzaya N et al 2013 Neuroanatomy of the female
Grant LA, Sala E, Griffin N 2010 Congenital and acquired conditions of the abdominopelvic region: a review with application to pelvic pain syn-
vulva and vagina on magnetic resonance imaging: a pictorial review. dromes. Clin Anat 26:66–76.
Semin Ultrasound CT MR 31:347–62. A detailed review of the somatic and autonomic nerve supply of the female
An article that reviews the typical imaging characteristics on MRI of the genital system and female pelvis.
normal vagina, as well as congenital and acquired conditions of the vulva Speroff L, Fritz M 2004 Clinical Gynecologic Endocrinology and Infertility.
and vagina. Philadelphia: Lippincott, Williams and Wilkins. | 1,808 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
COMMENTARY
The neurovascular bundles of
8.1
the prostate
Robert P Myers
The neurovascular bundles are discrete anatomical structures flanking The pelvic plexus consists of sympathetic and parasympathetic com-
the posterolateral surfaces of the prostate. They contain autonomic ponents (Fig. 8.1.1). A major portion of the plexus consists of the
nerves that become cavernous nerves once they enter the corpora cav- inferior hypogastric plexus, where the sympathetic innervation is
ernosa and corpus spongiosum more distally. The neurovascular centred on the lateral surfaces of the rectum, superior and posterior to
bundles are so named because, where they course along the prostate, the seminal vesicles. Nerve roots comprising the parasympathetic
the bundles, which serve as a visual marker in radical prostatectomies, portion exit sacral foramina S2–4 and join and intermix with the
contain small arteries and veins, as well as nerves (Walsh et al 1983). hypogastric plexus. Both sympathetic and parasympathetic nerve fibres
They extend distally from the vascular pedicle at the vesicoprostatic entering the neurovascular bundles emerge from the pelvic plexus
junction and base of the prostate, and reach all the way to the prostatic to embrace both the lateral surfaces of the seminal vesicles and the
apex. Nerves in the neurovascular bundles are derived from the pelvic posterolateral surfaces of the prostate. Proximal to the vascular pedicle
plexus. to the prostate, the nerves course particularly close to the lateral surfaces
Fig. 8.1.1 Pelvic plexus origins with ramifications
distally into the prostatic and cavernous plexuses,
with autonomic nerves to seminal vesicles,
bladder and rectum. Variable configurations
include prostate shape with blunt apex to
accentuate the inward turn of the neurovascular
bundle towards the prostato-urethral junction, and
anterior 90° prostatic urethral angulation into the
vesical neck. Inset: radical prostatectomy
specimen. (Used with permission of Mayo
Foundation for Medical Education and Research.)
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The neurovascular bundles of the prostate
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of the seminal vesicles (Lunacek et al 2005, Schlegel and Walsh 1987), et al 2005). This point of decussation is in proximity to the triangular
and thus mobilization of the seminal vesicles during radical prostatec- tip of Denonvilliers’ fascia as it merges to join the posterior median
tomy is of potential risk to nerve integrity. On occasion, nerves run in raphe of the urethra. On the basis of anatomical study, passing a needle
a mass anterior to the seminal vesicles (van der Zypen 1988). As nerves posteriorly close to this junction of the neurovascular bundles (Rocco
from the pelvic plexus run distally, branches are given off to the bladder, stitch; Rocco et al 2007) must be done carefully because there is certain
ureters, seminal vesicles, vasa deferentia, levator ani, rectum, prostate risk of nerve entrapment. The basket configuration makes the intrafas-
and membranous urethra (Walsh et al 1983, Costello et al 2004, cial dissection and removal of the prostate the most nerve-preserving
Durward 1953, Arai 2006). Individual variation in the distribution of technique (Walz et al 2010).
pelvic plexus nerves relative to where they join the neurovascular In an anatomical study of transverse prostate sections, Kiyoshima
bundle is well recognized, and four distribution types have been identi- and colleagues (2004) found that, in approximately half of prostates,
fied by intraoperative nerve stimulation and measurement of concomi- the nerves were in the typical bundle configuration dominant at the 4
tant intracavernosal corporal body pressures (Takenaka et al 2011). and 5 o’clock and the 7 and 8 o’clock positions, as was originally
These four tentative nerve distribution types have not yet been corrobo- described. However, in the other half of the specimens, the nerves were
rated by gross dissection specimens. more evenly distributed on the posterolateral surfaces of the prostate.
Residual autonomic branches of the neurovascular bundles pass This finding has affected the conduct of nerve-sparing radical retropubic
beneath the pubic arch to innervate the corpora cavernosa and corpus prostatectomies calling for mobilization of the nerves with initial high
spongiosum as the cavernous nerves (Walsh et al 1983, Durward 1953, lateral prostate fascial incision and release (Montorsi et al 2005). This
Paick et al 1993, Alsaid et al 2011, Müller 1836). Nerves branch both manœuvre allows as many nerves as possible to be mobilized laterally
posteriorly, into the corpus spongiosum, and anterolaterally, to away from the prostate, even if the major nerves are still found at the
intermesh with the dorsal sensory nerves of the penis; the latter act as 4 and 5 o’clock positions, as based on stimulation study (Kaiho et al
a scaffold for both proximal and distal entry of cavernous nerve fibres 2009). While dominance of nerves is demonstrated rectolaterally, one-
into the cavernous bodies. fifth to one-fourth of nerves have been found along the ventral circum-
After radical prostatectomy with prostate removed, the preserved ference of the prostate (Eichelberg et al 2007).
neurovascular bundles sit prominently on the rectal surface and course As autonomic nerves pass the prostato-urethral junction with a
distally from the bladder to embrace either side of the protruding medial swing inwards, hugging the prostate apex at the prostato-
membranous urethra and external striated urethral sphincter (rhab- urethral junction, they approach very close to the rhabdosphincter and
dosphincter) (Fig. 8.1.2). membranous urethra; anterolateral fibres extend as far anteriorly as the
Within neurovascular bundles next to the prostate, the major nerves 10 and 2 o’clock positions en route to becoming true cavernous nerves
vary in their distance from the underlying prostatic fascia or capsule. If (Costello et al 2004, Lepor et al 1985). In radical retropubic prostatec-
they are close, they are more easily injured in the lateral dissection of tomies, exceptional care must be taken to secure and transect the
the neurovascular bundles during radical prostatectomy. If they run next dorsal vascular complex without trapping these anteriorly directed
to a bleeding vessel that needs to be secured, there is greater likelihood nerve fibres with suture material or transecting them with blunt dissec-
that an adjacent nerve may be injured in the process. Within the neu- tion manœuvres and instruments passed distal to the prostato-urethral
rovascular bundles, cross-sectional nerve diameters of 0.04–0.37 mm junction. An immunohistochemical study found 15% of sympathetic
have been measured with a cross-reference human hair 0.02 mm in and 6.8% of parasympathetic fibres disposed anterolaterally at the
diameter (Myers 2002a). The periprostatic fascia is multilayered, and prostate apex; the distribution distal to the apex was not detailed (Cos-
compartmentalizes the neurovascular bundles on cross-section; pro- tello et al 2011). Beyond the prostatic plexus, a cavernous plexus has
erectile nerves are situated more posteriorly (Costello et al 2004). been described that is mixed within the anterior rhabdosphincter,
With the posterior Denonvilliers’ fascia removed, cadaveric dissec- distal to which fibres pass under the symphysis embedded in fibrous
tion shows the prostate situated literally in a basket of autonomic nerves tissue connecting the penile crura with the pubic arcuate ligament
(Costello et al 2004). The disposition of this basket may be altered as (Müller 1836).
a consequence of the development of benign prostatic hyperplasia, For years, patients undergoing radical prostatectomy for localized
which tends to favour a more posterolateral displacement of the neu- prostate cancer were almost always rendered impotent. Interest in pre-
rovascular bundles. Anteriorly, the top edges of the basket abut the serving potency was clear but the success rate was virtually nil; when it
lateral aspect of the dorsal vascular (venous) complex and the detrusor was reported, e.g. in radical perineal prostatectomy, the reason was
apron (Myers 2002b), both of which cover the anterolateral prostate. elusive (Finkle 1975). When surgery was the chosen method of treat-
Gross dissection demonstrates the rich abundance of nerves both later- ment, patients generally knew that erectile dysfunction or loss would
ally and posteriorly, with evident decussation of some nerves at the be likely to be an outcome in the quest to cure their cancer. This sad
prostato-urethral junction posteriorly (Costello et al 2004, Takenaka situation was to be reversed in the 1980s.
A B
Fig. 8.1.2 A–B, With the prostate removed, two neurovascular bundles (NVB), left and right, are shown as gross anatomical structures, isolated on the
rectal surface (R) as they course distally to embrace the transected striated sphincter (SS) and membranous urethra (U). Other abbreviations: B, bladder;
LA, levator ani; NVT, neurovascular triangle. (A, Adapted with permission from Myers RP, Cheville JC, Pawlina W; Making anatomic terminology of
the prostate and contiguous structures clinically useful: historical review and suggestions for revision in the 21st century. Clinical Anatomy. 2010
Jan;23(1):18–29. B, Used with permission of Mayo Foundation for Medical Education and Research.) | 1,810 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
ThE NEuROvAsCulAR buNdlEs Of ThE pROsTATE
e74
8
NOITCEs
A B
Fig. 8.1.3 A–B, After haemostatic clips are applied to secure the prostate vascular pedicle, a scissor cut releases the left neurovascular bundle (NVB)
isolated by combined retrograde and anterograde dissection during robotic-assisted laparoscopic prostatectomy. Other abbreviations: B, bladder; NVT,
neurovascular triangle; P, prostate; SV, seminal vesicle. (A, Video frame courtesy of V. Patel, MD, FACS, University of Central Florida, Altamonte Springs,
Florida. Used with permission. B, Used with permission of Mayo Foundation for Medical Education and Research.)
Finding the reason for the dysfunction and the means of preventing with more functional profile, membranous urethral sphincteric length
it was the focus of attention of Walsh and Donker (1982), who inde- (Presti et al 1990). Pudendal innervation of the sphincter complex from
pendently reported the course of autonomic nerves running distally below is well recognized (Hollabaugh et al 1997), and patients under-
from the pelvic plexus, some of which became cavernous nerves of the going prostate removal with no preservation of their neurovascular
penis. Their work corroborated that of Müller (1836), who, on the basis bundles can experience perfect urinary control.
of dissecting two male cadavers, described a cavernous plexus that was The neurovascular bundles are important. In surgery, patients sub-
a continuation of the prostatic plexus; major and minor cavernous jected to the least injury by virtue of maintaining the full number and
nerves infiltrated the corpora cavernosa and corpus spongiosum, ulti- integrity of all neurovascular bundle-related autonomic nerves, as well
mately and intimately connecting in their terminal distribution to the as those disposed to be cavernous in destination, will do best in terms
penile helicine arteries that are responsible for erection. of recovery of their erectile function and, possibly, urinary control.
In surgery devised to preserve potency successfully (Quinlan et al Despite universal recognition by the urological community, neurovas-
1991), the neurovascular bundles must be dissected bilaterally away cular bundles have yet to be recognized in official anatomical nomen-
from the posterolateral aspects of the prostate (Fig. 8.1.3). As originally clature (International Anatomical Nomenclature Committee 1989,
defined and emphasized by Walsh and colleagues (1983), the critical Federative Committee on Anatomical Terminology 1998). With this in
technical step in preservation of the neurovascular bundles in radical mind, a suggestion has been offered to update terminology with the
prostatectomy is to ligate the vascular pedicles to the inferior bladder Latin fasciculus neurovascularis prostatae [dexter et sinister] and, in English,
and prostate in a line anterior to the course of the neurovascular neurovascular bundle of prostate [right and left] (Myers et al 2010). Official
bundles. When the procedure is done correctly, the result is a neuro- recognition of these grossly reproducible structures would put anatom-
vascular triangle on each side in the region of the vascular pedicle at ists, urologists, surgical pathologists and other students of anatomy on
the junction of the prostate and the seminal vesicles (see Figs 8.1.2 and the same page.
8.1.3) (Tewari et al 2006).
Any role of nerves within the neurovascular bundles controlling
Acknowledgement
urinary continence is controversial. Nerve fibres from the neurovascular
bundles that enter the striated urethral sphincter may be simply passing
through the sphincter to innervate the smooth muscle sphincter (lis- Patrick C Walsh MD, University Distinguished Service Professor,
sosphincter) of the membranous urethra. The idea that autonomic James Buchanan Brady Urological Institute, Johns Hopkins Hospital,
nerves would ever innervate the specialized striated and slow-twitch Professor Anthony J Costello MD FRACS FRCSI (Hon) MBBS, The
rhabdosphincter is particularly contentious. The fact that patients who Royal Melbourne Hospital, and Stephen W Carmichael PhD DSc,
have surgery with preservation of neurovascular bundles seem to do Professor Emeritus of Anatomy, Mayo Clinic, provided invaluable
better has never been separated from the confounder that they are left advice.
REFERENCES
Alsaid B, Bessede T, Diallo D et al 2011 Division of autonomic nerves within Eichelberg C, Erbersdobler A, Michl U et al 2007 Nerve distribution along
the neurovascular bundles distally into corpora cavernosa and corpus the prostatic capsule. Eur Urol 51:105–10.
spongiosum components: immunohistochemical confirmation with Federative Committee on Anatomical Terminology 1998 Terminologia Ana-
three-dimensional reconstruction. Eur Urol 59:902–9. tomica: International Anatomical Terminology. Stuttgart: Thieme.
Arai Y 2006 Anatomy for open radical prostatectomy and cystectomy. In: Finkle JE, Finkle PS, Finkle AL 1975 Encouraging preservation of sexual
Yoshida O, Arai Y, Matsuda T (eds) Anatomy for Urologic Surgery. function postprostatectomy. Urology 6:697–702.
Tokyo: Medical View; Ch. 7, pp. 142–55.
Hollabaugh RS Jr, Dmochowski RR, Steiner MS 1997 Neuroanatomy of the
Costello AJ, Brooks M, Cole OJ 2004 Anatomical studies of the neurovas- male rhabdosphincter. Urology 49:426–34.
cular bundle and cavernosal nerves. BJU Int 94:1071–6.
International Anatomical Nomenclature Committee 1989 Nomina Ana-
Costello AJ, Dowdle BW, Namdarian B et al 2011 Immunohistochemical tomica, 6th ed. Edinburgh: Churchill Livingstone.
study of the cavernous nerves in the periprostatic region. BJU Int 107:
Kaiho Y, Nakagawa H, Saito H et al 2009 Nerves at the ventral prostatic
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capsule contribute to erectile function: initial electrophysiological
Durward A 1953 Fig. 967 Abdomino-pelvic plexuses in peripheral nervous assessment in humans. Eur Urol 55:148–54.
system. In: Brash JC (ed). Cunningham’s Textbook of Anatomy, 9th ed.
London: Oxford University Press, p. 1141. | 1,811 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Kiyoshima K, Yokomizo A, Yoshida T et al 2004 Anatomical features of Rocco F, Carmignani L, Acquati P et al 2007 Early continence recovery after
periprostatic tissue and its surroundings: a histological analysis of 79 open radical prostatectomy with restoration of the posterior aspect of
radical retropubic prostatectomy specimens. Jap J Clin Oncol 34: the rhabdosphincter. Eur Urol 52:376–83.
463–8. Schlegel PN, Walsh PC 1987 Neuroanatomical approach to radical cysto-
Lepor H, Gregerman M, Crosby R et al 1985 Precise localization of the prostatectomy with preservation of sexual function. J Urol 138:
autonomic nerves from the pelvic plexus to the corpora cavernosa: a 1402–6.
detailed anatomical study of the adult male pelvis. J Urol 133: Takenaka A, Murakami G, Matsubara A et al 2005 Variation in course of
207–12. cavernous nerve with special reference to details of topographic relation-
Lunacek A, Schwentner C, Fritsch H et al 2005 Anatomical radical retropubic ships near prostatic apex: histologic study using male cadavers. Urology
prostatectomy: ‘curtain dissection’ of the neurovascular bundle. BJU Int 65:136–42.
95:1226–31. Takenaka A, Soga H, Hinata N et al 2011 Classification of the distribution
Montorsi F, Salonia A, Suardi N et al 2005 Improving the preservation of of cavernous nerve fibers around the prostate by intraoperative electrical
the urethral sphincter and neurovascular bundles during open radical stimulation during laparoscopic radical prostatectomy. Int J Impot Res
retropubic prostatectomy. Eur Urol 48:938–45. 23:56–61.
Müller J 1836 Über die organischen Nerven der erectilen männlichen Gesch- Tewari A, Takenaka A, Mtui E et al 2006 The proximal neurovascular plate
lectsorgane des Menschen und der Säugethiere. Berlin: F. Dümmler. and the tri-zonal neural architecture around the prostate gland: impor-
Myers RP 2002a Gross and applied anatomy of the prostate. In: Kantoff PW, tance in the athermal robotic technique of nerve-sparing prostatec-
Carroll PR, D’Amico AV (eds) Prostate cancer: principles and practice. tomy. BJU Int 98:314–23.
Philadelphia: Lippincott Williams & Wilkins; Ch. 1, pp. 3–15. van der Zypen EM 1988 Composition and topographic anatomy of the
Myers RP 2002b Detrusor apron, associated vascular plexus, and avascular inferior hypogastric plexus (pelvic plexus). SANDORAMA III–IV:
plane: relevance to radical retropubic prostatectomy: anatomic and sur- 24–32.
gical commentary. Urology 59:472–9. Walsh PC, Donker PJ 1982 Impotence following radical prostatectomy:
Myers RP, Cheville JC, Pawlina W 2010 Making anatomic terminology of the insight into etiology and prevention. J Urol 128:492–7.
prostate and contiguous structures clinically useful: historical review Walsh PC, Lepor H, Eggleston JC 1983 Radical prostatectomy with preserva-
and suggestions for revision in the 21st century. Clin Anat 23:18–29. tion of sexual function: anatomical and pathological considerations.
Paick JS, Donatucci CF, Lue TF 1993 Anatomy of cavernous nerves distal to Prostate 4:473–85.
prostate: microdissection study in adult male cadavers. Urology 42: Walz J, Burnett AL, Costello AJ et al 2010 A critical analysis of the current
145–9. knowledge of surgical anatomy related to optimization of cancer control
Presti JC Jr, Schmidt RA, Narayan PA et al 1990 Pathophysiology of urinary and preservation of continence and erection in candidates for radical
incontinence after radical prostatectomy. J Urol 143:975–8. prostatectomy. Eur Urol 57:179–92.
Quinlan DM, Epstein JI, Carter BS et al 1991 Sexual function following
radical prostatectomy: influence of preservation of neurovascular
bundles. J Urol 145(5):998–1002. | 1,812 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
Real-time microscopy of the upper and lower
COMMENTARY
gastrointestinal tract and the hepatobiliary–
8.2
pancreatic system during endoscopy
Martin Götz
Introduction
Real-time histology during ongoing endoscopy has been a goal of endos-
copists since the very beginning of modern endoscopy. Technological
advancements have brought forward endomicroscopy and endocytos-
copy, two microscopic techniques that provide high-resolution (sub)
cellular images of the mucosa with approximately 1000-fold magnifica-
tion in vivo (Goetz et al 2014). These novel techniques have been exten-
sively studied for diseases of the upper gastrointestinal tract and the
lower gastrointestinal tract, and also, more recently, for intrabiliary and
intrapancreatic imaging. Imaging relies on the application of fluorescent
agents (mostly fluorescein) for endomicroscopy or of topical dyes for
endocytoscopy.
Real-time virtual histology (‘optical biopsy’) serves several needs in
clinical medicine: first, it provides an immediate diagnosis for the well-
trained endoscopist. This limits the need for biopsies and helps to
minimize sampling error. Second, microscopic imaging can predict
depth of invasion of lesions or assist in guiding immediate endoscopic
resection. Third, endomicroscopy has also been successfully evaluated
for functional and molecular imaging of the gastrointestinal mucosa,
providing deep insights into normal tissue function and disease pathol-
ogy in translational research.
Technology and devices
For confocal laser endomicroscopy (CLE), two devices are available for
clinical use: in an endoscope-based approach (eCLE), a miniaturized
confocal scanner is integrated into the distal end of a dedicated endo-
scope, whereas in probe-based CLE (pCLE), a flexible probe can be
introduced into the working channel of different endoscopes (Fig.
8.2.1). eCLE provides images with higher resolution and user-adaptable
imaging plane depth. pCLE is more flexible for use ‘on demand’, and
thin probes can be introduced into the bile or pancreatic duct. Fluores-
cein is the contrast agent most commonly used (5 ml/10% intrave-
nously), together with blue laser light excitation, but – since fluorescein
does not stain nuclei – acriflavine and cresyl violet have also been
studied for topical application. CLE provides transverse optical sections,
i.e. orientated at 90° to conventional histopathology, at the tissue
surface or below (up to 250 µm).
Endocytoscopy is an adaption of contact white light microscopy with
lens-based magnification (‘ultrahigh zoom-endoscopy’). After intravital
tissue staining, high-resolution images of the uppermost mucosal layer
(including nuclei) are visible. Systems are currently not marketed, limit-
ing the broad clinical application of endocytoscopy.
Upper gastrointestinal tract
In the healthy upper gastrointestinal tract, squamous epithelium of the
oesophagus, gastric mucosa and duodenal villi can be easily visualized
and differentiated with CLE by their characteristic structural features,
Fig. 8.2.1 For endomicroscopy, two systems are available: for probe-
even without visualization of nuclei (Fig. 8.2.2). In Barrett’s oesopha-
based imaging (right), a thin confocal probe is used together with a
gus, the visualization of goblet cells is the hallmark of intestinal meta-
conventional endoscope; for endoscope-integrated imaging (left), a
plasia. Barrett’s-associated neoplasia was diagnosed in a pilot trial with miniaturized scanner is integrated into a dedicated endoscope (protruding
high accuracy (Kiesslich et al 2006) (Fig. 8.2.3). When compared to tip). See text for details.
untargeted quadrant biopsies, the yield per biopsy was significantly
higher when eCLE was used, and two-thirds of patients did not need
any biopsy based on normal optical biopsies (Dunbar et al 2009).
Similarly, pCLE had a high negative predictive value for Barrett’s In the stomach, studies have addressed the use of CLE to diagnose
oesophagus (Pohl et al 2008). Since pan-endomicroscopy of larger gastritis (Wang et al 2010), Helicobacter pylori (Kiesslich et al 2005),
mucosal regions is not feasible, CLE is often used in conjunction with intestinal metaplasia (Guo et al 2008), and gastric hyperplastic and
chromoendoscopy to pinpoint the region of interest to be examined adenomatous polyps (Li et al 2010). In a large trial, eCLE was able to
subsequently by CLE. In squamous cell carcinoma, eCLE was able to diagnose high-grade neoplasia and superficial gastric cancer in a high-
predict malignant histology in unstained regions after chromoendos- risk population of 1786 patients (Li et al 2011). CLE can also help to
e76 copy with Lugol’s solution (Pech et al 2008). guide intervention and minimize sampling error prior to resection | 1,813 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
Real-time microscopy of the upper and lower gastrointestinal tract
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A B
C D
Fig. 8.2.2 Normal microscopic anatomy of the gastrointestinal tract. A, In the squamous cell lining of the oesophagus, intrapapillary capillary loops
(arrows) are orientated perpendicular to the tissue surface in a corkscrew fashion. Bright vessel contrast is found after intravenous fluorescein injection;
black dots within the vessel lumen correspond to unstained red blood cells. B, The gastric mucosa (antrum) typically shows a cobblestone-like surface
pattern; in subsurface sections, capillaries become visible (arrows). C, In the terminal ileum, the villi are easily seen. Below the columnar epithelium with
goblet cells (arrowheads), separated by the basal membrane, hairpin-like capillaries (arrows) can be seen within the lamina propria. D, The normal colon
shows crypts of fairly even size with an unstained (black) central lumen (arrows), surrounded by goblet cells with dark mucin inclusions (arrowheads) that
can be optically sectioned parallel (drop-like shape) or vertical (round shape) to the mucosa. Original magnification ×1000.
(Jeon et al 2011) or surveillance and reintervention after resection (Ji niques for prediction of histology, such as virtual chromoendoscopy
et al 2011). and high-definition endoscopy, but shows higher accuracy (Buchner
et al 2010).
Lower gastrointestinal tract Endocytoscopy has mostly been studied in the lower gastrointestinal
tract. A high accuracy and kappa agreement with histology have been
found for the diagnosis of colorectal lesions (Sasajima et al 2006).
The first study with eCLE in patients was performed in screening colon-
Endocytoscopy was non-inferior to histopathology but results were
oscopy, establishing criteria for normal mucosa, hyperplasia and neo-
available immediately (Mori et al 2013).
plasia (Kiesslich et al 2004) that were followed by a similar classification
system for pCLE (Kuiper et al 2011) (see Fig. 8.2.2). In ulcerative colitis,
Hepatobiliary and pancreatic system
combination of eCLE with chromoendoscopy found a four-fold increase
in the number of intraepithelial neoplasias with a 10-fold reduction
in biopsies compared to a quadrant biopsy protocol (Kiesslich et al Indeterminate biliary strictures pose a clinical dilemma and the
2007a), corroborating the concept of targeted, ‘smart’ biopsies for approach to obtain specimens for histopathology is often limited. CLE
optimized surveillance. CLE competes with non-microscopic tech- probes that are advanced into the bile duct via duodenoscopes have | 1,814 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
REAL-TIME MICROSCOPY OF THE UPPER AND LOWER GASTROINTESTINAL TRACT
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8
NOITCES
A B
Fig. 8.2.3 A, In Barrett’s oesophagus, the normal squamous epithelium is replaced by specialized intestinal metaplasia that resembles mucosa of the
small intestine (compare Fig. 8.2.2C). The double lining at the surface of the villi (arrows) corresponds to the brush border, while black dots (arrowheads)
indicate mucin inclusions in goblet cells, establishing the diagnosis of Barrett’s oesophagus during endoscopy. B, In Barrett’s-associated neoplasia
(same patient), the tissue structure is progressively lost. Residual gland structures are visible (arrows), and white contrast extravasation into the solid
tissue indicates increased vessel leakiness of tumour-associated neoangiogenesis. Original magnification ×1000.
demonstrated increased sensitivity in a first trial (Meining et al 2008). function. Similarly, in patients with H. pylori-associated gastritis, epithe-
Such thin CLE probes were also used for imaging in the pancreatic duct lial barrier damage was predominant: failure to reverse barrier function
(Meining et al 2012) and were advanced through needles targeted by indicated complications despite H. pylori clearance (Ji et al 2012).
endoscopic ultrasonography to pancreatic cystic lesions (Konda et al CLE has also been used for molecular imaging (Atreya and Goetz
2011). Rigid laparoscopic CLE devices have been used for microscopic 2013). Fluorescent labelling of single molecules highlighted adenoma-
liver imaging (Goetz et al 2010a). Interpretation of images from the tous lesions in patients (Hsiung et al 2008, Liu et al 2013). Targeting
hepatobiliary and pancreatic systems is less straightforward since struc- of specific surface receptors overexpressed on malignant cells has been
tural resolution is lower than in the gastrointestinal tract. The final used as a molecular beacon for colorectal (Goetz et al 2010b) and
clinical significance, therefore, remains to be established in larger trials. gastric cancers (Hoetker et al 2012) in murine models, and has been
linked to predicting response to targeted therapy (Goetz et al 2013). It
Perspective is too early to integrate these results into routine clinical protocols.
However, they indicate a way to individualizing therapy based on func-
tional and molecular microscopic imaging.
The introduction of CLE has augmented translational research. To date,
no other device is able to study microscopic events dynamically in the
Summary
natural micromilieu, free of artefacts and without disrupting tissue
integrity or perfusion. CLE was able to visualize intramucosal bacteria
in patients with inflammatory bowel diseases (IBD) (Moussata et al In the past 10 years, microscopic imaging during endoscopy has become
2011), exemplifying the high resolution that can be obtained in vivo. possible, and multiple trials have evaluated its relevance in imaging in
Gaps smaller than a single cell, punctuating the epithelial barrier of the the upper and lower gastrointestinal tracts and, recently, within the
healthy gut mucosa can be visualized, and probably correspond to hepatobiliary and pancreatic systems. Optical biopsies by microscopic
residual microlesions after normal cell shedding (Kiesslich et al 2007b). imaging have not replaced (or aimed at replacing) tissue sampling, but
Increased shedding was found in IBD (Liu et al 2011). Functional can help to target, complement or avoid conventional biopsies, decide
impairment of such gaps in endoscopically and histopathologically on and guide endoscopic resection and, broaden our understanding of
normal mucosa predicted IBD flares (Kiesslich et al 2012), potentially microarchitectural and molecular processes within the mucosa of the
constituting the microarchitectural correlate of the impaired barrier gastrointestinal tract.
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classification of colon polyps. Gastroenterology 138:834–42. endomicroscopy and endocytoscopy. Nat Rev Gastroenterol Hepatol
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comparative study. Gastrointest Endosc 74:772–80. factor receptor in patients with colorectal neoplasia using confocal laser
Ji R, Zuo XL, Li CQ et al 2011 Confocal endomicroscopy for in vivo predic- endomicroscopy. Cancer Lett 330:200–7.
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metaplasia: in vivo evaluation by confocal endomicroscopy. Gastroin- Meining A, Frimberger E, Becker V et al 2008 Detection of cholangiocarci-
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Konda VJ, Aslanian HR, Wallace MB et al 2011 First assessment of needle- of colorectal lesions when using the endocytoscopy system. Gastrointest
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Kuiper T, van den Broek FJ, van Eeden S et al 2011 New classification for bacter pylori-associated gastritis by confocal laser endomicroscopy. World
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Surg Endosc 24:517–24. | 1,816 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
CHAPTER Pelvic girdle and lower limb: overview
78
and surface anatomy
The structure of the lower limb is specialized for support of the body’s limb, which is especially important to physicians during various surgi-
weight, locomotion, and maintenance of body stability (balance). cal and clinical procedures.
Indeed, adaptations for weight-bearing and stability account for the
major structural and functional differences between the upper and
lower limbs. The inguinal (pelvicrural) and gluteal (buttock) regions SKIN, FASCIA AND SOFT TISSUES
are important anatomical junctional zones between the trunk and the
lower limb through which longitudinally running nerves and vessels
In the young adult and as an adaptation to weight-bearing, the skin of
travel (Fig. 78.1). The inguinal region includes the transitional zones
the lower limb is generally stronger and thicker than that of the upper
between the lower limb and abdominal cavity via the myopectineal
limb. The soft tissues of the sole of the foot are particularly thickened
orifice (the gap between the inguinal ligament and hip joint) and
in order to support weight during standing. The skin of the buttocks
inguinal canal, and provides a gateway for the passage of various struc-
and posterior thigh bears weight in the sitting position, and conse-
tures. Similarly, the obturator canal allows for the obturator nerve and
quently is relatively thick. The skin over the anteromedial aspect of the
vessels to traverse between the pelvis and thigh. The gluteal region com-
leg is particularly fragile and vulnerable in the elderly.
municates with the lower limb and the abdominopelvic cavity via the
greater sciatic foramen, and with the lower limb and pelvic cavity and
Subcutaneous tissue (tela subcutanea)
perineum via the lesser sciatic foramen.
This chapter will provide general information on the lower limb in
two sections. The first section is an overview of the general organization The subcutaneous tissue (tela subcutanea; hypodermis) of the lower
of the lower limb, with particular emphasis on the fasciocutaneous limb becomes thinner peripherally. It participates in the integrity of the
system, distribution of the major blood vessels and lymphatic channels, skin and provides support for subcutaneous structures such as super-
and the branches of the lumbar and sacral plexuses; it is intended to ficial veins and cutaneous nerves. It is connected to the adventitia of
complement the detailed regional anatomy described in Chapters the superficial veins by thin bands that prevent the displacement of the
80–84. The second section describes the surface anatomy of the lower veins during movement. The hypodermal plexus of arteries and veins
Greater sciatic foramen above piriformis:
Superior gluteal nerve, artery, vein
Sacrotuberous ligament
Piriformis
Sacrospinous ligament
Lesser sciatic foramen:
Obturator internus tendon
Pudendal nerve and internal pudendal
vessels pass into perineum
from gluteal region
Greater sciatic foramen below
piriformis:
Sciatic nerve Inguinal canal
Inferior gluteal nerve, artery, vein
Pudendal nerve Obturator canal:
Internal pudendal artery and vein Obturator nerve
Posterior femoral cutaneous nerve Obturator vessels
Nerve to obturator internus
Nerve to quadratus femoris
Gap between inguinal
ligament and pelvic bone:
Psoas major, iliacus,
pectineus
Femoral artery
Femoral vein
Lymphatics
Femoral branch of
genitofemoral nerve
Lateral femoral
cutaneous nerve
Fig . 78 .1 Gateways from the abdomen, pelvis and perineum to the lower limb . (With permission from Drake RL, Vogl AW, Mitchell A (eds), Gray’s
1316 Anatomy for Students, 2nd ed, Elsevier, Churchill Livingstone . Copyright 2010 .) | 1,819 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
Skin, fascia and soft tissues
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controls blood flow through the skin, thus helping to regulate body Fasciocutaneous system
temperature (Sterzi 1910). The fascial septa dictate the pathways of cutaneous arteries, which sub-
The deep fascia of the lower limb is a well-defined layer that forms sequently perforate and ramify on the fascial ‘stocking’ before supplying
a tough circumferential ‘stocking-like’ structure that constrains the mus- the skin.
culature (Fig. 78.2). Septa pass from the deep surface of this fascial
sheath to the bones within, confining the functional muscle groups Osteofascial compartments in the lower limb
within osteofascial compartments. The tough fascia gives additional The muscles of the thigh may be grouped into three compartments
areas of attachment to the muscles and ensures maximal function. according to their function: namely, anterior (extensor), posterior
According to Cruveilhier (1841), all aponeurotic fasciae are put under (flexor) and medial (adductor). Only the anterior and posterior com-
tension by specific myofascial expansions or dedicated muscles. Such partments possess distinct fascial boundaries. A very definite fascial
thickenings may act functionally as additional tendons. Elsewhere, separation into anterior (extensor), posterior (flexor) and lateral
thickenings in the fascial skeleton form fibrous retinacula where (evertor) compartments exists in the leg, and compartment syndrome
tendons cross joints. The pattern of soft tissue organization has a is most common in this region (see below). Osteofascial compartments
bearing on the physiological effects of the muscles and is crucial for in the foot are described on page 1420.
efficient venous return from the limb. The fascial planes also control Vessels and nerves run through all the osteofascial compartments
and direct the spread of pathological fluids (blood, pus) within the and supply the muscles contained within them. The muscles acting
limb and play an important part in determining the degree and direc- within these closed compartments assist in maintaining the anti-gravity
tion of displacement seen in long bone fractures. flow of venous blood.
A Anterior superior iliac spine B
lliac crest
Inguinal ligament
Tensor fasciae latae
Spermatic cord
Saphenous opening, cribriform fascia Superior horn Gluteal fascia
Falciform margin
Inferior horn
Tensor fasciae latae
Long saphenous vein
Iliotibial tract
Gluteal fold
Fascia lata
Iliotibial tract
Tendon of quadriceps femoris
Fascia lata
Patella
Subcutaneous prepatellar bursa Lateral patellar retinaculum
Patellar ligament
Fibula, head
Subcutaneous infrapatellar bursa Tendon of biceps femoris Popliteal fossa
Deep fascia of leg
Tibia, anterior border
Gastrocnemius
Deep fascia of leg
Tibia, medial surface
Tendon of tibialis anterior
Tendon of gastrocnemius
Superior extensor retinaculum
Inferior extensor retinaculum
Extensor hallucis brevis Tendons of extensor digitorum longus
Tendon of extensor hallucis longus Calcaneal tendon Medial malleolus
Dorsal fascia of foot
Fig . 78 .2 The deep fascia of the lower limb . A, Anterior view . B, Posterior view . (With permission from Waschke J, Paulsen F (eds), Sobotta Atlas of
Human Anatomy, 15th ed, Elsevier, Urban & Fischer . Copyright 2013 .) | 1,820 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
PElvIC GIRdlE ANd lOwER lImb: OvERvIEw ANd SuRFACE ANATOmy
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NOITCES
Compartment syndrome The fascial boundaries that limit the A B
osteofascial compartments are largely inelastic, which means that any Ilium
condition that leads to an increase in the volume of the compartmental
contents, e.g. muscle swelling caused by trauma, haemorrhage or local
infection, is likely to cause an increase in intracompartmental pressure.
If unrelieved, this increased pressure will lead to compressive occlusion
Sacrum
of the vessels in the compartment and consequent ischaemic damage
to the nerves and muscles of the compartment, a phenomenon known Pubis
as compartment syndrome. The normal compartmental pressure of
Coccyx
the leg is significantly higher in children than in adults: the average
pressure in the compartments varies between 13.3 and 16.6 mmHg in
Ischium
children, compared with 5.2 and 9.7 mmHg in adults (Staudt et al
2008).
The treatment of compartment syndrome relies on reducing abnor-
mally elevated tissue pressure. Surgical decompression of the restricting
compartment’s fasciae may be necessary; in order to prevent neurovas-
cular injury during a fasciotomy, the exact course of the nerves and
vessels within the affected compartment must be known (Apaydin et al
2008).
Femur
BONES AND JOINTS
The bones of the lower limb are the three fused components of the
pelvic girdle; the femur and patella (thigh); the tibia and fibula (leg);
and the tarsus, metatarsus, phalanges and sesamoid bones (foot) (Fig.
78.3). The pelvic bones (especially the ilium and ischium), femur, tibia
and bones of the hindfoot are strong and their external (cortical) and
internal (trabecular) structure is adapted for weight-bearing. Patella
The pelvic girdle connects the lower limb to the axial skeleton via
the sacroiliac joint, a plane synovial type of joint in which mobility has
been sacrificed for stability and strength, to allow for effective weight
transmission from the trunk to the lower limb. Anteriorly, the pelvic
girdle articulates with the contralateral girdle at the pubic symphysis, a
secondary cartilaginous joint that may display a slight degree of mobil-
ity during hip and sacroiliac movement, and during childbirth. The hip Tibia
joint, a synovial ball-and-socket joint, exhibits a very effective compro-
mise between mobility and stability that allows movement in all three
orthogonal planes. The more distal joints have gained mobility at the Fibula
expense of stability. The knee joint is a bicompartmental synovial artic-
ulation, which occurs mainly between the femur and the tibia, and
allows flexion, extension and some medial and lateral rotation of the
leg. It is not a true hinge joint because its axes of flexion and extension Talus
are variable and there is coupled rotation. The knee joint also includes
the articulation between the patella and femur. The tibia and fibula Calcaneus
articulate with each other at the superior and inferior tibiofibular joints. Navicular
The superior joint, a plane synovial joint, allows slight gliding move-
ment only. The inferior joint, a fibrous joint, lies just above the ankle Medial cuneiform
and allows a degree of fibular rotation linked to ankle motion. The
ankle (talocrural) joint is formed by the distal ends of the tibia and Metatarsal
fibula ‘gripping’ the talus, and allows dorsiflexion and plantar flexion.
There are multiple joints in the foot that may be classified topograph-
Phalanges
ically on the basis of whether they are in the hindfoot, midfoot or
forefoot. Collectively, these joints allow the complex movements
required as the foot fulfils its functional roles as a platform for standing
and for shock absorption and propulsion in gait.
Fig . 78 .3 An overview of the bones of the lower limb . A, Posterior aspect .
Both the knee and ankle are commonly subject to closed injuries,
B, Anterior aspect .
and the relatively superficial location of the knee renders it susceptible
to open injury and infection. Although the ankle is frequently injured
and is a major load-bearing joint, the incidence of clinically significant limb contains many muscles that act on more than one joint, and it is
degenerative arthritis is surprisingly low when compared with that unusual for any joint of the lower limb to move in isolation.
found in the hip and knee joints. Muscles of the lower limb may be subdivided into those of the iliac
and gluteal regions, and those of the thigh, leg and foot. Note that in
anatomical nomenclature, ‘leg’ refers to that part of the lower limb
MUSCLES
between the knee and ankle. The main muscles of the posterior abdomi-
nopelvic region are psoas major and iliacus (together called iliopsoas),
The effects of extension and medial rotation of the limb that occur the major flexors of the hip that run from the lumbar spine and inner
during fetal development are manifest in the relative positions of the surface of the ilium, respectively, to attach distally on to the lesser tro-
muscle groups in the thigh and the leg, and in the adult pattern of chanter of the femur. When present, the much less important psoas
segmental cutaneous innervation (dermatomes). The role of the muscles minor runs from the lumbar spine to the pubis. The muscles of the
of the lower limb in the maintenance of equilibrium during locomo- gluteal region include the three named gluteal muscles and the deeper
tion and in stance is rarely emphasized sufficiently. Many of the muscles short lateral rotators of the hip joint. Gluteus maximus lies most super-
act frequently or predominantly from their distal attachments. During ficially, running from the posterior pelvis to the proximal femur and
both stance and locomotion, the distal attachment is often fixed and fascia lata. It is a powerful extensor of the hip joint, acting more often
the proximal attachment is mobile, e.g. the predominant action of to extend the trunk on the femur than to extend the limb on the trunk.
gluteus medius is as a pelvic stabilizer rather than as a hip abductor. In Gluteus medius and minimus, attaching proximally to the outer surface
contrast, in the upper limb, the proximal muscle attachments are of the ilium and distally to the greater trochanter of the femur, are
usually fixed and the distal attachments are mobile, an arrangement abductors of the hip; their most important action is to stabilize the
that is consistent with the prehensile function of the hand. The lower pelvis on the femur during locomotion, and they are helped in this | 1,821 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
vascular supply and lymphatic drainage
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RETPAHC
function by tensor fasciae latae, a more anteriorly placed muscle that may reveal decreased distal pulses (e.g. of the posterior tibial artery),
arises from the anterolateral ilium and inserts via the iliotibial tract on pallor or a cool extremity.
to the proximal tibia. Two of the short lateral rotators of the hip, piri-
formis and obturator internus, arise from within the pelvis, while the Arterial perforators of the lower limb
others, obturator externus, the gemelli and quadratus femoris, originate
and surgical flaps
externally; all of these muscles are attached distally to the proximal
femur.
The muscles of the thigh lie in three functional compartments. The Achieving adequate and aesthetically satisfactory skin and soft tissue
anterior or extensor compartment includes sartorius and the quadriceps cover for large, superficial tissue defects is a perennial challenge in the
femoris. Sartorius and rectus femoris are attached proximally to the field of plastic and reconstructive surgery, and accounts for a substantial
pelvis and can thus act on the hip joint as well as on the knee, whereas part of the plastic surgeon’s workload. Generally, split-thickness and
the vasti are attached proximally to the femoral shaft and, acting as a full-thickness skin grafts are suitable only for very superficial defects. To
unit, are powerful knee extensors. The medial or adductor compartment achieve tissue coverage for deeper and larger tissue defects, the plastic
contains the named adductor muscles and gracilis; pectineus may also surgeon employs one of a variety of autologous tissue flaps. A fascio-
be included. These muscles are attached proximally to the anterior cutaneous flap is composed of skin, fat and deep fascia (fascia muscul-
aspect of the pelvis, and distally to the femur; gracilis has no femoral orum); a lower-extremity fasciocutaneous flap (Pontén 1981) is very
attachment, being attached distally to the proximal tibia, while a part useful in the repair of soft tissue defects of the leg.
of adductor magnus has a proximal attachment to the ischial tuberosity. The viability of a flap transplanted from one part of the body to
The posterior compartment includes semitendinosus, semimembrano- another is crucially dependent on the flap’s blood supply. An apprecia-
sus and biceps femoris. These muscles are attached proximally to the tion of the angiosome concept, coupled with technological advances in
ischial tuberosity and act both to extend the trunk on the femur and to reconstructive microsurgery, has stimulated the development and use
flex and rotate the knee. Adductor magnus, as may be inferred from the of perforator (or perforator-based) flaps. These are flaps of skin or sub-
extent of its proximal attachment and its dual innervation, shares the cutaneous tissue supplied by one or more fascial ‘perfora tors’, i.e. arter-
first of these functions with the hamstrings. Biceps femoris is the only ies, which reach the suprafascial plexus either directly from a source
muscle of the thigh that is attached distally to the fibula, and has no vessel, or indirectly from some other neighbouring tissue (Harry et al
tibial attachment. 2009) (Fig. 78.6). Perforator-based flaps are typically harvested with
In the leg, the anterior or extensor compartment includes the exten- sparing of underlying muscle tissue and minimal trauma; their use
sors (dorsiflexors) of the foot and the extrinsic extensors of the toes. is said to reduce postoperative pain, donor site morbidity and func-
Tibialis anterior, the main foot dorsiflexor, also inverts the foot at the tional loss.
subtalar joint, while the smallest muscle of the compartment, fibularis The lower limb is the largest donor site in the body for perforator-
(peroneus) tertius, is a dorsiflexor that everts the foot. The posterior or based flaps. Commonly used flaps include anterolateral thigh flaps,
flexor (plantar flexor) compartment has superficial and deep compo- which provide a large amount of skin; superior and inferior gluteal
nents. The superficial component contains gastrocnemius and soleus, artery perforator flaps used in breast reconstruction; vascularized fibular
powerful plantar flexors of the foot, and the small plantaris with its flaps for reconstruction of deficient bone; vascularized tensor fasciae
long slender tendon. Gastrocnemius and soleus are attached distally to latae flaps for tendon reconstruction; vascularized sural nerve flaps for
the foot via the calcaneal (Achilles) tendon. The deep component of nerve reconstruction; and the gracilis muscle flap, used in, for example,
the flexor compartment contains popliteus, a rotator of the knee; the reanimation of paralysed muscle.
extrinsic flexors of the toes; and tibialis posterior, the main invertor of In the context of perforator flap surgery, the lower limb may be
the foot. The lateral compartment contains the main evertors of the considered in terms of four anatomic regions: gluteal; anterior hip and
foot, fibularis (peroneus) longus and brevis; both muscles are also thigh; knee and leg; and ankle and foot. Each lower limb accounts for
plantar flexors of the foot. Gastrocnemius and plantaris are attached approximately 23% of the total body surface area (thigh 10.5%, leg
proximally to the femur and distally to the calcaneus; these two muscles 6.5%, buttock 2.5% and foot 3.5%) and contains an average of 90 art-
can therefore act on the knee as well as at the ankle. The intrinsic erial perforators (Fig. 78.7).
muscles of the sole of the foot are arranged in four layers. They facilitate
the actions of the extrinsic flexors of the toes, and provide subtle
changes in the shape of the foot, thereby contributing to the control of VEINS
foot posture in stance and locomotion.
The veins of the lower limb can be subdivided, like those of the upper
limb, into superficial and deep groups (Figs 78.8–78.9). The superficial
VASCULAR SUPPLY AND LYMPHATIC DRAINAGE
veins lie in the subcutaneous tissue; the deep veins (deep to the deep
fascia) accompany the major arteries. Valves are present in both groups,
ARTERIES but are more numerous in the deep veins and are more numerous in
the veins of the lower versus the upper limb. Venous plexuses occur
The femoral artery (the continuation of the external iliac artery) pro- within and between some of the lower limb muscles. The two principal
vides the principal arterial supply to the lower limb distal to the superficial veins are the long and short saphenous veins; their numer-
inguinal ligament and the gluteal fold (Figs 78.4–78.5). The femoral ous tributaries are mostly unnamed; however, changes in clinical prac-
artery courses within the subsartorial (adductor) canal, which is tice are driving a revision of the terminology. For further reading, see
located on the anteromedial aspect of the thigh. It passes through the Caggiati et al (2002, 2005). The long saphenous vein can be harvested
adductor hiatus to become the popliteal artery on entering the post- and used as a graft for peripheral vascular surgery, including coronary
erior compartment of the thigh and soon thereafter divides into the artery bypass (Kosinski 1926).
anterior and posterior tibial arteries. The obturator and inferior gluteal Deep veins of the lower limbs accompany the arteries and their
vessels also contribute to the supply of the proximal part of the limb. branches. Plantar digital veins arise from plexuses in the plantar regions
In the embryo, the inferior gluteal artery supplied the main axial artery of the toes, connect with dorsal digital veins and unite to form four
of the limb, which is represented in the adult by the artery to the plantar metatarsal veins. These run in the intermetatarsal spaces and
sciatic nerve. connect with dorsal veins by means of perforating veins. They then
The bones of the lower limb receive their arterial supply from nutri- connect with each other to constitute a deep plantar venous arch adja-
ent vessels, metaphysial arterial branches of the peri-articular anasto- cent to the deep plantar arch. From this venous arch, medial and lateral
moses, and the arteries supplying the muscles that attach to their plantar veins run near the corresponding arteries; they communicate
periosteum. The pattern of arterial supply is particularly relevant to with the long and short saphenous veins before forming the posterior
fracture healing, the spread of infection and malignancy, and the plan- tibial veins posterior to the medial malleolus. The posterior tibial veins
ning of reconstructive surgical procedures. For further details, consult accompany the posterior tibial artery. They receive veins from the calf
Cormack and Lamberty (1984), Taylor and Razaboni (1994) and Crock muscles, especially the venous plexus in soleus, and connect with super-
(1996). ficial veins and with the fibular veins. The latter, running with their
Ischaemia of the lower limb due to peripheral vascular disease is a artery, receive tributaries from soleus and from superficial veins.
tremendous burden on healthcare resources. Many diseases contribute The anterior tibial veins are continuations of the venae comitantes
to this pathology and include diabetes, hypertension and atherosclero- of the dorsalis pedis artery. They leave the extensor region between the
sis. Obesity and smoking also increase the risk of developing peripheral tibia and fibula, pass through the proximal end of the interosseous
vascular disease. Symptoms include intermittent claudication and membrane, and unite with the posterior tibial veins, at the distal border
wounds that do not heal well. Physical examination of such patients of popliteus, to form the popliteal vein. | 1,822 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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NOITCES
A B
Aorta External iliac artery
Common iliac artery Deep circumflex iliac artery
Internal iliac artery
Inferior epigastric artery Superior gluteal artery
Superficial circumflex iliac artery Inferior gluteal artery
External pudendal artery
Obturator artery Profunda femoris artery Lateral circumflex Medial circumflex femoral artery
femoral artery
Medial circumflex femoral artery Lateral circumflex femoral artery Profunda femoris artery
Femoral artery
Femoral artery
Perforating arteries Perforating arteries
Descending genicular artery
Popliteal artery Descending branch Site of hiatus in adductor magnus
Superior lateral genicular artery
Superior medial genicular artery
Superior medial genicular artery
Superior lateral genicular artery
Popliteal artery
Inferior lateral genicular artery Inferior lateral
genicular artery
Inferior medial genicular artery Inferior medial genicular artery
Anterior tibial artery
Anterior tibial recurrent artery
Fibular artery Posterior tibial artery
Anterior tibial artery
Perforating branch of
fibular artery
Perforating branch
Medial malleolar artery
Lateral malleolar network
Dorsalis pedis artery
Lateral tarsal artery
Medial tarsal artery Medial plantar artery
Arcuate artery Lateral plantar artery
Deep plantar branch Plantar arch
Deep branch of
First dorsal metatarsal artery Plantar metatarsal artery
dorsalis pedis artery
Dorsal digital arteries Plantar digital arteries
Fig . 78 .4 An overview of the arteries of the lower limb . A, Anterior aspect . B, Posterior aspect .
Venous (muscle) pumps in the connecting veins between the long saphenous vein and femoral
vein in the adductor canal may predispose to superficial varicosities
along the medial aspect of the thigh (Dodd and Cockett 1976).
While standing, venous return from the lower limb depends largely on
muscular activity, especially contraction of the calf and foot muscles,
venous plexuses
known as the ‘muscle pump’, whose efficiency is aided by the tight
sleeve of deep fascia (Ricci 2011). ‘Perforating’ veins connect the long Venous plexuses may be intramuscular (soleus) or intermuscular (in the
saphenous vein with the deep veins, particularly near the ankle, distal foot and gluteal region). The plexuses communicate with the axially
calf and knee. Their valves are arranged so as to prevent flow of blood running deep veins and are components of the ‘muscle pump’
from the deep to the superficial veins. At rest, pressure in a superficial mechanism.
vein is equal to the height of the column of blood extending from that
vein to the heart. When the posterior leg muscles contract, blood is
pumped proximally into the deep veins and is normally prevented from LYMPHATIC DRAINAGE
flowing into the superficial veins by the valves in the perforating veins.
During muscular relaxation, blood is drawn into the deep veins from Most lymph from the lower limb traverses a large intermediary inguinal
the superficial veins. If the valves in the perforating veins become group of nodes (Fig. 78.10). Peripheral nodes are few and all are deeply
incompetent, these veins become sites of ‘high-pressure leaks’ during sited. Except for an inconsistent node lying proximally on the interos-
muscular contraction, and the superficial veins become dilated and seous membrane near the anterior tibial vessels, they occur only in the
varicose. Similar perforating connections occur in the anterolateral popliteal fossa. Enlarged popliteal nodes may be palpated along the
region, where varicosities may also occur. Incompetence of the valves line of the popliteal vessels while the passively supported knee is | 1,823 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Posterior Anterior gradually moved from extension to semi-flexion. These are often due
Superficial epigastric artery to inflammation, malignancy or injury to the lateral side of the foot.
Inguinal lymph nodes are found superficial and deep to the deep fascia.
Superior gluteal artery Superficial circumflex iliac artery
The deep nodes are few and lie alongside the medial aspect of the
Inferior gluteal artery Superficial external pudendal artery femoral vein. The superficial nodes may be divided into a lower vertical
group that clothe the proximal part of the long saphenous vein, and an
Obturator and profunda Femoral artery upper group that lie parallel to, but below, the inguinal ligament and
femoris arteries which are related laterally to the superficial circumflex iliac and medi-
Deep external pudendal artery
Inferior gluteal artery ally to the superficial external pudendal vessels. Lymph from the lower
Lateral circumflex femoral artery limb passes from the inguinal lymph nodes to the external and common
iliac nodes, and ultimately drains to the lateral aortic nodes. Deep
Obturator and profunda
Perforating arteries
femoris arteries gluteal lymph reaches the same group through the internal and common
iliac lymphatic vessels.
Femoral artery
Popliteal artery
Lateral genicular arteries Superficial tissues
Sural arteries Medial genicular arteries
The superficial lymph vessels begin in subcutaneous plexuses. Collect-
Popliteal artery Descending genicular artery
ing vessels leave the foot medially, along the long saphenous vein, or
Fibular artery Anterior tibial artery laterally with the short saphenous vein. Medial vessels are larger and
more numerous; they start on the medial side of the dorsum of the
Posterior tibial artery foot, ascend anterior or posterior to the medial malleolus and accom-
Posterior tibial artery
pany the long saphenous vein. They drain to the distal superficial
Fibular artery
inguinal nodes. Lateral vessels begin on the fibular side of the dorsum
Dorsalis pedis artery
Dorsalis pedis artery of the foot; some cross anteromedially in the leg to join the medial
Lateral plantar artery
vessels and so pass to the distal superficial inguinal lymph nodes, while
Medial plantar artery
others accompany the short saphenous vein and drain to the popliteal
nodes. Superficial lymph vessels from the gluteal region run anteriorly
Fig . 78 .5 The anatomical territories served by the cutaneous blood supply
to the proximal superficial inguinal nodes.
to the lower limb .
Deeper tissues
The deep lymph vessels accompany the anterior and posterior tibial,
fibular, popliteal and femoral vessels. Popliteal nodes interrupt the deep
vessels from the foot and leg; those from the thigh pass to the deep
Subfascial plexus inguinal nodes. The deep lymphatic vessels of the gluteal region follow
their corresponding blood vessels. Those accompanying the superior
gluteal vessels end in a node near the intrapelvic part of the superior
gluteal artery, adjacent to the superior border of the greater sciatic
foramen, while those that follow the inferior gluteal vessels traverse one
Fascial feeder or two of the small nodes inferior to piriformis and then pass to the
internal iliac nodes.
Suprafascial plexus
Intrafascial plexus INNERVATION
Direct cutaneous perforator
OVERVIEW OF THE LUMBAR
Fascia
AND SACRAL PLEXUSES
Periosteocutaneous perforator
Nerves derived from the lumbar and sacral plexuses innervate the lower
Bone limb (Fig. 78.11). The lumbar plexus lies deep within psoas major,
anterior to the transverse processes of the first three lumbar vertebrae.
The sacral plexus lies in the pelvis on the anterior surface of piriformis,
external to the pelvic fascia, which separates it from the inferior gluteal
Intercompartmental perforator and internal pudendal vessels. The lumbosacral trunk (L4 and L5)
emerges medial to psoas major on the posterior abdominal wall and
lies on the ala of the sacrum before crossing the pelvic brim to join the
Musculocutaneous perforator ventral ramus of S1. Contributions to the lumbosacral trunk may also
be derived from the third lumbar nerve (Bergman et al 1988).
Muscle
Septocutaneous perforator Lesions of the lumbar and sacral plexuses
Neurocutaneous perforator The deep and protected situation of the plexuses means that lesions are
Nerve not common. The lumbar plexus may be involved in retroperitoneal
pathology, and the sacral plexus may be invaded by pelvic malignancies.
Tendocutaneous perforator Both may be involved in the reticuloses, affected by plexiform neuro-
mas, or damaged in fractures of the lumbar spine and pelvis or in other
conditions that cause severe retroperitoneal and pelvic haemorrhage.
Tendon
Temporary lesions may occur after pregnancy and childbirth, e.g. after
difficult forceps delivery of a large baby. Pain, which may be diffuse, is
the most common feature.
Sciatica is pain in the lower back and hip region, which radiates
Venocutaneous perforator inferiorly along the posterior thigh to the leg. It is often caused by a
herniated intervertebral disc, compressing the L5 or S1 ventral rami.
The so-called piriformis syndrome, which may result from a variant or
Vein
anomalous relationship between piriformis and the sciatic nerve, may
also produce hip pain that radiates inferiorly along the course of the
Fig . 78 .6 Types of arterial perforators . sciatic nerve. | 1,824 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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NOITCES
A B
Aorta External iliac artery
Common iliac artery Deep circumflex iliac artery
Internal iliac artery
Inferior epigastric artery Superior gluteal artery
Superficial circumflex iliac artery Inferior gluteal artery
External pudendal artery
Obturator artery
Profunda femoris artery Medial circumflex femoral artery
Lateral circumflex
Medial circumflex femoral artery Lateral circumflex femoral artery femoral artery
Profunda femoris artery
Femoral artery
Perforating arteries Perforating arteries Femoral artery
Descending genicular artery
Popliteal artery Descending branch Site of hiatus in adductor magnus
Superior lateral genicular artery
Superior medial genicular artery
Superior medial genicular artery
Superior lateral genicular artery
Popliteal artery
Inferior lateral genicular artery Inferior lateral
genicular artery
Inferior medial genicular artery Inferior medial genicular artery
Anterior tibial artery
Anterior tibial recurrent artery
Fibular artery Posterior tibial artery
Anterior tibial artery
Perforating branch of fibular
artery
Perforating branch
Medial malleolar artery
Lateral malleolar network
Dorsalis pedis artery
Lateral tarsal artery
Medial tarsal artery Medial plantar artery
Arcuate artery Lateral plantar artery
Deep plantar branch
Plantar arch
Deep plantar artery
First dorsal metatarsal artery Plantar metatarsal artery
Dorsal digital arteries Plantar digital arteries
Perforator
Fig . 78 .7 The source and location of the arterial perforators of the lower limb . A, Anterior aspect . B, Posterior aspect .
OVERVIEW OF THE PRINCIPAL NERVES Obturator nerve (L2–4)
OF THE LOWER LIMB
The obturator nerve is the nerve of the medial compartment of the
Femoral nerve (L2–4)
thigh. It arises from the anterior divisions of the second to fourth
lumbar ventral rami, descends through psoas major and emerges from
The femoral nerve is the nerve of the anterior compartment of the thigh. its medial border at the pelvic brim. It crosses the sacroiliac joint
It arises from the posterior divisions of the second to fourth lumbar behind the common iliac artery and lateral to the internal iliac vessels,
ventral rami, descends through psoas major and emerges on its lateral runs along the lateral pelvic wall medial to obturator internus, and
border to pass between it and iliacus. It enters the thigh behind the enters the thigh through the upper part of the obturator foramen.
inguinal ligament and lateral to the femoral sheath. Its terminal Near the foramen, it divides into anterior and posterior branches,
branches form in the femoral triangle about 2 cm distal to the inguinal which are separated at first by part of obturator externus and more
ligament. In the abdomen, the nerve supplies small branches to iliacus distally by adductor brevis. It provides articular branches to the hip
and a branch to the proximal part of the femoral artery. It subsequently and knee, and may supply skin on the medial thigh and leg. The
supplies a large cutaneous area on the anterior and medial thigh, obturator nerve is described in detail on page 1372. An accessory
medial leg and foot, and gives articular branches to the hip, knee and obturator nerve may also be present and leaves the pelvis anterior to
ankle. The femoral nerve is described in detail on page 1372. the pubis. | 1,825 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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A
Inferior vena cava Superficial circumflex iliac vein
Common iliac vein
Superficial epigastric vein
Internal iliac vein External iliac vein Saphenous opening, lateral edge
Superficial epigastric vein
Superficial circumflex Femoral vein
iliac vein
Superficial external Superficial external pudendal vein
pudendal vein
Femoral vein
Profunda femoris vein
Long saphenous vein
Long saphenous
vein
B
Popliteal vein
Popliteal vein
Deep fascia
Saphenous nerve
Venae comitantes of posterior Short saphenous vein
and anterior tibial arteries
Short saphenous vein
Sural communicating
Long saphenous vein
branch
Sural nerve
Dorsal venous arch
Superficial veins
Deep veins
Sural nerve
Fig . 78 .8 An overview of the veins of the lower limb .
Dorsal venous arch
Sciatic nerve (L4, L5, S1–3)
The sciatic nerve travels in the posterior compartment of the thigh and,
via its major branches, supplies the leg and foot. Formed in the pelvis
from the ventral rami of the fourth lumbar to third sacral spinal nerves,
it is typically 2 cm wide at its origin and is the thickest nerve in the
body. It enters the lower limb via the greater sciatic foramen inferior to
piriformis and descends between the greater trochanter and ischial
tuberosity. In its descent along the posterior thigh, it is crossed by the Fig . 78 .9 A, The long saphenous vein and its tributaries . B, The short
long head of biceps femoris and divides into the tibial and common saphenous vein and its tributaries .
fibular (peroneal) nerves proximal to the knee; however, the level of
bifurcation can be variable. Prior to diverging, the tibial and common
fibular nerves are structurally separate and only loosely held together
as the sciatic nerve. The tibial nerve is derived from the anterior divi- but not the short head of biceps femoris, are supplied by the medial
sions of the sacral plexus, and the common fibular nerve is made up of (tibial) component of the sciatic nerve. The short head of biceps femoris
the posterior divisions of the plexus. The sciatic nerve sends articular is supplied by the lateral (common fibular) component. The common
branches to the hip joint through its posterior capsule (these are some- variations of the sciatic nerve have been well described and have been
times derived directly from the sacral plexus) and to the knee joint. The classified into six types (Beason and Anson 1937). The sciatic nerve is
posterior thigh muscles, including the ischial part of adductor magnus described in detail on page 1373. | 1,826 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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NOITCES
the anterior and lateral compartments. It descends obliquely along the
lateral side of the popliteal fossa to the fibular head, lying between the
tendon of biceps femoris and the lateral head of gastrocnemius; it then
curves lateral to the neck of the fibula, lying on the bone deep to fibu-
laris longus, and divides into superficial and deep fibular (peroneal)
nerves. Before it divides, it gives branches to the knee and superior
External iliac nodes
tibiofibular joints, and to the skin. The cutaneous area supplied by the
common fibular nerve and its terminal branches includes the antero-
lateral leg and most of the dorsum of the foot. The common fibular
nerve is described in detail on page 1415.
Deep inguinal nodes
Gluteal nerves (L4, L5, S1, S2)
Superficial inguinal nodes
The gluteal nerves arise from the posterior divisions of the sacral plexus.
The superior gluteal nerve (L4, L5, S1) leaves the pelvis through the
greater sciatic foramen superior to piriformis and supplies gluteus
medius, gluteus minimus, tensor fasciae latae and the hip joint. The
inferior gluteal nerve (L5, S1, S2) passes through the greater sciatic
foramen inferior to piriformis and supplies gluteus maximus. The
gluteal nerves are described in detail on page 1374.
CUTANEOUS INNERVATION
The cutaneous nerves supplying the skin of the lower limb are all
branches of the lumbar and sacral plexuses, with the exception of some
proximal nerves. The areas of distribution and spinal segments of origin
of the cutaneous nerves of the lower limb are illustrated in Figure
78.12. Variations in the composition and course of the cutaneous
Popliteal node
nerves of the lower limb are common.
Dermatomes
Our knowledge of the extent of individual dermatomes, especially in
the limbs, is largely based on clinical evidence (Ladak et al 2014). The
dermatomes of the lower limb are innervated by spinal nerves T12 to
S3 (see Fig. 78.12; Figs 78.13–78.14).
AUTONOMIC INNERVATION
Superficial lymphatics
The autonomic nerve supply to the limbs is exclusively sympathetic.
Deep lymphatics
Preganglionic sympathetic fibres to the lower limb are derived from
Direction of lymph flow neurones in the lateral horn of the lower thoracic (T10, T11 and T12)
and upper lumbar (L1, L2) spinal cord segments. Fibres pass in white
rami communicantes to the sympathetic trunk and synapse in the
lumbar and sacral ganglia. Postganglionic fibres pass in grey rami com-
municantes to enter the lumbar and sacral plexuses; many are distrib-
uted to the skin via the cutaneous branches of the nerves derived from
these plexuses. The blood vessels to the lower limb receive their sym-
pathetic nerve supply via adjacent peripheral nerves. Postganglionic
fibres accompanying the iliac arteries are destined mainly for the pelvis
but may supply vessels in the proximal thigh.
Fig . 78 .10 An overview of the lymphatics of the lower limb .
MOVEMENTS, MUSCLES AND
SEGMENTAL INNERVATION
Tibial nerve (L4, L5, S1–3)
Most limb muscles are innervated by neurones derived from more than
The tibial nerve is derived from the anterior divisions of the sacral one segment of the spinal cord. The predominant segmental origin of
plexus. It descends along the posterior thigh and popliteal fossa to the the nerve supply for each of the muscles of the lower limb and for the
distal border of popliteus, then passes anterior to the soleus with the movements that take place at the joints of the lower limb is summarized
popliteal artery and continues into the leg. In the popliteal fossa, it lies in Tables 78.1–78.4 (Sharrard 1955).
lateral to the popliteal vessels, becomes superficial to them at the knee
and crosses to the medial side of the artery. In the leg, it is the nerve of Movements At the central nervous level of control, muscles are not
the posterior compartment and descends with the posterior tibial
recognized as individual actuators but as components of movement,
vessels to lie between the heel and the medial malleolus. It ends deep
and may therefore contribute to several types of motion, acting vari-
to the flexor retinaculum by dividing into the medial and lateral plantar
ously as prime movers, antagonists, fixators or synergists. Some muscles
nerves. The tibial nerve supplies articular branches to the knee and
have been included in more than one place in Table 78.3 on the basis
ankle joints. Its cutaneous supply, including its terminal branches, sup-
that a muscle that acts across one joint can produce a combination of
plies the back of the calf, the sole, the lateral border of the foot and the
movements (e.g. flexion with medial rotation, or extension with adduc-
medial and lateral sides of the heel. The tibial nerve is described in
tion) and a muscle that crosses two joints can produce more than one
detail on page 1415.
movement. It is also important to remember that these listings are not
exhaustive.
Common fibular nerve (L4, L5, S1, S2)
Spinal nerves There is no universal consensus concerning the con-
The common fibular nerve (common peroneal nerve) is derived from tribution that individual spinal nerves make to the innervation of indi-
the posterior divisions of the sacral plexus. In the leg, it is the nerve of vidual muscles; the most positive identifications, which are limited, | 1,827 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Pelvic girdle and lower limb: overview and surface anatomy
For example, the ilioinguinal and iliohypogastric nerves may arise malleolus and the medial side of the foot and hallux. The postaxial
from a common trunk or the ilioinguinal nerve may be absent. The border starts in the gluteal region and descends to the centre of the
ilioinguinal nerve may also join the iliohypogastric nerve at the iliac popliteal fossa, then deviates laterally to the lateral malleolus and the
crest. When the obturator nerve makes a more significant contribution lateral side of the foot. The ventral and dorsal axial lines exhibit cor-
to the cutaneous innervation, the medial cutaneous branch of the responding obliquity. The ventral axial line starts proximally at the
femoral nerve is relatively small. Alternatively, the cutaneous branch of medial end of the inguinal ligament and descends along the postero-
the obturator nerve may be absent. The lateral femoral cutaneous nerve medial aspect of the thigh and leg to end proximal to the heel. The
normally arises from L2 and L3, but L1 may also contribute. Although dorsal axial line begins in the lateral gluteal region and descends pos-
it usually bifurcates after it exits the pelvis, it may bifurcate within the terolaterally in the thigh to the knee; it inclines medially and ends
pelvic cavity. The nerve may be absent on one side and/or may be proximal to the ankle. Considerable overlap exists between adjacent
replaced by the ilioinguinal nerve or a branch of the anterior femoral dermatomes innervated by nerves derived from consecutive spinal cord
cutaneous nerve. The genital and femoral branches of the genitofemoral segments.
nerve may arise as separate offshoots of the lumbar plexus. The genital Surgical or chemical lumbar sympathectomy may be indicated in
branch may receive fibres from the twelfth thoracic nerve or may be arterial disease and in the management of plantar hyperhidrosis, and
completely absent, while the femoral branch may have an extensive may be used to treat rest pain or other troublesome sensory symptoms
distribution to the skin of the upper two-thirds of the thigh. The sural of arterial disease or in causalgia. A segment of the sympathetic trunk
nerve is subject to wide variation and may supply the dorsal cutaneous including the second and third lumbar ganglia is removed; preservation
aspect of the lateral two-and-a-half toes, or may terminate in the foot of the first lumbar ganglion is said to lessen the risk of ejaculatory
without any digital branches. problems.
The preaxial border starts near the midpoint of the thigh and
descends to the knee. It then curves medially, descending to the medial
Table 78.1 Segmental innervation of the muscles of the lower limb Table 78.2 Segmental innervation of joint movements of the lower limb
Segment Muscles supplied Region Muscles supplied Segment
L1 Psoas major, psoas minor Hip Flexors, adductors, medial rotators L1–3
L2 Psoas major, iliacus, sartorius, gracilis, pectineus, adductor longus, adductor Extensors, abductors, lateral rotators L5, S1
brevis Knee Extensors L3, 4
L3 Psoas major, quadriceps femoris, adductors (magnus, longus, brevis) Flexors L5, S1
L4 Psoas major, quadriceps femoris, tensor fasciae latae, adductor magnus, Ankle Dorsiflexors L4, 5
obturator externus, tibialis anterior, tibialis posterior Plantar flexors S1, 2
L5 Gluteus medius, gluteus minimus, obturator internus, semimembranosus, Foot Invertors L4, 5
semitendinosus, extensor hallucis longus, extensor digitorum longus, fibularis Evertors L5, S1
tertius, popliteus Intrinsic muscles S2, 3
S1 Gluteus maximus, obturator internus, piriformis, biceps femoris, semitendinosus,
popliteus, gastrocnemius, soleus, fibularis longus and fibularis brevis, extensor
digitorum brevis
S2 Piriformis, biceps femoris, gastrocnemius, soleus, flexor digitorum longus, flexor
hallucis longus, some intrinsic foot muscles
S3 Some intrinsic foot muscles (except abductor hallucis, flexor hallucis brevis,
flexor digitorum brevis, extensor digitorum brevis)
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Table 78.3 Movements, muscles and segmental innervation in the lower limb*
Joint Movement Muscle Innervation L1 L2 L3 L4 L5 S1 S2 S3
HIP FLEXION Psoas major Spinal nn. L1–3
Iliacus Femoral n.
Pectineus Femoral n. or accessory obturator n.
Rectus femoris Femoral n.
Adductor longus Obturator n.
Sartorius Femoral n.
EXTENSION Gluteus maximus Inferior gluteal n.
Adductor magnus Obturator and tibial nn.
Semitendinosus, semimembranosus, biceps femoris Tibial and common fibular nn.
MEDIAL ROTATION Iliacus Femoral n.
Gluteus medius and minimus Superior gluteal n.
Tensor fasciae latae Superior gluteal n.
LATERAL ROTATION Superior and inferior gemelli Nerve to obturator internus and nerve to quadratus
femoris, respectively
Quadratus femoris Nerve to quadratus femoris
Piriformis Nerve to piriformis
Obturator internus Nerve to obturator internus
Obturator externus Obturator n.
Sartorius Femoral n.
ADDUCTION Gracilis Obturator n.
Adductor longus Obturator n.
Adductor magnus Obturator and tibial nn.
Adductor brevis Obturator n.
Pectineus Femoral n. or accessory obturator n.
ABDUCTION Tensor fasciae latae Superior gluteal n.
Gluteus medius and minimus Superior gluteal n.
Piriformis Nerve to piriformis
KNEE FLEXION Semimembranosus Tibial n.
Semitendinosus Tibial n.
Biceps femoris Tibial and common fibular nn.
Gastrocnemius Tibial n.
EXTENSION Quadriceps femoris:
Rectus femoris Femoral n.
Vastus lateralis Femoral n.
Vastus intermedius Femoral n.
Vastus medialis Femoral n.
ANKLE DORSIFLEXION Tibialis anterior Deep fibular n.
Extensor digitorum longus Deep fibular n.
Extensor hallucis longus Deep fibular n.
Fibularis tertius Deep fibular n.
PLANTAR FLEXION Gastrocnemius Tibial n.
Soleus Tibial n.
Flexor digitorum longus Tibial n.
Flexor hallucis longus Tibial n.
Fibularis longus Superficial fibular n.
Tibialis posterior Tibial n.
INVERSION Tibialis anterior Deep fibular n.
Tibialis posterior Tibial n.
EVERSION Fibularis longus Superficial fibular n.
Fibularis tertius Deep fibular n.
Fibularis brevis Superficial fibular n.
TOES FLEXION Flexor digitorum longus Tibial n.
Flexor hallucis longus Tibial n.
Flexor hallucis brevis Medial plantar n.
Flexor digitorum brevis Medial plantar n.
Flexor accessorius (quadratus plantae) Lateral plantar n.
Flexor digiti minimi brevis Lateral plantar n.
Abductor hallucis Medial plantar n.
Abductor digiti minimi Lateral plantar n.
Lumbricals Medial and lateral plantar nn.
EXTENSION Extensor digitorum longus Deep fibular n.
Extensor hallucis longus Deep fibular n.
Extensor digitorum brevis Deep fibular n.
ABDUCTION Abductor hallucis Medial plantar n.
Abductor digiti minimi Lateral plantar n.
Dorsal interossei Lateral plantar n.
ADDUCTION Plantar interossei Lateral plantar n.
Adductor hallucis Lateral plantar n.
*Royal blue shading denotes nerve roots from which there is a known dominant contribution. Turquoise shading denotes nerve roots from which the contribution is of similar degree.
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Table 78.4 The movements and muscles tested to determine the location of a lesion in the lower limb
Movement Muscle Upper motor neurone* Spinal nerve level Reflex Nerve
Hip flexion Iliopsoas ++ L1, 2 Femoral
Hip adduction Adductors + L2, 3 (+) Obturator
Hip extension Gluteus maximus L5, S1 Inferior gluteal
Knee flexion Hamstrings + S1 Sciatic
Knee extension Quadriceps femoris L3, 4 ++ Femoral
Ankle dorsiflexion Tibialis anterior ++ L4 Deep fibular
Ankle eversion Fibularis longus and fibularis brevis L5, S1 Superficial fibular
Ankle inversion Tibialis posterior L4, 5 Tibial
Ankle plantar flexion Gastrocnemius/soleus + S1, 2 ++ Tibial
Great toe extension Extensor hallucis longus L5 Deep fibular
*The muscles listed in the ‘Upper motor neurone’ column are those that are preferentially affected in upper motor neurone lesions. The root level is the principal supply to a muscle.
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A B
Gluteus medius
Gluteus minimus
Iliacus
Superior gluteal nerve
Tensor fasciae latae
Femoral nerve Piriformis
Obturator nerve
Pectineus Inferior gluteal nerve
Cutaneous branch Sciatic nerve
Lateral femoral Gluteus maximus
Obturator externus cutaneous nerve
Posterior femoral Semitendinosus
Adductor brevis cutaneous nerve
Medial femoral Biceps femoris,
cutaneous nerve long head
Sartorius Semimembranosus
Adductor longus Biceps femoris,
Rectus femoris short head Adductor magnus
Vastus lateralis
Gracilis Quadriceps
Vastus intermedius femoris
Vastus medialis
Adductor magnus
Intermediate femoral
Tibial nerve
cutaneous nerve
Common fibular nerve
Gastrocnemius, medial head
Common fibular nerve Popliteus
Deep fibular nerve Superficial fibular nerve Gastrocnemius, lateral head Soleus
Tibialis anterior Fibularis longus Plantaris
Extensor digitorum longus Tibialis posterior
Fibularis brevis
Flexor hallucis longus
Flexor digitorum longus
Extensor hallucis longus
Tibial nerve
Lateral sural
Saphenous nerve cutaneous nerve Sural nerve
Fibularis tertius
Calcaneal branch
Lateral plantar nerve to:
Extensor digitorum brevis
Abductor digiti minimi Medial plantar nerve to:
Flexor accessorius Abductor hallucis
Flexor digiti minimi Flexor digitorum brevis
Adductor hallucis Flexor hallucis brevis
Lumbricals 2–4 First lumbrical
Interossei Cutaneous branches
Cutaneous branches
Fig . 78 .11 The nerves of the lower limb, with their cutaneous and muscular branches . A, Anterior aspect . B, Posterior aspect . Adductor magnus has
dual innervation .
have been obtained by electrically stimulating spinal nerves and record- as the tip of the handle of a percussion hammer. Normally, this action
ing the evoked electromyographic activity in the muscles. Much of the elicits flexion of the toes. However, in patients with upper motor
information in Tables 78.1–78.4 is based on the clinical appreciation neurone lesions, the response includes extension of the great toe
of deficits following lesions to various nerves. (Babinski’s sign).
Reflexes Neurological localization of a lesion
Knee reflex (L2–4) With the patient sitting and the knee supported
Available with the Gray’s Anatomy e-book
and partially flexed, the patellar ligament is struck with a finger or
percussion hammer, resulting in extension of the knee joint.
SURFACE ANATOMY
Ankle reflex (S1, 2) With the patient sitting and the lower limb later-
ally rotated and partially flexed at the hip and knee, the foot is dorsi-
SKELETAL LANDMARKS
flexed by the examiner and the calcaneal tendon struck with a percussion
hammer. This results in plantar flexion of the foot.
Pelvis
Plantar reflex The plantar reflex is an important part of the clinical
examination of the central nervous system. With the foot relaxed, the The inguinal or groin skin crease marks the junction of the anterior
outer edge of the sole is stroked longitudinally with a blunt object such thigh with the anterior abdominal wall. It lies distal to the inguinal | 1,831 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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In clinical practice, it is only necessary to test a relatively small number
of muscles in order to determine the location of a lesion. Any muscle
to be tested must satisfy a number of criteria. It should be visible, so
that wasting or fasciculation can be observed, and the muscle consist-
ency with contraction can be felt. It should have an isolated action, so
that its function can be tested separately. It should help to differentiate
between lesions at different levels in the neural axis and in the periph-
eral nerve, or between peripheral nerves. It should be tested in such a
way that normal can be differentiated from abnormal, so that slight
weakness can be detected early with reliability. Some preference should
be given to muscles with an easily elicited reflex. Table 78.4 gives a list
of movements and muscles chosen according to these criteria; in prac-
tice, these tests would be combined with tests of sensory function.
Knowledge of the sequence in which motor branches leave a peripheral
nerve to innervate specific muscles is very helpful in localizing the level
of a lesion.
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NOITCES
A B
Iliohypogastric, L1
Subcostal, T12
Subcostal, T12
Femoral branch of
genitofemoral, L1, 2 Dorsal rami, L1, 2, 3
Dorsal rami, S1, 2, 3
Ilioinguinal, L1 C
Lateral femoral
cutaneous, L2, 3 Medial plantar
Lateral plantar
Obturator, L2, 3, 4
Lateral femoral
Medial and intermediate cutaneous, L2, 3 Saphenous
femoral cutaneous, L2, 3
Obturator, L2, 3, 4
Sural
Medial cutaneous
of thigh, L2, 3 Tibial
Posterior cutaneous
of thigh, S1, 2, 3
D
Lateral sural cutaneous,
Lateral sural cutaneous,
L4, 5, S1
L5, S1, 2
Deep fibular
Saphenous, L3, 4
Saphenous, L3, 4 Sural
Saphenous
Superficial fibular,
L4, 5, S1 Superficial fibular,
L5, S1 Superficial fibular
Sural, S1, 2 Sural, L5, S1, 2
Deep fibular, L5
Medial calcaneal
branches of tibial, S1, 2
Fig . 78 .12 The cutaneous nerves of the lower limb: areas of distribution and spinal segments of origin . A, Anterior aspect . B, Posterior aspect . C, The
sole of the foot . D, The dorsum of the foot .
Posterior Anterior Fig . 78 .14 Dermatomes
of the lower limb . There
T12
is considerable variation
T10
L1 and overlap between
L3 L3
L2 T11 dermatomes, but the
overlap across axial lines
T12 (heavy black) is minimal .
S3 S4 S5 L1 (With permission from
S2 S2 S3 O’Brien M, Aids to the
Examination of the
S4 Peripheral Nervous
S4 L2 System, 5th Edition,
May 2010, Elsevier,
L2 Saunders .)
S3 S3 S2
L3
S5
L2 L2 L3
L2 L2
S2
Fig . 78 .13 Dermatomes of the perineum . (With permission from O’Brien L4
M, Aids to the Examination of the Peripheral Nervous System, 5th Edition, L5
May 2010, Elsevier, Saunders .) L5 L4
S1
L5 S1
S1
L5
Axial lines | 1,833 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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1
2
1
2
4 5
3
3
4 5 6
x x
xx 7
8 6 8
9 7
10 11
10
9
12 x
11
12
Fig . 78 .15 The inguinal region and femoral triangle . Key: 1, anterior
superior iliac spine; 2, lateral femoral cutaneous nerve and its zone of
emergence into femoral triangle (white): range 0 .3–7 .3 cm (mean
2 .1–3 .5 cm) from anterior superior iliac spine; 3, inguinal ligament;
4, femoral artery and zone of emergence into femoral triangle (white):
mid-inguinal point ± 1 cm either side, femoral nerve (yellow cross) and
vein (blue cross) sit lateral and medial, respectively, to the femoral artery;
5, femoral head: located 2–4 cm above the midpoint of the greater Fig . 78 .16 The gluteal region and sciatic nerve . Key: 1, zone of
trochanter to pubic tubercle line; 6, pubic tubercle; 7, greater trochanter supracristal plane intersection with vertebrae (white): ranges from the
to pubic tubercle line; 8, profunda femoris artery: almost always arises L2–L3 to the L4–L5 junction/interspinous space; 2, highest point of iliac
6 .5 ± 1 .5 cm distal to the mid-inguinal point, or superior crests (supracristal plane or Tuffier’s line): most commonly intersects the
to or at the level of the inguinal/groin crease; 9, zone of saphenofemoral L4 vertebra to the L4/5 junction; 3, zone of intersection between the
junction location: almost always sits within a 3 cm × 3 cm zone situated vertebrae and a horizontal plane between the posterior superior iliac
1–4 cm lateral and 0–3 cm inferior to the pubic tubercle; 10, sartorius; spines (white): ranges from the L5–S1 junction/interspinous space to S2
11, inguinal/groin crease; 12, adductor longus . (Adapted from Drake R, when determined via palpation, located at S2 via radiographs; 4, posterior
Vogl AW, Mitchell AW, et al, Gray’s Atlas of Anatomy, Elsevier 2008, superior iliac spine and interspinous plane: marked by a skin indentation
Churchill Livingstone .) (dimple of Venus); 5, safe zone (white) for gluteal region injection (upper
lateral quadrant), determined via a vertical line from the highest point of
the iliac crest to ischial tuberosity level, and a horizontal line passing
through its midpoint; 6, zone of termination of dural sac (blue): ranges
ligament by a mean of 6.7 ± 1.9 cm (Lechner et al 1988) (Fig. 78.15). from L5–S1 to S4, most commonly sitting from the lower part of S1 to the
The inguinal crease sits more distal to the inguinal ligament in females S2 level; 7, sacral hiatus bordered by sacral cornua, located at the apex
than in males (7.5 ± 1.9 cm versus 6.3 ± 1.9 cm) (Lechner et al 1988). of an approximately equilateral triangle with baseline measurement taken
The anterior superior iliac spine lies superior to the lateral end of the between the posterior superior iliac spines; 8, course of sciatic nerve:
fold, and from this point, the iliac crest is palpable along its entire from approximately one third of the way down a line joining the posterior
length. A line (Tuffier’s) joining the most superior aspects of the iliac superior iliac spine to the ischial tuberosity (black X and white zone) to
crests almost always crosses the L4 body or L4/L5 intervertebral disc the midpoint or middle third of a line joining the ischial tuberosity to the
(Render 1996, Walsh et al 2006, Chakraverty et al 2007) (Fig. 78.16). upper greater trochanter (blue X and white zone); 9, tip of coccyx within
This line is used as a landmark when performing a lumbar puncture; intergluteal cleft; 10, greater trochanter; 11, ischial tuberosity; 12, gluteal
localization via palpation, especially in females and patients with a fold . (Adapted from Drake R, Vogl AW, Mitchell AW, et al, Gray’s Atlas of
greater body mass index (BMI), often places it at a higher vertebral Anatomy, Elsevier 2008, Churchill Livingstone .)
level, up to the L2–L3 interspace (Chakraverty et al 2007, Kim et al
2007, Hale et al 2010). Vertebral column flexion in the adult has little
whose base is measured between the posterior superior iliac spines
effect on the level of Tuffier’s line (Kim et al 2003). In neonates, Tuffi-
(Senoglu et al 2005), although this arrangement may not always be
er’s line sits at the L4/L5 interlaminar space level whilst prone, moving
observed (Aggarwal et al 2009). The termination of the dural sac is
to the upper third of L5 during vertebral column flexion (van Schoor
et al 2014). The iliac crest terminates posteriorly as the posterior supe- located a mean of 31.6 ± 11.8 mm from the sacral hiatus apex (Aggar-
wal et al 2009), a point relevant to caudal anaesthetic administration.
rior iliac spine, which is marked superficially by the gluteal dimples
(dimples of Venus). Palpation places the posterior superior iliac spines
Femur
in the range of the L5–S1 vertebral junction to the S2 spinous process
level (Kim et al 2007), whereas radiographic assessment shows their
inferior margin to mark vertebral level S2 almost always (McGaugh The greater trochanter of the femur sits on the upper lateral thigh,
et al 2007). The caudal limit of the dura mater ranges from the L5–S1 inferior to the midpoint of the iliac crest and approximately level with
junction to S4 (Hansasuta et al 1999, Binokay et al 2006, Senoglu a horizontal plane passing through the pubic tubercle (see Fig. 78.15).
et al 2013), with the majority sitting at the lower S1 to the S2 level It can be used to guide surgeons during anterolateral approaches to the
(Senoglu et al 2013) and the mean position being lower in males hip joint. A line (Nelaton’s/Roser–Nelaton’s) drawn from the anterior
versus females (Binokay et al 2006). The ischial tuberosity is covered superior iliac spine to the ischial tuberosity passes superior to or over
by gluteus maximus and is palpable during hip flexion. The coccyx is the greater trochanter. In a patient with hip dislocation or femoral neck
palpable in the superior part of the intergluteal cleft, the deep vertical fracture, the greater trochanter can be palpated superior to this line. The
groove between the buttocks extending to the S3–S4 bony sacral seg- femoral shaft is not directly palpable but runs inferomedially from a
ments. The sacral hiatus sits superior to the tip of the coccyx at a mean point 2–3 cm medial to the lateral aspect of the greater trochanter to
of 57.5 ± 8.7 mm and is flanked by the raised palp able sacral cornua, the midpoint of the patella. The femoral head sits 2–4 cm superior to
which serve as reliable landmarks (Aggarwal et al 2009). The hiatus the midpoint of a line between the superior margin of the greater tro-
can also be located at the apex of an inverted equilateral triangle chanter and the pubic tubercle. | 1,834 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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NOITCES
When the knee is flexed, the medial surface of the medial condyle line and the edges of the patellar ligament. The iliotibial tract is attached
and the lateral surface of the lateral condyle of the femur may both be to a prominence, Gerdy’s tubercle, on the anterior aspect of the lateral
palpated, and portions of the femoral condylar articular surface can be condyle that is usually approximately 1 cm inferior to the joint line and
examined on each side of the patellar ligament. about 2 cm superolateral to the tibial tuberosity.
The head of the fibula forms a slight surface elevation on the poste-
Patella rior part of the proximal lateral leg. It lies vertically below the posterior
part of the lateral condyle of the femur, 1–2 cm inferior to the knee
joint line.
The entire patella is palpable except for its articular surface. When the
quadriceps femoris is relaxed in the fully extended knee, the patella
can be tilted and moved on the distal aspect of the femur. The inferior Leg and ankle
limit of the patella is located superior to the knee joint line by 1–2 cm
(Fig. 78.17).
The subcutaneous medial surface of the tibia corresponds to the flat
anteromedial aspect of the leg. Superiorly, this surface merges with the
Knee
medial condyle of the tibia, and inferiorly, it is continuous with the
visible prominence of the medial malleolus of the tibia (see Fig. 78.17;
The patella and the femoral condyles have been described above. The Figs 78.18–78.19). The anterior border of the tibia can be palpated
tibial condyles form visible and palpable landmarks on the medial and distinctly throughout most of its extent, but inferiorly, it is somewhat
lateral sides of the patellar ligament (see Fig. 78.17). The latter may be masked by the tendon of tibialis anterior, which lies to its lateral side.
traced inferiorly from the apex of the patella to the tibial tuberosity, The lateral malleolus of the fibula forms a conspicuous projection on
which is both visible and palpable. When the knee is flexed, the anterior the lateral side of the ankle; it descends to a more distal level than the
margins of the tibial condyles can be felt: each forms the lower bound- medial malleolus and is located on a more posterior plane. The lateral
ary of a depression at the side of the patellar ligament. The lateral aspect of the lateral malleolus is continuous superiorly with an elon-
condyle is the more prominent of the two. The joint line of the knee gated, subcutaneous, triangular area of the inferior shaft of the fibula.
(tibiofemoral joint) corresponds to the upper margins of the tibial The lateral part of the anterior margin of the inferior end of the tibia
condyles and can be represented by a line drawn round the limb at this can be palpated immediately anterior to the base of the lateral malleo-
level. The anterior horns of the menisci lie in the angles between this lus; the line of the ankle joint can be gauged from it.
Fig . 78 .17 The anterior aspect of the
knee and leg . Key: 1, vastus lateralis; Fig . 78 .18 The posterior aspect of the
2, vastus medialis; 3, iliotibial tract; knee and leg . Key: 1, popliteal artery:
4, quadriceps tendon overlying passing from a point (black X) 2 .5 cm
suprapatellar bursa; 5, sartorius; 6, x medial to the posterior midline of the
1 anterior horns of menisci: located above 1 thigh at the junction of its middle and
knee joint line (dotted line) and either lower thirds to a point halfway
2 side of patellar ligament; 7, Gerdy’s between the femoral condyles/the
3 4 tubercle; 8, fibular head; 9, patellar midaxial line of the calf (blue X); 2,
ligament insertion into tibial tuberosity; iliotibial tract; 3, tendon of biceps
10, anterior tibial artery and deep fibular 2 femoris and common fibular nerve
nerve: pass from halfway between fibular located medially; 4, semimembranosus
5 head and tibial tuberosity to a point and semitendinosus; 5, gracilis; 6,
6 6 halfway between the malleoli; 11, soleus 4 3 popliteal fossa; 7, head of fibula; 8,
and long saphenous vein (blue); 12, 5 gastrocnemius, lateral head; 9,
7 medial tibial border (subcutaneous); 13, gastrocnemius, medial head; 10,
8 medial malleolus: long saphenous vein soleus; 11, posterior tibial artery and
9 and saphenous nerve pass anterior; 14, 6 tibial nerve: run from the midaxial line
lateral malleolus; 15, tendon of tibialis of the calf at the fibular neck level to a
10 anterior . (Adapted from Drake R, Vogl point one-third of the way from the
AW, Mitchell AW, et al, Gray’s Atlas of x posterior border of the medial
Anatomy, Elsevier 2008, Churchill 7 malleolus to the calcaneal tendon; 12,
Livingstone .) medial malleolus; 13, lateral malleolus
and short saphenous vein passing
11 posteriorly; 14, calcaneal tendon
insertion into calcaneus . (Adapted
12 from Drake R, Vogl AW, Mitchell AW,
et al, Gray’s Atlas of Anatomy,
8 Elsevier 2008, Churchill Livingstone .)
9
10
11
13
15
14
12
14 13 | 1,835 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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1
1
2
3 1
2
5 4 3
6 4 5 6
8 7
7 8
9
9
10
10
Fig . 78 .20 The medial aspect of the foot and ankle . Key: 1, long
11 saphenous vein and saphenous nerve; 2, medial malleolus; 3, posterior
tibial artery and tibial nerve: located approximately one-third of the
distance along a line passing from the posterior border of the medial
malleolus to the calcaneal tendon; 4, tendon of tibialis anterior: insertion
into medial cuneiform; 5, navicular tuberosity and tibialis posterior
insertion; 6, sustentaculum tali; 7, dorsal venous arch; 8, region of the
posterior tibial artery bifurcation into medial and lateral plantar arteries;
9, medial border of plantar aponeurosis; 10, medial calcaneal tubercle
covered by fibro-fatty heel pad . (Adapted from Drake R, Vogl AW, Mitchell
AW, Gray’s Anatomy for Students, 2nd ed, Elsevier 2010, Churchill
Livingstone .)
Fig . 78 .19 The dorsal aspect of the foot and ankle . Key: 1, long
saphenous vein and saphenous nerve; 2, medial malleolus; 3, lateral
malleolus; 4, dorsalis pedis artery and deep fibular nerve: located
1
immediately lateral to the tendon of extensor hallucis longus;
5, intermediate dorsal cutaneous nerve: visible passing towards the fourth
digit during digit and ankle plantar flexion; 6, extensor digitorum brevis; 2
7, tendon of extensor hallucis longus; 8, tendon of tibialis anterior:
3
insertion into medial cuneiform; 9, tuberosity of fifth metatarsal; 10, dorsal 3
4
venous arch of foot; 11, tendon of extensor digitorum longus (to digit
two) . (Adapted from Drake R, Vogl AW, Mitchell AW, Gray’s Anatomy for
Students, 2nd ed, Elsevier 2010, Churchill Livingstone .) 5
6
Foot 7
8
The anterior part of the upper surface of the calcaneus can be identified
slightly anterior to the lateral malleolus on the dorsum of the foot.
When the foot is passively inverted, the upper and lateral parts of the
head of the talus can be both seen and palpated approximately 3 cm
anterior to the distal end of the tibia; the extensor tendons obscure
them when the toes are extended. Regional tenderness can indicate a
talar neck fracture.
The dorsal aspects of the bodies of the metatarsals can be felt more
or less distinctly, although they are partly obscured by the extensor Fig . 78 .21 The anterolateral aspect of the foot and ankle . Key: 1, tendons
of fibularis longus and brevis; 2, tendons of extensor digitorum longus
tendons of the toes. The tuberosity on the base of the fifth metatarsal
and fibularis tertius; 3, inferior extensor retinaculum; 4, lateral malleolus;
forms a distinct palpable and visible projection on the lateral border of
5, fibular tubercle/trochlea; 6, tendon of fibularis tertius; 7,
the foot.
calcaneocuboid joint and transverse tarsal joint line; 8, tuberosity of fifth
The flat lateral surface of the calcaneus can be palpated on the lateral
metatarsal and tarsometatarsal (Lisfranc) joint line (dotted) . (Adapted from
aspect of the heel and can be traced anteriorly and inferior to the lateral
Drake R, Vogl AW, Mitchell AW, Gray’s Anatomy for Students, 2nd ed,
malleolus, where the tendons of fibularis longus and brevis hide it. The
Elsevier 2010, Churchill Livingstone .)
fibular (peroneal) tubercle, when sufficiently large, can be palpated
2 cm inferior to the tip of the lateral malleolus. A palpable depression
just anterior to the lateral malleolus leads to the lateral end of the tarsal
sinus. tubercles of the calcaneus can be palpated on its inferior surface via the
On the medial side of the foot, the sustentaculum tali can be felt anterior region of the fibro-fatty heel pad, which covers and obscures
approximately 2 cm inferior to the medial malleolus, with the tendon them. The heads of the metatarsals are similarly covered by a fibro-fatty
of flexor hallucis longus located inferiorly (Fig. 78.20). The navicular pad on the plantar surface of the foot and can be palpated on the dorsal
tuberosity is palpable and usually visible approximately 2.5 cm anterior foot, with the digits in flexion.
to the sustentaculum tali. Anterior to this, the medial cuneiform can be The calcaneocuboid joint is about 2 cm posterior to the tuberosity
identified, with the tendon of tibialis anterior inserting on to it. The on the base of the fifth metatarsal and is almost in line with the talo-
upper and medial parts of the joint between the medial cuneiform and navicular joint, whose position may be gauged from the talar head
the first metatarsal can be felt as a narrow groove. (Fig. 78.21). The tarsometatarsal (Lisfranc) joints lie on a line joining
When the foot is placed on the ground, it rests on the posterior part the tuberosity of the fifth metatarsal to the tarsometatarsal joint of the
of the inferior surface of the calcaneus, the heads of the metatarsals and, great toe, which is located 2–3 cm anterior to the navicular tuberosity
to a lesser extent, on its lateral border. The medial longitudinal arch of and is palpable. The joint between the second metatarsal and the inter-
the foot, the instep, is elevated from the ground. The medial and lateral mediate cuneiform is located 2–3 mm posterior to the line of the other | 1,836 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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tarsometatarsal joints. The metatarsophalangeal joints lie about 2.5 cm tubercle and produces the flattened appearance of the lateral thigh. It
behind the web spaces of the toes and are palpable on the dorsal foot, forms a defined ridge that is visible on the lateral aspect of the knee
where they are accessible via needle. either when the knee is extended against gravity or when the opposite
limb is lifted from the floor while standing.
The muscles of the posterior thigh may be palpated from the ischial
MUSCULOTENDINOUS AND tuberosity inferiorly along the lateral (biceps femoris) and medial
LIGAMENTOUS LANDMARKS (semitendinosus and semimembranosus) aspects of the thigh.
See Video 78.1. Knee
Buttock and hip
The large depression visible posterior to the knee when the joint is
actively flexed against resistance corresponds to the popliteal fossa. The
The bulky prominence of the buttock is formed by gluteus maximus, a transverse skin crease of the popliteal fossa is located 2–3 cm superior
variable amount of subcutaneous fat and the normal alignment of the to the knee joint line. The fossa is bounded on the superolateral side
pelvis, which angles the ischium posteriorly (see Fig. 78.16). by the prominent tendon of biceps femoris, which can be palpated
The horizontal gluteal fold marks the upper limit of the posterior between the finger and thumb and traced inferiorly to the head of the
aspect of the thigh. It does not correspond to the lower border of gluteus fibula. Three tendons, of semitendinosus, gracilis and semimembrano-
maximus but is formed by fibrous connections between the skin and sus, can be felt on the superomedial side of the fossa. Semitendinosus
the deep fascia. The intergluteal cleft, which separates the buttocks is the most lateral and posterior, while gracilis is the most medial and
inferiorly, begins superiorly at the S3 or S4 vertebrae. The superior anterior; both tendons stand out sharply and can be seen when the knee
border of gluteus maximus begins on the iliac crest 5–7 cm superola- is flexed against resistance and the limb actively adducted. The tendon
teral to the posterior superior iliac spine and runs inferiorly and later- of semimembranosus may be palpated deeply in the interval between
ally towards the apex of the greater trochanter. Its lower border the tendons of semitendinosus and gracilis. It is much thicker than the
corresponds to a line drawn from the ischial tuberosity, through the other two tendons and broadens rapidly as it is traced proximally. The
midpoint of the gluteal fold, to a point approximately 9 cm below the upper borders of the two heads of gastrocnemius form the inferomedial
greater trochanter. Although gluteus maximus overlaps the ischial tuber- and inferolateral boundaries of the popliteal fossa.
osity in the standing position, on sitting, it slides superiorly posterior The cord-like fibular collateral ligament may be felt passing from the
to the tuberosity, leaving it free to bear weight. Gluteus maximus can apex of the fibular head to the lateral epicondyle of the femur when
be felt to contract when the hip is extended against resistance. the knee is flexed and laterally directed pressure (valgus force) is applied
Gluteus medius completely covers the underlying gluteus minimus. to the medial side of the knee. The medial patellar retinaculum may be
Both muscles lie in a slight depression superolateral to gluteus maximus felt as a flat, broad band overlying the medial femoral condyle in the
and inferior to the anterior portion of the iliac crest and both pass flexed knee, running between the midpoint of the medial side of the
inferiorly to insert into the greater trochanter. They constitute the major patella and the medial femoral epicondyle.
abductors of the hip and are demonstrated by asking the subject to
stand on one limb. The ipsilateral muscles contract to stabilize the
Leg
centre of gravity and maintain a relatively horizontal pelvic position.
Paresis or paralysis causes pelvic tilt towards the unsupported, contra-
lateral side (Trendelenburg’s sign). The muscles in the anterior osteofascial compartment of the leg form
a gentle prominence over the upper two-thirds of its anterolateral
Thigh aspect; this prominence is accentuated when the foot is actively dorsi-
flexed. These muscles are replaced by their tendons in the lower third
of the leg. The tendon of tibialis anterior can be seen just lateral to the
The inguinal ligament can be felt running between the anterior superior
anterior border of the tibia and traced inferiorly and medially across
iliac spine and the pubic tubercle, especially when the thigh is abducted
the anterior aspect of the ankle to the medial cuneiform (see Figs 78.17,
and laterally rotated (see Fig. 78.15). The groin/inguinal crease (Hold-
78.19). The other tendons cannot be examined satisfactorily superior
en’s line), where the deep layer of the subcutaneous tissue of the ant-
to the ankle. Immediately superior to the posterior border of the medial
erior abdominal wall meets the fascia lata of the thigh, is distal to the
malleolus and close to the medial border of the tibia, the tendons of
inguinal ligament and runs obliquely. It lies a mean of 6.7 ± 1.9 cm
tibialis posterior and flexor digitorum longus can be felt (rather indis-
distal to the inguinal ligament (Lechner et al 1988).
tinctly) when the foot is actively inverted and plantar flexed.
The femoral triangle is located on the proximal anterior thigh. It is
On the lateral aspect of the leg, fibularis longus can be seen as a
bounded superiorly by the inguinal ligament and laterally by the strap-
narrow ridge following the line of the lateral aspect of the fibula during
like sartorius, which can be both seen and felt in a reasonably thin and
active eversion and plantar flexion of the foot. It covers and hides fibu-
muscular subject when the hip is flexed in the sitting position, while
laris brevis. The shaft of the fibula can only be palpated indistinctly
the knee is kept extended and the thigh is slightly abducted and rotated
between its neck and the area above the lateral malleolus.
laterally. Sartorius can be traced inferomedially from the anterior supe-
The bulky prominence of the posterior leg is formed by gastro-
rior iliac spine to approximately halfway down the medial side of the
cnemius and soleus, both of which can be identified either when the
thigh; distally, it may be identified as a soft longitudinal ridge passing
foot is plantar flexed against resistance, or when the heel is raised from
towards the posterior part of the medial femoral condyle. The adductor
the ground by standing on tiptoes (see Fig. 78.18). The two heads of
group of muscles forms the bulky, fleshy mass at the upper part of the
gastrocnemius unite to form the inferior borders of the popliteal fossa.
medial thigh. The medial boundary of adductor longus forms the
The medial head of gastrocnemius descends to a more inferior level
medial boundary of the femoral triangle and can be felt as a distinct
than the lateral head. Soleus lies deep to gastrocnemius; when tensed,
ridge when the thigh is adducted against resistance. At its superior end,
it bulges from under the medial and lateral margins of gastrocnemius,
its prominent tendon of origin can be seen and palpated immediately
particularly on the lateral side, and its fleshy belly extends to a more
inferior to the pubic tubercle, which is a useful guide to this bony
distal level. Both muscles end inferiorly in the conspicuous calcaneal
landmark.
tendon, which can be palpated between the finger and thumb and fol-
The forward convexity of the anterior thigh is caused by the curvature
lowed inferiorly to its insertion into the posterior aspect of the
of the femur covered by the muscle mass of quadriceps femoris. Rectus
calcaneus.
femoris appears as a raised ridge passing down the anterior aspect of
the thigh to the patellar base, when the sitting subject flexes the hip
Foot
with the knee extended. Vastus medialis constitutes a bulge that is both
superior and medial to the patella (see Fig. 78.17). Vastus lateralis forms
an elevation superior and lateral to the patella that is more proximal When the toes are actively extended, the bellies of extensor digitorum
and less pronounced than that of vastus medialis. Vastus intermedius brevis and extensor hallucis brevis form a small elevation on the dorsal
is covered by the three other muscles in the group. The thick tendon of foot, just anterior to the lateral malleolus (see Fig. 78.19). During ankle
adductor magnus can be palpated on the distal medial thigh, deep inversion and extension of the toes, the prominent tendon of tibialis
within the indentation formed between vastus medialis anteriorly and anterior is visible on the medial side of the dorsal foot, passing inferi-
gracilis and sartorius posteriorly. orly and medially to the medial cuneiform. The tendon of extensor
The iliotibial tract, a thickened portion of the deep fascia of the thigh hallucis longus can be identified laterally; the tendons of extensor digi-
(fascia lata), runs from the lateral aspect of the iliac crest to Gerdy’s torum longus and fibularis tertius are further lateral as they pass deep | 1,837 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
Surface anatomy
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to the inferior extensor retinaculum and immediately anterior to the significant cardiac output in cases of circulatory collapse. It is a common
lateral part of the distal tibia. More distally, the tendons of extensor site for catheter insertion for radiological examinations such as cardiac
digitorum longus and fibularis tertius diverge and may be traced to their angiography and for arterial puncture for blood gas analysis.
insertions.
The tendon of tibialis posterior winds posterior to the medial malle- Popliteal artery The pulse of the popliteal artery is the most diffi-
olus and then curves anteriorly in the interval between this bony land- cult of the peripheral pulses to feel because the artery lies deep in the
mark and the sustentaculum tali to reach the tuberosity of the navicular popliteal fossa. It is best examined with the subject lying supine or
(see Fig. 78.20). The tendon is visible and palpable posterior to the prone, with the knee flexed in order to relax the tense popliteal fascia
malleolus when the foot is forcibly plantar flexed and inverted. The that roofs the popliteal fossa. The popliteal pulse is then felt over the
tendon of flexor digitorum longus lies immediately posterolateral to midline of the fossa by deep pressure against the popliteal surface of
that of tibialis posterior. It curves forwards inferior to tibialis posterior the femur.
and lies on the medial aspect of the sustentaculum tali. From there, it
passes anteriorly and laterally to the centre of the plantar foot, where Posterior tibial artery The pulse of the posterior tibial artery can
it divides into four tendons that pass to the lateral four toes. The tendon be felt by gentle palpation posterior to the medial malleolus as the
of flexor hallucis longus lies inferior to, and grooves, the sustentaculum artery lies between the tendons of flexor hallucis longus and flexor digi-
tali. As it passes towards the great toe, it crosses the line of the flexor torum longus, approximately one-third of the way along a line connect-
digitorum longus opposite the interval between the sustentaculum ing the posterior border of the medial malleolus to the calcaneal
tali and the tuberosity of the navicular. Abductor hallucis may be seen tendon.
in some subjects as a fleshy mass along the medial border of the
foot, passing from the medial calcaneal tubercle to the first metatarso- Dorsalis pedis artery The dorsalis pedis arterial pulse is found by
phalangeal joint. palpation against the underlying tarsals, immediately lateral to the
When the toes are maximally dorsiflexed, the plantar aponeurosis is tendon of extensor hallucis longus, from the midpoint between the
easily palpated along the medial border of the foot, from just distal to malleoli to the proximal end of the first intermetatarsal space.
the heel pad as far as the first metatarsophalangeal joint. It originates
from the calcaneal tubercles, which may be palpable via the anterior Veins
aspect of the heel pad.
The femoral vein is located immediately medial to the femoral artery
VESSELS, PULSES AND NERVES pulse, where it can be accessed (see Fig. 78.15). While femoral vein
puncture is relatively easy and supplies ready access to the right atrium,
the use of this approach is relatively unpopular for long-term cannul-
Arteries
ation because of a greater incidence of thrombosis and sepsis. However,
it is a useful site for venous sampling in a patient with collapsed veins.
The femoral artery normally enters the anterior thigh at the mid- For femoral vein cannulation, the skin puncture site is approximately
inguinal point ± 1 cm either side (medial to lateral) (Hale et al 2010) 1 cm medial to the femoral artery and just inferior to the inguinal
(see Fig. 78.15). The midinguinal point is halfway between the anterior ligament.
superior iliac spine and the pubic symphysis. The artery normally passes The dorsal venous arch of the foot is visible and curves across the
directly anterior to the hip joint; its course may be represented by the metatarsals (see Fig. 78.19). The long saphenous vein arises from the
upper two-thirds of a line joining its entry point into the thigh with the medial end of the arch, and the short saphenous vein arises from
adductor tubercle, when the thigh is flexed, slightly abducted and the lateral end. The long saphenous vein can be seen and palpated
rotated laterally. It travels deep to sartorius from the apex of the femoral anterior to the medial malleolus, after which it runs superiorly and
triangle to the adductor hiatus. The profunda femoris artery (deep artery posteriorly across the distal medial surface of the tibia: this is a useful
of the thigh) normally arises from the lateral side of the femoral artery, site for surgical venous access (cut-down) or venous harvesting for
6.5 ± 1.5 cm distal to the mid-inguinal point (Choy et al 2013), which cardiac bypass surgery (see Figs 78.17, 78.19). The vein then runs proxi-
is most commonly at or superior to the level of the inguinal/groin mally along the posterior aspect of the medial border of the tibia, where
crease (Lechner et al 1988). it is accompanied by the saphenous nerve, to reach a point a hand’s
The popliteal artery may be represented by a line extending from the breadth (7–10 cm) posterior to the medial patellar border. From here,
junction of the middle and lower thirds of the thigh, 2.5 cm medial to the vein ascends the thigh to the saphenous opening, where it passes
its posterior midline, to a point halfway between the femoral condyles, deep to enter the femoral vein. An image-based study found that the
and continuing inferolaterally to the level of the tibial tuberosity, saphenofemoral junction almost always occupied a 3 × 3 cm zone
medial to the fibular neck, where it bifurcates into the anterior and located 1–4 cm lateral and 0–3 cm inferior to the pubic tubercle
posterior tibial arteries (see Fig. 78.18). (Mirjalili et al 2014) (see Fig. 78.15). The junction was nearer to the
The anterior tibial artery may be represented by a line extending pubic tubercle in younger and thinner subjects.
from a point halfway between the tibial tuberosity and the fibular head The course of the short saphenous vein may be represented by a line
to a point midway between the anterior borders of the two malleoli from the posterior surface of the lateral malleolus superiorly along the
(see Fig. 78.17). It passes on to the dorsal foot lateral to the tendon of midline of the calf to the popliteal fossa; together with the sural nerve,
extensor hallucis longus, as the dorsalis pedis artery. The latter gives off this vein is the key anatomical guide to surgical dissection of the pop-
a medial branch that travels toward the first intermetatarsal space. liteal fossa (see Fig. 78.18).
The posterior tibial artery may be represented by a line drawn from
a midaxial point on the calf (approximately midway between the
Nerves
tibial condyles) at the level of the neck of the fibula, to a point one-
third of the way between the posterior border of the medial malleolus
and the calcaneal tendon (see Fig. 78.18). The same line represents In the proximal femoral triangle, the femoral nerve is located immedi-
the course of the tibial nerve. At first, the nerve lies lateral to the pop- ately lateral to the femoral artery pulse.
liteal artery but gradually crosses the vessel to gain its medial side. The The surface marking for the course of the saphenous nerve in the
posterior tibial artery bifurcates into the plantar arteries halfway leg matches that of the long saphenous vein (see above). The lateral
between the medial malleolus and the medial calcaneal tubercle (see femoral cutan eous nerve enters the femoral triangle 2.1–3.5 cm (range
Fig. 78.20). 0.3–7.3 cm) from the anterior superior iliac spine (see Fig. 78.15)
The medial plantar artery passes anteriorly towards the great toe. (Grothaus et al 2005, Bjurlin et al 2007, Ropars et al 2009). It then passes
The lateral plantar artery passes obliquely towards a point approxi- over the lateral border of sartorius up to 11.3 cm distal to the anterior
mately 2.5 cm medial to the tuberosity of the fifth metatarsal, after superior iliac spine (Grothaus et al 2005, Ropars et al 2009), and over the
which it enters the proximal part of the fourth intermetatarsal space. anterior border of tensor fasciae latae between 2.4 and 9.2 cm distal to
Digital arteries and nerves pass along the medial and lateral sides of the anterior superior iliac spine (Ropars et al 2009). The nerve is at risk
the toes. of damage during anterolateral surgical approaches to the hip.
The course of the sciatic nerve can be represented by a curved line
Pulses
that starts at a point 0.3 ± 0.05 of the distance down a line drawn from
Femoral artery The pulsations of the femoral artery can be felt at its the posterior superior iliac spine to the ischial tuberosity, and passes to
entry point into the proximal femoral triangle, where it can be com- a point 0.5 ± 0.05 of the distance along a line drawn from the ischial
pressed against either the superior pubic ramus or the hip joint. The tuberosity to the greater trochanter (see Fig. 78.16). It then continues
pulse of the femoral artery is of value in assessing whether there is any vertically and inferiorly in the midline of the posterior aspect of the | 1,838 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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thigh, deep to biceps femoris, to the upper angle of the popliteal fossa, Knee The lateral retropatellar approach is used. With the patient
where it divides into the tibial and common fibular nerves (if it has not supine and the knee extended, the needle is introduced at the level of
already done so at a more superior level). the superior border of the patella and guided towards the suprapatellar
The surface marking for the course of the tibial nerve in the leg bursa.
matches that of the posterior tibial artery (see above). The course of the
sural nerve at the ankle can be represented by a line running parallel Popliteal fossa Sciatic nerve blocks at the popliteal fossa in infants and
to the calcaneal tendon that is situated halfway between the tendon and children can be effectively performed above the popliteal skin crease by
the lateral malleolus: this position is variable and the sural nerve is at correcting the adult landmark of 10 cm by the ratio of the calculated
risk from surgery in this region. child femoral shaft length over the adult femoral shaft length (Bernière
The course of the common fibular nerve can be indicated by a line et al 2008).
that runs from the superior angle of the popliteal fossa, along the
medial side of the tendon of biceps femoris (see Fig. 78.18) and then Ankle The anterior approach entails introducing the needle between
curves inferiorly and anteriorly around the neck of the fibula approxi- the tendons of tibialis anterior and extensor hallucis longus with the
mately 3 cm distal to the superior tip of the fibula. The common fibular foot partially plantar flexed.
nerve is palpable medial and distal to the tendon of biceps femoris and
over the neck of the fibula, although here it becomes less distinct as it
Arthroscopy portals
passes deep to the origin of fibularis longus. At the neck of the fibula,
the nerve is at particular risk of damage either from a tightly applied
plaster cast or from a fracture. The placement of portals for arthroscopy is important for maximizing
The deep fibular nerve starts on the lateral aspect of the neck of the surgical access for visualization and for surgical instruments, and also
fibula, passes downwards and medially, and rapidly becomes associated for avoiding damage to structures such as nerves and blood vessels.
with the anterior tibial artery, with which it is landmarked (see Fig.
78.18). The superficial fibular nerve also begins on the lateral aspect of Hip Arthroscopy of the hip is not yet a common procedure but is
the neck of the fibula. It descends to a point on the anterior border of increasingly being used. A variety of entry portals have been described.
fibularis longus, at the junction of the middle and lower thirds of the The anterolateral portal is sited on the skin approximately 4 cm lateral
leg, where it pierces the deep fascia and divides into intermediate and to the femoral artery pulse and 4 cm inferior to the inguinal ligament.
medial dorsal cutaneous branches. The intermediate dorsal cutaneous Under fluoroscopy, a needle traversing the skin 30–45 degrees proxi-
branch is normally both visible and palpable over the dorsolateral mally is advanced into the joint. Other more lateral portals can be used;
aspect of the ankle and foot toward the fourth toe (see Fig. 78.19). The the lateral femoral cutaneous nerve and the sciatic nerve are potentially
medial dorsal cutaneous branch is rarely visible and passes towards the at risk.
second toe. These superficial nerves are at risk from surgery in the ant-
erior ankle region (especially during arthroscopy). Knee The knee is the joint most frequently examined with arthroscopy.
The standard portals are placed anteriorly. When the knee is flexed at a
right angle, ‘soft triangles’ bordered by the patellar ligament, the femoral
CLINICAL PROCEDURES condyles and the tibia and anterior horns of the menisci are palpable
on either side of the superior third of the patellar ligament. Small inci-
Nerve anaesthesia (nerve blocks) sions can be made in the apices of these triangular areas at about the
level of the inferior pole of the patella for the anterolateral portal, and
Nerves can be effectively anaesthetized with local anaesthetic injection slightly lower for the anteromedial portal. These portals will allow
for surgical or post-injury pain relief. Common injection sites for the passage of an arthroscope and instruments, with good access to most
lower limb are around the hip for thigh and knee pain, and around the of the joint. The patellar ligament and the infrapatellar branch of the
ankle for foot surgery. For the deeper nerves around the hip, the use of saphenous nerve are at risk from the skin incisions. The nerve is less
a nerve stimulator is very helpful in localizing the target nerve precisely vulnerable than the ligament; its position is variable but it usually lies
before infiltration of local anaesthetic. For example, blockade of the below the appropriate portal sites. In the days of open meniscal surgery,
sciatic nerve in the buttock, femoral nerve in the anterior thigh, and the nerve was usually divided and painful neuroma formation was not
obturator nerve in the medial thigh may be undertaken to provide pain uncommon.
relief for total knee replacement; the tibial nerve at the posteromedial Posteromedial and posterolateral portals are useful when better
ankle, the sural nerve at the posterolateral ankle and the superficial access to the posterior knee is required. The saphenous and common
fibular nerves at the anterior ankle may all be anaesthetized at the ankle fibular nerves, respectively, are at risk with these approaches, and ana-
to allow ‘awake foot surgery’. tomical knowledge is vital to ensure safe portal placement. Laterally,
the incision should be anterior to the tendon of biceps femoris, which
Intramuscular injection can easily be palpated. Medially, the situation is more difficult because
the saphenous nerve and long saphenous vein travel superficial to the
medial epicondylar region of the knee, approximately a hand’s breadth
Intramuscular injections into the buttock should be avoided to prevent
posterior to the medial border of the patella. It is essential that sharp
iatrogenic damage to the sciatic nerve. If the buttock is to be used, a
incision includes the skin only, and that dissection down to the joint
relatively safe area is the true upper and outer quadrant, which is iden-
capsule is undertaken bluntly. If the medial meniscus is sutured, the
tified with the whole buttock exposed. The injection is then given
capsule must be exposed before tying off sutures to avoid ensnaring the
mainly into gluteus medius rather than into gluteus maximus, pro-
nerve.
vided a sufficiently long needle is used; most so-called ‘intramuscular’
injections given into the buttock are actually given into the fat. A safe Ankle The use of ankle arthroscopy is well established, especially
alternative is to inject into the lateral aspect of the thigh (vastus
in treating sports-related injuries. Anterior portals are standard. The
lateralis).
anteromedial portal can be placed just medial to the tendon of tibialis
anterior, in the palpable soft spot. However, this comes close to the long
Joint injection and aspiration
saphenous vein and saphenous nerve; limiting the sharp incision to the
skin, followed by blunt deeper dissection, reduces the risk. Alternatively,
Careful aseptic technique is essential for all joint aspirations and the anteromedial portal can be chosen to pass between the lateral edge
injections. of tibialis anterior and extensor hallucis longus. The anterolateral portal
is placed with the help of the arthroscope in the joint to check the
Hip Intra-articular hip injections are typically performed under fluoro- position of a preliminary needle passed into it. The portal should pass
scopic or ultrasonographic guidance. With the patient lying supine, and lateral to fibularis tertius and extensor digitorum longus. The intermedi-
after the positions of the femoral artery and the anterior superior iliac ate dorsal cutaneous branch of the superficial fibular nerve is at risk
spine have been marked out, the needle is introduced anteriorly, as it crosses the ankle anterior to the lateral malleolus, and therefore
approximately 5 cm distal to the anterior superior iliac spine and 4 cm it is wise to mark the positions of the nerves and blood vessels with a
lateral to the femoral artery pulse, and passed posteriorly, a little proxi- pen before making any incision. The nerves can usually be felt at the
mally and medially. An alternative technique that is dependent on front of the ankle, even in obese patients. They are often seen if the
relative distances from surface landmarks, rather than imaging guid- ankle is maximally pulled into plantar flexion. Posterior ankle arthros-
ance, utilizes the site of the proximal anterolateral portal for hip copy is controversial: there is a view that the proximity of the neurov-
arthroscopy as the point of needle insertion (Masoud and Said 2013). ascular bundle (medially) and the sural nerve (laterally) renders it too | 1,839 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Key references
hazardous. Keeping lateral to the tendon of flexor hallucis longus will the saphenous nerve, means that there is always numbness lateral to a
safeguard the medial neurovascular bundle. longitudinal incision.
The extensile approach to the posterior knee is extensive. The key is
to expose the sural nerve and short saphenous vein and to trace them
Placement of surgical incisions
proximally. This will lead the surgeon into the popliteal fossa and, after
opening the deep fascia, safely to the neurovascular bundle. The wound
Hip Surgery of the hip joint is usually undertaken for congenital issues, crosses a flexure crease. A scar perpendicular to the crease might induce
slipped capital femoral epiphysis in children, trauma or arthroplasty. a fixed flexion contracture of the joint and therefore an S-shaped inci-
Anterior and anterolateral approaches, often used in children, put the sion is employed where the transverse segment runs in the line of the
lateral femoral cutaneous nerve at considerable risk. Even in more flexure crease.
lateral approaches, the lateral femoral cutaneous nerve and the femoral
and sciatic nerves are all at risk through traction. A popular anterolateral Ankle and foot Incisions around the foot and ankle frequently put
approach to the hip joint involves splitting and separating forwards the
cutaneous nerves at risk and such an injury can result in a neuroma.
anterior part of gluteus medius and vastus lateralis as a single sheet of
The sural nerve at the ankle has a notorious tendency to form neuromas
tissue for subsequent reattachment to the greater trochanter. This tech-
if transected, often after repair of a ruptured calcaneal tendon.
nique relies on the anatomical continuity of the tissue. If the splitting
of gluteus medius is more than a few centimetres superior to the tip of
the greater trochanter, then the superior gluteal nerve and vessels are at
Bonus e-book tables and video
risk, and weakness of hip abduction and a limp may result. In the
posterior approach to the hip joint, gluteus maximus is incised in
the line of its fibres. This is followed by division of the tendons of
Table 78 .1 Segmental innervation of the muscles of the lower limb .
the short lateral rotators (piriformis, obturator internus and externus
and gemelli) near their trochanteric attachments to reveal the joint
Table 78 .2 Segmental innervation of joint movements of the lower
capsule. Reflecting these cut tendons medially protects the sciatic nerve.
limb .
The inferior and superior gluteal nerves are at risk during posterior
approaches to the hip.
Table 78 .3 Movements, muscles and segmental innervation in the
lower limb .
Knee Most open knee surgery can be undertaken through an anterior
midline longitudinal incision, which gives good access and means that Table 78 .4 The movements and muscles tested to determine the
any future surgery can usually be undertaken via the same wound. New location of a lesion in the lower limb .
incisions run the risk of skin necrosis and poor wound healing as a
consequence of interfering with the cutaneous blood supply. Inevitable Video 78 .1 Lower limb surface anatomy .
interruption of cutaneous nerves, including the infrapatellar branch of
KEY REFERENCES
Beason LE, Anson BJ 1937 The relation of the sciatic nerve and its subdivi- A discussion of the venous plexuses within and between some of the lower
sions to the piriformis muscle. Anat Rec 70:1–5. limb muscles. The two principal superficial veins and their numerous
A classical description of the course of the sciatic nerve, including a tributaries are discussed and their use as grafts during peripheral vascular
classification system of the relation of the sciatic nerve with the piriformis surgery, including coronary artery bypass, is considered.
muscle.
Pontén B 1981 The fasciocutaneous flap: its use in soft tissue defects of the
Bergman RA, Thompson SA, Afifi AK et al 1988 Compendium of Human lower leg. Br J Plast Surg 34:215–20.
Anatomic Variations. Baltimore: Urban & Schwarzenberg. The first description of lower extremity fasciocutaneous flaps. Their use in
One of the best-known sources on anatomical variation in humans. the repair of soft tissue defects is discussed.
Variations of the human anatomy are systematically reviewed.
Ricci S 2011 Anatomy. In: Goldman MP, Guex J-J, Weiss RA (eds) Sclero-
Crock HV 1996 Atlas of Vascular Anatomy of the Skeleton and Spinal Cord. therapy: Treatment of Varicose and Telangiectatic Leg Veins, 5th ed.
London: Martin Dunitz. Ch. 1, pp. 1–24. Edinburgh: Elsevier, Saunders.
A review of the arterial supply of the bones from nutrient vessels, Sharrard WJW 1955 The distribution of the permanent paralysis in the lower
metaphysial arterial branches of the peri-articular anastomoses, and the limb in poliomyelitis: a clinical and pathological study. J Bone Joint
arteries supplying the muscles that attach to their periosteum. Surg Br 37-B:540–58.
Dodd H, Cockett FB 1976 The Pathology and Surgery of the Veins of the A definition of the innervation patterns of the lower limb. The segmental
Lower Limb, 2nd ed. Edinburgh: Churchill Livingstone. origin of the nerve supply for each of the muscles of the lower limb and for
A review of the structure of the superficial and deep veins of the lower the movements is discussed. The clinical consequences of damage to these
extremity. The pathological processes observed when the valves in the segments are considered.
perforating veins become incompetent are considered. The aetiological factors Sterzi G 1910 Il tessuto sottocutaneo [Subcutaneous Tissue]. Florence: Luigi
and the pathogenesis of varicose veins are discussed. Niccolai.
Harry LE, Sandison A, Pearse MF et al 2009 Comparison of the vascularity A discussion of the specific structure of the subcutaneous tissue of the lower
of fasciocutaneous tissue and muscle for coverage of open tibia fracture. limb and its participation in the integrity of the skin.
Plast Reconstr Surg 124:1211–9. Taylor GI, Razaboni RM (eds) 1994 Michel Salmon: Anatomic Studies, Book
A consideration of the major advantage of using a fasciocutaneous 1. Arteries of the Muscles of the Extremities and Trunk. St Louis: Quality
reconstruction in terms of the decreased incidence of bone infection. The Medical Publishing.
aesthetic results and the application to pathologies such as Volkmann’s A discussion of the arteries to the muscles of the lower extremity. The
contracture are discussed. pattern of arterial supply is particularly relevant to fracture healing, the
Kosinski C 1926 Observations on the superficial venous system of the lower spread of infection and malignancy, and the planning of reconstructive
extremity. J Anat 60:131–42. surgical procedures. | 1,840 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
87
RETPAHC
Pelvic girdle and lower limb: overview and surface anatomy
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Aggarwal A, Kaur H, Batra YK et al 2009 Anatomic consideration of caudal Kosinski C 1926 Observations on the superficial venous system of the lower
epidural space: a cadaver study. Clin Anat 22:730–7. extremity. J Anat 60:131–42.
Apaydin N, Basarir K, Loukas M et al 2008 Compartmental anatomy of the A discussion of the venous plexuses within and between some of the lower
superficial fibular nerve with an emphasis on fascial release operations limb muscles. The two principal superficial veins and their numerous
of the leg. Surg Radiol Anat 30:47–52. tributaries are discussed and their use as grafts during peripheral vascular
surgery, including coronary artery bypass, is considered.
Beason LE, Anson BJ 1937 The relation of the sciatic nerve and its subdivi-
sions to the piriformis muscle. Anat Rec 70:1–5. Ladak A, Tubbs RS, Spinner RJ 2014 Mapping sensory nerve communica-
A classical description of the course of the sciatic nerve, including a classification tions between peripheral nerve territories. Clin Anat 27:681–9.
system of the relation of the sciatic nerve with the piriformis muscle. Lechner G, Jantsch H, Waneck R et al 1988 The relationship between the
Bergman RA, Thompson SA, Afifi AK et al 1988 Compendium of Human common femoral artery, the inguinal crease, and the inguinal ligament:
Anatomic Variations. Baltimore: Urban & Schwarzenberg. a guide to accurate angiographic puncture. Cardiovasc Intervent Radiol
One of the best-known sources on anatomical variation in humans. 11:165–9.
Variations of the human anatomy are systematically reviewed. Masoud MA, Said HG 2013 Intra-articular hip injection using anatomic
surface landmarks. Arthrosc Tech 2:e147–9.
Bernière J, Schrayer S, Piana F et al 2008 A new formula of age-related ana-
tomical landmarks for blockade of the sciatic nerve in the popliteal fossa McGaugh JM, Brisme JM, Dedrick GS et al 2007 Comparing the anatomical
in children using the posterior approach. Paediatr Anaesth 18:602–5. consistency of the posterior superior iliac spine to the iliac crest as refer-
ence landmarks for the lumbopelvic spine: a retrospective radiological
Binokay F, Akgul E, Bicakci K et al 2006 Determining the level of the dural
study. Clin Anat 20:819–25.
sac tip: magnetic resonance imaging in an adult population. Acta Radiol
47:397–400. Mirjalili SA, Muirhead JC, Stringer MD 2014 Redefining the surface anatomy
of the saphenofemoral junction in vivo. Clin Anat 27:915–19.
Bjurlin MA, Davis KE, Allin EF et al 2007 Anatomic variations in the lateral
femoral cutaneous nerve with respect to pediatric hip surgery. Am J Pontén B 1981 The fasciocutaneous flap: its use in soft tissue defects of the
Orthop (Belle Mead NJ) 36:143–6. lower leg. Br J Plast Surg 34:215–20.
The first description of lower extremity fasciocutaneous flaps. Their use in
Caggiati A, Bergan JJ, Gloviczki P et al 2002 Nomenclature of the veins of
the repair of soft tissue defects is discussed.
the lower limbs: an international interdisciplinary consensus statement.
J Vasc Surg 36:416–22. Render CA 1996 The reproducibility of the iliac crest as a marker of lumbar
Caggiati A, Bergan JJ, Gloviczki P et al 2005 Nomenclature of the veins of spine level. Anaesthesia 51:1070–1.
the lower limb: extensions, refinements, and clinical application. J Vasc Ricci S 2011 Anatomy. In: Goldman MP, Guex J-J, Weiss RA (eds) Sclero-
Surg 41:719–24. therapy: Treatment of Varicose and Telangiectatic Leg Veins, 5th ed.
Chakraverty R, Pynsent P, Isaacs K 2007 Which spinal levels are identified Ch. 1, pp. 1–24. Edinburgh: Elsevier, Saunders.
by palpation of the iliac crests and the posterior superior iliac spines? Ropars M, Morandi X, Huden D et al 2009 Anatomical study of the lateral
J Anat 210:232–6. femoral cutaneous nerve with special reference to minimally invasive
Choy KW, Kogilavani S, Norshalizah M et al 2013 Topographical anatomy anterior approach for total hip replacement. Surg Radiol Anat 31:
of the profunda femoris artery and the femoral nerve: normal and 199–204.
abnormal relationships. Clin Ter 164:17–9. Senoglu N, Senoglu M, Oksuz H et al 2005 Landmarks of the sacral hiatus
Cormack GC, Lamberty BG 1984 Fasciocutaneous vessels: their distribution for caudal epidural block: an anatomical study. Br J Anaesth 95:
on the trunk and limbs, and their clinical application in tissue transfer. 692–5.
Anat Clin 6:121–31. Senoglu N, Senoglu M, Ozkan F et al 2013 The level of termination of the
Crock HV 1996 Atlas of Vascular Anatomy of the Skeleton and Spinal Cord. dural sac by MRI and its clinical relevance in caudal epidural block in
London: Martin Dunitz. adults. Surg Radiol Anat 35:579–84.
A review of the arterial supply of the bones from nutrient vessels, Sharrard WJW 1955 The distribution of the permanent paralysis in the lower
metaphysial arterial branches of the peri-articular anastomoses, and the limb in poliomyelitis: a clinical and pathological study. J Bone Joint
arteries supplying the muscles that attach to their periosteum. Surg Br 37-B:540–58.
A definition of the innervation patterns of the lower limb. The segmental
Cruveilhier J 1841 Descriptive Anatomy. London: Whittaker.
origin of the nerve supply for each of the muscles of the lower limb and for
Dodd H, Cockett FB 1976 The Pathology and Surgery of the Veins of the the movements is discussed. The clinical consequences of damage to these
Lower Limb, 2nd ed. Edinburgh: Churchill Livingstone. segments are considered.
A review of the structure of the superficial and deep veins of the lower
extremity. The pathological processes observed when the valves in the Staudt JM, Smeulders MJ, van der Horst CM 2008 Normal compartment
perforating veins become incompetent are considered. The aetiological factors pressures of the lower leg in children. J Bone Joint Surg Br 90:215–19.
and the pathogenesis of varicose veins are discussed. Sterzi G 1910 Il tessuto sottocutaneo [Subcutaneous Tissue]. Florence: Luigi
Niccolai.
Grothaus MC, Holt M, Mekhail AO et al 2005 Lateral femoral cutaneous
A discussion of the specific structure of the subcutaneous tissue of the lower
nerve: an anatomic study. Clin Orthop Relat Res 437:164–8.
limb and its participation in the integrity of the skin.
Hale SJ, Mirjalili SA, Stringer MD 2010 Inconsistencies in surface anatomy:
the need for an evidence-based reappraisal. Clin Anat 23:922–30. Taylor GI, Razaboni RM (eds) 1994 Michel Salmon: Anatomic Studies, Book
1. Arteries of the Muscles of the Extremities and Trunk. St Louis: Quality
Hansasuta A, Tubbs RS, Oakes WJ 1999 Filum terminale fusion and dural
Medical Publishing.
sac termination: study in 27 cadavers. Pediatr Neurosurg 30:176–9.
A discussion of the arteries to the muscles of the lower extremity. The
Harry LE, Sandison A, Pearse MF et al 2009 Comparison of the vascularity pattern of arterial supply is particularly relevant to fracture healing, the
of fasciocutaneous tissue and muscle for coverage of open tibia fracture. spread of infection and malignancy, and the planning of reconstructive
Plast Reconstr Surg 124:1211–9. surgical procedures.
A consideration of the major advantage of using a fasciocutaneous
reconstruction in terms of the decreased incidence of bone infection. The van Schoor A, Bosman MC, Bosenberg AT 2014 The value of Tuffier’s line
aesthetic results and the application to pathologies such as Volkmann’s for neonatal neuraxial procedures. Clin Anat 27:370–5.
contracture are discussed. Walsh JC, Quinlan JF, Butt K et al 2006 Variation in position of the L4/5
disc inter-space from the anatomical landmark: review of 450 radio-
Kim JT, Jung CW, Lee JR et al 2003 Influence of lumbar flexion on the posi-
graphs and clinical applications. Eur J Orthop Surg Traumatol 16:
tion of the intercrestal line. Reg Anesth Pain Med 28:509–11. 203–6.
Kim HW, Ko YJ, Rhee WI et al 2007 Interexaminer reliability and accuracy
of posterior superior iliac spine and iliac crest palpation for spinal level
estimations. J Manipulative Physiol Ther 30:386–9.
1333.e1 | 1,841 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
CHAPTER Development of the pelvic girdle and
79
lower limb
By stage 17, the lower limb still has a flattened foot plate and,
PELVIC GIRDLE DEVELOPMENT
although a hip region can be identified, there is no true knee as yet. In
stage 18, the lower limb appears to be flexed and abducted at the
The pelvic girdle develops in close proximity to cloacal structures. The hip with the knee bent, giving the appearance that the knee is facing
anterior portion of the pelvic girdle is intimately associated with the laterally. The femur and tibia form in cartilage, and the sciatic nerve
normal development of the caudal part of the urogenital system and extends distally to the tibia by stage 18. Very little skin of the thigh is
the anterior body wall. Studies on the development of the lower limb visible. The soles of the feet face the umbilical cord, and the foot plate
in avian species and the mouse show that the perineal muscles, includ- has digit rays. During stages 20–23, the digit rays separate and toes are
ing the sphincters, derive from somitic myoblasts that have previously clearly defined by stage 23. The feet can finally touch at stage 21, when
entered the hindlimb bud. Similar to the developmental process seen the umbilical cord becomes proportionally smaller and the embryo
in the upper limb, somitic myoblasts originating from the dorsoventral larger. For more details, see O’Rahilly and Gardner (1975).
edge of the dermomyotome migrate into the somatopleuric mesen-
chyme of the early lower limb bud. The myoblasts coalesce into a single
entity before dividing into dorsal and ventral muscle masses. The cells VESSELS
of the ventral muscle mass then divide again, with one population
continuing to develop within the limb and the other migrating ventrally Arteries
towards the genital tubercle (Valasek et al 2005). In the avian embryo,
myoblasts from somites 26–29 enter the limb only, and those from
The blood supply to the lower limb is derived from the lateral branch
somites 30–33 form both cloacal and limb muscles, whereas those from
of the fifth lumbar intersegmental artery, which arises from the dorsal
somite 34 form cloacal muscles solely. Within pelvic girdle develop-
root of the umbilical artery passing to the placenta, and continues into
ment, myoblasts do not attain their position by somitic hypaxial
the limb bud as the axial artery. The arterial supply to the developing
domain extension; all myoblasts migrate into the region. Interestingly,
lower limb is thus far less oxygenated than the arterial supply to the
the population of myoblasts giving rise to perineal muscles are inner-
upper limb, which receives blood directly from the heart via the sub-
vated by axons derived from neurones located in Onuf’s nucleus,
clavian artery. It is possible that the development of several arteries,
whereas those that remain in the limb bud gain innervation from ante-
some of which subsequently regress, in the distal part of the leg in the
rior horn cells (Valasek et al 2005).
embryonic period, is a reflection of the lower oxygenation of these
The bony pelvis forms from two hemipelves, each of which develops
tissues. During development, the lower limb undergoes medial rotation
from one cartilaginous focus. Ossification of the pelvis starts with the
and extension, so that the original dorsal (extensor) portion of the limb
ilium, which undergoes endochondral ossification at 9.5 weeks. Devel-
becomes directed ventrally. This relative movement suggests that very
opment of trabecular bone in the ilium is evident from about 22 weeks’
different patterning mechanisms operate in the lower limb compared
gestation and a mature trabecular morphology is present at birth (Cun-
to those in the upper limb: an early, complex vasculature may be a
ningham and Black 2009a, Cunningham and Black 2009b). It is sug-
product of that difference.
gested that the trabecular pattern, previously assumed to develop
There have been relatively few studies on the early development of
consequent to weight bearing and bipedal gait, is initiated through
the vasculature of the lower limb (Senior 1991a,b, Mandell et al 1985,
genetic patterning plus intrauterine muscular movements which confer
Levinsohn et al 1991). The terminology used to describe the developing
biomechanical loading onto the ilium and pelvis.
vessels is specific and will be used here: descriptions of developmental
The development of the superior pubic rami is related to the normal
vascular anomalies retain the original terminology. Table 79.1 describes
development of the cloacal membrane. In cases of bladder exstrophy
and illustrates the changes to the axial artery, the new vessels that arise
(see Fig. 72.11), the superior pubic rami are shortened and do not meet
and the vessels that regress, during stages 13–19 (corresponding to
at the pubic symphysis. There is a 4 cm pubic diastasis at birth, which
weeks 5–7 of development). The mature vascular pattern is established
increases to 8 cm at age 10 years, compared with a mean normal width
by the end of the embryonic period.
of the pubic symphysis of 0.6 cm at all ages (Wild et al 2011). The
ischiopubic segment of the pelvis is 30% shorter, the iliac wings are
Veins
externally rotated and the acetabuli are retroverted (Wild et al 2011).
The mechanisms suggested for this are premature rupture of an abnor-
mally cranially placed cloacal membrane, obstruction of medial migra- The superficial veins of the lower limb are derived from the marginal
tion of somatopleuric mesenchyme, and local apoptosis of ventral vein which runs along the periphery of the extending limb bud beneath
mesenchyme (Stec 2011). It is thought that some combination of the the pre- and post-axial limb borders. The preaxial vein becomes the long
three is likely. saphenous vein, which drains into the femoral vein at the saphenous
The sacroiliac joint can be recognized from 7 weeks; its development opening. The postaxial vein becomes the short saphenous vein, which
is slightly different from that of other synovial joints in that the devel- passes deep and joins the popliteal vein. The earliest valves in the short
opment of the ilium is ahead of that of the sacrum. Reconsideration of saphenous vein are noted at 13 weeks’ gestation. The number of valves
the role of the sacroiliac joint in the transfer of load from axial to increases from 1 to 8 between 13 and 18 weeks’ gestation; there are
appendicular skeleton has been prompted by study of the relative more valves present in the upper than in the lower portion of the short
growth of regional surface areas of the ilium from birth to adulthood saphenous vein (Czarniawska-Grzesińska and Bruska 2002).
(Yusof et al 2013). Cavitation of the hip joint has been reported at
7–8 weeks.
ULTRASOUND ANTENATAL IMAGING
LOWER LIMB DEVELOPMENT
Femur length is routinely measured to assess growth velocity (along
with head circumference and abdominal circumference) and to predict
The lower limb is first recognizable as a laterally projecting thickening the expected date of delivery. The longest axis of the ossified diaphysis
in the body wall opposite somites 24–29 at stage 13 (28 days); by stage is identified with soft tissue noted beyond both ends. The distal
14, it is closely associated with the wide umbilical cord. During stages epiphysis is excluded (Fig. 79.1). Fetal femur length is related to ethnic-
15–17, the limb projects laterally and outgrowth is fairly symmetrical. ity, and appropriate fetal biometry comparison charts are necessary for
The core of mesenchymal cells is derived from both somatopleuric and accurate evaluation; whether such data can be extrapolated to mixed
1334 paraxial mesenchyme. ethnicity fetal populations has been questioned (Ogasawara 2009). | 1,842 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
Neonatal lower limb
1335
97
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Table 79.1 The development of the arteries of the lower limb during stages 13–19 (corresponding to weeks 5–7 of development), showing the changes to the axial artery, the
new vessels that arise and the vessels that regress
Stage of Axial artery Developing arteries Regressing Arterial status
development arteries
11–12 First appearance of the lower
limb bud. The lower limb
axial artery arises from the
fifth lumbar intersegmental
branch of the aorta.
13–16 The axial artery courses Aorta Umbilical
through the lower limb bud
to the developing digital
plate where it branches into
Common
a terminal plexus (future
iliac
dorsal and plantar networks). Axial
16–17 The axial artery is now The external iliac artery, which arises Femoral RCS
described as ischiadic just proximal to the origin of the
proximally and popliteal ischiadic artery, extends distally towards
profunda (PP) and interossea the knee as the femoral artery. A branch,
(I) as it progresses distally. the ramus communicans superior (RCS),
passes dorsally to join the ischiadic
artery. Perforating branches of the Ischiadic PP I
profunda femoris artery initially
anastomose with the proximal part of the
ischiadic artery. Parts of the
axial artery
18 Elongation of the axial artery Two new vessels arise from the popliteal The proximal portion Femoral I
forms the popliteal superficialis artery. These are the tibialis of the ischiadic artery
superficialis (PS) between posterior superficialis (TPS) and the starts to regress. RCS
the popliteal profunda and peronea posterior superficialis (PPS). Parts persist in the
interossea arteries. Both vessels join the plantar network. adult as the inferior Ischiadic
There are now three arteries in the leg. gluteal artery and the
arteria comitans nervi
ischiadici.
PP PS TPS PPS
19 Two further vessels arise. They are the TApd
tibialis anterior pars distalis (TApd) from I
the interossea artery and the ramus
communicans inferior (RCI) from the
peronea posterior superficialis. The
original plantar network is remodelled
into a medial plantar artery (from the
distal part of tibialis posterior
superficialis) and a lateral plantar artery
(from the distal continuation of the
PP PS TPS PPS RCI
confluence of the interossea, ramus
communicans inferior and the peronea
posterior superficialis) which together
form the plantar arch.
There are now five arteries in the leg.
20 The arteries in the leg at this stage are Popliteal profunda, PP
the tibilalis anterior (TA), tibialis posterior interossea artery and TA
and the ramus communicans inferior. peronea posterior
The latter is confluent with the peronea superficialis arteries.
posterior superficialis in the tarsal region
and becomes the fibular (peroneal)
artery. The plantar arch is now supplied
solely by the tibialis posterior.
There are now three arteries in the leg.
PS TP RCI PPS
Identification of short femur length is associated with a higher risk of
chromosomal abnormalities (Mathiesen et al 2014) and a significantly
higher likelihood of the fetus being small for gestational age and at risk
of early preterm delivery (Mathiesen et al 2014, Özlü and Ozcan 2013).
It has been estimated that identification of isolated short femur length
below the tenth or fifth percentile at mid-gestation is associated with
more than a three-fold risk of the development of fetal growth retarda-
tion and increased risk of early preterm birth before 37 and 34 weeks
(Goetzinger et al 2012). Although the cause of this relationship must
be multifactorial, it is suggested that changes in placentation and
chronic fetal hypoxia may lead to a fetal adaptive response in which
highly oxygenated blood is diverted to the brain and heart at the
expense of the extremities.
NEONATAL LOWER LIMB
Fig. 79.1 An ultrasound image showing femur length. (With permission In the neonate, the pelvis is cone-shaped. The transverse diameter of
from To M, Pereira S 2015 Routine fetal anomaly scan, in Coady AM (ed) the true pelvis is 2.2 cm, its anteroposterior diameter is 2.8 cm, and the
Twining’s Textbook of Fetal Abnormalities, 3rd edition, Churchill length between the inlet and outlet is 2 cm. The sacrum is proportion-
Livingstone.) ately larger than in the adult and the sacral promontory is higher. When
walking begins, the sacrum descends between the ilia and the promon-
tory develops. The ilia, ischia and pubic bones are variably ossified at | 1,843 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
DEvEloPmENT of THE PElviC giRDlE AND lowER limb
1336
9
NoiTCES
birth; they meet at the acetabulum, which in the neonate is cartilagi- sia of the hip; magnetic resonance imaging (MRI) may be beneficial in
nous, relatively large and shallow. identifying the underlying bony and soft tissue anatomy.
The lower limbs are underdeveloped in the neonate when compared The collodiaphysial angle (CDA; neck–shaft angle, Mikulicz angle)
to the upper limbs. They are retained in a flexed position and the lower is the angle between the long axis of the femoral shaft and the head
leg is proportionately shorter than the thigh. Although the legs appear and neck of the femur; the normal range varies between 125° and 140°
to be bowed, the tibia and fibula are straight; the illusion of bow legs (see Fig. 81.10). Where the CDA is enhanced, usually above 135°, a
is caused by the shape of the soft tissues and the slightly more advanced coxa valga deformity occurs. Where CDA is decreased (usually defined
development of the lateral head of gastrocnemius compared to its as less than 120°), a coxa vara deformity occurs; the mechanism is
medial head. The femoral neck is much shorter and forms an acute thought to be a failure of medial growth of the physial plate. The result-
angle with the shaft. The latter is quite straight because the adult cur- ing lower limb is shortened and abduction is restricted. In both coxa
vature is acquired with walking. The head of the femur is larger than valga and coxa vara, the long-term unequal weight distribution may
the acetabular fossa and nearly one-third remains external, which result in excessive wear of articular cartilage.
means that the ligament of head of femur is relatively very long. Dislo- The femur normally aligns on the tibia obliquely, creating an angle
cation of the hip joint is relatively easy; the femoral head can be of 174° facing laterally. A medial angulation of the leg in relation to
removed from the acetabular fossa laterally but not posteriorly. The the thigh is a deformity called genu varum, whereas a lateral angulation
calcaneus and the talus have an ossification centre at birth, and a centre is called genu valgum. The hip–knee (femoral–tibial) angle in children
is present in the cuboid in half of neonates. is +3.6° (varum) between the ages of 1 and 2 years, and −2.5° (valgum)
The muscles of the lower limb are much less developed than those between the ages of 2 and 3 years. The prevalence of lower limb deform-
in the upper limb. The fetal position often assumed by postnatal babies ities physiologically decreases after 5 years of age; the angle is +0.3° after
keeps the thighs in continuous abduction, stretching the adductors. The the age of 7 years, which is within 1° of adult reference values (Sabhar-
muscles that will be used for walking are weak; the lack of gluteal wal and Zhao 2009). Both deformities cause unequal weight distribu-
development, in particular, gives the typically diminutive buttocks of tion that hastens destruction of knee cartilages; persistence of genu
the neonate. varum/valgum until late childhood may require correction in order to
In neonates, the feet are usually inverted and they have a greater prevent arthrosis. (For further reading, see Goldman and Green (2010).)
degree of dorsiflexion, caused by the relatively greater area of the tro- The patella may be absent or hyoplastic, a malformation that may be
chlea of the talus. Plantar flexion is limited, in part reflecting the short- isolated or may be associated with other defects (Mizobuchi et al 2007).
ness of the extensor muscles of the foot. At birth, the footprint outlines Congenital talipes equinovarus, or club foot, derives its name from
the whole plantar surface, reflecting the deposition of subcutaneous fat a combination of talus and pes, together with terms describing an ele-
beneath the longitudinal and transverse arches, and so most babies vated heel resembling that of a horse (equino), which is also turned
appear flat-footed. inwards (varus). It is a common neonatal anomaly and occurs in
approximately 1 per 1000 live births, with males affected twice as often
as females. There is some degree of inheritance, so it is not entirely an
DEVELOPMENTAL ANOMALIES OF THE
effect of intrauterine positioning or of oligohydramnios (abnormally
LOWER LIMB
little amniotic fluid). Both bones and soft tissues are affected and it is
difficult to tell which are primary effects and which are secondary. A
The categories of limb defects described by Swanson (1976) are given number of theories have been proposed to explain the underlying
on page 796. Although devised for the upper limb, they similarly apply pathogenetic mechanism(s), including abnormal tendon and ligament
to the lower limb. attachments, defective development of the talus and delayed muscle
Developmental dysplasia of the hip (previously known as congenital maturation. One theory is that the talus undergoes defective develop-
dislocation of the hip) refers to an abnormal configuration of, or rela- ment and that all the other deformities arise as a consequence of this
tionship between, the femoral head and the acetabulum that occurs initial defect. The talus is decreased in size by up to 25%. It has a fore-
either before or after birth in approximately 1 in 100 live births with a shortened neck and decreased body/neck angle, and the subtalar facets
female : male ratio of 6 : 1. (In 2% of cases, hip dislocation is not evident are medially rotated. The navicular is small and medially deviated rela-
at birth but manifests in the first few months of the life.) It covers a tive to the talus. The calcaneus is also small and shows varus displace-
continuum of disorders that ranges from shallowness of the acetabulum ment and equinus tilt; the anterior facets correspond to those of the
to instability and subluxation of the femoral head and, ultimately, to talus (Barlow and Clarke 1994). The entire affected foot and calf are
frank dislocation. Acetabular anteversion may occur (Li et al 2009). The smaller than their normal counterparts. The foot is inverted and supi-
aetiology is considered to be multifactorial and is associated with first nated, and the forefoot is adducted. The heel is small, rotated inwards
pregnancies, suggesting that both maternal and uterine musculature and elevated. The calcaneus is inverted beneath the talus. MRI analysis
restricts fetal movement and puts postural strain on the fetal hips. of the lower legs of patients who had been treated for idiopathic con-
Developmental dysplasia of the hip is seen more frequently in genital talipes equinovarus showed that leg muscle volume was consist-
breech delivery, especially if the child’s knees are extended. The inci- ently reduced (Duce et al 2013). Treatment varies between splintage
dence is similar in preterm and term infants born in the breech position and repeated complex surgery, which reflects the highly variable severity
(Quan et al 2013). The left hip is more frequently affected than the of the condition and individual response to therapy.
right, possibly because, in breech presentation, the fetus lies with the ‘Flat feet’ are common in childhood. The majority are ‘flexible’ and
right shoulder anterior and the left thigh closest to the maternal sacrum. simply related to posture, whereas ‘rigid’ flat feet are caused by structural
The physiological effects that cause the maternal ligaments to become abnormalities. The description of ‘rocker bottom’ foot is associated with
temporarily lax prior to delivery are also considered to affect the fetus many congenital syndromes. The foot is flat and rigid, and the plantar
and to contribute to laxity of the hip capsule. Risk factors are breech surface appears curved with the apex of the curve at the mid-tarsal joint.
delivery, female sex, a positive family history and clicking hips at clini- The condition shows an equinus position of the hindfoot. The talus
cal examination (de Hundt et al 2012). Ultrasound is beneficial in the may be vertical and palpable on the plantar surface. A majority of
early detection and assessment of children with developmental dyspla- infants with this condition have neurological abnormalities.
KEY REFERENCES
Cunningham CA, Black SM 2009a Development of the fetal ilium – chal- Senior HD 1991a The development of the arteries of the human lower
lenging concepts of bipedality. J Anat 214:91–9. extremity. 25:54–95.
Cunningham CA, Black SM 2009b Anticipating bipedalism: trabecular Senior HD 1991b An interpretation of the recorded arterial anomalies of
organization in the newborn ilium J Anat 214:897–29. the human leg and foot. J Anat 53:130–71.
Levinsohn EM, Hootnick DR, Packard DS 1991 Consistent arterial abnor- Swanson AB 1976 A classification for congenital limb malformations.
malities associated with a variety of congenital malformations of the J Hand Surg Am 1:8–22.
human lower limb. Invest Radiol 26:364–73. Details of an accepted classification for congenital limb malformations.
Mandell VS, Jaques PF, Delany DJ et al 1985 Persistent sciatic artery: Clinical, Yusof N, Soames RW, Cunningham CA, Black SM 2013 Growth of the
embryologic, and angiographic features. AJR 144:245–9. Human Ilium: the anomalous sacroiliac junction. Anat Rec 296:
O’Rahilly R, Gardner E 1975 The timing and sequence of events in the 1688–94.
development of the limbs in the human embryo. Anat Embryol (Berl)
148:1–23.
A description of the stages in human limb development. | 1,844 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
Development of the pelvic girdle and lower limb
1336.e1
97
RETPAHC
REFERENCES
Barlow I, Clarke NM 1994 Congenital talipes equinovarus. Surgery 12: Ogasawara KK 2009 Variation in fetal ultrasound biometry based on differ-
211–15. ences in fetal ethnicity. Am J Obstet Gynecol 200:676–8.
Cunningham CA, Black SM 2009a Development of the fetal ilium – chal- O’Rahilly R, Gardner E 1975 The timing and sequence of events in the
lenging concepts of bipedality. J Anat 214:91–9. development of the limbs in the human embryo. Anat Embryol (Berl)
Cunningham CA, Black SM 2009b Anticipating bipedalism: trabecular 148:1–23.
organization in the newborn ilium J Anat 214:897–29. A description of the stages in human limb development.
Czarniawska-Grzesińska M, Bruska M 2002 Development of valves in the Özlü T, Ozcan T 2013 Fetal isolated short femur in the second trimester and
small saphenous vein in human fetuses. Folia Morphol (Warsz) 61: adverse pregnancy outcomes. Prenat Diagn 33:1063–9.
37–42. Quan T, Kent AL, Carlisle H 2013 Breech preterm infants are at risk of
de Hundt M, Vlemmix F, Bais JM et al 2012 Risk factors for developmental developmental dysplasia of the hip. J Paediatr Child Health 49:
dysplasia of the hip: a meta-analysis. Eur J Obstet Gynecol Reprod Biol 658–63.
165:8–17. Sabharwal S, Zhao C 2009 The hip-knee-ankle angle in children: reference
Duce SL, D’Alessandro M, Du Y et al 2013 3D MRI analysis of the lower legs values based on a full-length standing radiograph. J Bone Joint Surg Am
of treated idiopathic congenital talipes equinovarus (clubfoot). PLoS 91:2461–8.
One 8:e54100. Senior HD 1991a The development of the arteries of the human lower
Goetzinger KR, Cahill AG, Macones GA et al 2012 Isolated short femur extremity. 25:54–95.
length on mid-trimester ultrasound: a marker for fetal growth restriction Senior HD 1991b An interpretation of the recorded arterial anomalies of
and other adverse perinatal outcomes. J Ultrasound Med 31:1935–41. the human leg and foot. J Anat 53:130–71.
Goldman V, Green DW 2010 Advances in growth plate modulation for lower Stec AA 2011 Embryology and bony and pelvic floor anatomy in the bladder
extremity malalignment (knock knees and bow legs). Curr Opin Pediatr exstrophy-epispadias complex. Semin Pediatr Surg 20:66–70.
22:47–53. Swanson AB 1976 A classification for congenital limb malformations.
Levinsohn EM, Hootnick DR, Packard DS 1991 Consistent arterial abnor- J Hand Surg Am 1:8–22.
malities associated with a variety of congenital malformations of the Details of an accepted classification for congenital limb malformations.
human lower limb. Invest Radiol 26:364–73. Valasek P, Evans DJ, Maina F et al 2005 A dual fate of the hindlimb muscle
Li LY, Zhang LJ, Zhao Q et al 2009 Measurement of acetabular anteversion mass: cloacal/perineal musculature develops from leg muscle cells.
in developmental dysplasia of the hip in children by two- and three- Development 132:447–58.
dimensional computed tomography. J Int Med Res 37:567–75. Wild AT, Sponseller PD, Stec AA et al 2011 The role of osteotomy in surgical
Mandell VS, Jaques PF, Delany DJ, Oberheu V 1985 Persistent sciatic artery: repair of bladder exstrophy. Semin Pediatr Surg 20:71–8.
Clinical, embryologic, and angiographic features. AJR 144:245–9. Yusof N, Soames RW, Cunningham CA, Black SM 2013 Growth of the
Mathiesen JM, Aksglaede L, Skibsted L et al 2014 Outcome of fetuses with Human Ilium: the anomalous sacroiliac junction. Anat Rec 296:
short femur length detected at second-trimester anomaly scan: a national 1688–94.
survey. Ultrasound Obstet Gynecol 44:160–5.
Mizobuchi RR, Galbiatti JA, Quirici Neto F et al 2007 Ultrasonographic
study of the femoropatellar joint and its attachments in normal infants
from birth to 24 months of age: part I. J Pediatr Orthop 16:262–5. | 1,845 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
CHAPTER
80
Pelvic girdle, gluteal region and thigh
The pelvic girdle consists of the paired hip bones (each composed of Innervation
the ilium, ischium and pubis) and the sacrum. The two pubic bones
articulate anteriorly at the pubic symphysis and the sacrum articulates
For the dermatomes and cutaneous nerves, see Figures 78.12B, 78.13,
posteriorly with the two iliac bones at the sacroiliac joint; the bones are
78.14.
virtually incapable of independent movement, except in the female
during parturition or as a result of pathological change. The pelvic girdle
is massively constructed and serves as a weight-bearing and protective SOFT TISSUES
structure, as an attachment for trunk and lower limb muscles, and as
the skeletal framework of a birth canal capable of accommodating Subcutaneous tissue
passage of the fetus.
The subcutaneous tissue (tela subcutanea) of the thigh and buttock
The gluteal region or buttock is an area demarcated by the gluteal
consists, as elsewhere in the limbs, of loose areolar tissue containing a
fold inferiorly, a line joining the greater trochanter and the anterior
variable quantity of fat. In some regions, particularly near the inguinal
superior iliac spine laterally, the iliac crest superiorly and the midline
ligament, it splits into recognizable layers, between which may be found
medially. It contains a large bulk of skeletal muscle that covers several
the branches of superficial vessels and nerves. It is thick in the inguinal
vulnerable neurovascular structures, and incorporates junctional zones
region, where its two layers enclose the superficial inguinal lymph
between the lower limb, pelvis and perineum at the sciatic foramina.
nodes, long saphenous vein and other smaller vessels. Here, the super-
Direct and indirect musculoskeletal injuries in this region may damage
ficial layer is continuous with that of the abdominal fascia. The deep
the sciatic nerve and gluteal vessels.
layer, a thin fibroelastic stratum, is most marked medial to the long
The thigh consists of a cylinder of compact bone, the femoral shaft,
saphenous vein and inferior to the inguinal ligament, and is interposed
surrounded by muscle groups traversed by important neurovascular
between the subcutaneous vessels and nerves and the deep fascia, fusing
structures. The muscles are grouped according to function and lie
with the latter a little below the ligament. This membranous layer of
within osteofascial compartments that are defined by fascial septa
subcutaneous tissue overlies the saphenous opening, blending with its
running between the femur and an enveloping tube of thick fascia, the
circumference and with the femoral sheath. Over the opening, it is
fascia lata. The femoral artery gives off its major branch, the profunda
perforated by the long saphenous vein, by the superficial branches of
femoris artery (deep artery of the thigh), in the anterior compartment,
the femoral artery other than the superficial circumflex iliac branch
and the sciatic nerve usually divides into its main branches, the tibial
(which perforates the fascia lata separately), and lymphatic vessels;
and common fibular nerves, as it passes through the posterior compart-
hence the term cribriform fascia. The subcutaneous tissue of the buttock
ment of the thigh. The femoral nerve divides soon after entering the
is continuous superiorly with that over the low back and contains a
anterior compartment of the thigh beneath the inguinal ligament; the
variable quantity of fat.
obturator nerve enters the medial thigh proximally and medially from
the pelvis and divides into its main branches, which run anterior and Deep fascia
posterior to adductor brevis.
The deep fascia (fascia musculorum) covering the gluteal muscles varies
in thickness. Over gluteus maximus it is thin, but over the anterior two-
SKIN AND SOFT TISSUES thirds of gluteus medius it forms the thick, strong gluteal aponeurosis.
This is attached to the lateral border of the iliac crest superiorly, and
splits anteriorly to enclose tensor fasciae latae and posteriorly to enclose
SKIN
gluteus maximus.
See also Chapter 78 (p. 1316). Fascia lata
The fascia lata, the wide, deep fascia of the thigh, is thicker in the proxi-
Cutaneous vascular supply
mal and lateral parts of the thigh where tensor fasciae latae and an
and lymphatic drainage
expansion from gluteus maximus are attached to it. It is thin posteriorly
and over the adductor muscles, but thicker around the knee, where it
Buttock is strengthened by expansions from the tendon of biceps femoris lat-
Most of the skin of the buttock is supplied by musculocutaneous per- erally, sartorius medially and quadriceps femoris anteriorly. The fascia
forating vessels from the superior and inferior gluteal arteries. There lata is attached superiorly and posteriorly to the back of the sacrum and
are also small peripheral contributions from similar branches of the coccyx, laterally to the outer margin of the iliac crest, anteriorly to the
internal pudendal, iliolumbar and lateral sacral arteries. inguinal ligament and superior ramus of the pubis, and medially to the
Cutaneous veins are tributaries of vessels that correspond to the inferior ramus of the pubis, the ramus and tuberosity of the ischium,
named arteries. Cutaneous lymphatic drainage is to the superficial and the lower border of the sacrotuberous ligament. From the iliac crest,
inguinal nodes. it descends as a dense layer over gluteus medius to the upper border of
gluteus maximus, where it splits into two layers, one passing superficial
Thigh and the other deep to the muscle, the layers reuniting at the lower
The skin of the thigh distal to the inguinal ligament and gluteal fold is border of the muscle.
supplied mainly by branches of the femoral and profunda femoris
arteries. There is some contribution from the obturator, inferior gluteal Iliotibial tract
and popliteal arteries, and from direct cutaneous, musculocutaneous Over the flattened lateral surface of the thigh, the fascia lata thickens to
and fasciocutaneous vessels. For further details, consult Cormack and form a strong band, the iliotibial tract. The upper end of the tract splits
Lamberty (1994). into two layers, where it encloses and anchors tensor fasciae latae and
Cutaneous veins are tributaries of vessels that correspond to the receives, posteriorly, most of the tendon of gluteus maximus. The super-
named arteries. Cutaneous lymphatic drainage is to the superficial ficial layer ascends lateral to tensor fasciae latae to the iliac crest; the
inguinal nodes, mainly via collecting trunks accompanying the long deeper layer passes up and medially, deep to the muscle, and blends
saphenous vein. with the lateral part of the capsule of the hip joint. Distally, the iliotibial 1337 | 1,846 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
Pelvic girdle, gluteal region and thigh
1338
9 noitceS
tract is attached to a smooth, triangular facet (Gerdy’s tubercle) on the Fascial compartments
anterolateral aspect of the lateral condyle of the tibia, where it is super-
There are three functional groups of muscle in the thigh: namely, ant-
ficial to, and blends with, an aponeurotic expansion from vastus latera-
erior (extensor), posterior (flexor) and medial (adductor). The anterior
lis. When the knee is extended against resistance, it stands out as a
and posterior groups occupy separate osteofascial compartments that
strong, visible ridge on the anterolateral aspect of the thigh and knee.
are limited peripherally by the fascia lata and separated from each other
Distally, the fascia lata is attached to all exposed bony points around
by the femur and the medial and lateral intermuscular septa (Fig. 80.2).
the knee joint, such as the condyles of the femur and tibia, and the
The adductor muscles do not possess a separate compartment limited
head of the fibula. On each side of the patella, the deep fascia is re-
by fascial planes. Nevertheless, it is customary to speak of three com-
inforced by transverse fibres, which receive contributions from the
partments: anterior, posterior and medial. The muscles of the three
lateral and medial vasti. The stronger lateral fibres are continuous with
compartments are described below. Adductor magnus, adductor longus
the iliotibial tract.
and pectineus could each be considered to be constituents of two com-
partments, i.e. adductor magnus in the posterior and the medial com-
Intermuscular septa
partments, and adductor longus and pectineus in the anterior and the
The deep surface of the fascia lata yields two intermuscular septa, which
medial compartments.
are attached to the whole of the linea aspera and to its proximal and
The nerve supply to the compartments of the thigh mainly follows
distal prolongations. The lateral septum, thicker and stronger than the
the ‘one compartment – one nerve’ principle. Thus, the femoral nerve
medial one, extends from the attachment of gluteus maximus to the
supplies the anterior compartment muscles, the obturator nerve sup-
lateral femoral condyle; it lies between vastus lateralis in front and
plies the medial compartment muscles, and the sciatic nerve supplies
the short head of biceps femoris behind, and provides partial attach-
those in the posterior compartment. The dual functional and compart-
ment for them. The medial, thinner and weaker septum lies between
mental attribution of adductor magnus, adductor longus and pectineus
vastus medialis and the adductors and pectineus. Numerous smaller
are reflected in their dual nerve supplies.
septa, such as that separating the thigh adductors and flexors, pass
In contrast to the motor innervation, the arterial supply to the com-
between the individual muscles, ensheathing them and sometimes
partmental muscle groups does not exhibit such a direct relationship.
providing partial attachment for their fibres.
All groups receive a supply from the femoral system, particularly from
the profunda femoris artery and its branches. The adductors receive a
Saphenous opening
contribution from the obturator artery, and the hamstrings receive a
The saphenous opening is an aperture in the deep fascia, inferolateral
proximal supply from the inferior gluteal artery. Further details are
to the medial end of the inguinal ligament, which allows passage for
given in the descriptions of the individual muscles.
the long saphenous vein and other smaller vessels (Fig. 80.1). The
cribriform fascia, which is pierced by these structures, fills in the aper- Femoral sheath
ture and must be removed to reveal it. Adjacent subsidiary openings
The femoral sheath is a funnel-shaped distal prolongation of extraperi-
may exist to transmit venous tributaries. In the adult, the approximate
toneal fascia, formed of transversalis fascia anterior to the femoral
centre of the saphenous opening is 3 cm lateral to a point just distal to
vessels, and of the iliac fascia posteriorly. It is wider proximally and its
the pubic tubercle. The length and width of the opening vary consider-
tapered distal end fuses with the vascular adventitia 3 or 4 cm distal to
ably. The fascia lata in this part of the thigh displays superficial and
the inguinal ligament. At birth the sheath is shorter; it elongates when
deep strata (not to be confused with the superficial and deep layers of
extension at the hips becomes habitual. The femoral branch of the
the subcutaneous tissue described above). They lie, respectively, anterior
genitofemoral nerve perforates its lateral wall. The medial wall slopes
and posterior to the femoral sheath, with the saphenous opening situ-
laterally and is pierced by the long saphenous vein and lymphatic
ated where the two layers are in continuity. This serves to explain the
vessels. Like the carotid sheath, the femoral sheath encloses a mass of
somewhat oblique and spiral configuration of the saphenous opening.
connective tissue in which the vessels are embedded. Three compart-
The superficial layer, lateral and superior to the saphenous opening,
ments are described: a lateral one containing the femoral artery; an
is attached, in continuity, to the crest and anterior superior spine of the
intermediate one for the femoral vein; and a medial compartment, the
ilium, to the whole length of the inguinal ligament, and to the pecten
femoral canal, which contains lymph vessels and an occasional lymph
pubis and lacunar ligament. It is reflected inferolaterally from the pubic
node embedded in areolar tissue. The presence of this canal allows the
tubercle as the arched falciform margin, which forms the superior,
femoral vein to distend. The canal is conical and approximately 1.25 cm
lateral and inferior boundaries of the saphenous opening; this margin
in length. Its proximal (wider) end, termed the femoral ring, is bounded
adheres to the anterior layer of the femoral sheath, and the cribriform
in front by the inguinal ligament, behind by pectineus and its fascia
fascia is attached to it. The falciform margin is considered to have
and the pectineal ligament, medially by the crescentic, lateral edge of
superior and inferior horns. The inferior horn is well defined, and is
the lacunar ligament and laterally by the femoral vein. The spermatic
continuous behind the long saphenous vein with the deep stratum of
cord, or the round ligament of the uterus, is just above its anterior
the fascia lata.
margin, while the inferior epigastric vessels are near its anterolateral
The deep layer is medial to the saphenous opening and is continu-
rim. It is larger in women than in men: this is due partly to the relatively
ous with the superficial stratum at its lower margin. Traced upwards,
greater width of the female pelvis and partly to the smaller size of the
it covers pectineus, adductor longus and gracilis, passes behind the
femoral vessels in women. The ring is filled by condensed extraperito-
femoral sheath, with which it blends, and continues to the pecten pubis.
neal tissue, the femoral septum, which is covered on its proximal aspect
by the parietal peritoneum. Numerous lymph vessels that connect the
deep inguinal to the external iliac lymph nodes traverse the femoral
Psoas major Iliacus
septum (Fig. 80.3).
Femoral nerve
Psoas minor tendon Femoral hernia
Inguinal ligament Femoral hernia is described with other groin hernias on page 1081.
Iliopectineal arch
Deep inguinal iliac fascia
lymph node
The iliac fascia covers psoas and iliacus. It is thin above but thickens
Fascia lata
Superficial circumflex progressively towards the inguinal ligament. The part covering psoas is
iliac vein thickened above as the medial arcuate ligament. Medially, the fascia
Superficial Saphenous over psoas is attached by a series of fibrous arches to the intervertebral
epigastric vein opening discs, the margins of vertebral bodies, and the upper part of the sacrum.
Laterally, it blends with the fascia anterior to quadratus lumborum
E pux dte er nn da al l veins Femoral vein above the iliac crest, and with the fascia covering iliacus below the crest.
The iliac part is connected laterally to the whole of the inner lip of
Long saphenous the iliac crest and medially to the pelvic brim, where it blends with the
vein periosteum. It is attached to the iliopubic ramus, where it receives a slip
from the tendon of psoas minor, when this muscle is present. The
external iliac vessels are anterior to the fascia but the branches of the
Fig. 80.1 The saphenous opening following removal of the cribriform lumbar plexus are posterior to it. The fascia is separated from the peri-
fascia. (With permission from Waschke J, Paulsen F (eds), Sobotta Atlas toneum by loose extraperitoneal tissue. Lateral to the femoral vessels,
of Human Anatomy, 15th ed, Elsevier, Urban & Fischer. Copyright 2013.) the iliac fascia is continuous with the posterior margin of the inguinal | 1,847 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
Bones
1339
08
retPahc
A Fig. 80.2 A transverse (axial)
section through the thigh.
A, At the level of the apex of
Rectus femoris the femoral triangle. B, At
the level of the mid-thigh.
Sartorius Vastus lateralis
Branches of femoral nerve
Long saphenous vein
Vastus intermedius
Femoral artery Femur
Femoral vein
Adductor longus Vastus medialis
Profunda femoris artery and veins
Adductor brevis
Obturator nerve Adductor magnus
Gracilis
Sciatic nerve
Semimembranosus Gluteus maximus
Biceps femoris (long head)
and semitendinosus
B
Rectus femoris Vastus lateralis
Vastus medialis
Vastus intermedius
Nerve to vastus medialis
Saphenous nerve
Femur
Femoral artery in adductor canal
Sartorius
Profunda femoris artery
Femoral vein
Long saphenous vein Biceps femoris (short head)
Gracilis
Sciatic nerve
Biceps femoris (long head)
Adductor longus
Semitendinosus
Adductor magnus
Semimembranosus Posterior femoral cutaneous nerve
ligament and the transversalis fascia. Medially, it passes behind the
BONES
femoral vessels to become the pectineal ligament, attached to the pecten
pubis. At the junction of its lateral and medial parts, it is attached to
the iliopubic ramus and the capsule of the hip joint. It thus forms a The pelvic girdle is an entity consisting of the two hip bones and the
septum between the inguinal ligament and the hip bone, dividing the sacrum (strictly speaking, the sacrum is part of the vertebral column).
space here into a lateral part, the muscular space, containing psoas The pelvic girdle is massively constructed and serves as a weight-bearing
major, iliacus and the femoral nerve, and a medial part, the vascular and protective structure, an attachment for trunk and limb muscles, and
space, transmitting the femoral vessels (see Fig. 80.3). The iliac fascia as the skeletal framework of the birth canal.
continues downwards to form the posterior wall of the femoral sheath.
obturator membrane HIP BONE
The obturator membrane (Fig. 80.4) is a thin aponeurosis that closes
(obturates) most of the obturator foramen, leaving a superolateral aper- The hip bone is large, irregular, constricted centrally and expanded
ture, the obturator canal, through which the obturator vessels and nerve above and below (Fig. 80.5). Its lateral surface has a deep, cup-shaped
leave the pelvis and enter the thigh. The membrane is attached to the acetabulum, articulating with the femoral head, anteroinferior to which
sharp margin of the obturator foramen except at its inferolateral angle, is the large, oval or triangular obturator foramen. Above the acetabu-
where it is fixed to the pelvic surface of the ischial ramus, i.e. internal lum, the bone widens into an undulant plate surmounted by a sinu-
to the foramen. Its fibres are arranged mainly transversely in interlacing ously curved iliac crest.
bundles; the uppermost bundle, which is attached to the obturator The bone articulates in front with its fellow and posteriorly with the
tubercles, completes the obturator canal. The outer and inner surfaces side of the sacrum to form the pelvic girdle. Each hip bone has three
of the obturator membrane provide attachment for the obturator exter- parts – ilium, ischium and pubis, connected to each other by cartilage
nus and internus, respectively. Some fibres of the pubofemoral ligament in youth but united as one bone in adults. The principal union is in
of the hip joint are attached to the outer surface. the acetabulum. The ilium includes the upper acetabulum and expanded | 1,848 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
Pelvic girdle, gluteal region and thigh
1340
9
noitceS
Fig. 80.3 Structures
passing beneath the
inguinal ligament. (With
Femoral branch of genitofemoral nerve Lateral femoral cutaneous nerve permission from Waschke
J, Paulsen F (eds),
Femoral artery and vein Anterior superior iliac spine Sobotta Atlas of Human
Anatomy, 15th ed,
Inguinal ligament
Elsevier, Urban & Fischer.
Deep inguinal lymph node
Iliopsoas Copyright 2013.)
Femoral nerve
Lacunar ligament
Iliopectineal arch
Spermatic cord (cut)
Pectineal ligament
Pubic tubercle
Pectineus
Pubic symphysis
Obturator membrane
Obturator artery and vein
Obturator canal
Obturator nerve
obturator foramen
The obturator foramen lies below and slightly anterior to the acetabu-
Pectineal ligament Inguinal ligament
lum, between the pubis and ischium. It is bordered above by the
Lacunar ligament grooved obturator surface of the superior pubic ramus, medially by the
pubic body and its inferior ramus, below by the ischial ramus, and later-
Interpubic disc ally by the anterior border of the ischial body, including the margin of
the acetabulum. The foramen is almost closed by the obturator mem-
Cavity in interpubic disc
brane (see above), which is attached to its margins, except superolat-
erally, where a communication remains between the pelvis and thigh.
This free edge of the membrane is attached to an anterior obturator
tubercle at the anterior end of the inferior border of the superior pubic
Acetabular labrum ramus, and a posterior obturator tubercle on the anterior border of
the acetabular notch; these tubercles are sometimes indistinct. Since
the tubercles lie in different planes and the obturator groove crosses the
upper border of the foramen, the acetabular margin is in fact a spiral.
The foramen is large and oval in males, but smaller and nearly triangu-
Transverse acetabular
ligament lar in females.
Structure
The thicker parts of the hip bone are trabecular, encased by two layers
of compact bone, while the thinner parts, as in the acetabulum and
Obturator canal central iliac fossa, are often translucent and consist of a single lamina
of compact bone. In the upper acetabulum and along the arcuate line,
Obturator membrane
i.e. the route of weight transmission from the sacrum to the femur, the
amount of compact bone is increased and the subjacent trabecular bone
Fig. 80.4 An anterolateral view of left bony pelvis, showing associated displays two sets of pressure lamellae. These start together near the
ligaments and the obturator membrane. upper auricular surface and diverge to meet two strong buttresses of
compact bone, from which two similar sets of lamellar arches start and
converge on the acetabulum. The anterior part of the iliac crest has been
much studied with regard to distribution of cortical and trabecular
area above it; the ischium includes the posteroinferior acetabulum and bone. Whitehouse (1977) described the cortical bone as very porous,
bone posteroinferior to it; the pubis forms the anteroinferior being only 75% bone, decreasing to 35% near the anterior superior iliac
acetabulum. spine.
Studies of the internal stresses within the hip bone have revealed a
acetabulum
pattern of trabeculae that corresponds well with the theoretically
The acetabulum (Fig. 80.5A,C) is an approximately hemispherical expected patterns of stress trajectories (Holm 1980). These patterns
cavity situated about the centre of the lateral aspect of the hip bone. It are considerably more complex than in any other major bone. Stresses
faces anteroinferiorly and is circumscribed by an irregular margin defi- are higher in the acetabular than in the iliac region. In the ilium, the
cient inferiorly at the acetabular notch. The acetabular fossa forms the pelvic surface is subjected to considerably less stress than is the gluteal
central floor and is rough and non-articular. The articular lunate surface surface.
is widest above (the ‘dome’), where weight is transmitted to the femur.
Consequently, fractures through this region tend to be associated with Muscle attachments
unsatisfactory outcomes. All three components of the hip bone contrib- See individual bones.
ute to the acetabulum, although unequally. The pubis forms the antero-
superior fifth of the articular surface, the ischium forms the floor of the vascular supply
fossa and rather more than the posteroinferior two-fifths of the articular In the infant, nutrient arteries are clearly demonstrable for each com-
surface, and the ilium forms the remainder. Occasionally, a linear defect ponent of the hip bone. Each nutrient artery branches in a fan-like
may be seen to cross the acetabular surface from the superior border to fashion within its bone of supply (Crock 1996). Later, a periosteal art-
the acetabular fossa. This does not correspond to any junction between erial network develops, with contributions from numerous local arteries
the main morphological parts of the hip bone. (see under individual bones). | 1,849 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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A
Inner lip
Intermediate zone
Iliac crest
Outer lip
Ala of ilium
Tubercle of iliac crest
Anterior gluteal line
Ala of ilium Inferior gluteal line Gluteal surface
Anterior superior iliac spine
Posterior gluteal line
Posterior superior iliac spine
Body of ilium
Anterior inferior iliac spine
Posterior inferior iliac spine
Supra-acetabular groove
Greater sciatic notch
Lunate surface
Acetabular margin
Acetabular fossa
Pecten pubis Acetabular notch
(pectineal line)
Ischial spine
Pubic tubercle Lesser sciatic notch
Oburator crest
Body of ischium
Inferior pubic ramus
Anterior obturator tubercle
Ischial tuberosity
Obturator foramen
B
Ramus of ischium
Iliac crest
Intermediate zone
Ala of ilium
Inner lip
Sacropelvic
surface
Iliac fossa
Iliac tuberosity Anterior superior
iliac spine
Auricular surface
Posterior superior
iliac spine
Anterior inferior
Posterior inferior iliac spine
iliac spine
Arcuate line
Greater sciatic notch
Iliopubic ramus
Body of ischium Obturator groove
Superior pubic ramus,
Ischial spine pecten pubis (pectineal line)
C Lesser sciatic notch
Obturator foramen
Ischial tuberosity
Symphysial surface
Inner lip
Ramus of ischium
Intermediate zone
Iliac tuberosity Iliac crest Inferior pubic ramus
Ala of ilium
Outer lip
Sacropelvic surface
Iliac fossa
Anterior superior iliac spine
Auricular surface
Body of ilium
Iliopubic ramus Supra-acetabular groove
Body of pubis Anterior inferior iliac spine
Superior pubic ramus
Obturator crest
Pecten pubis Acetabular margin
(pectineal line) Lunate surface
Acetabulum
Pubic tubercle Acetabular fossa
Acetabular notch
Pubic crest
Symphysial Body of ischium
surface
Obturator foramen
Inferior pubic ramus
Ramus of ischium Ischial tuberosity
Fig. 80.5 The left hip bone. A, Outer aspect. B, Inner aspect. C, Anterosuperior view. (With permission from Waschke J, Paulsen F (eds), Sobotta Atlas
of Human Anatomy, 15th ed, Elsevier, Urban & Fischer. Copyright 2013.) | 1,850 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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innervation conjoined ischial and pubic rami, and continues to the pubic symphy-
Periosteal innervation is by a network of nerves derived from branches sial surface and along the pubic crest to the pubic tubercle.
of local nerves. These nerves also supply muscles attaching to the peri- The ossifying ischium and pubis fuse to form a continuous ischio-
osteum and the joints involving the hip bone. Autonomic nerves pubic ramus at the seventh or eighth year. Secondary centres, other than
accompany nutrient arteries and branch within the bone. for the acetabulum, appear at about puberty and fuse between the fif-
teenth and twenty-fifth years. There are usually two for the iliac crest
ossification (which fuse early), and single centres for the ischial tuberosity (in car-
Ossification (Figs 80.6–80.7) is by three primary centres: one each for tilage close to the inferior acetabular margin and spreading forwards),
the ilium, ischium and pubis. The iliac centre appears above the greater anterior inferior iliac spine (although it may ossify from the triradiate
sciatic notch prenatally at about the ninth week; the ischial centre in cartilage) and symphysial surface of the pubis (the pubic tubercle and
its body in the fourth month; and the pubic centre in its superior ramus crest may have separate centres). Progression of ossification of the iliac
between the fourth and fifth months. The pubis is often not recovered crest in girls is an index of skeletal maturity and is useful in determining
from prenatal remains due to its size and fragility and because it is the the optimal timing of surgery for spinal deformity.
last of the hip bones to begin ossification (Scheuer and Black 2004). At Between the ages of 8 and 9 years, three major centres of ossification
birth the whole iliac crest, the acetabular floor and the inferior margin appear in the acetabular cartilage. The largest appears in the anterior
are cartilaginous. Gradual ossification of the three components of the wall of the acetabulum and fuses with the pubis, the second in the iliac
acetabulum results in a triradiate cartilaginous stem extending medially acetabular cartilage superiorly, fusing with the ilium, and the third in
to the pelvic surface as a Y-shaped epiphysial plate between the ilium, the ischial acetabular cartilage posteriorly, fusing with the ischium. At
ischium and pubis, and including the anterior inferior iliac spine. Car- puberty, these epiphyses expand towards the periphery of the acetabu-
tilage along the inferior margin also covers the ischial tuberosity, forms lum and contribute to its depth (Ponseti 1978). Fusion between the
three bones within the acetabulum occurs between the sixteenth and
eighteenth years. Delaere et al (1992) have suggested that ossification
A B of the ilium is similar to that of a long bone, possessing three cartilagi-
nous epiphyses and one cartilaginous process, although it tends to
Ilium
undergo osteoclastic resorption comparable with that of cranial bones.
During development, the acetabulum increases in breadth at a faster
rate than it does in depth.
Avulsion fractures of pelvic apophyses may occur from excessive pull
on tendons, usually in athletic adolescents. The most frequent examples
of such injuries are those to the ischial tuberosity (hamstrings) and
anterior inferior iliac spine (rectus femoris).
Iliac crest Pubis
Acetabulum
The pubis (see Figs 80.5–80.6) is the ventral part of the hip bone and
Pubis forms a median cartilaginous pubic symphysis with its fellow. The body
of the pubis occupies the anteromedial part of the bone, and from the
body a superior ramus passes up and back to the acetabulum and an
inferior ramus passes back, down and laterally to join the ischial ramus
inferomedial to the obturator foramen.
Body
Ischial The body, anteroposteriorly compressed, has anterior, posterior and
tuberosity symphysial (medial) surfaces and an upper border, the pubic crest. The
Ischium anterior surface also faces inferolaterally; it is rough superomedially and
smooth elsewhere, giving attachment to medial thigh muscles. The
Unossified (cartilaginous) regions
smooth posterior surface faces upwards and backwards as the oblique
Fig. 80.6 The hip bone. A, At birth. B, In adolescence; more heavily anterior wall of the lesser pelvis and is related to the urinary bladder.
stippled areas indicate the secondary centres of ossification. The symphysial surface is elongated and oval, united by cartilage to its
fellow at the pubic symphysis. Denuded of cartilage, it has an irregular
surface of small ridges and furrows or nodular elevations, varying con-
siderably with age, features that are of forensic interest. The pubic crest
is the rounded upper border of the body and overhangs the anterior
surface; the pubic tubercle is a small rounded eminence on its lateral
end. Both crest and tubercle are palpable; the latter partly is obscured
1 in males by the spermatic cord that crosses above it from the scrotum
to the anterior abdominal wall. The pubic rami diverge posterolaterally
from the superolateral corners of the body.
The anterior surface of the pubic body faces the adductor region. The
2
anterior pubic ligament attaches to its medial part along a rough strip,
3 which is wider in females. The posterior surface is separated from the
urinary bladder by retropubic fat. The puboprostatic ligaments are
4
attached to this surface medial to levator ani.
5 Superior pubic ramus
4 7 The superior pubic ramus passes upwards, backwards and laterally from
the body, superolateral to the obturator foramen, to reach the acetabu-
8
6 lum. It is triangular in section and has three surfaces and borders. Its
anterior, pectineal surface, tilted slightly up, is triangular in outline and
extends from the pubic tubercle to the iliopubic ramus. It is bounded
in front by the rounded obturator crest and behind by the sharp pecten
pubis (pectineal line), which, with the crest, is the pubic part of the
linea terminalis (i.e. anterior part of the pelvic brim). The posterosupe-
rior, pelvic surface, medially inclined, is smooth and narrows into the
Fig. 80.7 An anteroposterior radiograph of the pelvis of a boy aged posterior surface of the body, which is bounded above by the pecten
7 years. Key: 1, ilium; 2, part of triradiate growth cartilage; 3, superior pubis and below by a sharp inferior border. The obturator surface,
femoral epiphysis; 4, cartilaginous growth plates; 5, ossifying greater directed down and back, is crossed by the obturator groove sloping
trochanter; 6, ischium; 7, pubis; 8, cartilage between inferior pubic and down and forwards. Its anterior limit is the obturator crest and its pos-
ischial rami. terior limit is the inferior border. | 1,851 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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inferior pubic ramus sacropelvic and iliac (internal) surfaces. The posterolateral gluteal
The inferior pubic ramus, an inferolateral process of the body, descends surface is an extensive rough area; the anteromedial iliac fossa is smooth
inferolaterally to join the ischial ramus medial to, and below, the obtu- and concave; and the sacropelvic surface is medial and posteroinferior
rator foramen. The union may be locally thickened, but not obviously to the fossa, from which it is separated by the medial border.
so in adults. The ramus has two surfaces and borders. The anterolateral
iliac crest
surface, continuous above with that of the pubic body, faces the thigh
and is marked by muscles. It is limited laterally by the margin of the The iliac crest is the superior border of the ilium. It is convex upwards
obturator foramen, and medially by the rough anterior border. The but sinuous from side to side, being internally concave in front and
posteromedial surface is continuous above with that of the body and convex behind. Its ends project as anterior and posterior superior iliac
is transversely convex; its medial part is often everted in males and gives spines. The anterior superior iliac spine is palpable at the lateral end of
attachment to the crus of the penis. This surface faces the perineum the inguinal fold; the lateral end of the inguinal ligament is attached
medially, its smooth lateral part tilted up towards the pelvic cavity. to the anterior superior iliac spine. The posterior superior iliac spine is
The internal surface is indistinctly divided into medial, intermediate not palpable but is often indicated by a dimple, approximately 4 cm
and lateral areas. The medial area faces inferomedially in direct contact lateral to the second sacral spinous process, above the medial gluteal
with the crus of the penis or clitoris and is limited above and behind region.
by an indistinct ridge for attachment of the fascia overlying the super- The iliac crest has ventral and dorsal segments. The ventral segment
ficial perineal muscles. The medial margin of the ramus, strongly occupies slightly more than the anterior two-thirds of the iliac crest and
everted in males, provides attachment for the fascia lata and the stratum its prominence is associated with changes in iliac form as a result of the
membranosum perinei. emergence of the upright posture. It has internal and external lips and
a rough intermediate zone that is narrowest centrally. The dorsal
Pubic tubercle segment, which occupies approximately the posterior one-third in
The pubic tubercle provides attachment to the medial end of the humans, is a feature of all land vertebrates. It has two sloping surfaces
inguinal ligament. It forms part of the floor of the superficial inguinal separated by a longitudinal ridge ending at the posterior superior spine.
ring and is crossed by the spermatic cord. The interosseous and posterior sacroiliac ligaments arise from the
medial margin of the dorsal segment. The tubercle of the iliac crest
Pecten pubis projects outwards from the outer lip approximately 5 cm posterosupe-
The pecten pubis is the sharp, superior edge of the pectineal surface. rior to the anterior superior spine. The summit of the iliac crest, a little
The conjoint tendon (inguinal falx) and lacunar ligament are attached behind its midpoint, is level with the fourth lumbar vertebral body in
at its medial end and a strong, fibrous pectineal ligament is attached adults and with the fifth lumbar vertebral body in children aged 10 years
along the rest of its surface. The smooth pelvic surface is separated from or less (Tame and Burstal 2003).
parietal peritoneum only by areolar tissue, in which the lateral umbili-
anterior border
cal ligament descends forwards across the ramus and, laterally, the vas
deferens (ductus deferens) passes backwards. The obturator groove, The anterior border descends to the acetabulum from the anterior
which is converted to a canal by the upper borders of the obturator superior spine. Superiorly it is concave forwards. Inferiorly, immediately
membrane and obturator muscles, transmits the obturator vessels and above the acetabulum, is a rough anterior inferior iliac spine, which is
nerve from the pelvis to the thigh. Some fibres of the pubofemoral liga- divided indistinctly into an upper area for the straight head of rectus
ment are attached to the lateral end of the obturator crest. femoris and a lower area extending laterally along the upper acetabular
margin to form a triangular impression for the proximal end of the
Muscle attachments iliofemoral ligament.
The tendon of adductor longus is attached on the anterior (external)
surface of the body, below the pubic crest. Below adductor longus, Posterior border
gracilis is attached to a line near the lower margin extending down on The posterior border is irregularly curved and descends from the pos-
to the inferior ramus. Above gracilis, adductor brevis is attached to the terior superior spine, at first forwards, with a posterior concavity forming
body and inferior ramus. Above again, obturator externus is attached a small notch. At the lower end of the notch is a wide, low projection:
to the anterior surface, spreading on to inferior pubic and ischial rami. the posterior inferior iliac spine. Here the border turns almost horizont-
Adductor magnus usually extends from the ischial ramus on to the ally forwards for approximately 3 cm, then down and back to join the
lower part of the inferior pubic ramus between adductor brevis and posterior ischial border. Together these borders form a deep notch, the
obturator externus. Pectineus is attached to the pectineal surface of the greater sciatic notch, which is bounded above by the ilium and below
superior ramus along its upper part. Ascending loops of cremaster are by the ilium and ischium. The upper fibres of the sacrotuberous liga-
attached to the pubic tubercle. The lateral part of rectus abdominis and, ment are attached to the upper part of the posterior border. The superior
inferiorly, pyramidalis, are attached lateral to the tubercle, on the pubic rim of the notch is related to the superior gluteal vessels and nerve. The
crest. Medially, the crest is crossed by the medial part of rectus abdominis, lower margin of the greater sciatic notch is covered by piriformis and
ascending from ligamentous fibres that interlace in front of the pubic is related to the sciatic nerve.
symphysis. Anterior fibres of levator ani are attached on the posterior
(internal) surface of the body near its centre. More laterally, obturator Medial border
internus is attached on this surface, extending on to both rami. Psoas The medial border separates the iliac fossa and the sacropelvic surface.
minor, when present, is attached near the centre of the pecten pubis. It is indistinct near the crest, rough in its upper part, then sharp where
it bounds an articular surface for the sacrum, and finally rounded.
vascular supply The latter part is the arcuate line, which inferiorly reaches the poste-
The pubis is supplied by a periosteal anastomosis of branches from the rior part of the iliopubic ramus, marking the union of the ilium and
obturator, inferior epigastric and medial circumflex femoral arteries. pubis.
The superficial and deep external pudendal arteries may also contribute.
Multiple vascular foramina are present, mainly at the lateral (acetabu- gluteal surface
lar) end of the bone, but there is no consistently placed nutrient The gluteal surface, facing inferiorly in its posterior part and laterally
foramen. and slightly downwards in front, is bounded above by the iliac crest,
and below by the upper acetabular border and by the anterior and
innervation
posterior borders. It is rough and curved, convex in front, concave
The pubic periosteum is innervated by branches of the nerves that behind, and marked by three gluteal lines. The posterior gluteal line is
supply muscles attached to the bone, the hip joint and the symphysis shortest, descending from the external lip of the crest approximately
pubis. 5 cm in front of its posterior limit and ending in front of the posterior
inferior iliac spine. Above, it is usually distinct, but inferiorly it is poorly
ossification defined and frequently absent. The anterior gluteal line, the longest,
Ossification of the pubis is described on page 1342. begins near the midpoint of the superior margin of the greater sciatic
notch and ascends forwards into the outer lip of the crest, a little anter-
Ilium
ior to its tubercle. The inferior gluteal line, seldom well marked, begins
posterosuperior to the anterior inferior iliac spine, curving posteroinfe-
The ilium has upper and lower parts and three surfaces (see Figs 80.5, riorly to end near the apex of the greater sciatic notch. Between the
80.6). The smaller, lower part forms a little less than the upper two-fifths inferior gluteal line and the acetabular margin is a rough, shallow
of the acetabulum. The upper part is much expanded, and has gluteal, groove. Behind the acetabulum, the lower gluteal surface is continuous | 1,852 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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with the posterior ischial surface, the conjunction marked by a low upper fibres of gluteus maximus and the lower, smooth region to part
elevation. of the sacrotuberous ligament and iliac head of piriformis. Gluteus
The articular capsule is attached to an area adjoining the acetabular medius is attached between the posterior and anterior lines, below the
margin, most of which is covered by gluteus minimus. Posteroinferiorly, iliac crest, and gluteus minimus is attached between the anterior and
near the union of the ilium and ischium, the bone is related to inferior lines. The fourth area, below the inferior line, contains vascular
piriformis. foramina.
The reflected head of rectus femoris attaches to a curved groove
iliac fossa above the acetabulum. Iliacus is attached to the upper two-thirds of the
The iliac fossa, the internal concavity of the ilium, faces anterosuperi- iliac fossa and is related to its lower one-third. The medial part of
orly. It is limited above by the iliac crest, in front by the anterior border quadratus lumborum is attached to the anterior part of the sacropelvic
and behind by the medial border, separating it from the sacropelvic surface, above the iliolumbar ligament. Piriformis is sometimes partly
surface. It forms the smooth and gently concave posterolateral wall of attached lateral to the pre-auricular sulcus, and part of obturator int-
the greater pelvis. Below it is continuous with a wide shallow groove, ernus is attached to the more extensive remainder of the pelvic surface.
bounded laterally by the anterior inferior iliac spine and medially by
the iliopubic ramus. vascular supply
The converging fibres of iliacus occupy the wide groove between Branches of the iliolumbar artery run between iliacus and the ilium;
the anterior inferior iliac spine and the iliopubic ramus laterally and one or more enter large nutrient foramina lying posteroinferiorly in the
the tendon of psoas major medially; the tendon is separated from the iliac fossa. The superior gluteal, obturator and superficial circumflex
underlying bone by a bursa. The right iliac fossa contains the caecum, iliac arteries contribute to the periosteal supply. The obturator artery
and often the vermiform appendix and terminal ileum. The left iliac may supply a nutrient branch. Vascular foramina on the ilium underly-
fossa houses the terminal part of the descending colon and the proxi- ing the gluteal muscles may lead into large vascular canals in the bone.
mal sigmoid colon.
innervation
Sacropelvic surface The periosteum is innervated by branches of nerves that supply muscles
The sacropelvic surface, the posteroinferior part of the medial iliac attached to the bone, the hip joint and the sacroiliac joint.
surface, is bounded posteroinferiorly by the posterior border, antero-
ossification
superiorly by the medial border, posterosuperiorly by the iliac crest and
anteroinferiorly by the line of fusion of the ilium and ischium. It is Ossification of the ilium is described on page 1342.
divided into iliac tuberosity and auricular and pelvic surfaces. The iliac
tuberosity, a large, rough area below the dorsal segment of the iliac crest, Ischium
shows cranial and caudal areas separated by an oblique ridge and con-
nected to the sacrum by the interosseous sacroiliac ligament. The sac- The ischium, the inferoposterior part of the hip bone, has a body and
ropelvic surface gives attachment to the posterior sacroiliac ligaments ramus. The body has upper and lower ends and femoral, posterior and
and, behind the auricular surface, to the interosseous sacroiliac liga- pelvic surfaces (see Figs 80.5–80.7). Above, it forms the posteroinferior
ment. The iliolumbar ligament is attached to its anterior part. The part of the acetabulum; below, its ramus ascends anteromedially at an
auricular surface, immediately anteroinferior to the tuberosity, articu- acute angle to meet the inferior pubic ramus, thereby completing the
lates with the lateral sacral mass. Shaped like an ear, its widest part is boundary of the obturator foramen. The ischiofemoral ligament is
anterosuperior, and its ‘lobule’ posteroinferior and on the medial aspect attached to the lateral border below the acetabulum (Fuss and Bacher
of the posterior inferior spine. Its edges are well defined but the surface, 1991).
though articular, is rough and irregular. It articulates with the sacrum The femoral surface faces downwards, forwards and laterally towards
and is reciprocally shaped. The anterior sacroiliac ligament is attached the thigh. It is bounded in front by the margin of the obturator foramen.
to its sharp anterior and inferior borders. The narrow part of the pelvic The lateral border, indistinct above but well defined below, forms the
surface, between the auricular surface and the upper rim of the greater lateral limit of the ischial tuberosity. At a higher level, the femoral
sciatic notch, often shows a rough pre-auricular sulcus (that is usually surface is covered by piriformis, from which it is partially separated by
better defined in females) for the lower fibres of the anterior sacroiliac the sciatic nerve and the nerve to quadratus femoris. The posterior
ligament. For the reliability of this feature as a sex discriminant, refer surface, facing superolaterally, is continuous above with the iliac gluteal
to Finnegan (1978) and Brothwell and Pollard (2001). The pelvic surface, and here a low convexity follows the acetabular curvature.
surface is anteroinferior to the acutely curved part of the auricular Inferiorly, this surface forms the upper part of the ischial tuberosity,
surface, and contributes to the lateral wall of the lesser pelvis. Its upper above which is a wide, shallow groove on its lateral and medial aspects.
part, facing down, is between the auricular surface and the upper limb Above the ischial tuberosity, the posterior surface is crossed by the
of the greater sciatic notch. Its lower part faces medially and is separated tendon of obturator internus and the gemelli. The nerve to quadratus
from the iliac fossa by the arcuate line. Anteroinferiorly, it extends to femoris lies between these structures and the ischium. The ischial tuber-
the line of union between the ilium and ischium. Though usually osity is a large, rough area on the lower posterior surface and inferior
obliterated, it passes from the depth of the acetabulum to approxi- extremity of the ischium. Though obscured by gluteus maximus in hip
mately the middle of the inferior limb of the greater sciatic notch. extension, it is palpable in hip flexion. It is 5 cm from the midline and
about the same distance above the gluteal fold. It is elongated and
Muscle attachments widest above, and tapers inferiorly. The ischial posterior aspect lies
The attachment of sartorius extends down the anterior border below the between the lateral and posterior borders. The posterior border blends
anterior superior iliac spine. The iliac crest gives attachment to the ant- above with that of the ilium, helping to complete the inferior rim of
erolateral and dorsal abdominal muscles, and to the fasciae and muscles the greater sciatic foramen, the posterior end of which has a conspicu-
of the lower limb. The fascia lata and iliotibial tract are attached to the ous ischial spine. Below this, the rounded border forms the floor of the
outer lip and tubercle of its ventral segment. Tensor fasciae latae is lesser sciatic foramen, between the ischial spine and tuberosity. The
attached anterior to the tubercle. The lower fibres of external oblique pelvic surface is smooth and faces the pelvic cavity; inferiorly, it forms
and, just behind the summit of the crest, the lowest fibres of latissimus part of the lateral wall of the ischio-anal fossa.
dorsi are attached to its anterior two-thirds. A variable interval exists
between the most posterior attachment of external oblique and the most ischial ramus
anterior attachment of latissimus dorsi, and here the crest forms the base The ischial ramus has anteroinferior and posterior surfaces continuous
of the lumbar triangle through which herniation of abdominal contents with the corresponding surfaces of the inferior pubic ramus. The antero-
may rarely occur. Internal oblique is attached to the intermediate area of inferior surface is roughened by the attachment of the medial thigh
the crest. Transversus abdominis is attached to the anterior two-thirds of muscles. The smooth posterior surface is partly divided into perineal
the inner lip of the crest, and behind this to the thoracolumbar fascia and pelvic areas, like the inferior pubic ramus. The upper border com-
and quadratus lumborum. The highest fibres of gluteus maximus are pletes the obturator foramen; the rough lower border, together with the
attached to the dorsal segment of the crest on its lateral slope. Erector medial border of the inferior pubic ramus, contributes to the pubic
spinae arises from the medial slope of the dorsal segment. The straight arch. The fascia overlying the superficial muscles of the perineum is
head of rectus femoris is attached to the upper area of the anterior infe- attached below the ridge between the perineal and pelvic areas of the
rior spine. Some fibres of piriformis are attached in front of the posterior posterior surface of the ischial ramus. Above the ridge, areas give attach-
inferior spine on the upper border of the greater sciatic foramen. ment to the crus of the penis or clitoris and the external urethral
The gluteal surface is divided by three gluteal lines into four areas. sphincter. The lower border of the ramus provides an attachment for
Behind the posterior line, the upper rough part gives attachment to the the fascia lata and the stratum membranosum perinei. | 1,853 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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ischial tuberosity
The ischial tuberosity is divided nearly transversely into upper and L4 vertebra
lower areas. The upper area is subdivided by an oblique line into Sacroiliac
superolateral and inferomedial parts. The lower area, narrowing as it joint
curves on to the inferior ischial aspect, is subdivided by an irregular
vertical ridge into lateral and medial areas. The medial area is covered Ala of the
sacrum
by fibroadipose tissue that usually contains the sciatic bursa of gluteus
maximus, which supports the body in sitting. Medially, the tuberosity
Anterior
is limited by a curved ridge that passes on to the ramus and which gives
superior
attachment to the sacrotuberous ligament and its falciform process. iliac spine
ischial spine Coccyx
The ischial spine projects downwards and a little medially (see Fig.
Superior
80.5A,B). The sacrospinous ligament is attached to its margins, separat-
pubic ramus
ing the greater from the lesser sciatic foramen. The ligament is crossed
Obturator
posteriorly by the internal pudendal vessels, pudendal nerve and the
foramen
nerve to obturator internus.
Lesser
Muscle attachments trochanter
Part of obturator externus is attached to the lower femoral surface of
the ischial body. Part of obturator externus, the anterior fibres of adduc-
tor magnus and, near the lower border, gracilis are all attached to the
anterior surface of the ischial ramus. Between adductor magnus and A
gracilis, the attachment of adductor brevis may descend from the infe-
rior pubic ramus. The posterior surface is divided into pelvic and peri-
neal areas. The pelvic area, facing back, has part of obturator internus
attached to it. The perineal area faces medially; its upper part is related
to the crus of the penis or clitoris, and its lower part gives attachment
Spinous process
to sphincter urethrae, ischiocavernosus and the superficial transverse of L5
perineal muscle.
Posterior superior
The ischial tuberosity gives attachment to the posterior thigh iliac spine
muscles. Quadratus femoris is attached along the upper part of its
lateral border. The upper area of the tuberosity is subdivided by an
Sacral hiatus
oblique line into a superolateral part for semimembranosus and an
inferomedial part for the long head of biceps femoris and semitendi-
nosus. The lower area is subdivided by an irregular vertical ridge into
Head of femur
lateral and medial areas. The larger lateral area is for part of adductor
magnus. Superomedial to the tuberosity, the posterior surface has a
wide, shallow groove, usually covered by hyaline cartilage, with a bursa
between it and the tendon of obturator internus. Gemellus inferior is Ischial tuberosity
attached to the lower margin of the groove, near the tuberosity. Gemel-
lus superior is attached to the upper margin, near the ischial spine.
Forceful contraction of the hamstrings can result in an avulsion fracture
of the ischial tuberosity.
The pelvic surface of the ischial spine gives attachment to coccygeus
and to the most posterior fibres of levator ani. Obturator internus is
attached to the upper part of the smooth pelvic ischial surface and B
converges on the bony part of the lesser sciatic foramen, covering the
rest of this surface other than the pelvic aspect of the ischial spine; the Fig. 80.8 Anterior (A) and posterior (B) views of the female pelvis, upper
muscle and its fascia separate the bone from the ischio-anal fossa. femur and lower lumbar spine, using three-dimensional computed
tomography. (Courtesy of Dr Yoginder Vaid and Mr Jon C Betts, Jr.)
vascular supply
There are multiple vascular foramina at the acetabular margins and a
few are usually present on the pelvic surface. Branches of the obturator, region where the trunk and lower limbs meet (Fig. 80.8). It is used here
medial circumflex femoral and inferior gluteal arteries supply the in the skeletal sense, to describe the irregular osseous girdle between
ischium. the femoral heads and fifth lumbar vertebra. It is large because its
primary function is to withstand the forces of body weight and muscu-
innervation
lature. In this section, its obstetric, forensic and anthropological signifi-
The periosteum is innervated by branches of nerves that supply the hip cance will be considered.
joint and muscles attached to the bone. The pelvis can be regarded as having greater and lesser segments, the
true and false pelves. The segments are arbitrarily divided by an oblique
ossification
plane passing through the sacral promontory posteriorly and the lineae
Ossification of the ischium is described on page 1342. terminales elsewhere. Each linea terminalis includes the iliac arcuate
line, pectineal line (pecten pubis) and pubic crest.
SACRUM Greater pelvis
The greater pelvis consists of the ilium and pubis above the lineae
See page 726. terminales and the base of the sacrum. This junctional zone is structur-
ally massive and forms powerful arches from the acetabular fossae to
the vertebral column around the visceral cavity, which is part of the
COCCYX
abdomen. It has little anterior wall because of the pelvic inclination.
Pelvic inlet (superior pelvic aperture)
See page 729.
The pelvic inlet or brim may be round or oval in shape, and is indented
posteriorly by the sacral promontory. The pelvic brim is obstetrically
BONY PELVIS AS A WHOLE important and has also long been measured for anthropological
reasons, as has the pelvic cavity.
The term pelvis (‘basin’) is applied variously to the skeletal ring formed By convention, the pelvic inlet is described in three dimensions. The
by the hip bones and the sacrum, the cavity therein, and even the entire anteroposterior diameter (true conjugate) is measured between the | 1,854 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
Pelvic girdle, gluteal region and thigh
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midpoints of the sacral promontory and upper border of the pubic the rectum, urinary bladder and parts of the reproductive organs. The
symphysis, and on average is 10 cm in the adult male and 11.2 cm in cavity in females must also permit passage of the fetus.
the adult female. The transverse diameter is the maximum distance The pelvic cavity diameters are measured at approximately the mid-
between similar points (assessed by eye) on opposite sides of the pelvic level. The anteroposterior diameter is measured between the midpoints
brim, and is on average 12.5 cm in the adult male and 13.1 cm in the of the third sacral segment and posterior surface of the pubic symphysis,
adult female. The oblique diameter is measured from the iliopubic and is about 10.5 cm in the adult male and 13 cm in the adult female.
ramus to the opposite sacroiliac joint, and is on average 12 cm in the The transverse diameter is the widest transverse distance between the
adult male and 12.5 cm in the adult female. These measurements vary side walls of the cavity, and often the greatest transverse dimension in
with the individual and with racial group. In children, dimensions of the whole cavity. It measures about 12 cm in the adult male and
the thorax and spine are significantly correlated with the width of the 12.5 cm in the adult female. The oblique diameter is the distance from
pelvic inlet, which are age-independent predictors of paediatric chest the lowest point of one sacroiliac joint to the midpoint of the contral-
width and may be useful in assessing growth of the thorax and spine ateral obturator membrane, and measures about 11 cm in the adult
in children with early-onset spinal deformity (Emans et al 2005). male and 13.1 cm in the adult female. All measurements vary with the
individual and with racial group.
Articulated bony pelvis
Pelvic outlet (inferior pelvic aperture)
The lesser pelvis encloses a true basin when soft tissues of the pelvic
floor are in place. Skeletally, it is a narrower continuation of the greater Less regular in outline than the pelvic inlet, the pelvic outlet is indented
pelvis, with irregular but more complete walls around its cavity. Of behind by the coccyx and sacrum, and bilaterally by the ischial tuberos-
obstetric importance, it has a curved median axis, and superior and ities. Its perimeter thus consists of three wide arcs. Anteriorly is the
inferior openings. The superior opening is occupied by viscera. The pubic arch, between the converging ischiopubic rami. Posteriorly and
pelvic floor, viscera and subjacent perineal sphincters close the inferior laterally on both sides are the sciatic notches between the sacrum and
opening. ischial tuberosities. The sciatic notches are divided by the sacrotuberous
and sacrospinous ligaments into greater and lesser sciatic foramina
Cavity of the lesser pelvis
(Fig. 80.9).
The cavity of the lesser pelvis is short, curved, and markedly longer in With ligaments included, the pelvic outlet is rhomboidal. Its anterior
its posterior wall. Anteroinferiorly, it is bounded by pubic bones, their limbs are the ischiopubic rami (joined by the inferior pubic ligament)
rami and symphysis. Posteriorly, it is bounded by the concave anterior and its posterior margins are the sacrotuberous ligaments, with the
sacral surface and coccyx. Laterally on each side, its margins are the coccyx in the midline. The outlet is thus not rigid in its posterior half,
smooth quadrangular pelvic aspect of the fused ilium and ischium. being limited by ligaments and the coccyx, all slightly yielding. Even
The region so enclosed is the pelvic cavity proper, through which pass with the sacrum taken as the posterior midline limit (more reliable for
A
L4 vertebra
Iliolumbar ligament
Sacroiliac joint, anterior sacroiliac ligament
Iliac crest
Greater sciatic foramen
Sacrospinous ligament
Anterior superior iliac spine
Sacrotuberous ligament Inguinal ligament
Lesser sciatic foramen
Muscular space
Straight head of rectus femoris Iliopectineal arch
Iliofemoral ligament Greater trochanter
Vascular space
Superior pubic ligament
Obturator foramen Pubic arch
B
Iliolumbar ligament
Supraspinous ligament
Posterior sacroiliac
ligament
Greater sciatic
Sacrotuberous foramen
ligament
Sacrospinous
ligament
Fig. 80.9 Joints and ligaments of the pelvis.
A, Anterior aspect. Note the arrows indicating vascular
and muscular spaces. B, Posterior aspect. (With
permission from Waschke J, Paulsen F (eds), Sobotta
Deep posterior Atlas of Human Anatomy, 15th ed, Elsevier, Urban &
sacrococcygeal ligament Fischer. Copyright 2013.) | 1,855 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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measurement), there may be slight mobility at the sacroiliac joints. descends in the axis of the inlet as far as the level of the ischial spines;
Note also that a plane of the pelvic outlet is merely conceptual. The it is then directed forwards into the axis of the vagina at right angles to
anterior, ischiopubic part has a plane that is inclined down and back that axis. The form of this pelvic axis and the disparity in depth between
to a transverse line between the lower limits of the ischial tuberosities, the anterior and posterior contours of the cavity are prime factors in
and the posterior half has a plane approximating to the sacrotuberous the mechanism of fetal transit in the pelvic canal.
ligaments, sloping down and forwards to the same line. In the standing position, the pelvic canal curves obliquely backwards
Three measurements are made for the pelvic outlet. The anteropos- relative to the trunk and abdominal cavity. The whole pelvis is tilted
terior diameter is usually measured from the apex of the coccyx to the forwards, the plane of the pelvic brim making an angle of 50–60° with
midpoint of the lower rim of the pubic symphysis. The lowest sacral the horizontal. The plane of the pelvic outlet is tilted to about 15°.
point may also be used (on average: male 8 cm, female 12.5 cm). The Strictly, the pelvic outlet has two planes: an anterior passing backwards
transverse (bituberous) diameter is measured between the ischial tuber- from the pubic symphysis and a posterior passing forwards from the
osities at the lower borders of their medial surfaces (on average: male coccyx, both descending to meet at the intertuberous line. In standing,
8.5 cm, female 11.8 cm). The oblique diameter extends from the mid- the pelvic aspect of the pubic symphysis faces nearly as much upwards
point of the sacrotuberous ligament on one side to the contralateral as backwards and the sacral concavity is directed anteroinferiorly. The
ischiopubic junction (on average: male 10 cm, female 11.8 cm). All front of the pubic symphysis and anterior superior iliac spines are in
measurements vary among individuals and racial groups. the same vertical plane. While sitting, body weight is transmitted
through the inferomedial parts of the ischial tuberosities, with variable
Other measurements
soft tissues intervening. The anterior superior iliac spines are in a verti-
Apart from these main measurements, by consensus the basis of pelvic cal plane through the acetabular centres, and the whole pelvis is tilted
osteometry, other planes and measurements are used in obstetric prac- back with the lumbosacral angle somewhat diminished at the sacral
tice. The plane of greatest pelvic dimensions is an obstetric concept. It promontory.
represents the most capacious pelvic level, between the pelvic brim and
midlevel plane, and corresponds with the latter anteriorly at the middle Pelvic mechanism
part of the pubic symphysis and posteriorly at the level of the second The skeletal pelvis supports and protects the contained viscera but is
and third sacral segments. primarily part of the lower limbs, affording wide attachment for muscles
The plane of least dimensions is said to be at about mid-pelvic level. of the thigh, leg and trunk. It constitutes the major mechanism for
Its transverse diameter is between the apices of the ischial spines. This transmitting the weight of the head, trunk and upper limbs to the lower
measurement is about 9.5 cm in an adult female and is just wide limbs. It may be considered as two arches divided by a coronal trans-
enough to allow passage of the biparietal diameter of a fetal head acetabular plane. The posterior arch, chiefly concerned in transmitting
(about 9 cm). Not surprisingly, most difficulty in parturition occurs weight, consists of the upper three sacral vertebrae and strong pillars of
here. bone from the sacroiliac joints to the acetabular fossae. The anterior
The above measurements are sometimes made in clinical practice arch, formed by the pubic bones and their superior rami, connects these
using radiographs or magnetic resonance imaging (MRI) pelvimetry. lateral pillars as a tie beam to prevent separation; it also acts as a com-
Precise measurement is not possible without radiological techniques, pression strut against medial femoral thrust. The sacrum, as the summit
and even these do not take into account the adjacent soft tissues. In the of the posterior arch, is loaded at the lumbosacral joint. Theoretically,
past, measurements were made at physical (e.g. vaginal) examinations. this force has two components: one thrusting the sacrum downwards
However, these manual measurements have proved to be of little clini- and backwards between the iliac bones, the other thrusting its upper
cal value and are now more or less obsolete. end downwards and forwards. Sacral movements are regulated by
Morphological classification of pelves osseous shape and massive ligaments. The first component therefore
acts against the wedge, its tendency to separate iliac bones resisted by
the sacroiliac and iliolumbar ligaments and pubic symphysis.
Available with the Gray’s Anatomy e-book
Vertical coronal sections through the sacroiliac joints suggest divi-
sion of the (synovial) articular region of the sacrum into three segments.
Pelvic axes and inclination
In the anterosuperior segment, involving the first sacral vertebra, the
The axis of the superior pelvic aperture traverses its centre at right angles articular surfaces are slightly sinuous and almost parallel. In the middle
to its plane, directed down and backwards (Fig. 80.10). When pro- segment, the posterior width between the articular markings is greater
longed (projected), it passes through the umbilicus and mid-coccyx. An than the anterior, and centrally a sacral concavity fits a corresponding
axis is similarly established for the inferior aperture: projected upwards, iliac convexity, an interlocking mechanism relieving the strain on the
it impinges on the sacral promontory. Axes can likewise be constructed ligaments produced by body weight. In the posteroinferior segment, the
for any plane, and one for the whole cavity is a concatenation of an anterior sacral width is greater than the posterior and here its sacral
infinite series of such lines (see Fig. 80.10). The fetal head, however, surfaces are slightly concave. Anteroinferior sacral dislocation by the
second component (of force) is prevented, therefore, mainly by the
middle segment, owing to its cuneiform shape and interlocking mecha-
nism. However, some rotation occurs, in which the anterosuperior
segment tilts down and the posteroinferior segment up. ‘Superior’ seg-
mental movement is limited to a small degree by wedging but primarily
by tension in the sacrotuberous and sacrospinous ligaments. In all
movements, the sacroiliac and iliolumbar ligaments and pubic symphy-
sis resist separation of the iliac bones.
Sacral
promontory
SEXUAL DIFFERENCES IN THE PELVIS
The pelvis provides the most marked skeletal differences between male
Pelvic inlet and female. Distinction can be made even during fetal life, particularly
Axis of
pelvic outlet in the subpubic arch. In infancy, dimensions of the whole pelvis are
greater in males than in females, but the size of the pelvic cavity is
usually greater in females. This distinction prevails in childhood but
the difference is maximal at about 22 months. Sexual differences in
Axis of adults are divisible into metrical and non-metrical features; the range
Axis of cavity of most features overlaps between the sexes.
Pubic inlet plane of Differences are inevitably linked to function. While the primary
outlet
symphysis pelvic function in both sexes is locomotor, the pelvis, particularly the
lesser pelvis, is adapted to parturition in females, and these changes
variably affect the proportions and dimensions of the greater pelvis.
Horizontal plane Since males are distinctly more muscular and therefore more heavily
50–60º 15º built, overall pelvic dimensions, such as the intercristal distance (dis-
Fig. 80.10 A median sagittal section through the female pelvis, showing tance between the iliac crests), are greater, markings for muscles and
the planes of the inlet and outlet and the axis of the pelvic cavity. ligaments more pronounced, and general architecture more robust. The | 1,856 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Pelvic girdle, gluteal region and thigh
Interest in the dimensions described above is primarily obstetric and,
less frequently, forensic. All pelvic measurements display individual
variation and the values quoted are means from limited surveys. These
measurements have been analysed by many anatomists, anthropolo-
gists, obstetricians and radiologists in attempts to classify human
pelves, especially female. The four most common terms used today are
gynaecoid, anthropoid, platypelloid and android. The gynaecoid pelvis
is the traditional Western female pelvis with a heart-shaped brim and
the range of measurements quoted above. An anthropoid pelvis has a
larger mid-cavity and a wide anteroposterior inlet, which is oval in
shape; it is more common in women of African origin and may be
associated with a ‘high-assimilation’ pelvis where there is an additional
lumbar vertebra. A platypelloid pelvis is flat and oval from side to side
at the brim; it is a contracted pelvis that is rarely seen nowadays, having
previously been associated with rickets. An android pelvis has a trian-
gular brim and is the shape of a male pelvis.
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Pelvic girdle, gluteal region and thigh
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male iliac crest is more rugged and more medially inclined at its ant- strength with the weight and muscular forces it is required to withstand.
erior end; in females the iliac crests are less curved in all parts. The iliac Its shaft, almost cylindrical along most of its length, is bowed forwards.
alae are more vertical in females but do not ascend so far; the iliac fossae It has a proximal rounded, articular head projecting medially from its
are therefore shallower. These iliac peculiarities probably account for short neck, which, in turn, is a medial extension of the proximal shaft.
the greater prominence of female hips. The distal extremity is wider and more substantial, and presents a
The male is relatively and absolutely more heavily built above the double condyle that articulates with the tibia. In standing, the femoral
pelvis, with consequent differences at the lumbosacral and hip joints. shafts show an inclination upwards and outwards from their tibial
The sacral basal articular facet for the fifth lumbar vertebra and interven- articulations, with the femoral heads being separated by the pelvic
ing intervertebral disc is more than one-third of the total sacral basal width. Since the tibia and fibula descend vertically from the knees, the
width in males but less than one-third in females, in whom the sacrum ankles are also in the line of body weight in standing or walking. The
is also relatively broader, accentuating this difference. The female has degree of femoral obliquity varies between individuals but is generally
relatively broader sacral alae. The male acetabulum is absolutely larger, greater in women, reflecting the relatively greater pelvic breadth and
and its diameter is approximately equal to the distance between its shorter femora. Proximally, the femur consists of a head, neck and
anterior rim and pubic symphysis. In females, acetabular diameter is greater and lesser trochanters.
usually less than this distance, not only because it is absolutely smaller
but also because the anterolateral wall of the cavity is comparatively Femoral head
and often absolutely wider. The height of the female pubic symphysis The femoral head faces anterosuperomedially to articulate with the
and adjoining parts of the pubis and ischium, which form the anterior acetabulum (Fig. 80.13). The head, often described as rather more than
pelvic wall, are also absolutely less, producing a somewhat triangular half a ‘sphere’, is not part of a true sphere but is spheroidal. Its smooth-
obturator foramen, which is more ovoid in males. Differing pubic ness is interrupted posteroinferior to its centre by a small, rough fovea.
growth is also expressed in the pubic arch below the pubic symphysis The head is intracapsular and is encircled, distal to its equator, by the
and between the inferior pubic rami. It is more angular in males, being acetabular labrum. Its articular margin is distinct, except anteriorly,
50–60°; in females it is rounded, less easy to measure and usually where the articular surface extends on to the neck. The ligamentum teres
80–85°. A greater separation of the pubic tubercles in females contrib- is attached to the fovea. The anterior surface of the head is separated
utes to the pubic width. The ischiopubic rami are also much more inferomedially from the femoral artery by the tendon of psoas major,
lightly built and narrowed near the symphysis; in males they bear a the iliopectineal bursa and the articular capsule.
distinctly rough, everted area for attachment of the penile crura, the
corresponding attachment for the clitoris being poorly developed. The Femoral neck
ischial spines are closer in males and are more inturned. The greater The femoral neck (see Fig. 80.13) is approximately 5 cm long, narrow-
sciatic notch is usually wider in females: mean values for males and est in its mid part and widest laterally, and connects the head to the
females are 50.4° and 74.4°, respectively. The greater female values for shaft at an average angle of 127° (Gilligan et al 2013) (angle of incli-
angle and width are associated with increased backward sacral tilt and nation; neck–shaft angle): this facilitates movement at the hip joint,
greater anteroposterior pelvic diameter, especially at lower levels. enabling the limb to swing clear of the pelvis. The neck also provides
The sacrum also displays metrical sexual differences. Female sacra a lever for the action of the muscles acting about the hip joint, which
are less curved, the curvature being most marked between the first and are attached to the proximal femur. The neck–shaft angle is widest at
second segments and the third and fifth, with an intervening flatter birth and diminishes gradually until the age of 10 years (Birkenmaier
region. Male sacra are more evenly curved, and relatively long and et al 2010); it is smaller in females. The neck is laterally rotated with
narrow, and more often exceed five segments (by addition of a lumbar respect to the shaft (angle of anteversion) some 10–15°, although
or coccygeal vertebra). The sacral index compares sacral breadth values of this angle vary between individuals and between populations
(between the most anterior points on the auricular surfaces) with length (Eckhoff et al 1994). The contours of the neck are rounded; the upper
(between midpoints on the anterior margins of the promontory and surface is almost horizontal and slightly concave, while the lower is
apex): average values for males and females are 105% and 115%, respec- straighter but oblique, directed inferolaterally and backwards to the
tively. Auricular surfaces are relatively smaller and more oblique in shaft near the lesser trochanter. On all aspects the neck expands as it
females, but extend on to the upper three sacral vertebrae in both sexes. approaches the articular surface of the head. The anterior surface of
The dorsal auricular border is more concave in females. Many differ- the neck is flat and marked at the junction with the shaft by a rough
ences may be summarized in the generalization that the pelvic cavity is intertrochanteric line. The posterior surface, facing posteriorly and
longer and more conical in males, and shorter and more cylindrical in superiorly, is transversely convex, and concave in its long axis; its junc-
females; the axis is curved in both. Differences are greater at the inferior tion with the shaft is marked by a rounded intertrochanteric crest.
aperture than at the brim, where in absolute measurements males are There are numerous vascular foramina, especially anteriorly and
not as different from females as sometimes stated. posterosuperiorly.
In forensic practice, identification of human skeletal remains (which The anterior surface is intracapsular, the capsule attaching laterally
are sometimes fragmentary) usually involves determination of sex, and to the intertrochanteric line. Facets, often covered by extensions of
this is most reliably established from an examination of the pelvis. Even articular cartilage, and various imprints frequently occur here. These
fragments of the pelvis may be useful in this respect. Several studies of facets may sometimes be associated with squatting. On the posterior
metrical characteristics in various pelvic regions have been made, surface the capsule does not reach the intertrochanteric crest; little more
leading to the establishment of various indices. The ilium has received than the medial half of the neck is intracapsular. The anterior surface
particular attention, e.g. one index compares the pelvic and sacroiliac adjoining the head and covered by cartilage is related to the iliofemoral
parts of the bone. A line is extended back from the iliopubic ramus to ligament. A groove, produced by the tendon of obturator externus as it
the nearest point on the anterior auricular margin and thence to the approaches the trochanteric fossa, spirals across the posterior surface of
iliac crest. The auricular point divides this chilotic line into anterior the neck of the femur in a proximolateral direction.
(pelvic) and posterior (sacral) segments, each expressed as a percentage
of the other. Chilotic indices display reciprocal values in the sexes: the greater trochanter
pelvic part of the chilotic line is predominant in females, and the sacral The greater trochanter is large and quadrangular, projecting up from the
part in males. Detailed metrical studies of the ilium have indicated its junction of the neck and shaft (see Fig. 80.13). Its posterosuperior
limited reliability in ‘sexing’ pelves. However, the higher incidence and region projects superomedially to overhang the adjacent posterior
definition of the female pre-auricular sulcus is recognized. The desira- surface of the neck and here its medial surface presents the rough tro-
bility of correlating all available metrical data is to be emphasized; chanteric fossa. The proximal border of the trochanter lies approxi-
when a range of pelvic data can be combined, especially if they are mately a hand’s breadth below the iliac tuberculum, level with the
metrical, 95% accuracy should be achieved. Complete accuracy has centre of the femoral head. It has an anterior rough impression. Its
been claimed when the rest of the skeleton is available. Assessment of lateral surface, continuous distally with the lateral surface of the femoral
sex from isolated and often incomplete human remains is less reliable. shaft, is crossed anteroinferiorly by an oblique, flat strip, which is wider
For further details, consult Mays (1998) and Brothwell and Pollard above. This surface is palpable, especially when the muscles are relaxed.
(2001). The trochanteric fossa occasionally presents a tubercle or exostosis.
lesser trochanter
FEMUR The lesser trochanter is a conical posteromedial projection of the shaft
at the posteroinferior aspect of its junction with the neck. Its summit
The femur is the longest and strongest bone in the human body (Figs and anterior surface are rough, but its posterior surface, at the distal
80.11–80.12). Its length is associated with a striding gait, and its end of the intertrochanteric crest, is smooth. It is not palpable. | 1,858 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
Bones
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Neck
B
A
Sacrospinous ligament;
Fovea for ligament of head Rectus femoris
ischiococcygeus
Trochanteric fossa Iliopectineal bursa
Head
Greater trochanter Pectineus
Neck Obturator externus Gluteus minimus
Intertrochanteric line
Adductor longus Vastus lateralis
Lesser trochanter Adductor brevis Iliopsoas
Gracilis
Vastus intermedius
Adductor magnus
Vastus medialis
Quadratus femoris
Biceps femoris
Semimembranosus
Shaft
Articularis genus
Vastus medialis Quadriceps femoris
Adductor magnus
Biceps femoris
Fibular collateral ligament
Adductor tubercle
Sartorius Lateral patellar retinaculum
Medial epicondyle Lateral epicondyle
Gracilis
Extensor digitorum longus
Patellar surface
Fig. 80.11 The femur, anterior aspect. A, Osseous features. B, Muscle attachments. (With permission from Waschke J, Paulsen F (eds), Sobotta Atlas of
Human Anatomy, 15th ed, Elsevier, Urban & Fischer. Copyright 2013.)
intertrochanteric line indistinct. The posterolateral surface is bounded posteriorly by the
The intertrochanteric line, a prominent ridge at the junction of the broad, rough linea aspera, usually a crest with lateral and medial edges.
anterior surfaces of the neck and shaft, descends medially from a tuber- Its subjacent compact bone is augmented to withstand compressive
cle on the upper part of the anterior aspect of the greater trochanter to forces, which are concentrated here by the anterior curvature of the
a point on the lower border of the neck, anterior to the lesser trochanter, shaft. The linea aspera gives attachment to adductor longus, intermus-
where there may also be a tubercle. This line is the lateral limit of the cular septa and the short head of biceps femoris, all inseparably blended
hip joint capsule anteriorly. The upper and lower bands of the iliofemo- at their attachments. Perforating arteries cross the linea aspera laterally
ral ligament are attached to its proximal and distal ends and the associ- under tendinous arches in adductor magnus and biceps femoris. Nutri-
ated tubercles. Distally, it is continuous with the spiral line. ent foramina, directed proximally, appear in the linea aspera, varying
in number and site, one usually near its proximal end, a second usually
intertrochanteric crest near its distal end. The posteromedial surface, smooth like the others,
The intertrochanteric crest, a smooth and prominent ridge at the junc- is bounded in front by the indistinct medial border and behind by the
tion of the posterior surface of the neck with the shaft, descends medi- linea aspera. In its proximal third the shaft has a fourth, posterior
ally from the posterosuperior angle of the greater trochanter to the surface, bounded medially by a narrow, rough spiral line that is continu-
lesser trochanter. A little above its centre is a low, rounded quadrate ous proximally with the intertrochanteric line and distally with the
tubercle. It is covered by gluteus maximus, from which it is separated, medial edge of linea aspera. Laterally, this surface is limited by the
medial to the tubercle, by quadratus femoris and the upper border of broad, rough gluteal tuberosity, ascending a little laterally to the greater
adductor magnus. trochanter and descending to the lateral edge of the linea aspera. In its
distal one-third, the posterior surface of the shaft presents a further
gluteal tuberosity surface, the popliteal surface (see below) between the medial and lateral
The gluteal tuberosity may be an elongated depression or a ridge. It may supracondylar lines. These lines are continuous above with the corre-
at times be prominent enough to merit the title of a third trochanter. sponding edges of the linea aspera. The lateral line is most distinct in
its proximal two-thirds, where the short head of biceps femoris and
Shaft lateral intermuscular septum are attached. Its distal third has a small,
The shaft is surrounded by muscles and is impalpable (see Figs 80.11– rough area for the attachment of plantaris, often encroaching on the
80.12). The distal anterior surface, for 5–6 cm above the patellar articu- popliteal surface. The medial line is indistinct in its proximal two-
lar surface, is covered by a suprapatellar bursa, between bone and thirds, where vastus medialis is attached. Distally, the femoral vessels
muscle. The distal lateral surface is covered by vastus intermedius. The entering the popliteal fossa from the adductor canal cross the medial
medial surface, devoid of attachments, is covered by vastus medialis. line obliquely. Further distally, the line is often sharp for 3 or 4 cm
The shaft is narrowest centrally, expanding a little at its proximal proximal to the adductor tubercle.
end, and substantially more at its distal end. Its long axis makes an The popliteal surface, triangular in outline, lies between the medial
angle of approximately 10° with the vertical, and diverges 5–7° from and lateral supracondylar lines. In its distal medial part, it is rough and
the long axis of the tibia. Its middle one-third has three surfaces and slightly elevated. Forming the proximal part of the floor of the popliteal
borders. The extensive anterior surface, smooth and gently convex, is fossa, the popliteal surface is covered by a variable amount of fat that
between the lateral and medial borders, which are both round and separates the popliteal artery from bone. The superior medial genicular | 1,859 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
Pelvic girdle, gluteal region and thigh
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A B
Head Obturator internus
Fovea of ligament of head Piriformis
Greater trochanter Rectus femoris
Neck Obturator externus
Quadrate tubercle Gluteus medius
Intertrochanteric crest Obturator internus
Gluteus minimus
Lesser trochanter Trochanteric bursa of
gluteus medius
Pectineal line (spiral line) Levator ani
Gluteal tuberosity Quadratus femoris
Subcutaneous Deep transverse perineal muscle
trochanteric bursa
Gluteus maximus Gemellus superior
Pectineus
Sciatic bursa of obturator internus
Adductor magnus
Gemellus inferior
Adductor brevis Semitendinosus
Lateral lip
Linea aspera Vastus medialis lliopsoas
Medial lip
Vastus intermedius
Adductor longus
Biceps femoris
Vastus lateralis
Lateral supracondylar line
Medial supracondylar line
Adductor magnus
Popliteal surface
Medial subtendinous
Gastrocnemius bursa of gastrocnemius
Lateral epicondyle Adductor tubercle Plantaris Semimembranosus
Fibular collateral ligament
Sartorius
Lateral condyle Medial condyle Biceps femoris Gracilis
Intercondylar fossa Intercondylar line Popliteus Semitendinosus
Semimembranosus
Fig. 80.12 The femur, posterior aspect. A, Osseous features. B, Muscle attachments. (With permission from Waschke J, Paulsen F (eds), Sobotta Atlas
of Human Anatomy, 15th ed, Elsevier, Urban & Fischer. Copyright 2013.)
Trochanteric fossa Head Patellar surface
Fovea for
ligament of head
Greater trochanter
Neck Medial epicondyle
Quadrate tubercle
Lateral epicondyle
Intertrochanteric crest Medial condyle
Lateral condyle
Lesser trochanter
Intercondylar fossa
Gluteal tuberosity
Fig. 80.14 The distal end of the femur, articular surface. (With permission
from Waschke J, Paulsen F (eds), Sobotta Atlas of Human Anatomy, 15th
Pectineal line (spiral line)
ed, Elsevier, Urban & Fischer. Copyright 2013.)
Linea aspera, medial lip
lateral condyle but is separated from bone by the attachment of plantaris
to the distal part of the lateral supracondylar line.
Fig. 80.13 The proximal end of the femur, posterior aspect. (With
permission from Waschke J, Paulsen F (eds), Sobotta Atlas of Human distal end
Anatomy, 15th ed, Elsevier, Urban & Fischer. Copyright 2013.) The distal end of the femur is widely expanded as a bearing surface for
transmission of weight to the tibia (Fig. 80.14). It bears two massive
condyles, which are partly articular. Anteriorly, the condyles are conflu-
artery, a branch of the popliteal artery, arches medially above the medial ent and continue into the shaft; posteriorly, they are separated by a deep
condyle. It is separated from bone by the medial head of gastrocnemius. intercondylar fossa and project beyond the plane of the popliteal
The latter is attached a little above the condyle; further distally, there surface. The articular surface is a broad area, like an inverted U, for the
may be a smooth facet underlying a bursa for the medial head of patella and the tibia. The patellar surface extends anteriorly on both
gastrocnemius. More medially, there is often an imprint proximal to condyles, especially the lateral. It is transversely concave, vertically
the articular surface; in flexion, this is close to a rough tubercle on convex and grooved for the posterior patellar surface. The tibial surface
the medial tibial condyle for the attachment of semimembranosus. The is divided by the intercondylar fossa but is anteriorly continuous with
superior lateral genicular artery arches up laterally proximal to the the patellar surface. Its medial part is a broad strip on the convex | 1,860 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
Bones
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inferoposterior surface of the medial condyle, and is gently curved with
a medial convexity. Its lateral part covers similar aspects of the lateral
condyle but is broader and passes straight back. The tibial surfaces are
convex in all directions. The medial and lateral tibial surfaces have dis-
similar anteroposterior curvatures. However, views differ as to the exact
representation of these differences. One view holds that in both tibial
portions of the femoral condyles, the sagittal radius of curvature is ever-
decreasing (a ‘closing helix’). More recently, it has been suggested that
the medial articular surface describes arcs of two circles. The more
posterior has a smaller radius. Laterally, there may only be one arc of
1
fixed curvature with a radius similar to that of the posterior arc of the
medial femoral articular surface. These differences are believed to be
important determinants of knee joint motion.
2
Patellar surface
The patellar surface extends more proximally on the lateral side. Its
3
proximal border is therefore oblique and runs distally and medially,
separated from the tibial surfaces by two faint grooves that cross the 4
condyles obliquely. The lateral groove is the more distinct. It runs lat- 5
erally and slightly forwards from the front of the intercondylar fossa
and expands to form a faint triangular depression, resting on the ante-
6
rior edge of the lateral meniscus when the knee is fully extended. The
medial groove is restricted to the medial part of the medial condyle and
rests on the anterior edge of the medial meniscus in full extension.
Where it ceases, the patellar surface continues back to the lateral part
of the medial condyle as a semilunar area adjoining the anterior region Fig. 80.15 The distal end of the femur, lateral aspect. Key: 1, attachment
of the intercondylar fossa. This area articulates with the medial vertical of plantaris; 2, attachment of lateral head of gastrocnemius; 3, lateral
facet of the patella in full flexion; its outline is indistinct in most epicondyle; 4, attachment of fibular collateral ligament; 5, groove for
femora. In habitual squatters articular cartilage may extend to the lateral popliteus in full flexion; 6, attachment of popliteus.
aspect of the lateral condyle under vastus lateralis.
and the medullary cavity most capacious. Proximally and distally, the
Intercondylar fossa compact wall becomes progressively thinner, and the cavity gradually
The intercondylar fossa separates the two condyles distally and behind. fills with trabecular bone. The extremities, especially where articular,
In front, the distal border of the patellar surface limits it, and behind consist of trabecular bone within a thin shell of compact bone, their
an intercondylar line limits it, separating it from the popliteal surface. trabeculae being disposed along lines of greatest stress. At the proximal
It is intracapsular but largely extrasynovial. Its lateral wall, the medial end, the main trabeculae form a series of plates orthogonal to the
surface of the lateral condyle, bears a flat posterosuperior impression articular surface, converging to a central dense wedge, which is sup-
that spreads to the floor of the fossa near the intercondylar line for the ported by strong trabeculae passing to the sides of the neck, especially
proximal attachment of the anterior cruciate ligament. The medial wall along its upper and lower profiles (Fig. 80.16). Force applied to the
of the fossa, i.e. the lateral surface of the medial condyle, bears a similar femoral head is therefore transmitted to the wedge and from there to
larger area, but far more anteriorly, for the proximal attachment of the the junction of the neck and shaft. This junction is strengthened by
posterior cruciate ligament. Both impressions are smooth and largely dense trabeculae extending laterally from the lesser trochanter to the
devoid of vascular foramina, whereas the rest of the fossa is rough and end of the superior aspect of the neck, thus resisting tensile or shearing
pitted by vascular foramina. A bursal recess between the ligaments may forces applied to the neck through the head (Fig. 80.17). Tensile and
ascend to the fossa. The capsular ligament and, laterally, the oblique compressive tests indicate that axial trabeculae of the femoral head
popliteal ligament are attached to the intercondylar line. The infrapatel- withstand much greater stresses than peripheral trabeculae. A smaller
lar synovial fold is attached to the anterior border of the fossa. bar across the junction of the greater trochanter with the neck and shaft
resists shearing produced by muscles attached to it. These two bars are
Lateral condyle proximal layers of arches between the sides of the shaft and transmit to
The lateral condyle (see Fig. 80.14) is larger anteroposteriorly than the it forces applied to the proximal end. A thin vertical plate, the so-called
medial. Its most prominent point is the lateral epicondyle to which the calcar femorale, ascends from the compact wall near the linea aspera
fibular collateral ligament is attached (Fig. 80.15). A short groove, into the trabeculae of the neck (see Fig. 80.17). Medially, it joins the
deeper in front, separates the lateral epicondyle inferiorly from the posterior wall of the neck; laterally, it continues into the greater tro-
articular margin. This groove allows the tendon of popliteus to run deep chanter, where it disperses into general trabecular bone. It is thus in a
to the fibular collateral ligament and insert inferior and anterior to the plane anterior to the trochanteric crest and base of the lesser trochanter.
ligament insertion. Adjoining the joint margin is a strip of condyle, Dixon (1910) demonstrated that the trabecular framework of the proxi-
1 cm broad. It is intracapsular and covered by synovial membrane mal femur was spiral, and that the ‘arches’ were simplified sectional
except for the attachment of popliteus. profiles of this spiral. At the distal end of the femur, trabeculae spring
The medial surface is the lateral wall of the intercondylar fossa. Its from the entire internal surface of compact bone, descending perpen-
lateral surface projects beyond the shaft. Part of the lateral head of dicular to the articular surface. Proximal to the condyles these are
gastrocnemius is attached to an impression posterosuperior to the strongest and most accurately perpendicular. Horizontal planes of
lateral epicondyle. trabecular bone, arranged like crossed girders, form a series of cubical
compartments.
Medial condyle
The medial condyle has a bulging, convex medial aspect, which is easily Muscle attachments
palpable. Proximally, its adductor tubercle, which may only be a facet The greater trochanter provides attachment for gluteus minimus and
rather than a projection, receives the tendon of adductor magnus. The medius. Gluteus minimus is attached to its rough anterior impression
medial prominence of the condyle, the medial epicondyle, is antero- and gluteus medius to its lateral oblique strip. The bone is separated
inferior to the tubercle. The lateral surface of the condyle is the medial from the tendon of gluteus medius by a bursa. The area behind it is
wall of the intercondylar fossa. The condyle projects distally so that, covered by deep fibres of gluteus maximus, with part of its trochanteric
despite the obliquity of the shaft, the profile of the distal end is almost bursa interposed. The tendon of piriformis is attached to the upper
horizontal. A curved strip, 1 cm wide and adjoining the medial articular border of the trochanter and the common (tricipital) tendon of obtura-
margin, is covered by synovial membrane and is inside the joint capsule. tor internus and the gemelli is attached to its medial surface. The tro-
Proximal to this, the medial epicondyle receives the tibial collateral chanteric fossa receives the tendon of obturator externus. Psoas major
ligament. is attached to the summit and anteromedial surface of the lesser tro-
chanter. Iliacus is attached to the medial or anterior surface of its base,
Structure descending a little behind the spiral line as its tendon fuses with that
The femoral shaft is a cylinder of compact bone with a large medullary of psoas major. Adductor magnus (upper part) passes over its posterior
cavity. The wall is thick in its middle third, where the femur is narrowest surface, sometimes separated by an interposed bursa. | 1,861 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
Pelvic girdle, gluteal region and thigh
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Fig. 80.16 A coronal section
through the left hip joint.
Lunate surface
Tensor fasciae latae (With permission from
Joint capsule Waschke J, Paulsen F (eds),
Head of femur Gluteus medius Sobotta Atlas of Human
Anatomy, 15th ed, Elsevier,
Acetabular fossa
Gluteus minimus Urban & Fischer. Copyright
Ligament of head of femur
2013.)
Fovea for ligament of head
Obturator internus Trochanteric fossa
Greater trochanter
Neck of femur
Tendon of gluteus maximus
Acetabular labrum
Trochanteric bursa of gluteus maximus
Trochanteric bursa of gluteus medius
Obturator externus
Iliotibial tract
Tendon of iliopsoas
Lesser trochanter Vastus lateralis
Head of femur Greater trochanter tor magnus. Distal to this, adductor magnus is attached to the linea
aspera and, by an aponeurosis, to the proximal part of the medial
supracondylar ridge. Its remaining fibres form a large tendon attached
to the adductor tubercle, with an aponeurotic expansion to the distal
part of the medial supracondylar ridge.
Pectineus and adductor brevis are attached to the posterior femoral
surface between the gluteal tuberosity and spiral line. The pectineal
attachment is a line, sometimes slightly rough, from the base of the
lesser trochanter to the linea aspera. Adductor brevis is attached lateral
to pectineus and beyond this to the proximal part of the linea aspera,
medial to adductor magnus. Adductor longus, intermuscular septa and
the short head of biceps femoris are attached to the linea aspera. Vastus
lateralis has a linear attachment from the anterior surface of the base
of the greater trochanter to the proximal end of the gluteal tuberosity,
Compact bone and along the lateral margin of the latter to the proximal half of the
lateral edge of the linea aspera. Vastus medialis is attached from the
distal end of the intertrochanteric line along the spiral line to the medial
edge of the linea aspera and thence to the medial supracondylar line,
which also receives many fibres from the aponeurotic attachments of
Calcar femorale adductor magnus.
The medial head of gastrocnemius is attached to the posterior surface
Lesser trochanter a little above the medial condyle. The short head of biceps femoris is
attached to the proximal two-thirds of the lateral supracondylar line.
Plantaris attaches to the line distally. Vastus medialis is attached to the
proximal two-thirds of the medial supracondylar line.
Part of the lateral head of gastrocnemius is attached posterosuperi-
orly to the lateral epicondyle. Popliteus is attached anteriorly in the
groove on the outer aspect of the lateral epicondyle. Its tendon passes
Spongy (trabecular) bone deep to the fibular collateral ligament (see Fig. 80.15). The tendon lies
in the groove in full knee flexion; in extension it crosses the articular
margin and may form an impression on it.
vascular supply
The blood supply of the femoral head is derived from an arterial ring
around the neck, just outside the attachment of the fibrous capsule,
constituted by the medial and lateral circumflex femoral arteries with
minor contributions from the superior and inferior gluteal vessels (see
‘Trochanteric anastomosis’) (Fig. 80.18). From this ring, ascending cer-
vical branches pierce the capsule (under its zona orbicularis) to ascend
the neck beneath the reflected synovial membrane. These vessels
become the retinacular arteries and form a subsynovial intracapsular
anastomosis. Here the vessels are at risk with a displaced fracture of the
Fig. 80.17 A coronal section through the proximal end of the femur
femoral neck. Interruption of blood supply in this way can lead to
showing the trabecular architecture, calcar femorale and variations in
avascular necrosis of the femoral head. If the fracture is intracapsular,
cortical thickness. (With permission from Waschke J, Paulsen F (eds),
Sobotta Atlas of Human Anatomy, 15th ed, Elsevier, Urban & Fischer. not only is the intraosseous blood supply damaged but the retinacular
Copyright 2013.) vessels are also vulnerable. If the fracture is extracapsular, the retinacular
vessels will remain intact and avascular necrosis of the femoral head is
much less likely. The ascending cervical vessels give off metaphysial
The most proximal fibres of vastus lateralis are attached to the proxi- branches that enter the neck, while the intracapsular ring gives off
mal end of the intertrochanteric line, and those of vastus medialis to lateral and inferior epiphysial branches. A small medial epiphysial
the distal end. Quadratus femoris is attached to the quadrate tubercle supply, of importance in early childhood, reaches the head along the
and the immediately distal bone. Vastus intermedius is attached to the ligament of the head of femur by the acetabular branches of the obtura-
anterior and lateral surfaces of the proximal three-quarters of the tor and medial circumflex femoral arteries, which anastomose with
femoral shaft. Slips of articularis genus are attached distal to this. the other epiphysial vessels. During growth, the epiphysial plate sepa-
The gluteal tuberosity receives the deeper fibres of the distal half of rates the territories of the metaphysial and epiphysial vessels; these
gluteus maximus and, at its medial edge, the uppermost fibres of adduc- vessels anastomose freely after osseous union of the head and neck. | 1,862 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
Joints
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Joins shaft
Abdominal
eighteenth to
aorta Inferior epigastric nineteenth
Common artery year
iliac artery
Median Iliolumbar
Joins shaft
sacral artery artery
eighteenth
Deep circumflex
L5 vertebra iliac artery year
End of Fourth Fourteenth
Internal Superior gluteal artery At birth first year year Puberty year
iliac artery Inguinal ligament
Lateral sacral artery
Lateral circumflex
Obturator artery femoral artery Joins shaft
eighteenth
Medial circumflex to twentieth
Inferior gluteal artery femoral artery year
Profunda Fig. 80.19 Stages in ossification of the femur (not to scale).
femoris artery
External pudendal artery
Femoral artery
inferomedial part of the articular surface is on the neck. The medial
epiphysial margin later grows over this part of the articular surface.
Perforating branches of Thus, the mature epiphysis is a hollow cup on the summit of the neck.
profunda femoris artery The epiphysial line follows the articular margin except where it is sepa-
Lateral circumflex
rated superiorly from the articular surface by a non-articular area where
femoral artery
blood vessels enter the head (Trueta 1957). The epiphyses fuse inde-
pendently: the lesser trochanter soon after puberty, followed by the
greater trochanter. The capital epiphysis fuses in the fourteenth year in
females and seventeenth year in males. The epiphysis at the distal end
fuses in the sixteenth year in females, and eighteenth year in males. The
Descending genicular artery distal epiphysial plate traverses the adductor tubercle.
Growth plate considerations
Fig. 80.18 The collateral circulation around the hip and upper thigh, Trauma to any epiphysial plate can lead to bony union between epiphy-
anterior aspect. sis and metaphysis, and so cause premature cessation of growth. Any
surgery in the hip region in children can injure the growth plate, result-
ing in abnormal proximal femoral development. In the case of fractures
Observations of developmental patterns of this supply in late fetal and involving the epiphysis, expeditious restoration of normal bony align-
early postnatal periods have revealed that although medial and lateral ment is essential in order to minimize the risk of subsequent abnormal
circumflex femoral arteries at first contribute equally, two major growth.
branches of the medial provide the final supply, both posterior to the The growth plate represents a line of weakness and predisposes to
neck. The supply from the lateral circumflex artery diminishes and fracture from injury. Such acute injuries affecting the capital epiphysis
the arterial ring is interrupted. As the femoral neck elongates, the extra- are uncommon. However, a more chronic fracture through the capital
capsular circle becomes more distant from the epiphysial part of epiphysis occurs in slipped capital femoral epiphysis (SCFE) (see Fig.
the head. 81.9). The condition affects pubescent adolescents, especially males.
The trochanteric regions and subtrochanteric shaft are supplied by Endocrinological abnormality may be related. The femoral head epi-
the trochanteric and cruciate arterial anastomoses. More distally in the physis displaces posteriorly off the femoral neck. If it heals in this
shaft, nutrient foramina, directed proximally, are found in the linea position, lower limb deformity and restricted hip movement occur. A
aspera, varying in number and site: one is usually near its proximal end classic hallmark is obligatory lateral rotation of the femur as the hip is
and a second usually near its distal end. The main nutrient artery is flexed. Treatment varies according to the time taken for the ‘slip’ to
usually derived from the second perforating artery (see ‘Profunda occur. Normal anatomical restoration is not attempted because of an
femoris artery’). If two nutrient arteries occur, they may branch from increased incidence of avascular necrosis. The position of the femoral
the first and third perforators. Periosteal vessels arise from the perfora- head may be accepted as it is and fixed with screws in this position to
tors and from the profunda femoris artery, and run circumferentially stop further displacement. This treatment will deliberately cause pre-
rather than longitudinally. The distal metaphysis has many vascular mature growth plate fusion and so prevent future ‘slippage’. Since the
foramina. Arterial supply here is from the genicular anastomosis. For distal femoral growth plate accounts for most of the normal increase
further details, consult Crock (1980, 1996). in longitudinal growth of the femoral shaft, an acceptable limb length
In general, the pattern of venous drainage of the head and neck cor- difference usually results.
responds to that of the arteries, though there may be a single large cervi- Infection of bone in neonates and young children tends to arise via
cal vein posteroinferiorly. bacteria in the blood stream that usually ‘seed’ in the metaphysial
region, probably as a consequence of the vascular ‘arcade’ arrangement
innervation of arteries in this part of the bone. The proximal femoral growth plate
The periosteal innervation is derived proximally from nerves that supply is intra-articular. As a result, infection in the proximal femoral meta-
the hip joint, distally from those supplying the knee, and in all areas physis can spread into the joint and result in a septic arthritis that can
from nerves that innervate muscles attached to the bone. destroy the hip joint permanently.
The distal end of the femur is the only epiphysis in which ossific-
ossification ation consistently starts just before birth; the phenomenon therefore
The femur ossifies from five centres: in the shaft, head, greater and lesser serves as a reliable indicator of the gestational maturity of a stillborn
trochanters and the distal end (Fig. 80.19). Other than the clavicle, it baby. Since the epiphysial plate is level with the adductor tubercle, the
is the first long bone to ossify. The process starts in the mid-shaft in the epiphysis is partly extra-articular. Operations here may damage the
seventh prenatal week and extends to produce a miniature shaft that is distal epiphysial cartilage in children and result in subsequent shorten-
largely ossified at birth. Secondary centres appear in the distal end ing of the leg.
(from which the condyles and epicondyles are formed) during the
ninth month, in the head during the first six months after birth
JOINTS
(Fig. 80.20), in the greater trochanter during the fourth year and in
the lesser trochanter between the twelfth and fourteenth years. In the
infant, the femoral head is entirely cartilaginous; it cannot be seen on PUBIC SYMPHYSIS
plain radiographs and is best visualized using ultrasound (Fig. 80.21).
The centre in the cartilaginous head is restricted to it until the tenth The pubic bones meet in the midline at the pubic symphysis, a second-
year, so that the epiphysial line (see Fig. 80.7) is horizontal and the ary cartilaginous joint (see Fig. 80.4). | 1,863 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Pelvic girdle, gluteal region and thigh
Fig. 80.21 An ultrasound image of a 4-week-old baby taken in the lateral
Fig. 80.20 A radiograph of the pelvis of a 9-month-old infant showing the position and demonstrating the cartilaginous femoral head (yellow arrow)
centre of ossification of the femoral epiphysis (arrow). (Courtesy of Mr and edge of the acetabulum (red arrow). (Courtesy of Mr Christopher
Christopher Edward Bache.) Edward Bache.)
1353.e1 | 1,864 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Articulating surfaces The articulating surfaces are the medial (sym- anteriorly than posteriorly in adults. The thinner cartilage on the iliac
physial) surfaces of the pubic bones, each covered by a thin layer of surface is also hyaline in type, as confirmed by the presence of type II
tightly adherent hyaline cartilage (surface growth cartilage in the collagen.
young). The junction is not flat but is marked by reciprocal crests and
papillae. Theoretically, this would resist shearing. The surfaces of hyaline Fibrous capsule The capsule is attached close to both articular
cartilage are connected by fibrocartilage, varying in thickness and con- margins.
stituting the interpubic disc. The symphysis often contains a cavity,
probably due to absorption. It rarely appears before the tenth year and Ligaments The ligaments of the sacroiliac joint are the anterior,
is non-synovial. The cavity, which is better developed in females, is interosseous and posterior sacroiliac, iliolumbar, sacrotuberous and
usually posterosuperior but may reach the front or even occupy most sacrospinous ligaments.
of the cartilage.
Anterior sacroiliac ligament The anterior sacroiliac ligament (see Fig.
Ligaments The interpubic disc is strengthened anteriorly by several 80.9A), an anteroinferior capsular thickening, is particularly well devel-
interlacing collagenous fibrous layers, passing obliquely from bone to oped near the arcuate line and the posterior inferior iliac spine, where
bone, decussating with fibres of the external oblique aponeuroses and it connects the third sacral segment to the lateral side of the pre-
the medial tendons of the recti abdominis. These layers constitute the auricular sulcus. It is thin elsewhere.
anterior pubic ligament. There are less well developed posterior fibres,
sometimes named the posterior pubic ligament. The main ligaments of Interosseous sacroiliac ligament The interosseous sacroiliac liga-
the joint are the superior and arcuate pubic ligaments. The superior ment is the major bond between the bones, filling the irregular space
pubic ligament connects the bones above, extending to the pubic tuber- posterosuperior to the joint. The posterior sacroiliac ligament covers it
cles. The arcuate pubic ligament, a thick arch of fibres, connects the superficially. Its deeper part has superior and inferior bands passing
lower borders of the symphysial pubic surfaces bounding the pubic from depressions posterior to the sacral auricular surface to those on
arch. It blends superiorly with the interpubic disc and extends laterally the iliac tuberosity. These bands are covered by, and blend with, a
attached to the inferior pubic rami. Its inferior edge is separated from more superficial fibrous sheet connecting the posterosuperior margin
the anterior border of the perineal membrane by an opening, which is of a rough area posterior to the sacral auricular surface to the corre-
traversed by the deep dorsal vein of the penis or clitoris. sponding margins of the iliac tuberosity. This sheet is often partially
divided into superior and inferior parts, the former uniting the supe-
Vascular supply The pubic symphysis is supplied by pubic branches rior articular process and lateral crest on the first two sacral segments
of the obturator, superficial external pudendal and inferior epigastric to the neighbouring ilium as a short posterior iliac ligament (see Fig.
arteries. 43.68).
Innervation The pubic symphysis is innervated by branches from the Posterior sacroiliac ligament The posterior sacroiliac ligament (see
iliohypogastric, ilioinguinal and pudendal nerves. Fig. 80.9B) overlies the interosseous ligament: the dorsal rami of the
sacral spinal nerves and vessels intervene. It consists of several weak
Factors maintaining stability The interpubic disc and the superior fasciculi connecting the intermediate and lateral sacral crests to the
and arcuate ligaments are the main stabilizing factors of the pubic posterior superior iliac spine and posterior end of the internal lip of
symphysis. the iliac crest. Inferior fibres, from the third and fourth sacral segments,
ascend to the posterior superior iliac spine and posterior end of the
Movements Angulation, rotation and displacement are possible but internal lip of the iliac crest; they may form a separate long posterior
slight, and are likely during movement at the sacroiliac and hip joints. sacroiliac ligament. This ligament is continuous laterally with part of
The movements at the pubic symphysis range between 0.1 and 2 mm the sacrotuberous ligament and medially with the posterior lamina of
and are higher along the vertical axis than along the sagittal and trans- the thoracolumbar fascia.
verse axes (Walheim et al 1984). Excessive movement may occur fol-
lowing an injury. Some separation occurs late in gestation and during Iliolumbar ligament See page 738.
childbirth; on occasion, this is considerable.
Sacrotuberous ligament The sacrotuberous ligament (see Figs 80.9,
Relations Anteriorly, the pubic symphysis is related to subcutaneous 43.68) is attached by its broad base to the posterior superior iliac spine,
tissue and skin. Because of the obliquity of the joint, the proximal ends the posterior sacroiliac ligaments (with which it is partly blended),
of the penile or clitoral shafts lie anterior to the lower half of the joint. lateral sacral crest, and the lateral margins of the lower sacrum and
Inferiorly, the urethra lies about 2.5 cm away in the male, and some- upper coccyx. Its oblique fibres descend laterally, converging to form a
what closer in the female, as it passes through the perineal membrane. thick, narrow band that widens again below and is attached to the
Closer to the joint, the deep dorsal vein of the penis or clitoris passes medial margin of the ischial tuberosity. It then spreads along the ischial
between the arcuate ligament and the anterior border of the perineal ramus as the falciform process, whose concave edge blends with the
membrane. Posteriorly, the upper part of the joint is separated from the fascial sheath of the internal pudendal vessels and pudendal nerve. The
inferolateral surfaces of the urinary bladder by the retropubic fat pad. lowest fibres of gluteus maximus are attached to the posterior surface
Inferiorly in the male, the prostatic venous plexus separates the prostate of the ligament; superficial fibres of the lower part of the ligament
from the lower part of the joint. The region is sometimes termed the continue into the tendon of biceps femoris. The coccygeal branches of
retropubic space (of Retzius). These relationships explain why traumatic the inferior gluteal artery, the perforating cutaneous nerve and filaments
disruption of the anterior bony pelvis may be associated with serious of the coccygeal plexus pierce the ligament.
urogenital injury.
Sacrospinous ligament The thin, triangular sacrospinous ligament
(see Fig. 80.9) extends from the ischial spine to the lateral margins of
SACROILIAC JOINT the sacrum and coccyx anterior to the sacrotuberous ligament, with
which it blends in part. Its anterior surface is in fact the coccygeus
The sacroiliac joint occurs between the sacral and iliac auricular surfaces muscle, i.e. muscle and ligament are coextensive. The sacrospinous liga-
and, in essence, is a stress-relieving joint (Bogduk 1997) (see Fig. ment is often regarded as a degenerate part of coccygeus.
80.8A). The joint consists of syndesmotic and synovial parts. Fibrous
adhesions and gradual obliteration occur in both sexes, earlier in males, Sciatic foramina The sacrotuberous and sacrospinous ligaments
and after menopause in females. Radiological evidence of obliteration convert the sciatic notches into foramina (see Fig. 80.9).
in normal subjects is occasionally seen before 50 years but is not
uncommon thereafter; in old age, the joint may be completely fibrosed Greater sciatic foramen The greater sciatic foramen is bounded
and occasionally even ossified. anterosuperiorly by the greater sciatic notch, posteriorly by the sacro-
tuberous ligament and inferiorly by the sacrospinous ligament and
Articulating surfaces The surfaces are nearly flat in infants, whereas ischial spine (see Fig. 80.9). It is partly filled by the emerging piriformis,
in adults they are irregular, often markedly so, and sometimes undu- above which the superior gluteal vessels and nerve leave the pelvis.
lant. The curvatures and irregularities, greater in males, are reciprocal; Below it, the inferior gluteal vessels and nerve, internal pudendal vessels
they restrict movements and contribute to the considerable strength of and pudendal nerve, sciatic and posterior femoral cutaneous nerves and
the joint in transmitting weight from the vertebral column to the lower the nerves to obturator internus and quadratus femoris all leave the
limbs. The sacral surface is covered by hyaline cartilage, which is thicker pelvis. | 1,865 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Lesser sciatic foramen The lesser sciatic foramen is bounded anteri- Psoas major
orly by the ischial body, superiorly by its spine and sacrospinous liga- Attachments Psoas major is a long muscle that lies on either side
ment, and posteriorly by the sacrotuberous ligament (see Fig. 80.9A). of the lumbar vertebral column and the pelvic brim (Fig. 80.22, see
It transmits the tendon of obturator internus, the nerve to obturator Fig. 62.7). Its proximal attachments are complex. They include the
internus, and the internal pudendal vessels and pudendal nerve. anterior surfaces and lower borders of the transverse processes of all the
lumbar vertebrae. There are five digitations, each from the bodies of two
Vascular supply The arterial supply of the sacroiliac joint is derived adjoining vertebrae and their intervertebral disc. The highest of these
from the iliolumbar, superior gluteal and superior lateral sacral arteries, arises from the lower margin of the body of the twelfth thoracic verte-
with corresponding venous drainage. Lymphatic drainage follows the bra, the upper margin of the body of the first lumbar vertebra and the
arteries, reaching the iliac and lumbar nodes. interposed intervertebral disc. The lowest arises from the adjacent
margins of the bodies of the fourth and fifth lumbar vertebrae and the
Innervation Nerve fibres ramify within the joint capsule and adjoin-
interposed disc. A series of tendinous arches extend across the narrow
ing ligaments, but their source is uncertain. It is thought that the joint
parts of the bodies of the lumbar vertebrae between the digitations
probably receives branches from the anterior and posterior rami of the
already described. The lumbar arteries and veins, and filaments from
first two sacral spinal nerves, and from the superior gluteal nerve, and
that there may also be contributions from the obturator nerve and the
lumbosacral trunk.
The sacroiliac joint has sometimes been implicated as the source of
pain in the lower back and buttocks. Diagnosing sacroiliac joint-
mediated pain is difficult because the presenting complaints are similar
to those seen with other causes of back pain. Patients with sacroiliac
joint-mediated pain rarely report pain above the level of L5; most local-
ize their pain to the area around the posterior superior iliac spine.
Quadratus lumborum
Factors maintaining stability The sacroiliac joint is one of the
Psoas minor
most stable joints in the body and supports the weight of the trunk.
The reciprocal irregularity of the joint surfaces allows very little move- Psoas major
ment. The tendency of the sacrum to be forced downwards by the trunk
is resisted by the extremely strong posterior ligaments, while the ilio- Iliacus
lumbar ligaments help to resist displacement of the fifth lumbar verte-
bra over the sacrum. The sacrotuberous and sacrospinous ligaments Anterior superior iliac spine
oppose upward tilting of the lower part of the sacrum when downward
thrust is applied at its upper end. Inguinal ligament
Piriformis
Movements Primary movement of the sacroiliac joint is minimal. All
Coccygeus
muscles that cross the joint act on the lumbar spine or on the hip. Such
Levator ani
movements as do occur are secondarily imposed on the joint as the
pelvis moves. Data from living subjects are technically difficult to Pubic tubercle
obtain, and those based on plain radiographs are unreliable. Studies
Tensor fasciae latae
using implanted tantalum spheres and biplanar radiography have
shown mean rotational ranges of less than 2°. Even when there is Pectineus
recordable movement, the direction of movement is irregular. Biplanar
radiography has also shown that the axes of movement of the sacroiliac Adductor longus
joint during hip movement are oblique, and that the axes differ in
flexion and extension.
Gracilis
During pregnancy, the pelvic joints and ligaments loosen under the
influence of the hormone relaxin. Movements in the joints increase.
Relaxation renders the sacroiliac locking mechanism less effective, per- Sartorius
mitting greater rotation and perhaps allowing alterations in pelvic
diameters at childbirth, although the effect is probably small. The Adductor magnus
impaired locking mechanism diverts the strain of weight-bearing to the
ligaments, with frequent sacroiliac strain after pregnancy.
Rectus femoris
Relations The sacroiliac joints have many important anterior rela-
tions. The internal and external iliac veins join to form the common
Iliotibial tract
iliac veins immediately anteriorly, separating the joints from the bifur-
cations of the common iliac arteries and, more anteriorly, the ureters.
The lumbosacral trunk and the obturator nerve cross the anterior aspect
of the joint behind the vessels. Piriformis partly attaches to the anterior Vastus lateralis
capsule, separating the joint from the upper part of the sacral plexus.
Vastus medialis
Variants Accessory sacroiliac articulations are not uncommon. They
develop behind the articular surface between the lateral sacral crest and
posterior superior iliac spine and iliac tuberosity, and are acquired
fibrocartilaginous joints resulting from the stresses of weight-bearing.
They have a joint capsule, are saddle-shaped, and may be single, double,
unilateral or bilateral (Weisl 1954).
MUSCLES
MUSCLES OF THE ILIAC REGION
Although there is no ‘iliac region’ as such, this heading conveniently
describes a group of three muscles that originate from the lumbar ver-
tebral column (psoas major and minor) and the ilium (iliacus). Psoas
major and iliacus are attached together on the femur as flexors of the
hip joint and are often considered as a functional unit, iliopsoas. Psoas
minor only reaches the pubis, and acts on the spine and sacroiliac joint. Fig. 80.22 The hip flexors and superficial muscles of the thigh. | 1,866 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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the sympathetic trunk, pass medial to these arches. The upper four Vascular supply The main arterial supply to psoas minor is from
lumbar intervertebral foramina bear important relations to these attach- the lumbar arteries, though there may be minor contributions from
ments of the muscle. The foramina lie anterior to the transverse proc- other vessels of the network that supplies psoas major.
esses and posterior to the attachments to vertebral bodies, intervertebral
discs and tendinous arches. Thus, the roots of the lumbar plexus enter Innervation Psoas minor is innervated by a branch from L1.
the muscle directly, the plexus is lodged within it, and its branches
emerge from its borders and surfaces. Actions Psoas minor is probably a weak flexor of the trunk.
The muscle descends along the pelvic brim, continues posterior to
the inguinal ligament and anterior to the capsule of the hip joint, and Testing Psoas minor cannot be tested clinically.
converges to a tendon that, having received on its lateral side nearly all
the fibres of iliacus, becomes attached to the lesser trochanter of the Iliacus
femur. The large subtendinous iliac bursa, which occasionally commu-
Attachments Iliacus (see Figs 80.22, 62.7) is a triangular sheet of
nicates with the cavity of the hip joint, separates the tendon from the
muscle that arises from the superior two-thirds of the concavity of the
pubis and the capsule of the joint.
iliac fossa, the inner lip of the iliac crest, the ventral sacroiliac and iliol-
The complex vertebral attachments of psoas major sometimes
umbar ligaments, and the upper surface of the lateral part of the sacrum
display minor numerical variations.
(see Fig. 43.49). In front, it reaches as far as the anterior superior and
ant erior inferior iliac spines, and receives a few fibres from the upper
Relations The upper limit of psoas major is posterior to the dia-
part of the capsule of the hip joint (iliocapsularis, p. 1377). Most of its
phragm in the lowest part of the posterior mediastinum. It may be in
fibres converge into the lateral side of the strong tendon of psoas major,
contact with the posterior extremity of the pleural sac. In the abdomen,
and the muscles then insert together into the lesser trochanter, but some
its anterolateral surface is related to the medial arcuate ligament (a
fibres are attached directly to the femur 2.5 cm below and in front of
linear, arched thickening in the psoas fascia), extraperitoneal tissue and
the lesser trochanter.
peritoneum, the kidney, psoas minor, renal vessels, ureter, testicular or
ovarian vessels and the genitofemoral nerve. Anteriorly, the right psoas
Relations In the abdomen, the anterior surface of iliacus is related to
is overlapped by the inferior vena cava and crossed by the terminal part
its fascia (which separates the muscle from extraperitoneal tissue and
of the ileum; the colon crosses the left psoas. Its posterior surface is
peritoneum), the lateral femoral cutaneous nerve, the caecum (on the
related to the transverse processes of the lumbar vertebrae and the
right) and the iliac part of the descending colon (on the left). On its
medial edge of quadratus lumborum. The lumbar plexus is embedded
posterior surface is the iliac fossa, and at its medial border, psoas major
posteriorly in the substance of psoas major. Medially, the muscle is
and the femoral nerve. In the thigh, its anterior surface is in contact
related to the bodies of the lumbar vertebrae and lumbar vessels. Along
with the fascia lata, rectus femoris, sartorius and the profunda femoris
its anteromedial margin, it is in contact with the sympathetic trunk,
artery, and its posterior surface is in contact with the capsule of the hip
aortic lymph nodes and, along the pelvic brim, with the external iliac
joint, from which it is partially separated by a bursa it shares with psoas
artery. This margin is covered by the inferior vena cava on the right side,
major.
and lies posterior and lateral to the abdominal aorta on the left side.
In the thigh, iliopsoas is related anteriorly to the fascia lata and the
Vascular supply Iliacus is supplied by the same arterial network as
femoral artery, and posteriorly to the capsule of the hip joint, from
psoas major, and there is mutual overlap of the arterial territories of
which it is separated by a bursa. At its medial border, it is related to
each muscle. The main supply is from the iliac branches of the iliolum-
pectineus and the medial circumflex femoral artery, and to the femoral
bar artery, with contributions from the deep circumflex iliac and obtur-
vein, which may overlap it slightly. At its lateral border, it is related to
ator arteries, and branches of the femoral artery.
the femoral nerve and iliacus. The femoral nerve descends at first
through the fibres of psoas major, and then in the furrow between it
Innervation Iliacus is innervated by branches of the femoral nerve,
and iliacus.
L2 and 3.
Branches of the lumbar plexus diverge from the abdominal part of
psoas major. Emerging from the lateral border, from above downwards,
Actions Psoas major, acting from above together with iliacus, flexes
are the iliohypogastric, ilioinguinal and lateral femoral cutaneous and
the thigh on the pelvis. Electromyographic studies do not support the
femoral nerves. Emerging from the anterolateral surface is the genito-
common view that psoas major acts as a medial rotator of the hip joint,
femoral nerve. The obturator and accessory obturator nerves (when
but activity has been described in lateral rotation, particularly in the
present) and the upper root of the lumbosacral trunk all emerge from
young. When psoas major and iliacus of both sides act from below, they
the medial border.
contract powerfully to bend the trunk and pelvis forwards against resist-
ance, as in raising the trunk from the recumbent to the sitting posture
Vascular supply Psoas major is supplied by a rich network of arteries
when undertaking a ‘sit-up’ exercise.
derived from the lumbar, iliolumbar, obturator, external iliac and
Electromyography does not support the commonly held belief that
femoral arteries. In general terms, the upper part of the muscle is sup-
unilateral action of psoas major causes lateral and forward flexion of
plied by the lumbar arteries, the mid part by the anterior branch of the
the trunk to that side (Joseph 1975).
iliolumbar artery (the main artery to the muscle) with contributions
In symmetrical upright stance, iliopsoas has some action from below
from the deep circumflex and external iliac arteries, and the distal part
to maintain the vertebral column upright. Psoas major is active in bal-
by the femoral artery and its branches. The psoas sheath has an arterial
ancing the trunk while sitting.
supply independent from that of the muscle, though the same vessels
contribute.
Testing Both psoas and iliacus may be the sites of pathological col-
lections of fluid. An abscess (typically tuberculous) of vertebral origin
Innervation Psoas major is innervated by the ventral rami of the
may track down through psoas and present as a mass in the thigh.
lumbar spinal nerves, mainly L1 and 2 with some contribution from
Haematoma or infection within the iliacus fascia may present as a mass
L3.
or as a flexion deformity of the hip.
Iliopsoas may be tested clinically by actively flexing the hip against
Actions Psoas major acts together with iliacus; the combination is
resistance, in the supine position with the hip and knee flexed.
referred to as iliopsoas. See below (‘Iliacus’).
Testing See below (after ‘Iliacus’).
MUSCLES OF THE GLUTEAL REGION
Psoas minor
Attachments Psoas minor (see Fig. 80.22) is sometimes absent. Tensor fasciae latae
When present, it lies anterior to psoas major, entirely within the Attachments Tensor fasciae latae (see Fig. 80.22) arises from the
abdomen. It arises from the sides of the bodies of the twelfth thoracic anterior 5 cm of the outer lip of the iliac crest, from the lateral surface
and first lumbar vertebrae, and from the intervertebral disc between of the anterior superior iliac spine and part of the border of the notch
them. It ends in a long, flat tendon that is attached to the pecten pubis, below it, between gluteus medius and sartorius, and from the deep
iliopubic ramus and, laterally, to the iliac fascia. surface of the fascia lata. Proximal attachments may extend to the
aponeurotic fascia superficial to gluteus medius. It descends between,
Relations Psoas minor lies on psoas major, and its proximal anterior and is attached to, the two layers of the iliotibial tract of the fascia lata
relations are those of the anterior or anteromedial surface of that muscle. and usually ends approximately one-third of the way down the thigh, | 1,867 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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although it may occasionally extend as far as the lateral femoral
condyle. Gluteal fascia (cut)
Vascular supply The muscle itself is supplied mainly by a large
ascending branch of the lateral circumflex femoral artery. The tensor
fasciae latae musculocutaneous flap is raised on this pedicle. The supe- Gluteus medius
rior part of the muscle receives branches from the superior gluteal artery.
The fascia surrounding the muscle is supplied on its superficial aspect
by the superficial circumflex iliac artery and on its deep surface by the
lateral circumflex femoral artery.
Gluteus maximus
Innervation Tensor fasciae latae is innervated by the superior gluteal
nerve, L4, 5 and S1.
Actions Tensor fasciae latae, acting through the iliotibial tract, extends
the knee with lateral rotation of the leg; it may also assist in abduction Coccyx
and medial rotation of the thigh, though its role as an abductor is
debatable. The muscle helps to maintain upright posture while mini-
mizing energy expenditure on muscle activity: when the subject is
Greater trochanter
standing it acts from below to steady the pelvis on the head of the femur
and, through the iliotibial tract, to steady the condyles of the femur on
the tibial condyles while the knee extensors are relaxed. The muscle aids
gluteus medius in postural abduction at the hip. Postural control is its
main function.
In the last 20° or so of extension, the pull of the iliotibial tract is
Adductor magnus
anterior to the flexion axis of the knee and so the tensor fasciae latae is
a weak extensor. Flexion of greater than 20° leads to the iliotibial tract
passing posterior to the axis of flexion so that the muscle becomes a Biceps femoris
weak flexor.
Testing When the thigh is flexed against gravity and the knee is Semitendinosus
extended, an angular depression appears immediately below the ant-
erior superior iliac spine; its lateral boundary is tensor fasciae latae. If
the thigh is then abducted against resistance, the muscle can be felt and Fascia lata
sometimes seen.
Gluteus maximus Gracilis
Attachments Gluteus maximus (Fig. 80.23) is the largest and most
superficial muscle in the gluteal region. It is a broad, thick, quadrilateral
mass, which, with its overlying adipose fascia, forms the familiar promi-
nence of the buttock. Gluteus maximus is thicker and more extensive
in humans than in any non-human primate, features that presumably
Fig. 80.23 Gluteus maximus, posterior view with the posterior thigh
correlate with the evolutionary transition to bipedality and a perma-
muscles seen through the overlying fascia lata.
nently upright posture. The muscle has a coarse fascicular architecture,
with large bundles of fibres separated by fibrous septa. It arises from
the posterior gluteal line of the ilium and the rough area of bone,
including the crest, immediately above and behind it; from the aponeu- fold (the posterior flexure line of the hip joint), which marks the upper
rosis of erector spinae; the dorsal surface of the lower part of the sacrum limit of the back of the thigh on the surface.
and the side of the coccyx; the sacrotuberous ligament; and the fascia
(gluteal aponeurosis) that covers gluteus medius. There may be addi- Vascular supply The dominant vascular pedicle is usually that of
tional slips from the lumbar aponeurosis or ischial tuberosity. The the inferior gluteal artery, which supplies approximately two-thirds of
muscle may also be bilaminar. The fibres descend laterally; the upper the muscle. The remainder is supplied mainly by the superior gluteal
part of the muscle, together with the superficial fibres of the lower part, artery, though this may sometimes be the dominant vessel. The lateral
ends in a thick tendinous lamina that passes lateral to the greater tro- and distal borders of the muscle receive a supply from the first perfora-
chanter and is attached to the iliotibial tract of the fascia lata. The tor given off from the profunda femoris artery and from the medial
deeper fibres of the lower part of the muscle are attached to the gluteal circumflex femoral artery. Minor branches may be derived from the
tuberosity between vastus lateralis and adductor magnus. lateral circumflex femoral, lateral sacral and internal pudendal
arteries.
Relations A thin fascia separates the superficial surface of gluteus Gluteus maximus musculocutaneous flaps may be based on either
maximus from the overlying thick, adipose subcutaneous tissue. The of the gluteal vessels or on the first perforator given off from the pro-
deep surface of the muscle is related to the ilium, sacrum, coccyx, sac- funda femoris artery, depending on the site and size of the defect requir-
rotuberous ligament, part of gluteus medius, piriformis, the gemelli, ing coverage.
obturator internus, quadratus femoris, the ischial tuberosity, greater
trochanter, and the attachments of biceps femoris, semitendinosus, Innervation Gluteus maximus is innervated by the inferior gluteal
semimembranosus and adductor magnus to the ischial tuberosity. nerve, L5, S1 and S2.
Three bursae lie deep to gluteus maximus: trochanteric, over the greater
trochanter; gluteofemoral, between the tendon of gluteus maximus and Actions Acting from the pelvis, gluteus maximus can extend the flexed
that of vastus lateralis; and ischiofemoral, over the gluteal tuberosity, thigh and bring it into line with the trunk. Acting from its distal attach-
which is less commonly present. ment, it may prevent the forward momentum of the trunk from produc-
The superficial division of the superior gluteal artery reaches the ing flexion at the supporting hip during bipedal gait. The muscle is
deep surface of the muscle between piriformis and gluteus medius. The inactive during standing, when swaying forwards at the ankle joints, or
inferior gluteal and internal pudendal vessels, the sciatic, pudendal and when bending forwards at the hip joints to touch the toes. However, it
posterior femoral cutaneous nerves, muscular branches from the sacral acts with the hamstrings in raising the trunk after stooping, by rotating
femoral cutaneous nerves, and muscular branches from the sacral the pelvis backwards on the head of the femur. It is intermittently active
plexus all leave the pelvis below piriformis. The first perforating artery in the walking cycle and in climbing stairs, and continuously active in
and the terminal branches of the medial circumflex femoral artery are strong lateral rotation of the thigh. Its upper fibres are active in powerful
also deep to the lower part of gluteus maximus. Its upper border is thin abduction of the thigh. It is a tensor of the fascia lata, and through the
and overlies gluteus medius. Its prominent lower border is free and iliotibial tract it stabilizes the femur on the tibia when the extensor
slopes downwards and laterally. It is crossed by the horizontal gluteal muscles of the knee are relaxed. | 1,868 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Vascular supply The main supply to gluteus medius is from the deep
branch of the superior gluteal artery (Fig. 80.25A). The distal part of
A
the muscle is supplied by the trochanteric anastomosis.
Innervation Gluteus medius is innervated by the superior gluteal
nerve, L4, 5 and S1.
Gluteus medius
Actions These are considered below with gluteus minimus.
Testing This is considered below with gluteus minimus.
Gluteus minimus
Attachments Gluteus minimus lies deep to gluteus medius (see
Fig. 80.24B). The fan-shaped muscle arises from the outer surface of the
ilium between the anterior and inferior gluteal lines and, behind, from
the margin of the greater sciatic notch. The fibres converge below to the
deep surface of an aponeurosis that ends in a tendon attached to an
anterolateral ridge on the greater trochanter and contributes an expan-
sion to the capsule of the hip joint.
The muscle may divide into anterior and posterior parts. Separate
slips may pass to piriformis, gemellus superior or vastus lateralis.
Relations Branches of the deep division of the superior gluteal artery
and nerve run on the superficial surface of the muscle. The reflected
tendon of rectus femoris and the capsule of the hip joint are deep to
gluteus minimus. A bursa (trochanteric bursa of gluteus minimus) sepa-
B rates the tendon from the medial part of the anterior surface of the
greater trochanter.
Vascular supply Gluteus minimus is supplied from both its surfaces,
from the main trunk and the deep branch of the superior gluteal artery,
with a contribution at its femoral attachment from the trochanteric
anastomosis (see Fig. 80.25).
Gluteus minimus
Innervation Gluteus minimus is innervated by the superior gluteal
nerve, L4, 5 and S1.
Piriformis
Gemellus superior Actions of gluteus medius and minimus
Both gluteus medius and minimus, acting from the pelvis, abduct the
thigh, and their anterior fibres rotate it medially. Acting from the femur,
Gemellus inferior
they play an essential part in maintaining the trunk upright when the
Quadratus femoris
foot of the opposite side is raised from the ground in walking and
Obturator internus running. In this phase, the body weight tends to make the pelvis sag
downwards on the unsupported side. This is counteracted by the gluteus
medius and minimus of the supporting side, which, acting from below,
exert such powerful traction on the hip bone that the pelvis is actually
raised a little on the unsupported side. In symmetrical standing with
the feet somewhat separated, the abductor muscles are usually ‘silent’
on electromyography, but with the feet placed parallel and close
together they are active.
Fig. 80.24 A, Gluteus medius, posterior view. B, Gluteus minimus and
short lateral rotators of the hip, posterior view.
Testing The supportive effect of the glutei (medius and minimus) on
the pelvis when the contralateral foot is raised depends on the following
conditions. The two muscles, and their innervation, must be function-
ing normally. The components of the hip joint, which forms the
Testing Gluteus maximus may be tested by extension of the hip fulcrum, must be in their usual relation. The neck of the femur must
against resistance, in the supine or prone position. be intact, with its normal angulation to the shaft.
When any one of these conditions is not fulfilled, e.g. in paralysis
Gluteus medius
of the glutei, developmental dysplasia of the hip or coxa vara, the sup-
Attachments Gluteus medius is a broad, thick muscle (see Fig. 80.23; porting mechanism is upset and the pelvis sinks on the unsupported
Fig. 80.24A). It arises from the outer surface of the ilium between the side when the patient tries to stand on the affected limb. This is known
iliac crest and posterior gluteal line above, and the anterior gluteal line clinically as Trendelenburg’s sign. Individuals with paralysis of gluteus
below, and also from the strong fascia superficial to its upper part. The medius and minimus have a characteristic lurching gait. Provided that
fibres converge to a flat tendon that attaches to a ridge that these two muscles are intact, paralysis of other muscles acting on the
slants downwards and forwards on the lateral surface of the greater hip joint produces remarkably little deficit in walking, or even in
trochanter. running.
A deep slip of the muscle may be attached to the upper border of Gluteus medius and minimus may be tested together by medial
the trochanter. The posterior edge of gluteus medius sometimes blends rotation of the thigh against resistance, in the supine position with hip
with piriformis. and knee flexed. Both muscles may be tested together with tensor
fasciae latae by abduction of the lower limb against resistance, in the
Relations The posterior third of gluteus medius is covered by gluteus supine position with the knee extended.
maximus but it is superficial in its anterior two-thirds, where a strong
Piriformis
layer of deep fascia covers it. Its deep surface is related to gluteus
minimus. Branches of the deep divisions of the superior gluteal nerve Attachments Piriformis (see Figs 80.24B, 80.25A) occupies a central
and artery run between the medius and minimus muscles, and are position in the buttock, where it lies in the same plane as gluteus
vulnerable during anterolateral and lateral approaches to the hip medius. It arises from the anterior surface of the sacrum by three digit-
that involve splitting gluteus medius. Where the tendon glides on the ations, which are attached to the portions of bone between the pelvic
anterosuperior part of the lateral surface of the trochanter, a bursa sacral foramina, and to the grooves leading from the foramina (see
(trochanteric bursa of gluteus medius) separates it from the bone. Fig. 43.49). It also arises from the gluteal surface of the ilium near the | 1,869 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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A B
Superior gluteal artery
Psoas major and Iliacus
Inferior gluteal artery
Piriformis Sartorius
Lateral circumflex
femoral artery
Profunda femoris artery
Lateral circumflex femoral artery
Cruciate anastomosis Rectus femoris
Medial circumflex
femoral artery
Medial circumflex femoral artery Pectineus
Adductor longus
First perforating artery
Adductor brevis
Second perforating artery First, second and third
perforating arteries
Third perforating artery
Terminal segment of profunda
femoris artery
Adductor magnus
Vastus intermedius
Terminal segment of profunda
femoris artery
Adductor magnus
Vastus lateralis
Adductor hiatus
Vastus medialis, cut
Tendon of quadriceps femoris
Popliteal artery
Gracilis
Fig. 80.25 The arteries and muscles of the left gluteal and femoral regions. A, Posterior aspect. B, Anterior aspect. (With permission from Drake RL, Vogl
AW, Mitchell A (eds), Gray’s Anatomy for Students, 2nd ed, Elsevier, Churchill Livingstone. Copyright 2010.)
posterior inferior iliac spine, from the capsule of the adjacent sacroiliac the inferior gluteal artery (see Fig. 80.25A). In the pelvis, the main
joint, and sometimes from the upper part of the pelvic surface of the supply is from the lateral sacral artery, with contributions from both
sacrotuberous ligament. The muscle passes out of the pelvis through gluteal vessels.
the greater sciatic foramen, which it substantially fills. Here it consti-
tutes an important surgical landmark in the identification of structures Innervation Piriformis is innervated by branches from S1 and 2
that emerge above and below it. It inserts into the medial side of the (sometimes only from S2). It may also contain fibres from L5.
upper border of the greater trochanter of the femur via a rounded
tendon that lies behind and above, but is often partially blended with, Actions Piriformis rotates the extended thigh laterally, but abducts the
the common tendon of obturator internus and the gemelli. The muscle flexed thigh.
itself may be fused with gluteus medius.
Testing Clinically, it is not possible to test piriformis alone; however,
Relations Within the pelvis, the anterior surface of piriformis is for suspected injury to piriformis the best provocative test is to ask the
related to the rectum (especially on the left), the sacral plexus of nerves seated subject to abduct the thighs. Buttock pain suggests piriformis
and branches of the internal iliac vessels. The posterior surface lies injury.
against the sacrum. Outside the pelvis, its anterior surface is in contact
Obturator internus
with the posterior surface of the ischium and capsule of the hip joint,
and its posterior surface with gluteus maximus. Its upper border is in Attachments Obturator internus (see Figs 80.24B, 80.27) is situated
contact with gluteus medius and the superior gluteal vessels and nerve, partly within the true pelvis and partly posterior to the hip joint. It
its lower border with coccygeus and gemellus superior. The inferior arises from the internal surface of the anterolateral wall of the lesser
gluteal and internal pudendal vessels, the sciatic, posterior femoral pelvic cavity. Its attachments, which almost surround the obturator
cutaneous and pudendal nerves, and muscular branches from the sacral foramen, are to the inferior ramus of the pubis, the ischial ramus, and
plexus appear in the buttock in the interval between piriformis and the pelvic surface of the hip bone below and behind the pelvic brim,
gemellus superior. The relationship between piriformis and the sciatic to the upper part of the greater sciatic foramen above and behind, to
nerve is variable. The undivided nerve may emerge above the muscle or the obturator foramen below and in front. It also arises from the
through the muscle. The major divisions of the nerve may lie either side medial part of the pelvic surface of the obturator membrane, from the
of the muscle, or (the most common variant) one division passes tendinous arch that completes the obturator canal, and, to a small
between the heads of a divided muscle and one division either above extent, from the obturator fascia that covers the muscle. The fibres
or below. converge towards the lesser sciatic foramen and end in four or five
Piriformis can occasionally cause entrapment of the sciatic nerve in tendinous bands on the deep surface of the muscle. These bands make
the buttock, giving rise to the so-called ‘piriformis syndrome’. a lateral right-angled turn around the grooved surface of the ischium
between its spine and tuberosity. The grooved surface is covered with a
Vascular supply In the buttock, piriformis is supplied mainly from smooth layer of hyaline cartilage and is separated from the tendon by
the superior gluteal artery, with contributions from the gemellar a bursa; ridges on the surface correspond to furrows between the tendi-
branches of the internal pudendal. There may be a separate branch from nous bands. These bands leave the pelvis through the lesser sciatic | 1,870 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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foramen and unite to form a single flattened tendon that passes hori- Relations A bursa, which communicates with the hip joint, may be
zontally across the capsule of the hip joint. The gemelli fuse with this interposed between the tendon and the hip joint capsule and femoral
tendon before it inserts on to an anterior impression on the medial neck. The obturator vessels lie between the muscle and the obturator
surface of the greater trochanter anterosuperior to the trochanteric membrane. The anterior branch of the obturator nerve reaches the
fossa. A long, narrow bursa is usually interposed between the tendon thigh by passing in front of the muscle, and the posterior branch by
and the capsule of the hip joint, and occasionally communicates with piercing it.
the bursa between the tendon and the ischium.
Vascular supply Obturator externus receives a variable pattern of
Relations Within the pelvis, the anterolateral surface of the muscle is supply from the obturator and medial circumflex femoral arteries.
in contact with the obturator membrane and inner surface of the lateral
wall of the pelvis. Its posteromedial surface is related to the obturator Innervation Obturator externus is innervated by the posterior branch
fascia, the origin of levator ani, and the sheath that surrounds the of the obturator nerve, L3 and 4.
internal pudendal vessels and pudendal nerve, and forms the lateral
wall of the ischio-anal fossa. Outside the pelvis, the muscle is covered Actions It has been suggested that the short muscles around the hip
by gluteus maximus, is crossed posteriorly by the sciatic nerve and joint (pectineus, piriformis, obturator externus and internus, the gemelli
passes behind the hip joint. As the tendon of obturator internus emerges and quadratus femoris) are more important as postural muscles than
from the lesser sciatic foramen, it is overlapped both above and below as prime movers, acting as adjustable ligaments to maintain the stability
by the two gemelli, which form a muscular canal for it. Near its termi- and integrity of the hip. However, these muscles are largely inaccessible
nation, the gemelli pass anterior to the tendon and form a groove in to direct observation, and, because of the hazards presented by their
which it lies. close relationship to important neurovascular structures, there is a lack
of electromyographic data in humans. In both bipedal walking and
Vascular supply The main arterial supply of the extrapelvic part of vertical climbing, obturator externus is recruited during the early part
obturator internus is from the gemellar branches of the internal puden- of the swing phase; in climbing it effects lateral rotation of the thigh,
dal artery. Intrapelvic and extrapelvic parts are supplied by the branches and in walking it probably counteracts the tendency to medial rotation
of the obturator artery. produced by the anterior adductor muscles at this stage of the cycle.
Obturator internus differs from obturator externus in its pattern of use
Innervation Obturator internus is innervated by the nerve to obtura- but its role in bipedal walking remains unclear. Its attachments suggest
tor internus, L5 and S1.
Actions See below actions of obturator externus.
Obturator externus
Attachments Obturator externus (Figs 80.26–80.29; see Fig. 80.16)
is a flat, triangular muscle covering the external surface of the anterior
Gluteus medius
pelvic wall. It arises from the anteromedial two-thirds of the external
surface of the obturator membrane, and from the adjacent bone of the
pubic and ischial rami, extending for a short distance on to their pelvic
surfaces between the margin of the obturator foramen and the obtura- Gluteus minimus Gluteus maximus
tor membrane. The whole muscle, and the tendon into which its fibres
converge, spiral backwards, laterally and upwards, and thus cross the Piriformis
inferior aspect and then the back of the neck of the femur and lower
part of the capsule of the hip joint to end in the trochanteric fossa of Gemellus superior
the femur.
Obturator internus
Gemellus inferior
Quadratus femoris
Trochanteric bursa
Gluteus maximus
Adductor magnus
Semitendinosus
Biceps femoris, short head
Biceps femoris, long head Semimembranosus
Popliteal artery
Gastrocnemius
Obturator externus
Fig. 80.27 The posterior thigh and gluteal muscles with gluteus maximus
Fig. 80.26 Obturator externus, anterior aspect. (Adapted from Drake RL, and medius partially removed. (With permission from Waschke J, Paulsen
Vogl AW, Mitchell A (eds), Gray’s Anatomy for Students, 2nd ed, Elsevier, F (eds), Sobotta Atlas of Human Anatomy, 15th ed, Elsevier, Urban &
Churchill Livingstone. Copyright 2010.) Fischer. Copyright 2013.) | 1,871 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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that it, like the gemelli, is a lateral rotator of the extended thigh and an Anterior compartment
abductor of the flexed thigh. These actions may be used to antagonize
unwanted components of movement produced by the primary locomo-
The muscles of the anterior compartment (see Figs 80.2, 80.22) include
tor muscles.
sartorius and rectus femoris, which can act at both the hip and knee
joints, and vasti medialis, lateralis and intermedius, which act
Testing The short rotators cannot be tested individually, but lateral
only at the knee. Articularis genus completes the group: it retracts the
rotation of the extended hip and abduction of the flexed hip against
synovial capsule of the knee joint. Rectus femoris and the vasti extend
resistance tests them as a group.
the knee joint through a common tendon and hence are collectively
termed quadriceps femoris. Adductor longus and pectineus are some-
Gemellus inferior and gemellus superior
times considered to be part of both the anterior and the adductor
Attachments Gemellus inferior arises from the upper part of the
compartments.
lateral surface of the ischial tuberosity, immediately below the groove
for the tendon of obturator internus (Fig. 80.27). It blends with the Sartorius
lower border of this tendon, and inserts with it into the medial surface Attachments Sartorius is a narrow strap muscle and is the longest
of the greater trochanter. muscle in the body (see Fig. 80.31). It arises by tendinous fibres from
Gemellus superior, the smaller of the two gemelli, arises from the the anterior superior iliac spine and the upper half of the notch below
dorsal surface of the ischial spine, blends with the upper border of the it. It crosses the thigh obliquely over to the medial side and then
tendon of obturator internus, and inserts with it into the medial surface descends more vertically to the medial side of the knee. The muscle
of the greater trochanter. It is sometimes absent. fibres terminate at this point and a thin, flattened tendon curves
The two gemelli can be regarded as accessory to obturator internus obliquely forwards and expands into a broad aponeurosis. The aponeu-
(see Fig. 80.24B). rosis is attached to the proximal part of the medial surface of the tibia
in front of gracilis and semitendinosus, together forming the so-called
Relations The relations of the gemelli are as described for the extrapel- pes anserinus (Fig. 80.28). A slip from its upper margin blends with
vic part of obturator internus. the capsule of the knee joint, and another from its lower margin merges
with the superficial layer of the deep fascia on the medial side of the
Vascular supply Gemellus superior is supplied by the internal leg. This sheet of tissue passes inferiorly to lie superficial to and over
pudendal artery and its gemellar branches; by the inferior gluteal artery; the distal insertions of gracilis and semitendinosus. It has to be split by
and sometimes also by the superior gluteal artery. Gemellus inferior is sharp dissection to reveal these two tendons if they need to be har-
supplied mainly by the medial circumflex femoral artery. vested, e.g. in cruciate ligament surgery.
In some cases, sartorius is absent, while in others, the muscle may
Innervation Gemellus superior is innervated by the nerve to obturator possess an extra head; when the latter occurs, the extra head is attached
internus, L5, S1 and S2. Gemellus inferior is innervated by the nerve to to the pectineal line or to the femoral sheath. Variations in the distal
quadratus femoris, L4, L5 and S1. attachment of sartorius, in the vicinity of the knee, have been described.
Actions The gemelli rotate the extended thigh laterally and abduct the Relations The relations of sartorius are described in the femoral tri-
flexed thigh. angle (see below).
Testing See testing of obturator externus above. Vascular supply The main arterial supply to sartorius is derived from
multiple branches of the femoral system and enters the medial half of
Quadratus femoris
the muscle from its deep surface. Vessels supplying the proximal third
Attachments Quadratus femoris (see Fig. 80.24B) is a flat, quadri- of sartorius may arise from the femoral artery, the profunda femoris
lateral muscle lying between gemellus inferior and the upper margin of artery, the ‘artery of the quadriceps’ or the lateral circumflex femoral
adductor magnus, from which it is separated by the transverse branch artery. There may be an additional proximal supply from the superficial
of the medial circumflex femoral artery. It arises from the upper part of circumflex iliac artery. Those vessels supplying the middle third of the
the external aspect of the ischial tuberosity and inserts on to a small
tubercle a little above the middle of the trochanteric crest of the femur
and into the bone for a short distance below. It may be absent.
Relations The muscle passes behind the hip joint and the neck of the
femur, separated from them by the tendon of obturator externus and
the ascending branch of the medial circumflex femoral artery (which
may cause troublesome bleeding if injured during the posterior Sartorius
approach to the hip). The sciatic nerve crosses the muscle posteriorly.
Gracilis Vastus
A bursa is often present between the muscle and the lesser trochanter. medialis
Tendon of adductor
Vascular supply Branches pass to the superficial surface of the magnus Tendon of
muscle from the inferior gluteal artery and from the medial circumflex Tendon of semitendinosus quadriceps
femoral artery, which also supplies the deep surface. Medial epicondyle of femur femoris
Tendon of semimembranosus
Innervation Quadratus femoris is innervated by the nerve to quadra-
tus femoris, L5 and S1. Tibial collateral ligament Patella
Semimembranosus
Actions Quadratus femoris produces lateral rotation of the thigh. bursa
Anserine bursa Medial patellar
retinaculum
Testing See testing of obturator externus.
Tendon of
semitendinosus Patellar ligament
MUSCLES OF THE THIGH Tendon of
gracilis Tendon of sartorius
The presence and position of the femoral neck cause the femoral shaft
to lie obliquely; consequently, the anterior (extensor) muscle group,
quadriceps femoris, runs obliquely distally and medially and so applies Gastrocnemius Tibial tuberosity
a pull to the patella that is both laterally and proximally directed. The
adductor muscles occupy the region between quadriceps femoris and
the medial margin of the thigh. They are attached distally to the post- Soleus
erior surface of the femur and lie more posteriorly than quadriceps
femoris. The posterior muscle group, the hamstrings, lie behind the
adductors. The attachments of these muscles determine the nature and
direction of displacement of femoral shaft fractures. Fig. 80.28 The distal attachment of muscles of the thigh, medial aspect. | 1,872 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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muscle arise from the femoral artery. The distal vessels arise from the into the thick, flat tendon by which it is attached to the base of the
femoral artery within the adductor canal and from the descending patella. This constitutes the superficial central part of the quadriceps
genicular artery. femoris tendon. A third head of rectus femoris may exist; it attaches
deeply to the iliofemoral ligament and superficially to the tendon of
Innervation Sartorius is innervated by the femoral nerve, L2 and 3. gluteus minimus as it attaches on to the femur (Tubbs et al 2006).
Rectus femoris may also arise from the anterior superior iliac spine, and
Actions Sartorius assists in flexing the leg, and the thigh on the pelvis, its reflected head may be absent.
particularly when these two movements are combined. It also helps to
abduct the thigh and to rotate it laterally. Together with inversion of Relations Proximally, the muscle is covered by tensor fasciae latae,
the foot, these movements bring the sole of the foot into direct view. iliacus and sartorius. The reflected head lies beneath gluteus minimus.
The fact that sartorius represents only 1% of the physiological cross- The capsule of the hip joint, vastus intermedius, the anterior borders of
sectional area of all muscles that cross the hip or knee joint would vasti lateralis and medius, the lateral circumflex femoral artery and
appear to suggest that its role in walking is a minor one. In a subject some branches of the femoral nerve all lie deep to rectus femoris.
ascending steps, electromyographic activity of sartorius increases during
lateral rotation of the thigh at the end of the swing phase immediately Vascular supply There are two main vascular pedicles: a superior
preceding heel strike, which presumably decelerates the limb. Sartorius and an inferior. The superior enters rectus femoris at the junction of
may therefore have a significant involvement in climbing. its upper and middle thirds, and arises from the ‘artery of the quadri-
ceps’. The inferior and larger branch arises from the ‘artery of the quad-
Testing When it contracts against gravity, as it usually does, sartorius riceps’ at about mid-thigh level and enters the muscle a few centimetres
can be both seen and felt in the living subject. more distally. There are additional contributions from the lateral cir-
cumflex femoral artery and, less often, from the superficial circumflex
Femoral triangle
iliac artery.
The femoral triangle is a depressed, intermuscular space in the antero-
medial aspect of the proximal thigh, lying immediately distal to the vastus medialis and vastus medialis obliquus
inguinal ligament. The latter constitutes the base of the femoral trian- Attachments Vastus medialis arises from the lower part of the inter-
gle’s inverted triangular outline. Its lateral boundary is the medial trochanteric line, spiral line, medial lip of the linea aspera, proximal
margin of sartorius. Its medial boundary is the medial margin of adduc- part of the medial supracondylar line, the tendons of adductor longus
tor longus. Its distal extremity, the apex, is where sartorius overlaps and magnus, and the medial intermuscular septum. Its fibres pass
adductor longus (see Fig. 80.31). Its floor is provided laterally by iliacus downwards and forwards at an average angle of 15° to the long axis of
and psoas major, and medially by pectineus and adductor longus. Its the femur, most of them into an aponeurosis on the deep surface of the
roof is the overlying fascia lata. The femoral vessels, passing from mid- muscle that is attached to the medial border of the patella and to the
base to apex, are in the deepest part of the triangle. Lying lateral to the quadriceps femoris tendon. An expansion from this aponeurosis re-
artery and outside the femoral sheath is the femoral nerve, which, on inforces the capsule of the knee joint and is attached below to the
entering the femoral triangle divides into multiple branches. The trian- medial condyle of the tibia.
gle also contains fat and lymph nodes. The lowest fibres are nearly horizontal and form a bulge in the living
subject, medial to the upper half of the patella. Some authors distin-
Quadriceps femoris
guish this part of the muscle as the vastus medialis obliquus, with fibres
Quadriceps femoris (see Figs 80.2, 80.22, 80.31), the great extensor that originate largely from the tendon of adductor magnus and insert
muscle of the leg, covers almost all of the front and sides of the femur. into the medial border of the patella. It plays an important role in the
It can be divided into four parts, each named individually. One, rectus function of patellofemoral joint.
femoris, arises from the ilium and travels straight down the middle of
the thigh, its shape and path determining its name. The other three arise Relations Vastus medialis is partly covered by rectus femoris and
from the shaft of the femur and surround it (apart from the linea sartorius. In the central part of the thigh it forms the lateral wall of the
aspera) from the trochanters to the condyles: vastus lateralis is lateral adductor (Hunter’s) canal.
to the femur, vastus medialis is medial to it, and vastus intermedius lies
anterior to the femur. Rectus femoris crosses both hip and knee joints, Vascular supply Vastus medialis is supplied by three branches of the
while the three vasti only cross the knee joint. femoral artery. The superior and middle branches arise, sometimes from
The tendons of the four components of quadriceps femoris unite a common trunk, proximal to the adductor canal, while the inferior
in the lower part of the thigh to form a single strong tendon attached arises within the canal. There may also be minor branches from the
to the base of the patella, and some fibres continue over it to blend profunda femoris artery and descending genicular arteries.
with the patellar ligament. The patella is a sesamoid bone in the quad-
riceps femoris tendon, and the patellar ligament, which extends from vastus lateralis
the patellar apex to the tibial tuberosity, is the continuation of the main Attachments Vastus lateralis is the largest component of quadriceps
tendon. The medial and lateral patellar retinacula are expansions from femoris. It arises by a broad aponeurosis from the upper part of the
its borders. The suprapatellar bursa (a synovial extension of the knee intertrochanteric line, the anterior and inferior borders of the greater
joint) lies between the femur and the suprapatellar part of the quadri- trochanter, the lateral lip of the gluteal tuberosity, and the proximal half
ceps femoris tendon. The deep infrapatellar bursa lies between the of the lateral lip of the linea aspera. This aponeurosis covers the proxi-
patellar ligament and the proximal end of the tibia. mal three-quarters of the muscle; many additional fibres arise from its
The arterial supply to the quadriceps femoris has been traditionally deep surface. A few fibres also arise from the tendon of gluteus maximus
ascribed to a single branch of either the profunda femoris artery or the and the lateral intermuscular septum between vastus lateralis and the
lateral circumflex femoral artery, the ‘artery of the quadriceps’. This short head of biceps femoris. The muscular mass thus formed is attached
vessel, which may be large, occasionally arises directly from the femoral to a strong aponeurosis on the deep surface of the lower part of the
artery. However, according to Taylor and Razaboni (1994), this artery muscle. This narrows to a flat tendon, which is attached to the base and
does not supply all four components of quadriceps femoris; vastus lateral border of the patella and blends into the compound quadriceps
medialis is supplied directly from the femoral artery. The supply of the femoris tendon. It contributes an expansion to the capsule of the knee
individual muscle components is described below; their sheaths may joint that descends to the lateral condyle of the tibia and blends with
have an additional and variable supply. the iliotibial tract.
Quadriceps femoris as a group shows little anatomical variation.
Relations Vastus lateralis is covered laterally by the fascia lata and the
rectus femoris aponeurotic insertions of tensor fasciae latae and gluteus maximus. It
Attachments Rectus femoris is fusiform. Its superficial fibres are is separated from vastus intermedius by branches of the femoral nerve
bipennate, the deep fibres parallel. It has a double origin on the ilium: and the lateral circumflex femoral artery. Posteriorly, it is separated from
a straight tendon arises from the anterior inferior iliac spine, and a biceps femoris by the lateral intermuscular septum.
thinner, flatter reflected tendon from a groove above the acetabulum
and from the fibrous capsule of the hip joint. The two unite at an acute Vascular supply There are three main arteries of supply: the superior
angle and spread into an aponeurosis that is prolonged downwards on medial artery arises directly from the lateral circumflex femoral artery;
the anterior surface of the muscle; the muscular fibres arise from this the inferior medial (the largest of the three) from the ‘artery of the
aponeurosis. The fibres end in a broad, thick aponeurosis that forms quadriceps’; and the lateral from the first perforating branch given off
over the lower two-thirds of its posterior surface and gradually narrows from the profunda femoris artery. | 1,873 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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vastus intermedius
Attachments Vastus intermedius arises from the anterior and lateral
Piriformis Iliopsoas
surfaces of the upper two-thirds of the femoral shaft, and from the lower
part of the lateral intermuscular septum. Its fibres end on the anterior
surface of the muscle in an aponeurosis that forms the deep part of the Pectineus Rectus femoris
quadriceps femoris tendon and is attached to the lateral border of the
patella and the lateral condyle of the tibia. Adductor longus Iliopectineal bursa
Vastus intermedius appears to be inseparable from vastus medialis. Gluteus medius
However, when rectus femoris is reflected, a narrow cleft can be seen
extending upwards from the medial border of the patella between the Iliopsoas
Adductor brevis
two muscles, sometimes as far as the lower part of the intertrochanteric
line; proximal to this, the two muscles are frequently fused. Obturator externus Lesser trochanter
Quadratus femoris
Relations Vastus intermedius is almost completely covered by the Pectineus
other components of quadriceps femoris, except laterally, where a small
part becomes superficial behind vastus lateralis. Adductor brevis
Adductor magnus
Vascular supply Vastus intermedius receives a lateral artery of Vastus lateralis
supply, which arises from the ‘artery of the quadriceps’, and a medial
artery that arises directly from the profunda femoris artery. Arteries to Adductor longus
the other components of quadriceps femoris may also contribute. There
is an anastomotic network deep to the muscle that supplies the supra-
patellar bursa and articularis genus, and may form a collateral pathway Gracilis Vastus medialis
when the femoral artery is blocked.
articularis genus Adductor hiatus
Articularis genus is a small muscle, usually distinct from vastus inter-
medius but occasionally blending with it. It consists of several muscular Vastus intermedius
bundles that arise from the anterior surface of the lower part of the
femoral shaft and are attached to a proximal reflection of the synovial
membrane of the knee joint. It is visible during knee arthroscopy when
viewed looking superiorly from within the suprapatellar bursa (see Femur
Commentary 9.3).
innervation of quadriceps femoris
Quadriceps femoris and articularis genus are supplied by the femoral
nerve, L2, 3 and 4.
actions of quadriceps femoris Sartorius
Quadriceps femoris extends the knee. Rectus femoris helps to flex the Gracilis Tendons of
thigh on the pelvis; if the thigh is fixed, it helps to flex the pelvis on Semitendinosus
Anserine bursa
the thigh. Rectus femoris can flex the hip and extend the knee simulta-
neously. Electromyographic studies indicate that the three vasti are not
equally active in different phases of extension or rotation. There is little
Fig. 80.29 The adductor muscles of the thigh, anterior aspect. (With
or no activity in quadriceps femoris during standing. Rectus femoris
permission from Waschke J, Paulsen F (eds), Sobotta Atlas of Human
pulls the patella along the line of the mechanical axis of the lower limb
Anatomy, 15th ed, Elsevier, Urban & Fischer. Copyright 2013.)
(i.e. the line connecting the centres of the hip, knee and ankle) because
its attachment is anterior to the hip joint. The remaining muscles in the
group are attached to the shaft of the femur and their pull is lateral as Gracilis
well as proximal. An extremely important dynamic function of vastus Attachments Gracilis (see Figs 80.2, 80.29) is the most superficial of
medialis obliquus is to counter this lateral vector on the patella during the adductor group. It is thin and flat, broad above, and narrow and
knee motion. Other static factors that help are the depth of the femoral tapering below. It arises by a thin aponeurosis from the medial margins
patellar surface, the buttressing effect of the lateral femoral condyle in of the lower half of the body of the pubis, the whole of the inferior
the groove, and the restraining action of the medial patellofemoral liga- pubic ramus, and the adjoining part of the ischial ramus. The fibres
ment. Inadequacy of vastus medialis obliquus is a factor in producing descend vertically into a rounded tendon, often harvested as a knee
patellar instability and pain. Strengthening of this muscle to improve ligament graft, which passes across the medial condyle of the femur
patellar ‘tracking’ on the femur is an important part of physiotherapy posterior to the tendon of sartorius. It then curves around the medial
regimens for patellofemoral problems. condyle of the tibia, where it fans out and is attached to the upper part
Articularis genus retracts the synovial suprapatellar bursa proximally of the medial surface of the tibia, just below the condyle, forming part
during extension of the leg, presumably to prevent interposition of of the pes anserinus (see Fig. 80.28). A few fibres from the lower part
redundant synovial folds between patella and femur. of the tendon continue into the deep fascia of the lower leg. Often there
is a slip that blends with the tendon of the medial head of gastrocne-
Testing The quadriceps femoris is tested by extending the knee against mius. Unless divided, this can lead to problems during surgical harvest-
resistance, in the supine position with the hip flexed. ing of the gracilis tendon.
Adductor compartment Relations The muscle is covered medially by the fascia lata through-
out most of its length. Deep to gracilis lie adductor brevis and adductor
The muscles of the adductor compartment – gracilis, pectineus, adduc- magnus. The tibial attachment is immediately proximal to that of semi-
tor longus, adductor brevis, and adductor magnus (Fig. 80.29) – have tendinosus, and the tendon of sartorius, with which it is partly blended,
evolved, as their nerve supply suggests, from both flexor and extensor overlaps its upper edge. It is separated from the tibial collateral ligament
columns. All five muscles cross the hip joint but only gracilis reaches of the knee joint by the anserine bursa.
beyond the knee. They are known collectively as the adductors of the
thigh, although their actions are more complex than this, e.g. acting Vascular supply The arterial supply to gracilis enters via its lateral
from below they have important roles in balancing the trunk on the surface. The main pedicle arises from the ‘artery to the adductors’, a
lower limb during walking. branch of the profunda femoris artery, and enters at the junction of the
Their blood supply is derived from the profunda femoris artery, upper and middle thirds of the muscle. The gracilis musculocutaneous
medial circumflex femoral, femoral and obturator arteries. The pro- flap is based on this pedicle. A less important artery enters the distal
funda femoris artery (or sometimes the first perforator) supplies a large third of the muscle from the femoral artery. There is a minor proximal
branch, the ‘artery of the adductor muscles’. supply from the medial circumflex femoral artery. | 1,874 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Innervation Gracilis is innervated by the obturator nerve, L2 and 3. Actions The actions of the named adductors as a group are discussed
below, after each muscle has been described.
Actions Gracilis flexes the leg and rotates it medially. It may also act
as an adductor of the thigh. When the foot is fixed, gracilis rotates the Testing Adductor brevis is tested in the same way as adductor
femur and pelvis laterally on the tibia, and helps balance the trunk longus.
during walking.
Adductor magnus
Testing While palpating over the tendon posteromedially at the Attachments Adductor magnus (see Figs 80.2, 80.25A, 80.29, 80.30),
flexed knee, the knee is actively further flexed and the leg actively
a massive triangular muscle, arises from a small part of the inferior
rotated medially. Gracilis can also be tested with the other adductors
ramus of the pubis, from the conjoined ischial ramus, and from the
of the hip.
inferolateral aspect of the ischial tuberosity. The short, horizontal fibres
Adductor longus from the pubic ramus are inserted into the medial margin of the gluteal
tuberosity of the femur, medial to gluteus maximus; this part of the
Attachments Adductor longus (see Figs 80.2, 80.22), the most ant-
muscle, in a plane anterior to the rest, is sometimes called adductor
erior of the three adductors, is a large, fan-shaped muscle that lies in
minimus. The fibres from the ischial ramus fan out downwards and
the same plane as pectineus. It arises by a narrow tendon with a flat-
laterally, to insert via a broad aponeurosis into the linea aspera and the
tened (sometimes C-shaped) cross-section, which is attached to the
proximal part of the medial supracondylar line. The medial part of the
front of the pubis in the angle between the crest and the symphysis. It
muscle, composed mainly of fibres from the ischial tuberosity, is a thick
expands into a broad fleshy belly that descends posterolaterally and
mass that descends almost vertically, and ends in the lower third of the
inserts by an aponeurosis into the linea aspera in the middle third of
thigh in a rounded tendon, which can be palpated proximal to its
the femur, between vastus medialis and adductors magnus and brevis,
attachment to the adductor tubercle on the medial condyle of the
usually blending with all of them. Its proximal attachment is vulnerable
femur. The tendon is connected by a fibrous expansion to the medial
to overload from sporting activity: this is one cause of sport-related
supracondylar line.
groin pain.
The long, linear attachment of the muscle is interrupted by a series
Adductor longus is occasionally double.
of osseo-aponeurotic openings, bridged by tendinous arches attached
to the bone. The upper four are small and transmit the perforating
Relations Anterior to adductor longus are the spermatic cord, fascia
branches and the termination of the profunda femoris artery. The
lata (which separates it from the long saphenous vein) and, near its
lowest is large and allows the femoral vessels to cross to the popliteal
attachment, the femoral artery and vein and sartorius. Posterior to it are
fossa.
adductor brevis and adductor magnus, the anterior branch of the obtu-
The vertical, ischiocondylar part of the muscle varies in its degree of
rator nerve and, near its attachment, the deep artery and vein of the
separation from the rest. The upper border of adductor magnus may
thigh. Lateral and medial to adductor longus are, respectively, pectineus
fuse with quadratus femoris.
and gracilis.
Relations Anteriorly lie pectineus, adductor brevis and adductor
Vascular supply The main supply to adductor longus is to the
longus, the femoral and deep femoral vessels, and the posterior branch
central part of the muscle from the ‘artery to the adductors’, a branch
of the obturator nerve. A bursa separates the proximal part of the muscle
of the profunda femoris artery. There is an additional proximal supply
from the lesser trochanter of the femur. Posteriorly are the sciatic nerve,
from the medial circumflex femoral artery, and a more distal supply
gluteus maximus, biceps femoris, semitendinosus and semimembrano-
from the femoral artery and sometimes the descending genicular
sus. The superior border is parallel with quadratus femoris, and the
artery.
transverse branch of the medial circumflex femoral artery passes
between the muscles. The medial border is related to gracilis, sartorius
Innervation Adductor longus is innervated by the anterior division of
and the fascia lata.
the obturator nerve, L2, 3 and 4.
Vascular supply As expected from its position, adductor magnus is
Actions The actions of the named adductors as a group are discussed
supplied from both its anterior and its posterior aspects. The contribu-
below, after each muscle has been described.
tion from the anterior compartment is the more important. The pro-
funda femoris artery, obturator artery and femoral artery all contribute;
Testing The adductors are tested as a group by adduction of the thigh
the main supply comes directly from the distal part of the profunda
against resistance, in the supine position and with the knee extended.
femoris artery. Distally, there may be contributions from the femoral
Adductor brevis and descending genicular arteries. Posteriorly, there are branches from
the medial circumflex femoral, the first and second perforating and the
Attachments Adductor brevis (see Fig. 80.2A; Fig. 80.25B) lies pos-
popliteal vessels.
terior to pectineus and adductor longus. It arises by a narrow attach-
ment from the external aspect of the body and inferior ramus of the
Innervation Adductor magnus is composite and is doubly innervated
pubis, between gracilis and obturator externus. Like adductor longus, it
by the obturator nerve and by the tibial division of the sciatic nerve (L2,
is somewhat triangular, and expands as it descends posterolaterally to
3 and 4), which supplies the ischiocondylar part. Both nerves are
insert via an aponeurosis into the femur, along a line from the lesser
derived from anterior divisions in the lumbosacral plexus, indicating a
trochanter to the linea aspera, and on the upper part of the linea imme-
primitive flexor origin for both parts of the muscle.
diately behind pectineus and the upper part of adductor longus.
Adductor brevis often has two or three separate parts, or may be
Actions of the adductors
integrated into adductor magnus.
Extensive or forcible adduction of the femur is not often required.
Relations Anteriorly lie pectineus, adductor longus, the profunda Although the adductors can act in this way, they more commonly act
femoris artery and the anterior branch of the obturator nerve; posteri- as synergists in the complex patterns of gait activity, and to some degree
orly are adductor magnus and the posterior branch of the obturator as controllers of posture. They are active during flexion and extension
nerve. The upper border of adductor brevis is related to the medial of the knee. Adductors magnus and longus are probably medial rotators
circumflex femoral artery, obturator externus, and the conjoined tendon of the thigh. The adductors are inactive during adduction of the
of psoas major and iliacus. Its lower border is related to gracilis and abducted thigh in the erect posture (when gravity assists), but active in
adductor magnus. The second perforating artery, or first and second other postures, such as the supine position, or during adduction of the
perforating arteries, pierces it near its femoral attachment. flexed thigh when standing. They are also active during flexion (longus)
and extension (magnus) of the thigh at the hip joint. In symmetrical
Vascular supply The vascular supply to adductor brevis is variable. easy standing their activity is minimal.
Usually the main supply is directly from the profunda femoris artery
distally and from the ‘artery to the adductors’ more proximally. There Testing of the adductors The adductors are usually tested as a
is an additional proximal supply from the medial circumflex femoral group by adduction of the thigh against resistance, in the supine posi-
artery. The deep surface receives branches from the obturator artery. tion with the knee extended. The tendon of adductor magnus can be
felt just proximal to the adductor tubercle on the medial condyle of the
Innervation Adductor brevis is innervated by the obturator nerve, L2 femur. Clinical testing of the other actions mentioned above is not
and 3. feasible for the individual muscles. | 1,875 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Iliac crest Fig. 80.30 The posterior thigh and
gluteal regions with associated
neurovascular structures. (With
Gluteus medius Gluteus maximus permission from Netter, FH, Atlas of
Human Anatomy, 5th ed, Elsevier,
Saunders. Copyright 2011.)
Gluteus minimus
Superior gluteal artery and nerve
Tensor fasciae latae
Piriformis
Gemellus superior
Inferior gluteal artery and nerve
Gemellus inferior
Nerve to obturator internus
Gluteus medius
Ischial tuberosity
Greater trochanter of femur
Pudendal nerve
Quadratus femoris
Obturator internus
Medial femoral circumflex artery Inferior clunial nerves
Sciatic nerve
Perineal branches of posterior
Gluteus maximus femoral cutaneous nerve
Adductor magnus
First perforating artery Adductor magnus
(from profunda femoris artery)
Muscular branches of sciatic nerve
Gracilis
Vastus lateralis and iliotibial tract
Second and third perforating arteries
(from profunda femoris artery)
Semitendinosus (retracted)
Semimembranosus
Fourth perforating artery
(from profunda femoris artery)
Long head (retracted)
Biceps femoris
Short head
Popliteal artery and vein
Adductor hiatus
Superior medial genicular artery
Tibial nerve
Plantaris Medial epicondyle of femur
Common fibular (peroneal nerve)
Gastrocnemius (lateral head) Gastrocnemius (medial head)
Small saphenous vein
Pectineus lat erally, to psoas major and the medial circumflex femoral vessels; and
Attachments Pectineus (see Fig. 80.22) is a flat, quadrangular medially, to the lateral margin of adductor longus.
muscle in the femoral triangle. It may also be considered as part of the
anterior compartment of the thigh. It arises from the pecten pubis, from Vascular supply The main arterial supply to pectineus is derived
the bone anterior to it between the iliopubic ramus and the pubic from the medial circumflex femoral artery, which enters the superficial
tubercle, and from the fascia on its own anterior surface. The fibres surface of the muscle. There may be a branch from the femoral artery
descend, initially posteromedially and then posterolaterally, to be more proximally, and a deep supply from the obturator artery.
attached along a line from the lesser trochanter to the linea aspera.
Proximally, it may be partially or wholly attached to the capsule of the Innervation Pectineus is innervated by the femoral nerve, L2 and 3, and
hip joint. the accessory obturator nerve, L3 (when present). Occasionally, it receives
a branch from the obturator nerve. The muscle may be incompletely
Relations Pectineus is related anteriorly to the deep lamina of the divided into dorsal and ventral layers, which are supplied by the obtura-
fascia lata, which separates it from the femoral vessels and long saphen- tor and femoral (or rarely, accessory obturator) nerves, respectively.
ous vein; posteriorly, to the capsule of the hip joint, adductor brevis,
obturator externus and the anterior branch of the obturator nerve; Actions Pectineus adducts the thigh and flexes it on the pelvis. | 1,876 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Testing The action of pectineus cannot be tested clinically in Semimembranosus
isolation. Attachments Semimembranosus (see Figs 80.2, 80.30), so named
because of the flattened form of its upper attachment, is posteromedial
Adductor canal
in the thigh. It arises by a long, flat tendon from a superolateral impres-
The adductor canal (Hunter’s canal; subsartorial canal) is a trough- sion on the ischial tuberosity (see Fig. 80.5). Inferomedially, the tendi-
shaped intermuscular tunnel occupying the distal two-thirds of the nous fibres intermingle to some extent with those of biceps femoris and
medial aspect of the thigh (see Fig. 80.2B). It starts at the apex of the semitendinosus. The tendon receives, from the ischial tuberosity and
femoral triangle and extends distally as far as the distal attachment of ramus, two fibrous expansions that flank adductor magnus. It then
the tendon of adductor magnus. It is triangular in section and is broadens and descends deep to semitendinosus and the long head of
bounded anterolaterally by vastus medialis; posteromedially by adduc- biceps femoris. Muscle fibres arise from the tendon at about mid-thigh
tor longus; and distal to adductor longus, by adductor magnus. Its and converge to a second aponeurosis on the posterior aspect of the
anteromedial boundary (often referred to as the roof) is a strong and lower part of the muscle, which tapers to the heavy, rounded tendon of
dense fascia that extends from the medial surface of vastus medialis to the distal attachment. The tendon divides at the level of the knee into
the medial edge of the adductors longus and magnus, overlapping in five components. The main one is attached to a tubercle (sometimes
its stride the femoral vessels in the adductor canal. This fascia, on called the tuberculum tendinis) on the posterior aspect of the medial
account of being overlain by sartorius, is termed the subsartorial fascia. tibial condyle. The others are: a series of slips to the medial margin of
The adductor canal contains the femoral artery and vein, the descend- the tibia, immediately behind the tibial collateral ligament; a thin
ing genicular and muscular branches of the femoral artery and their fibrous expansion to the fascia over popliteus; a cord-like tendon to the
corresponding venous tributaries, the saphenous nerve, and the nerve inferior lip and adjacent part of the groove on the back of the medial
to vastus medialis (until it enters its muscle). The femoral vessels pass tibial condyle, deep to the tibial collateral ligament; and a strong expan-
from the adductor canal into the popliteal fossa via the adductor hiatus, sion that passes obliquely upwards to the femoral intercondylar line
an opening in the tendon of adductor magnus adjacent to the femoral and lateral femoral condyle, and forms much of the oblique popliteal
shaft, two-thirds of the way down the adductor canal. ligament of the knee joint.
Semimembranosus varies considerably in size and may be absent. It
Posterior compartment may be double, and arise mainly from the sacrotuberous ligament. Slips
to the femur or to adductor magnus may occur.
The posterior thigh muscles, biceps femoris, semitendinosus and semi-
membranosus, are colloquially termed the ‘hamstrings’. They cross both Relations Semimembranosus overlaps the popliteal vessels and is
hip and knee joints, and integrate extension at the hip with flexion at itself partly overlapped by semitendinosus throughout its extent (see
the knee. As the muscles span the back of the knee, they form the Fig. 80.2). Its deep surface lies on adductor magnus. The sciatic nerve
proximal lateral and medial margins of the popliteal fossa. The actions lies laterally and surprisingly close to the surface. The distal end of the
of these muscles and their clinical anatomy will be considered as a muscle partially overlies the medial head of gastrocnemius before
group after they have been described individually. passing anteromedially to it. An important bursa lies between the semi-
The muscles of the posterior compartment (see Figs 80.2, 80.25A, membranosus tendon and gastrocnemius, and often communicates
80.27) receive their blood supply from the perforating branches of the with the knee joint and with a smaller bursa between the tendon and
profunda femoris artery, most importantly through the first perforator the posterior tibial margin.
given off from this artery. This vessel has important anastomoses with
the inferior gluteal artery (on or within semitendinosus) and with the Vascular supply Semimembranosus is supplied from the perforat-
medial circumflex femoral artery, while the third perforator anastomo- ing arteries, usually from all, though predominantly from the first.
ses with the superior medial genicular artery within the short head of Sometimes the predominant artery arises from the fourth perforator. A
biceps femoris. This anastomotic chain forms an important collateral branch of the femoral or popliteal artery supplies the distal part of the
arterial pathway when the femoral artery is blocked. muscle, and there may be a contribution from the inferior gluteal artery
at the proximal attachment.
Semitendinosus
Attachments Semitendinosus (see Figs 80.2B, 80.30), notable for the Innervation Semimembranosus is innervated by the sciatic nerve, L5,
length of its tendon, lies posteromedial in the thigh. It arises from an S1 and 2, through its tibial division.
inferomedial impression on the upper area of the ischial tuberosity (see
Fig. 80.5), by a tendon it shares with the long head of biceps femoris, Biceps femoris
and from an aponeurosis connecting the adjacent surfaces of the two Attachments Biceps femoris (see Figs 80.2, 80.30) occupies a
muscles for 7.5 cm from their common origin. The belly is fusiform posterolateral position in the thigh. It has two proximal attachments.
and ends a little below mid-thigh in a long, rounded tendon that runs One, the long head, arises from an inferomedial impression on the
on the posterior surface of semimembranosus. The tendon curves upper area of the ischial tuberosity (see Fig. 80.5), via a tendon that it
around the medial condyle of the tibia, passes over the tibial collateral shares with semitendinosus, and from the lower part of the sacrotuber-
ligament (from which it is separated by the anserine bursa), and inserts ous ligament. The other, the short head, arises from the lateral lip of
into the upper part of the medial surface of the tibia behind the attach- the linea aspera, between adductor magnus and vastus lateralis. This
ment of sartorius and distal to that of gracilis (see Fig. 80.28). At its attachment extends proximally almost to gluteus maximus and distally
termination, it is united with the tendon of gracilis and gives off a along the lateral supracondylar line to within 5 cm of the lateral femoral
prolongation to the deep fascia of the leg and to the medial head of condyle, and from the lateral intermuscular septum. The long head
gastrocnemius. A tendinous intersection is usually present near the forms a fusiform belly that descends laterally across the sciatic nerve.
midpoint of the muscle, which may also receive a muscular slip from The fibres end in an aponeurosis that covers the posterior surface of the
the long head of biceps femoris. These connections with the medial muscle. This aponeurosis receives on its deep surface the fibres of the
head of gastrocnemius and biceps femoris can cause difficulty when short head, and gradually narrows to a tendon (the lateral hamstring).
harvesting the tendon surgically for a graft. The main part of the tendon splits round the fibular collateral ligament
and is attached to the head of the fibula. The remainder splits into three
Relations Semitendinosus lies on semimembranosus throughout its laminae. The intermediate lamina fuses with the fibular collateral liga-
length. The relations of the distal part of the muscle are described above ment, while the others pass superficial and deep to the ligament to
and with the pes anserinus. attach to the lateral condyle of the tibia.
The short head may be absent. Additional slips may arise from the
Vascular supply The two main arteries of supply to semitendinosus ischial tuberosity, linea aspera or medial supracondylar line.
are superior and inferior. The superior is derived from either the medial
circumflex femoral artery or the first perforating artery. The inferior and Relations Proximally, biceps femoris is covered by gluteus maximus,
larger branch arises from the first perforator distal to the origin of the but elsewhere it lies relatively superficially. Deep to it lie semimem-
superior branch. An accessory supply at the ischial attachment is derived branosus proximally, and the sciatic nerve, adductor magnus and the
from the inferior gluteal artery, and at the tibial attachment from the lateral head of gastrocnemius more distally. Semitendinosus and semi-
inferior medial genicular artery. membranosus lie medially. A bursa may lie between the tendon and
the fibular collateral ligament. The common fibular nerve descends
Innervation Semitendinosus is innervated by the sciatic nerve, L5, S1 along the medial border of the tendon of biceps femoris, separating it
and 2, through its tibial division (see Fig. 80.30). distally from the lateral head of gastrocnemius. | 1,877 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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As a guide during surgery, it is safest to find a nerve proximally and ARTERIES
dissect it free distally. The common fibular nerve is found emerging
posterior to the biceps femoris tendon, which is a useful guide to locat- Gluteal vessels
ing the nerve and avoiding iatrogenic injury. The nerve is adherent to
the tendon; if part of the fibular head or the attachment of the tendon
The superior and inferior gluteal arteries (see Fig. 80.30) are described
of biceps femoris, usually with the insertion of the fibular collateral
on pages 1226 and 1227, respectively.
ligament, is avulsed, then the tendon will exert proximal traction on
the nerve, which may contribute to common fibular nerve traction
Arteria comitans nervi ischiadici
injury. When the lateral meniscus is sutured arthroscopically, care must
(artery to sciatic nerve)
be taken that all needle passages are anterior to biceps femoris. A proxi-
mal fibular fracture may result in the nerve being trapped in the fracture
line. The arteria comitans nervi ischiadici is a direct or indirect branch of the
internal iliac artery, and runs on the surface of, or within, the sciatic
Vascular supply The long head of biceps femoris is supplied by the nerve. It represents the primitive axial artery of the lower limb. The
first and second perforating arteries. There are accessory supplies at the artery is usually a very small vessel; occasionally, it persists as a large
ischial attachment from the inferior gluteal and medial circumflex vessel, in which case the femoral artery is correspondingly reduced in
femoral arteries, and in the distal quarter from the superior lateral size. The artery may participate in collateral circulatory pathways.
genicular artery. The short head is supplied superiorly by the second or
third perforating artery and inferiorly by the superior lateral genicular Femoral artery
artery.
The femoral artery (see Figs 78.4, 80.2–80.3; Figs 80.31–80.32) is a
Innervation Biceps femoris is innervated by the sciatic nerve, L5, S1 continuation of the external iliac artery (Benninger 2014). It begins
and 2: the long head through the tibial division and the short head behind the inguinal ligament, midway between the anterior superior
through the common fibular division, a distribution that reflects the
composite derivation from flexor and extensor musculature.
Actions of posterior thigh muscles
External iliac Inguinal ligament
Acting from above, the posterior thigh muscles flex the knee. Acting artery and vein
from below, they extend the hip joint, pulling the trunk upright from Lateral femoral
a stooping posture against the influence of gravity, biceps femoris being Internal iliac cutaneous nerve
artery
the main agent. When the knee is semi-flexed, biceps femoris can act
as a lateral rotator and semimembranosus and semitendinosus as Femoral nerve
medial rotators of the lower leg on the thigh at the knee. When the hip
Iliopsoas
is extended, biceps femoris is a lateral rotator and semimembranosus
Pectineus
and semitendinosus are medial rotators of the thigh. As is the case with Femoral nerve
quadriceps femoris, the adductors and gluteus maximus, the hamstrings Long Profunda femoris
saphenous vein
are quiescent in easy symmetrical standing. However, any action that artery
takes the centre of gravity in front of a transverse axis through the hip Femoral artery
joints, e.g. forward reaching, forward sway at the ankle joints or forward
Tensor fasciae latae
bending at the hips, is immediately accompanied by strong contraction
of the hamstrings. This is in marked contrast to gluteus maximus, which Femoral vein
contracts only when there is a call for powerful extension at the hip
joint.
When the knee is flexed against resistance, the tendon of biceps Adductor longus
femoris can be felt lateral to the popliteal fossa. Medial to the fossa, the
Rectus femoris
tendons of gracilis (which is the more medial) and semitendinosus
stand out sharply. The semimembranosus tendon is just palpable in the
Gracilis
interval between them (and also by deep pressure from a ‘pincer’ grip
beyond their margins). There is some evidence that semimembranosus,
semitendinosus and biceps femoris, although they cross both hip and
knee joints, may produce movement at one of these joints without Sartorius
resisting antagonists at the other. Usually, however, each of these
muscles contracts as a whole, and whether or not movement takes place
at hip or knee is determined by other muscles that act as fixators of
these joints.
Testing The posterior thigh muscles are tested clinically by active knee Vastus lateralis
flexion against resistance in the supine or prone position. In the prone
position, the individual hamstring tendons can be identified more
easily.
When relaxed, these muscles show considerable variation in length; Vastus medialis
in some individuals, the muscles are so short as to impose a serious
limitation on flexion of the trunk at the hip joints when the knees are
kept extended. Movements such as stooping must then be accom-
plished by flexing the vertebral column or squatting. Perhaps the need
for more stress on the lumbar spine accounts for the occurrence of
Articular branch
hamstring tightness in adolescents who develop spondylolysis. These
(descending genicular artery)
muscles are prone to tearing, which may be related to the relative com-
plexity of muscles that cross two joints, or to the fact that they are
subject to large forces including eccentric contractions. Patellar anastomosis
VASCULAR SUPPLY AND LYMPHATIC DRAINAGE
Patellar ligament
Iliac vessels and external iliac arteries
and veins
Fig. 80.31 The left femoral triangle. (With permission from Waschke J,
The iliac vessels are described on page 1224, and the external iliac arter- Paulsen F (eds), Sobotta Atlas of Human Anatomy, 15th ed, Elsevier,
ies and veins on pages 1227 and 1228, respectively. Urban & Fischer. Copyright 2013.) | 1,878 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Femoral artery Obturator nerve
Lateral femoral
Obturator nerve cutaneous nerve Long saphenous External iliac vein
Acetabular branch of vein External iliac artery
obturator artery Medial circumflex Femoral nerve
femoral artery
Anterior branch of Femoral nerve lliacus
obturator artery
Obturator nerve Profunda femoris
Iliopsoas
Obturator nerve artery
Obturator artery Ascending
Medial circumflex
branch
femoral artery Lateral circumflex
Femoral vein Lateral
femoral artery
Pectineus circumflex
Profunda
femoral
Profunda femoris vein
artery
femoris artery
Adductor brevis
Sartorius Adductor Descending
longus branch
Descending branch
Femoral vein of lateral circumflex Muscular branches
Perforating artery of femoral nerve
femoral artery
Femoral artery Rectus femoris
Cutaneous branch of
obturator nerve Rectus femoris Adductor longus
Perforating artery
Saphenous nerve
Femoral vein
Anteromedial Muscular branch of Gracilis
intermuscular septum femoral nerve Vastus lateralis
(subsartorial fascia) Adductor magnus
Muscular branch
Gracilis Femoral artery of femoral nerve
Adductor hiatus
Rectus femoris
Descending
Saphenous nerve
genicular artery, Vastus medialis
saphenous branch
Sartorius Vastus medialis Saphenous nerve
Sartorius
Articular branch of
descending
genicular artery
Descending genicular artery,
articular branches
Superior medial
genicular artery
Popliteal
artery
Genicular anastomosis
Inferior medial
genicular artery
Fig. 80.32 The neurovascular structures of the anteromedial thigh. (With Fig. 80.33 The neurovascular structures of the anterior thigh. This is a
permission from Waschke J, Paulsen F (eds), Sobotta Atlas of Human deeper dissection than is shown in Figure 80.32. (With permission from
Anatomy, 15th ed, Elsevier, Urban & Fischer. Copyright 2013.) Waschke J, Paulsen F (eds), Sobotta Atlas of Human Anatomy, 15th ed,
Elsevier, Urban & Fischer. Copyright 2013.)
iliac spine and the pubic symphysis, descends along the anteromedial
part of the thigh in the femoral triangle, enters and passes through the to the medial side. Posteriorly, the posterior wall of the femoral sheath
adductor (subsartorial) canal, and becomes the popliteal artery as it separates the artery from the tendons of psoas, pectineus and adductor
passes through an opening in adductor magnus near the junction of longus. The artery is separated from the hip joint by the tendon of psoas
the middle and distal thirds of the thigh. Its first 3 or 4 cm are enclosed, major, from pectineus by the femoral vein and deep femoral vessels,
with the femoral vein, in the femoral sheath. The femoral artery gives and from adductor longus by the femoral vein. Proximally, the nerve
off several branches in the proximal thigh, including the superficial to pectineus passes medially behind the artery. The femoral nerve lies
epigastric, superficial circumflex iliac, superficial external pudendal, lateral to the artery, outside the femoral sheath. The femoral vein is
deep external pudendal and the profunda femoris artery. It gives off the medial to the artery in the proximal part of the triangle and becomes
descending genicular artery within the adductor canal. posterior distally at the apex.
Rarely, the femoral artery divides, distal to the origin of the profunda Within the adductor canal, the artery is covered by skin, subcutan-
femoris artery, into two trunks that reunite near the adductor opening. eous tissue, deep fascia, sartorius and the fibrous roof (subsartorial
The inferior gluteal artery, accompanying the sciatic nerve to the pop- fascia) of the canal. The saphenous nerve lies at first lateral, then ant-
liteal fossa and representing a persistence of the original axial artery, erior and finally medial to the artery. Adductor longus and adductor
may replace it. The external iliac artery is then small, ending as the deep magnus are posterior, vastus medialis and its nerve are anterolateral,
artery of the thigh. and the femoral vein is also posterior proximally but it becomes lateral
distally (see Figs 80.31–80.32; Fig. 80.33).
Relations
Compression of the femoral artery is most effective just distal to the
Anterior to the artery in the femoral triangle are the skin, subcutaneous inguinal ligament, where it is superficial and separated from the bone
tissue, superficial inguinal lymph nodes, fascia lata, femoral sheath, (iliopubic ramus) only by the psoas tendon. For this reason, arterial
superficial circumflex iliac vein (crossing in the subcutaneous tissue) injury proximal to the inguinal ligament, such as laceration by a knife,
and the femoral branch of the genitofemoral nerve (which is at first cannot be controlled simply by compression. Gaining proximal control
lateral and then anterior). Near the apex of the triangle, the medial of bleeding involves major exposure of the more proximal arteries as a
femoral cutaneous nerve crosses in front of the artery from the lateral life-saving manœuvre. | 1,879 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Branches Lateral circumflex femoral artery The lateral circumflex femoral
The branches of the femoral artery include the superficial epigastric, artery (see Figs 80.32–80.33) is a laterally running branch given off near
superficial circumflex iliac, superficial external pudendal, deep external the root of the profunda femoris artery. It passes between the divisions
pudendal arteries, muscular branches, the profunda femoris artery and of the femoral nerve, posterior to sartorius and rectus femoris, and
the descending genicular artery (see Fig. 78.4). divides into ascending, transverse and descending branches. The ascend-
ing branch ascends along the intertrochanteric line, under tensor fasciae
Superficial epigastric artery latae, lateral to the hip joint. It anastomoses with the superior gluteal
The superficial epigastric artery arises anteriorly from the femoral artery and deep circumflex iliac arteries, supplying the greater trochanter, and,
approximately 1 cm distal to the inguinal ligament, and traverses the with branches of the medial circumflex femoral, forms an anastomotic
cribriform fascia to ascend anterior to the ligament and run in the ring round the femoral neck, from which the femoral neck and head
abdominal subcutaneous tissue almost to the umbilicus. It supplies are supplied. The ascending branch forms the pedicle of the tensor
the superficial inguinal lymph nodes, subcutaneous tissue and skin, and fasciae latae musculocutaneous flap. The descending branch descends
anastomoses with branches of the inferior epigastric artery and its con- posterior to rectus femoris, along the anterior border of vastus lateralis,
tralateral fellow. which it supplies; a long branch descends in vastus lateralis to the knee,
anastomosing with the superior lateral genicular branch of the popliteal
Superficial circumflex iliac artery artery, accompanied by the nerve to vastus lateralis. The fasciocutaneous
The superficial circumflex iliac artery is the smallest superficial branch perforators that arise from the descending branch supply the antero-
of the femoral artery and arises near or with the superficial epigastric lateral thigh fasciocutaneous flap. The transverse branch, the smallest,
artery. It usually emerges through the fascia lata, lateral to the saphen- passes laterally anterior to vastus intermedius and pierces vastus latera-
ous opening, and turns laterally distal to the inguinal ligament towards lis to wind round the femur, just distal to the greater trochanter. It
the anterior superior iliac spine. It supplies the skin, subcutaneous anastomoses with the medial circumflex, inferior gluteal and first per-
tissue and superficial inguinal lymph nodes, anastomosing with the forating arteries, forming a cruciate anastomosis.
deep circumflex iliac, superior gluteal and lateral circumflex femoral The lateral circumflex femoral artery may arise from the femoral
arteries. artery or as a common trunk with the profunda femoris artery and the
The superficial circumflex iliac artery is the basis for the important medial circumflex femoral artery. The ascending and descending
axial-pattern pedicled groin skin flap. Free flaps based on the vessel may branches may occasionally arise separately (Siddharth et al 1985).
also be raised.
Medial circumflex femoral artery The medial circumflex femoral
Superficial external pudendal artery artery (see Figs 80.32–80.33) usually originates from the posteromedial
The superficial external pudendal artery arises medially from the aspect of the profunda femoris artery, but sometimes originates from
femoral artery, close to the preceding branches. Emerging from the the femoral artery itself or as a common trunk with either the profunda
cribriform fascia, it passes medially, usually deep to the long saphenous femoris artery or the lateral circumflex femoral artery or both (Sid-
vein, across the spermatic cord (or round ligament) to supply the lower dharth et al 1985). It supplies the adductor muscles and curves medi-
abdominal, penile, scrotal or labial skin, and anastomoses with ally round the femur between pectineus and psoas major and then
branches of the internal pudendal artery. obturator externus and adductor brevis, finally appearing between
quadratus femoris and the upper border of adductor magnus, dividing
deep external pudendal artery into transverse and ascending branches. The transverse branch takes
The deep external pudendal artery passes medially across pectineus and part in the cruciate anastomosis. The ascending branch ascends on the
anterior or posterior to adductor longus, covered by fascia lata, which tendon of obturator externus, anterior to quadratus femoris, to the
it pierces to supply the skin of the perineum and scrotum or labium trochanteric fossa, where it anastomoses with branches of the gluteal
majus. Its branches anastomose with the posterior scrotal or labial and lateral circumflex femoral arteries. An acetabular branch at the
branches of the internal pudendal artery. proximal edge of adductor brevis enters the hip joint under the trans-
verse acetabular ligament with one from the obturator artery. It supplies
Muscular branches
the fat in the fossa and reaches the femoral head along its ligament. For
These branches supply sartorius, vastus medialis and the adductors. details of the blood supply of the proximal end of the femur, consult
Crock (1996).
Profunda femoris artery (deep artery of the thigh)
The profunda femoris artery (see Figs 80.2B, 80.25, 80.32–80.33) is a Perforating arteries The perforating arteries (see Fig. 80.25) perfo-
large branch that arises posterolaterally from the femoral artery about rate the femoral attachment of adductor magnus to reach the flexor
3.5 cm distal to the inguinal ligament. At first lateral to the femoral aspect of the thigh. There are three perforating branches, and the ter-
artery, it spirals posterior to this and the femoral vein to reach the minal part of the profunda femoris artery itself becomes the fourth
medial side of the femur. It passes between pectineus and adductor perforator. They pass close to the linea aspera under small tendinous
longus, then between the latter and adductor brevis, before it descends arches and give off muscular, cutaneous and anastomotic branches.
between adductor longus and adductor magnus. It pierces adductor Diminished, they pass deep to the short head of biceps femoris (the
magnus and anastomoses with the upper muscular branches of the first usually through the attachment of gluteus maximus), traverse the
popliteal artery. This terminal part is sometimes named the fourth lateral intermuscular septum and enter vastus lateralis. The first arises
perforating artery. proximal, the second anterior, and the third distal to adductor brevis.
The profunda femoris artery is the main supply to the adductor, The first perforating artery passes back between pectineus and adductor
extensor and flexor muscles, and also anastomoses with the internal brevis (sometimes through the latter), pierces adductor magnus near
and external iliac arteries above and with the popliteal artery below. the linea aspera to supply adductor brevis, adductor magnus, biceps
It is a major collateral artery of the lower limb in patients with femoro- femoris and gluteus maximus, and anastomoses with the inferior
popliteal arterial occlusive disease (see Fig. 80.33) (Shakeri et al gluteal, medial and lateral circumflex femoral and second perforating
2010). arteries. The larger second perforating artery, often arising with the first,
The profunda femoris artery sometimes arises from the posterior pierces the attachments of adductor brevis and magnus, divides into
aspect of the femoral artery, and more rarely from the medial aspect. If the ascending and descending branches supplying the posterior thigh
it arises posteriorly, it may cross anterior to the femoral vein and then muscles and anastomoses with the first and third perforating arteries.
pass backwards around its medial side. The femoral nutrient artery usually arises from it. When two nutrient
arteries exist, they usually arise from the first and third perforators. The
Relations third perforating artery starts distal to adductor brevis, pierces the
Posteriorly, in proximodistal order, lie iliacus, pectineus, adductor attachment of adductor magnus and divides into branches to the pos-
brevis and adductor magnus. Anteriorly, the femoral and deep femoral terior thigh muscles. It anastomoses proximally with the perforating
veins, and distally, adductor longus, separate the profunda femoris arteries, and distally with the end of the profunda femoris artery and
artery from the femoral artery. Laterally, vastus medialis separates the muscular branches of the popliteal. The femoral nutrient artery may
proximal part of the artery from the femur. arise from it. Side branches of the diaphysial nutrient and other
branches of the profunda femoris artery provide subsidiary cortical
Branches arteries.
The profunda femoris artery gives off the lateral and medial circumflex The perforating arteries form a double chain of anastomoses,
arteries in the proximal thigh, and perforating and muscular branches initially in the adductor muscles and subsequently near the linea
more distally. aspera. | 1,880 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Muscular branches Numerous muscular branches arise from the Perforator flaps in the hip and thigh
profunda femoris artery. Some end in the adductors, and others pierce
adductor magnus, supply the flexors and anastomose with the medial Gluteal region
circumflex femoral artery and superior muscular branches of the pop-
The gluteal region of the lower limb has an average of 21 perforators,
liteal artery. The profunda femoris artery is thus the main supply to the
which arise from three main source arteries: namely, the superior and
thigh muscles.
inferior gluteal and the internal pudendal arteries (see Fig. 78.7). The
descending genicular artery flaps based on these perforators are used as free flaps for breast recon-
struction and as local flaps for covering defects in the sacral and perineal
The descending genicular artery (see Figs 82.1, 80.32–80.33), the distal
region.
branch of the femoral artery, arises just proximal to the adductor
opening and immediately supplies a saphenous branch. It then descends Hip and thigh region
in vastus medialis, anterior to the tendon of adductor magnus, to
The hip and thigh region has six source arteries and an average of 50
the medial side of the knee, where it anastomoses with the superior
arterial perforators. The thigh can be divided into four areas: antero-
medial genicular artery. Muscular branches supply vastus medialis and
medial; anterolateral and trochanteric; posteromedial; and posterola-
adductor magnus, and give off articular branches that anastomose
teral. The perforators that supply the anteromedial thigh are derived
round the knee joint. One articular branch crosses above the femoral
from the femoral artery, and those for the anterolateral thigh are derived
patellar surface, forming an arch with the superior lateral genicular
from branches of the lateral circumflex femoral artery. Perforators that
artery and supplying the knee joint. The saphenous branch (saphe nous
supply the skin over the posteromedial and posterolateral thigh regions
artery) emerges distally through the roof of the adductor canal to
are derived from the profunda femoris artery and the popliteal arteries.
accompany the saphenous nerve to the medial side of the knee. It passes
Skin flaps based on the superficial circumflex iliac, superficial external
between sartorius and gracilis, and supplies the skin of the proximome-
pudendal and superficial inferior epigastric arteries have been used as
dial area of the leg; it anastomoses with the inferior medial genicular
local flaps, tube pedicles and free tissue transfers. Other popular skin
artery.
flaps are TFL (tensor fasciae latae) perforator flaps, ALT (anterolateral
thigh) and AMT (anteromedial thigh) flaps, gracilis perforator flap and
Arterial anastomoses around the hip
posterior thigh flaps.
In the fetus, a peri-acetabular vascular circle formed by the superior and
inferior gluteal, internal pudendal and obturator arteries reduces the VEINS
risk of bony necrosis of this region in children. However, there is a zone
at the anterior portion of the acetabulum where the blood supply is Femoral vein
less abundant (Damsin et al 1992).
Anastomoses on the back of the thigh The femoral vein accompanies its artery, beginning at the adductor
opening as the continuation of the popliteal vein, and ending posterior
An important chain of anastomoses extends on the back of the
to the inguinal ligament as the external iliac vein (see Figs 78.8, 80.1–
thigh from the gluteal region to the popliteal fossa. It is formed in
80.3, 80.31). The vein is posterolateral to the femoral artery in the distal
proximodistal order by anastomoses between the gluteal arteries and
adductor canal. More proximally in the canal, and in the distal femoral
terminal branches of the medial circumflex femoral artery; the circum-
triangle (i.e. at its apex), the vein lies posterior to the artery and proxi-
flex femoral arteries and the first perforating artery; the perforating
mally, at the base of the triangle, the vein lies medial to the artery. The
arteries themselves; and between the fourth perforating artery and the
vein occupies the middle compartment of the femoral sheath, between
superior muscular branches of the popliteal artery (see Fig. 80.18). The
the femoral artery and femoral canal; fat in the canal permits expansion
trochanteric and cruciate anastomoses are the proximal elements of this
of the vein.
chain.
The femoral vein has numerous muscular tributaries. The profunda
femoris vein (deep vein of the thigh, deep femoral vein) joins the
trochanteric anastomosis
femoral vein posteriorly 4–12 cm distal to the inguinal ligament, and
The so-called trochanteric anastomosis lies near the trochanteric fossa
the long saphenous vein then enters anteriorly. Veins accompanying the
of the femur and is an anastomosis between the ascending branch of
superficial epigastric, superficial circumflex iliac and external pudendal
the medial circumflex femoral artery and descending branches of the
arteries join the long saphenous vein before it enters the saphenous
superior and inferior gluteal arteries (see Fig. 80.18). The lateral cir-
opening. Lateral and medial circumflex femoral veins are usually tribu-
cumflex femoral artery and the first perforating artery from the pro-
taries of the femoral vein. There are usually four or five valves in the
funda femoris artery may also contribute, creating an extracapsular
femoral vein; the two most constant are just distal to the entry of pro-
‘arterial ring of the femoral neck’ (Crock 1996). Branches from this
funda femoris and near the inguinal ligament.
ring, the retinacular vessels, pierce the capsule and ascend along the
femoral neck to give the main blood supply to the head of the Profunda femoris vein (Deep vein of the thigh)
femur.
Profunda femoris lies anterior to its artery and receives tributaries cor-
responding to the branches of the artery. Through these tributaries it
cruciate anastomosis
connects distally with the popliteal vein and proximally with the infe-
The cruciate anastomosis lies at the level of the lesser trochanter,
rior gluteal veins. It sometimes drains the medial and lateral circumflex
near the lower edge of the femoral attachment of quadratus femoris,
femoral veins and has a valve just before it empties into the femoral
and is an anastomosis between the transverse branches of the medial
vein.
and lateral circumflex femoral arteries, a descending branch of the
inferior gluteal artery and an ascending branch from the first perforating Long saphenous vein
artery. The long saphenous vein (great saphenous vein) (see Fig. 78.9A), the
longest vein in the body, starts distally as a continuation of the medial
Collateral circulation in proximal femoral
marginal vein of the foot, and ends in the femoral vein a short dis-
artery occlusion
tance distal to the inguinal ligament. It ascends immediately anterior
After occlusion of the femoral artery proximal to the origin of the pro- to the tibial malleolus, crosses the distal third of the medial surface of
funda femoris artery, five main anastomotic channels are available. the tibia obliquely in an anteroposterior direction to reach its medial
These are between branches of the superior and inferior gluteal arteries, border, and then ascends a little behind the border to the knee. Proxi-
the medial and lateral circumflex femoral arteries and the first perforat- mally, it is posteromedial to the medial tibial and femoral condyles
ing branch of the profunda femoris artery; the obturator branch of the (lying the breadth of the subject’s hand posterior to the medial edge
internal iliac artery and the medial circumflex femoral artery; the inter- of the patella), and then ascends the medial aspect of the thigh. It
nal pudendal branch of the internal iliac artery and the superficial and passes through the saphenous opening and finally opens into the
deep external pudendal branches of the femoral artery; a deep circum- femoral vein. The ‘centre’ of the opening is often said to be 2.5–3.5 cm
flex iliac branch of the external iliac artery, the lateral circumflex femoral inferolateral to the pubic tubercle, and the vein is then represented
branch of the deep artery of the thigh and the superficial circumflex by a line drawn from this point to the adductor tubercle. However,
iliac branch of the femoral artery; and the inferior gluteal branch of the the saphenous opening varies greatly in size and disposition so that
internal iliac artery and perforating branches of the profunda femoris this ‘centre’ is not a reliable surface marking for the saphenofemoral
artery. junction. | 1,881 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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In its course through the thigh, the long saphenous vein is accom- nodes along the termination of the long saphenous vein. They receive
panied by the medial branches of the anterior cutaneous branches of all the superficial vessels of the lower limb, except those from the pos-
the femoral nerve. At the knee, the saphenous branch of the descending terolateral calf. All superficial inguinal nodes drain to the external iliac
genicular artery (the saphenous artery) and, in the leg and foot, the nodes, some via the femoral canal and others anterior or lateral to the
saphenous nerve all lie anterior to the vein. The vein is often duplicated, femoral vessels. Numerous vessels interconnect individual nodes.
especially distal to the knee. It has 10–20 valves, which are more numer- Superficial inguinal nodes are frequently enlarged in disease or
ous in the leg than in the thigh. One is present just before the vein injury in their region of drainage. Thus the proximal inguinal nodes are
pierces the cribriform fascia, another at its junction with the femoral almost invariably affected in malignant or infective disease of the
vein. In almost its entire extent the vein lies in subcutaneous tissue, but prepuce, penis, labia majora, scrotum, perineum, anus and lower
it has many connections with the deep veins, especially in the leg. vagina, or in diseases affecting the skin and superficial structures in
these regions, in the infra-umbilical part of the abdominal wall or in
tributaries the gluteal region. The distal group is implicated only in disease or
At the ankle, the long saphenous vein drains the sole by medial mar- injury of the limb.
ginal veins. In the leg, it often connects with the short saphenous vein
and with deep veins via perforating veins. Just distal to the knee, it Deep inguinal nodes
usually receives three large tributaries from the front of the leg, the tibial
malleolar region (connecting with some of the ‘perforating’ veins) and The deep inguinal nodes vary from one to three, and are situated medial
the calf (communicating with the short saphenous vein). The tributary to the femoral vein. One lies just distal to the saphenofemoral junction,
draining the tibial malleolar region is formed distally from a fine another in the femoral canal, and the most proximal node lies laterally
network or ‘corona’ of delicate veins over the medial malleolus, and in the femoral ring. The middle node is the most inconstant and the
then ascends the medial aspect of the calf as the posterior arch vein proximal node is often absent. All receive deep lymphatics that accom-
(Dodd and Cockett 1976). This vein was first illustrated by Leonardo pany the femoral vessels, lymph vessels from the glans penis or clitoris
da Vinci, whose name is sometimes given to it. It connects with poste- and a few efferents from the superficial inguinal nodes. Their own
rior tibial venae comitantes by a series of perforating (communicating) efferents traverse the femoral canal to the external iliac nodes.
veins. There are usually three, equally spaced between the medial malle-
olus and the mid-calf. More than three such perforators are uncommon,
and an arch vein perforator above mid-calf is only very rarely found. INNERVATION
Above the posterior crural arch vein, perforating veins join the long
saphenous vein or one of its main tributaries at two main sites. The first LUMBAR PLEXUS AND BRANCHES
is at a level in the upper calf indicated by its name, the tibial tubercle
perforator; the second is in the lower/intermediate third of the thigh, The lumbar plexus is formed by the first three and most of the fourth
where it perforates the deep fascia roof of the subsartorial canal to join lumbar ventral rami (see Fig. 62.15). The iliohypogastric, ilioinguinal
the femoral vein. and genitofemoral nerves are described on pages 1094–1096.
In the thigh, the long saphenous vein receives many tributaries.
Some open independently, while others converge to form large named Lateral femoral cutaneous nerve
channels that frequently pass towards the basal half of the femoral
triangle before joining the long saphenous near its termination. These
The lateral femoral cutaneous nerve (lateral cutaneous nerve of the
may be grouped as follows: one or more large posteromedial tributaries,
thigh) arises from the dorsal branches of the second and third lumbar
one or more large anterolateral tributaries, and four or more peri-
ventral rami and emerges from the lateral border of psoas major, cross-
inguinal veins. The posteromedial vein of the thigh, large and some-
ing iliacus obliquely towards the anterior superior iliac spine. It supplies
times double, drains a large superficial region indicated by its name; it
the parietal peritoneum in the iliac fossa. The right nerve passes poste-
has (as have the other tributaries) radiological and surgical significance.
rolateral to the caecum, separated from it by the fascia iliaca and peri-
One of its lower radicles is often continuous with the short saphenous
toneum; the left passes behind the lower part of the descending colon.
vein. The posteromedial vein is sometimes named the accessory saph-
Both pass behind or through the inguinal ligament, variably medial to
enous vein, though some restrict the term accessory to a lower (more
the anterior superior iliac spine (commonly 1 cm) and anterior to or
distal) posteromedial tributary when two (or more) are present. Another
through sartorius into the thigh, where they divide into anterior and
large vessel, the anterolateral vein of the thigh (anterior femoral cutan-
posterior branches. The anterior branch becomes superficial approxi-
eous vein), usually commences from an anterior network of veins in
mately 10 cm distal to the anterior superior iliac spine and supplies the
the distal thigh and crosses the apex and distal half of the femoral tri-
skin of the anterior and lateral thigh as far distally as the knee. It con-
angle to reach the long saphenous vein. As the latter traverses the
nects terminally with the cutaneous branches of the anterior division
saphenous opening, it is joined by the superficial epigastric, superficial
of the femoral nerve and the infrapatellar branch of the saphenous
circumflex iliac and superficial external pudendal veins. Their mode of
nerve, forming the peripatellar plexus. The posterior branch pierces the
union varies. Superficial epigastric and circumflex iliac veins drain the
fascia lata higher than the anterior, and divides to supply the skin on
inferior abdominal wall, the latter also receiving tributaries from the
the lateral surface from the greater trochanter to about mid-thigh. It
proximolateral region of the thigh. The superficial epigastric or the
may also supply skin of the gluteal region.
femoral vein may connect with the lateral thoracic veins by means of a
thoracoepigastric vein that runs superficially on the anterolateral aspect lesions of the lateral femoral cutaneous nerve
of the trunk. This vein connects the inferior and superior caval areas of The lateral femoral cutaneous nerve may become entrapped at three
drainage and may be dilated and visible in cases of inferior caval sites along its course: close to the vertebral column; within the abdomi-
obstruction. Superficial external pudendal veins drain part of the nal cavity as the nerve travels across the pelvis; and as it leaves the pelvis.
scrotum/labia; one is joined by the superficial dorsal vein of the penis/ This last site is where the nerve is most commonly damaged, and
clitoris. The deep external pudendal veins join the long saphenous vein entrapment is thought to occur as the nerve passes through or deep to
at the saphenous opening. the inguinal ligament just medial to the anterior superior iliac spine.
The long saphenous vein is often harvested for grafts used in both The angulation of the nerve as it crosses the iliac crest means that it is
peripheral and coronary arterial surgery. vulnerable to compression during movement, e.g. hip extension may
increase angulation and tension on the nerve.
Injury produces an area of impaired sensation, often with pain and
LYMPHATIC DRAINAGE
paraesthesia on the anterolateral aspect of the thigh (meralgia paraes-
thetica) in the distal cutaneous distribution of the nerve. This area does
Superficial inguinal nodes
not extend across the midline anteriorly, it does not extend below the
knee and it does not extend behind the hamstring tendons laterally.
The superficial inguinal nodes form proximal and distal groups. The Symptoms may be exacerbated when wearing tight belts or tight-waisted
proximal group usually consists of five or six nodes just distal to the clothes or as a result of a recent weight gain or pregnancy. Exceptionally,
inguinal ligament. Its lateral members receive afferent vessels from the posterior branch of the lateral femoral cutaneous nerve, which sup-
the gluteal region and the adjoining infra-umbilical anterior abdominal plies a thin strip from the greater trochanter of the femur down about
wall. Medial members receive superficial vessels from the external geni- two-thirds of the way to the knee, may be affected separately. This
talia (including the inferior vagina), inferior anal canal and perianal branch leaves the main trunk of the nerve, usually distal to the inguinal
region, adjoining abdominal wall, umbilicus and vessels accompanying ligament, and it then turns laterally to pierce tensor fasciae latae, where
the round ligament. The distal group usually consists of four or five it may become entrapped. | 1,882 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
Pelvic girdle, gluteal region and thigh
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Femoral nerve lesions of the femoral nerve
The main trunk of the femoral nerve is not subject to an entrapment
The femoral nerve is the largest branch of the lumbar plexus and arises neuropathy, but it may be compressed by retroperitoneal tumours or
from the dorsal branches (posterior divisions) of the second to fourth retroperitoneal haemorrhage in patients on anticoagulants or with a
lumbar ventral rami (see Figs 78.11A, 80.31–80.33). It descends through bleeding diathesis. A localized lesion of the femoral nerve may occur
psoas major, emerging low on its lateral border, and then passes in diabetes mellitus (one of the forms of diabetic amyotrophy). The
between psoas and iliacus, deep to the iliac fascia. Passing behind the most striking feature of femoral neuropathy is wasting and weakness of
inguinal ligament into the thigh, it is split into anterior and posterior quadriceps femoris, which results in considerable difficulty in walking
divisions by the lateral circumflex femoral artery. Behind the inguinal and a tendency for the leg to collapse. Pain and paraesthesia may occur
ligament, it is separated from the femoral artery by part of psoas major. on the anterior and medial aspect of the thigh, extending down the
In the abdomen, the nerve supplies small branches to iliacus and medial aspect of the leg in the distribution of the saphenous branch of
pectineus and a branch to the proximal part of the femoral artery; the the femoral nerve.
latter branch sometimes arises in the thigh.
Obturator nerve
nerve to pectineus
The nerve to pectineus branches from the medial side of the femoral The obturator nerve arises from the ventral branches of the second to
nerve near the inguinal ligament. It passes behind the femoral sheath fourth lumbar ventral rami. The branch from the third is the largest
and enters the anterior aspect of the muscle. while that from the second is often very small. The nerve descends in
psoas major, emerging from its medial border at the pelvic brim to pass
anterior division of the femoral nerve behind the common iliac vessels and lateral to the internal iliac vessels.
The anterior division of the femoral nerve supplies intermediate and It then descends forwards along the lateral wall of the lesser pelvis on
medial femoral cutaneous nerves and branches to sartorius. obturator internus, anterosuperior to the obturator vessels, to the obtu-
rator foramen, entering the thigh by its upper part. Near the foramen,
Medial femoral cutaneous nerve of the thigh The medial it divides into anterior and posterior branches, separated at first by part
of obturator externus and lower down by adductor brevis.
femoral cutaneous nerve (medial cutaneous nerve of the thigh) is at
first lateral to the femoral artery. It crosses ant erior to the artery at the anterior branch
apex of the femoral triangle and divides into anterior and posterior
The anterior branch (see Fig. 80.33) leaves the pelvis anterior to obtur-
branches. Before doing so, it sends a few rami through the fascia lata
ator externus, descending in front of adductor brevis, behind pectineus
to supply the skin of the medial side of the thigh, near the long saphe-
and adductor longus. At the lower border of adductor longus it com-
nous vein; one ramus emerges via the saphe nous opening, while
municates with the medial cutaneous and saphenous branches of the
another becomes subcutaneous about mid-thigh. The anterior branch
femoral nerve, to form a subsartorial plexus that supplies the skin on
descends on sartorius, perforates the fascia lata beyond mid-thigh, and
the medial side of the thigh (see below). It descends on, and supplies,
divides into a branch that supplies the skin as low as the medial side
the femoral artery. Near the obturator foramen, the anterior branch
of the knee, and another that runs lateral to the former and connects
supplies the hip joint. Behind pectineus it supplies adductor longus,
with the infrapatellar branch of the saphenous nerve. The posterior
gracilis, usually adductor brevis and often pectineus, and connects with
branch descends along the posterior border of sartorius to the knee,
the accessory obturator nerve (when present). Occasionally, the com-
pierces the fascia lata, connects with the saphenous nerve and gives off
municating branch to the femoral medial cutaneous and saphenous
several cutaneous rami, some as far as the medial side of the leg. The
branches continues as a cutaneous branch to the thigh and leg. When
nerve contributes to the subsartorial plexus (see below).
this occurs, the nerve emerges from behind the distal border of adductor
longus to descend along the posterior margin of sartorius to the knee,
Intermediate cutaneous nerve of the thigh The intermediate where it pierces the deep fascia and connects with the saphenous nerve
femoral cutaneous nerve (intermediate cutaneous nerve of the thigh) to supply the skin halfway down the medial side of the leg.
usually pierces the fascia lata some 8 cm below the inguinal ligament,
either as two branches or as one trunk that quickly divides into two. Subsartorial nerve plexus The medial cutaneous nerve of the
These descend on the front of the thigh, supplying the skin as far as the thigh forms a subsartorial plexus with branches of the saphenous and
knee and ending in the peripatellar plexus. The lateral branch of the obturator nerves, deep to the fascia lata, at the lower border of adductor
intermediate cutaneous nerve communicates with the femoral branch longus. When the communicating branch of the obturator nerve is large
of the genitofemoral nerve, frequently piercing sartorius and sometimes and reaches the leg, the posterior branch of the medial cutaneous nerve
supplying it. is small, and ends in the plexus from which it gives rise to a few cutan-
eous filaments.
Nerve to sartorius The main nerve to sartorius arises from the
Posterior branch
femoral nerve in common with the intermediate cutaneous nerve of the
thigh. The posterior branch pierces obturator externus anteriorly, supplies it
and passes behind adductor brevis to the front of adductor magnus,
Posterior division of the femoral nerve dividing into branches to this and adductor brevis when the latter is
not supplied by the anterior division. It usually sends an articular fila-
The branches of the posterior division of the femoral nerve are the
ment to the knee joint, which either perforates adductor magnus dis-
saphenous nerve and branches to quadriceps femoris and the knee joint.
tally or traverses its opening with the femoral artery to enter the
popliteal fossa. Within the fossa, the nerve descends on the popliteal
Saphenous nerve See page 1399.
artery to the back of the knee, pierces its oblique posterior ligament and
supplies the articular capsule. It gives filaments to the popliteal artery.
Muscular branches The muscular branches of the posterior divi-
sion of the femoral nerve supply quadriceps femoris. A branch to rectus lesions of the obturator nerve
femoris enters its proximal posterior surface and also supplies the hip Isolated lesions of the obturator nerve are extremely rare, but may
joint. A larger branch to vastus lateralis forms a neurovascular bundle occasionally occur as a result of direct trauma (sometimes during par-
with the descending branch of the lateral circumflex femoral artery in turition) or in anterior dislocations of the hip. The nerve may also be
its distal part and also supplies the knee joint. A branch to vastus damaged by an obturator hernia, or be involved together with the
medialis descends through the proximal part of the adductor canal, femoral nerve in retroperitoneal lesions that occur close to the origins
lateral to the saphenous nerve and femoral vessels, and enters the of the lumbar plexus. Compression of the nerve by herniated bowel
muscle at about its midpoint, sending a long articular filament distally loops at the obturator foramen can result in pain referred to the hip,
along the muscle to the knee. Two or three branches to vastus inter- medial thigh and knee, the so-called Howship–Romberg sign. A more
medius enter its anterior surface about mid-thigh; a small branch from distal nerve entrapment syndrome causing chronic medial thigh pain
one of these descends through the muscle to supply articularis genus has been described in athletes with large adductor muscles.
and the knee joint.
Accessory obturator nerve
vascular branches
Vascular branches of the femoral nerve supply the femoral artery and Occasionally present, the accessory obturator nerve is small and arises
its branches. from the ventral branches of the third and fourth lumbar ventral rami. | 1,883 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
innervation
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Table 80.1 The branches of the sacral plexus
Ventral divisions Dorsal divisions
Nerve to quadratus femoris and gemellus L4, 5, S1
inferior
Nerve to obturator internus and gemellus L5, S1, 2
superior
Greater sciatic foramen
Nerve to piriformis (L5), S1, 2
Superior gluteal L4, 5, S1 Sciatic nerve
Posterior femoral
Inferior gluteal L5, S1, 2
cutaneous nerve
Posterior femoral cutaneous S2, 3 S1, 2
Tibial (sciatic) L4, 5, S1, 2, 3
Common fibular (sciatic) L4, 5, S1, 2 Inferior clunial nerves
Perforating cutaneous S2, 3 Perineal branches of
Common fibular nerve posterior femoral cutaneous nerve
Pudendal S2, 3, 4
Tibial nerve
Branches to levator ani, coccygeus and S4
external anal sphincter Adductor magnus
(also partially supplied
by obturator nerve)
It descends along the medial border of psoas major, crosses the superior Long head of
pubic ramus behind pectineus and divides into branches; one branch biceps femoris
enters the deep surface of pectineus, another supplies the hip joint, and
a third connects with the anterior branch of the obturator nerve. Some-
times the accessory obturator nerve is very small and only supplies
pectineus. Any branch may be absent and others may occur; an addi-
tional branch sometimes supplies adductor longus. Semitendinosus
Short head of
biceps femoris
SACRAL PLEXUS AND BRANCHES
Long head of
The branches of the sacral plexus (see Fig. 78.11B) are shown in biceps femoris
Table 80.1.
Semimembranosus
Sciatic nerve Tibial nerve Articular branch
The sciatic nerve is 2 cm wide at its origin and is the thickest nerve in Plantaris
the body. It leaves the pelvis via the greater sciatic foramen below piri-
formis and descends between the greater trochanter and ischial tuberos- Lateral sural
ity, along the back of the thigh, dividing into the tibial and common cutaneous nerve
fibular nerves at a varying level proximal to the knee (Fig. 80.34; see Medial sural cutaneous nerve
Fig. 78.11B). Superiorly, it lies deep to gluteus maximus, resting first on
the posterior ischial surface with the nerve to quadratus femoris between Sural communicating
them. It then crosses posterior to obturator internus, the gemelli and branch
quadratus femoris, separated by the latter from obturator externus and
the hip joint. It is accompanied medially by the posterior femoral cuta-
neous nerve and the inferior gluteal artery. More distally, it lies behind Gastrocnemius
adductor magnus and is crossed posteriorly by the long head of biceps
femoris. Its course corresponds to a line drawn from just medial to the
midpoint between the ischial tuberosity and greater trochanter to the
apex of the popliteal fossa. Sural nerve
Articular branches arise proximally to supply the hip joint through
its posterior capsule; these are sometimes derived directly from the
sacral plexus. Muscular branches are distributed to biceps femoris,
semitendinosus, semimembranosus and the ischial part of adductor Soleus
magnus.
The point of division of the sciatic nerve into its tibial and common
fibular components is very variable. The common site is at the junction
of the middle and lower thirds of the thigh, near the apex of the pop-
liteal fossa, but the division may occur at any level above this point
Lateral calcaneal branches Tibial nerve
and, rarely, may occur below it.
Medial calcaneal branches
Blood supply to the sciatic nerve
In the gluteal region, the sciatic nerve is supplied by the inferior gluteal Lateral dorsal cutaneous nerve
Medial and lateral plantar nerves
artery and cruciate anastomosis (the medial and lateral circumflex
femoral arteries, inferior gluteal artery and the first perforating branch
of the profunda femoris artery) (see Fig. 80.30). On rare occasions, it
is supplied by branches from the superior gluteal or internal pudendal
arteries, which reach the nerve on its medial side. Lower in the thigh,
arterial branches derived from the perforating branches of the profunda
femoris artery or the anastomotic chain between them or, occasionally,
from the popliteal artery, enter the nerve on its lateral or anterolateral
side (Sunderland 1945). The numerous arterial branches to the sciatic
nerve anastomose with each other to form extraneural and intraneural Fig. 80.34 The sciatic nerve and its branches, posterior view.
arterial chains (Sunderland 1945, Ugrenovic et al 2013).
lesions of the sciatic nerve
The sciatic nerve supplies the knee flexors and all the muscles below
the knee, which means that a complete palsy of the sciatic nerve results
in a flail foot and severe difficulty in walking. Fortunately, complete | 1,884 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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sciatic nerve palsy is very rare. The nerve is vulnerable in posterior dis- Nerve to obturator internus
location of the hip. As it leaves the pelvis, it passes either behind piri-
formis or sometimes through the muscle, and at that point it may very
The nerve to obturator internus arises from the ventral branches of the
rarely become entrapped or tethered; the piriformis syndrome is a
fifth lumbar and first and second sacral ventral rami. It leaves the pelvis
controversial condition in which an anomalous relationship between
via the greater sciatic foramen below piriformis, supplies a branch to
piriformis and the sciatic nerve is thought to cause pain in the buttocks
the upper posterior surface of gemellus superior, crosses the ischial
and along the course of the sciatic nerve. External compression over the
spine lateral to the internal pudendal vessels, re-enters the pelvis via the
buttock, e.g. in patients who lie immobile on a hard surface for a con-
lesser sciatic foramen, and enters the pelvic surface of obturator
siderable length of time, can injure the nerve. However, the most
internus.
common cause of serious sciatic nerve injury (and of the resulting major
medicolegal claims) is iatrogenic (Dillow et al 2013). The nerve may
Posterior femoral cutaneous nerve (posterior
be damaged in misplaced therapeutic injections into gluteus maximus.
cutaneous nerve of the thigh)
Sciatic nerve palsy occurs after total hip replacement or similar surgery
in 1% of cases, and may be caused by sharp injury, burning from bone
cement, traction from instruments, manipulation of the hip, inadvert- The posterior femoral cutaneous nerve (posterior cutaneous nerve
ent lengthening of the femur, or haematoma surrounding the nerve. For of the thigh) arises from the dorsal branches of the first and second,
some reason, possibly anatomical, the common fibular component of and the ventral branches of the second and third sacral rami. It leaves
the sciatic nerve is more usually affected; the patient has a foot drop the pelvis via the greater sciatic foramen below piriformis and descends
and a high-stepping gait. under gluteus maximus with the inferior gluteal vessels, lying posterior
or medial to the sciatic nerve (see Fig. 80.30). It descends in the back
Inferior gluteal nerve of the thigh superficial to the long head of biceps femoris, deep to the
fascia lata. It pierces the deep fascia behind the knee and accompanies
the short saphenous vein to mid-calf, its terminal twigs connecting with
The inferior gluteal nerve arises from the dorsal branches of the fifth
the sural nerve. Its branches are cutaneous and are distributed to the
lumbar and first and second sacral ventral rami. It leaves the pelvis via
gluteal region, perineum, posterior thigh and proximal posterior leg.
the greater sciatic foramen below piriformis, and divides into branches
Three or four gluteal branches (inferior clunial nerves) curl round
that enter the deep surface of gluteus maximus (see Fig. 80.30).
the lower border of gluteus maximus to supply the skin over the infero-
lateral portion of the muscle. The perineal branch supplies the supero-
Superior gluteal nerve
medial skin in the thigh, curves forwards across the hamstrings below
the ischial tuberosity, pierces the fascia lata and then runs in the super-
The superior gluteal nerve arises from the dorsal branches of the fourth ficial perineal fascia to the scrotal or labial skin. It communicates with
and fifth lumbar and first sacral ventral rami. Accompanied by the the inferior rectal and posterior scrotal or labial branches of the perineal
superior gluteal vessels, the nerve leaves the pelvis via the greater sciatic nerve, and gives numerous branches to the skin of the back and medial
foramen above piriformis, and divides into superior and inferior side of the thigh, the popliteal fossa and the proximal part of the back
branches (see Fig. 80.30). The superior branch accompanies the upper of the leg. One study found the perineal branch of the posterior cutane-
branch of the deep division of the superior gluteal artery to supply ous nerve of the thigh in about one-half of specimens (Tubbs et al
gluteus medius and occasionally gluteus minimus. The inferior branch 2009).
runs with the lower ramus of the deep division of the superior gluteal
artery across gluteus minimus, supplies the glutei medius and minimus, Nerve to piriformis
and ends in tensor fasciae latae.
The nerve to piriformis usually arises from the dorsal branches of the
Pudendal nerve
first and second sacral ventral rami (sometimes only the second) and
enters the anterior surface of piriformis.
See Figure 62.15 and pages 1230 and 1236.
Visceral and pelvic muscular branches
Perforating cutaneous nerve
of sacral plexus
The perforating cutaneous nerve usually arises from the posterior
Visceral branches of the sacral plexus are described on page 1229. Pelvic
aspects of the second and third sacral ventral spinal rami. It pierces the
muscular branches are described on page 1221.
sacrotuberous ligament, curves round the inferior border of gluteus
maximus and supplies the skin over the inferomedial aspect of this
muscle. The nerve may arise from the pudendal nerve or it may be
absent, in which case it may be replaced either by a branch from the
posterior femoral cutaneous nerve or from the third and fourth, or Bonus e-book images
fourth and fifth, sacral ventral rami.
Nerve to quadratus femoris
Fig. 80.20 An ultrasound image of a 4-week-old baby taken in the
lateral position and demonstrating the cartilaginous femoral head
The nerve to quadratus femoris arises from the ventral branches of the and edge of the acetabulum.
fourth lumbar to the first sacral ventral rami. It leaves the pelvis via the
greater sciatic foramen below piriformis, descends on the ischium deep Fig. 80.21 A radiograph of the pelvis of a 9-month-old infant
to the sciatic nerve, the gemelli and the tendon of obturator internus, showing the centre of ossification of the femoral epiphysis.
and supplies gemellus inferior, quadratus femoris and the hip joint.
KEY REFERENCES
Dixon AF 1910 The architecture of the cancellous tissue forming the upper An analysis of over 8000 femora representing 100 human groups, which
end of the femur. J Anat Physiol 44:223–30. found a markedly lower average femoral neck-shaft angle of 127°.
A neglected and original work with far-reaching implications for the
Holm NJ 1980 The internal stress pattern of the os coxae. Acta Orthop Scand
understanding of femoral structure.
51:421–8.
Finnegan M 1978 Non-metric variation of the infracranial skeleton. J Anat Biomechanical information, relevant to the function of the hip and pelvis.
125:33–7.
Scheuer L, Black S 2004 The Juvenile Skeleton. London: Elsevier, Academic
A reference text for forensic and osteo-archaeological work.
Press.
Gilligan I, Chandraphak S, Mahakkanukrauh P 2013 Femoral neck-shaft An invaluable reference to the skeleton of the juvenile. Relevant to the fields
angle in humans: variation relating to climate, clothing, lifestyle, sex, of anthropology, archaeology, anatomy, skeletal biology and forensic science.
age and side. J Anat 223:133–151. | 1,885 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Key references
Shakeri A, Tubbs RS, Shoja MM et al 2010 Analysis of the profunda femoris A translated, updated and edited version of a classic French text, first
artery with superficial femoral artery occlusive disease. Biomed Int 1: published in 1933. Now a major source book in plastic surgery.
62–5.
Tubbs RS, Miller J, Loukas M et al 2009 Surgical and anatomical landmarks
An original study emphasizing the significance of the profunda femoris
for the perineal branch of the posterior femoral cutaneous nerve: impli-
artery as a collateral artery of the lower limb.
cations in perineal pain syndromes. Laboratory investigation. J Neuro-
Siddharth P, Smith NL, Mason RA et al 1985 Variational anatomy of the surg 111:332–5.
deep femoral artery. Anat Rec 212:206–9. A recent and original study on the perineal branch of the posterior femoral
A detailed study of the variations in the origin of the deep femoral artery cutaneous nerve.
and lateral and medial circumflex arteries in 100 thighs.
Whitehouse WJ 1977 Cancellous bone in the anterior part of the iliac crest.
Sunderland S 1945 Blood supply of the sciatic nerve and its popliteal divi- Calcif Tissue Res 23:67–76.
sions in man. Arch Neurol Psych 54:283–9. Detailed information on the internal structure of a site that is commonly
A neglected and original work with detailed information on the blood supply used for marrow biopsy.
of the sciatic nerve.
Taylor GI, Razaboni RM (eds) 1994 Michael Salmon: Anatomic Studies.
Book 1, Arteries of the Muscles of the Extremities and the Trunk.
St Louis: Quality Medical Publishing. | 1,886 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
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Pelvic girdle, gluteal region and thigh
REFERENCES
Benninger B 2014 Novel femoral artery terminology: integrating anatomy Mays S 1998 The Archaeology of Human Bones. London: Routledge.
and clinical procedures leading to standardized intuitive nomenclature. Ponseti IV 1978 Growth and development of the acetabulum in the normal
Clin Anat 27:1085–8. child. J Bone Joint Surg 60:575–85.
Birkenmaier C, Jorysz G, Jansson V et al 2010 Normal development of the Scheuer L, Black S 2004 The Juvenile Skeleton. London: Elsevier, Academic
hip: a geometrical analysis based on planimetric radiography. J Pediatr Press.
Orthop B 19:1–8. An invaluable reference to the skeleton of the juvenile. Relevant to the fields
Bogduk N 1997 Clinical Anatomy of the Lumbar Spine and Sacrum, 3rd ed. of anthropology, archaeology, anatomy, skeletal biology and forensic science.
Edinburgh: Elsevier, Churchill Livingstone.
Shakeri A, Tubbs RS, Shoja MM et al 2010 Analysis of the profunda femoris
Brothwell DR, Pollard AM (eds) 2001 Handbook of Archaeological Sciences. artery with superficial femoral artery occlusive disease. Biomed Int 1:
Chichester: Wiley. 62–5.
Cormack GC, Lamberty BGH 1994 The Arterial Anatomy of Skin Flaps. An original study emphasizing the significance of the profunda femoris
Edinburgh: Elsevier, Churchill Livingstone. artery as a collateral artery of the lower limb.
Crock HV 1980 An atlas of the arterial supply of the head and neck of the Siddharth P, Smith NL, Mason RA et al 1985 Variational anatomy of the
femur in man. Clin Orthop 152:17–25. deep femoral artery. Anat Rec 212:206–9.
Crock HV 1996 Atlas of Vascular Anatomy of the Skeleton and Spinal Cord. A detailed study of the variations in the origin of the deep femoral artery
London: Martin Dunitz. and lateral and medial circumflex arteries in 100 thighs.
Damsin JP, Lazennec JY, Gonzales M et al 1992 Arterial supply of the Sunderland S 1945 Blood supply of the sciatic nerve and its popliteal divi-
acetabulum in the fetus: application to periacetabular surgery in child- sions in man. Arch Neurol Psych 54:283–9.
hood. Surg Radiol Anat 4:215–21. A neglected and original work with detailed information on the blood supply
Delaere O, Kok V, Nyssen-Behets C et al 1992 Ossification of the human of the sciatic nerve.
fetal ilium. Acta Anat 143:330–4.
Tame SJ, Burstal R 2003 Investigation of the radiological relationship
Dillow JM, Rosett RL, Petersen TR et al 2013 Ultrasound-guided parasacral between iliac crests, conus medullaris and vertebral level in children.
approach to the sciatic nerve block in children. Paediatr Anaesth Paediatr Anaesth 13:676–80.
23:1042–7.
Taylor GI, Razaboni RM (eds) 1994 Michael Salmon: Anatomic Studies.
Dixon AF 1910 The architecture of the cancellous tissue forming the upper Book 1, Arteries of the Muscles of the Extremities and the Trunk.
end of the femur. J Anat Physiol 44:223–30. St Louis: Quality Medical Publishing.
A neglected and original work with far-reaching implications for the A translated, updated and edited version of a classic French text, first
understanding of femoral structure. published in 1933. Now a major source book in plastic surgery.
Dodd H, Cockett FB 1976 The Pathology and Surgery of the Veins of the Trueta J 1957 The normal vascular anatomy of the femoral head during
Lower Limb, 2nd ed. Edinburgh: Elsevier, Churchill Livingstone. growth. J Bone Joint Surg 39B:353–8.
Eckhoff DG, Kramer RC, Watkins JJ et al 1994 Variation in femoral antever- Tubbs RS, Miller J, Loukas M et al 2009 Surgical and anatomical landmarks
sion. Clin Anat 7:72–5. for the perineal branch of the posterior femoral cutaneous nerve: impli-
Emans JB, Ciarlo M, Callahan M et al 2005 Prediction of thoracic dimen- cations in perineal pain syndromes. Laboratory investigation. J Neuro-
sions and spine length based on individual pelvic dimensions in chil- surg 111:332–5.
dren and adolescents: an age-independent, individualized standard A recent and original study on the perineal branch of the posterior femoral
for evaluation of outcome in early onset spinal deformity. Spine 30: cutaneous nerve.
2824–9.
Tubbs RS, Stetler W Jr, Savage AJ et al 2006 Does a third head of the rectus
Finnegan M 1978 Non-metric variation of the infracranial skeleton. J Anat femoris muscle exist? Folia Morphol (Warsz) 65:377–80.
125:33–7.
Ugrenovic SZ, Jovanovic ID, Kovacevic P et al 2013 Similarities and dissimi-
A reference text for forensic and osteo-archaeological work.
larities of the blood supplies of the human sciatic, tibial, and common
Fuss FK, Bacher A 1991 New aspects of the morphology and function of the peroneal nerves. Clin Anat 26:875–82.
human hip joint ligaments. Am J Anat 192:1–13. Walheim G, Olerud S, Ribbe T 1984 Mobility of the pubic symphysis: meas-
Gilligan I, Chandraphak S, Mahakkanukrauh P 2013 Femoral neck-shaft urements by an electromechanical method. Acta Orthop Scand 55:
angle in humans: variation relating to climate, clothing, lifestyle, sex, 203–8.
age and side. J Anat 223:133–51. Weisl H 1954 The articular surfaces of the sacroiliac joint and their relation
An analysis of over 8000 femora representing 100 human groups, which to the movements of the sacrum. Acta Anat 22:1–14.
found a markedly lower average femoral neck-shaft angle of 127°.
Whitehouse WJ 1977 Cancellous bone in the anterior part of the iliac crest.
Holm NJ 1980 The internal stress pattern of the os coxae. Acta Orthop Scand Calcif Tissue Res 23:67–76.
51:421–8. Detailed information on the internal structure of a site that is commonly
Biomechanical information, relevant to the function of the hip and pelvis. used for marrow biopsy.
Joseph J 1975 Movements at the hip joint. Ann R Coll Surg Eng 56:
192–201.
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CHAPTER
81
Hip
ligament. The acetabular labrum is triangular in section, attached by its
TOPOGRAPHY
base to the acetabular margin and blending with adjacent articular
cartilage; its acute free edge projects beyond the acetabular margin. The
The hip joint is a synovial joint of ball-and-socket (multiaxial spheroi- diameter of the acetabular cavity is constricted by the labral rim, which
dal) type between the head of the femur and the cup-shaped (cotyloid) embraces the femoral head, thereby contributing to the stability of the
acetabulum; its centre lies a little inferior to the middle one-third of the articulation. The acetabular labrum increases the surface area for joint
inguinal ligament. contact as well as sealing the joint, allowing optimal intra-articular
distribution of synovial fluid (Ferguson et al 2003, Cadet et al 2012). It
Articular surfaces thus facilitates nutrition of the articular cartilage and helps to reduce
intra-articular friction (Safran et al 2011, Song et al 2012). Nerve
endings found within the labrum suggest this structure may be a source
The femoral head can be landmarked from the surface roughly 2–4 cm
of proprioception or, when injured, of pain (Kim and Azuma 1995). A
superior to an approximate midpoint of a line joining the superior
torn acetabular labrum can be detected using MRI, to identify the site
margin of the greater trochanter to the pubic tubercle. The articular
and severity of the lesion (Fig. 81.2).
surfaces of the femoral head and the acetabulum are reciprocally curved
but neither coextensive nor completely congruent (Fig. 81.1; see Fig.
80.16). The close-packed position of the hip joint is one of full exten- Acetabular labrum and impingement injury
sion, with slight abduction and medial rotation (see also Table 5.4).
This position winds up most of the joint’s capsular ligaments, which Available with the Gray’s Anatomy e-book
can provide an important element of articular stability. The femoral
head is covered by articular cartilage, except over the rough pit where
Fibrous capsule
the ligament of the head of the femur is attached. Anteriorly, the carti-
lage extends laterally over a small area on the adjoining neck. Articular
cartilage is, generally, thicker centrally than peripherally. Cartilage thick- The fibrous capsule of the hip joint is strong and dense (Fig. 81.4). It
ness is maximal anterosuperiorly in the acetabulum and anterolaterally is attached superiorly to the acetabular margin 5–6 mm medial to the
on the femoral head, the two areas that correspond to the principal labral attachment, anteriorly to the outer labral aspect and, near the
load-bearing areas within the joint. The acetabular articular surface, the acetabular notch, to the transverse acetabular ligament and the adjacent
lunate surface, is an incomplete ring, broadest anterosuperiorly where rim of the obturator foramen. From its acetabular attachment, it extends
the pressure of body weight falls in the erect posture, and narrowest in laterally to surround the femoral head and neck, and is attached ante-
its pubic region. It is deficient inferiorly opposite the acetabular notch. riorly to the intertrochanteric line, superiorly to the base of the femoral
The lunate surface is covered by articular cartilage, which is thickest neck, posteriorly 1 cm superomedial to the intertrochanteric crest, and
where the surface is broadest. The acetabular fossa, the central non- inferiorly to the femoral neck near the lesser trochanter. Anteriorly,
articular area in the floor of the acetabulum, is devoid of cartilage but many fibres ascend along the neck as longitudinal retinacula, contain-
contains fibroelastic fat largely covered by synovial membrane. The ing blood vessels for both the femoral head and the neck. The capsule
acetabular labrum, a fibrocartilaginous rim attached to the acetabular is thicker anterosuperiorly, where maximal stress occurs, particularly
margin, serves to deepen the acetabulum and bridges the acetabular while standing with the hip extended. Posteroinferiorly, it is relatively
notch by attaching to the peripheral edge of the transverse acetabular thin and loosely attached. The capsule as a whole has two sets of fibres,
Fig. 81.1A Anteroposterior radiograph of an adult female
pelvis. 1, sacral promontory; 2, margin of anterior sacral
foramen; 3, linea terminalis; 4, fovea for ligament of head;
10 5, lesser trochanter of left femur; 6, left ischial tuberosity;
7, left obturator foramen; 8, coccyx; 9, left anterior
inferior iliac spine; 10, gas in sigmoid colon.
1 (B, continued online)
2
3 9
8
4
7
6
5
A
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18
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Hip
Fig. 81.1B Anteroposterior radiograph of an
adult male pelvis (the hip joint is normal).
1, ossification in right iliolumbar ligament; 2, pubic
1
symphysis; 3, inferior margin of left sacroiliac joint;
4, left anterior superior iliac spine.
4
3
2
B
Fig. 81.3 Pre-surgical radiograph of a hip with a cam deformity of the
femoral head–neck junction (arrow). Note the loss of sphericity in the
femoral head and the loss of the tapering of the neck. (Image courtesy of
John T Heinrich MD, Milwaukee Orthopaedic Group Limited, Milwaukee,
WI, USA.)
Fig. 81.2 T1-weighted fat-saturated MR arthrogram of the left hip joint
(coronal section). The arrow points to a torn acetabular labrum at the
anterosuperior margin of the acetabulum.
The shape of the bones of the hip normally limits large and potentially create damaging impingement between the hard and bulbous femoral
damaging contact stress on adjacent connective tissues, especially neck and the softer acetabular labrum. The anterosuperior section of
during the extremes of movement. Consider, for example, the normal the labrum is particularly vulnerable to this type of injury, which is a
shape of the femoral head and neck region. Similar to the shape of a painful and often motion-limiting condition referred to as femoral-
light bulb, the spherical femoral head narrows gradually at its junction acetabular impingement syndrome. The repeatedly traumatized section
with the neck of the femur. This tapering limits large contact stress of the labrum can become enlarged, fragmented or torn. When the
between the femoral neck and the margin of the acetabulum. However, acetabular labrum is torn, a hip joint may become unstable as a con-
tapering may be lost as a result of natural variation or underlying sequence of the loss of the natural suction seal around the joint. In
pathology, resulting in a specific deformity that has been referred to as some advanced cases, the impingement trauma may create lesions at
a cam deformity because the head and neck of the femur, together, the chondrolabral junction, resulting in damage to the adjacent articu-
resemble a camshaft. Although often subtle, this deformity may be lar cartilage, potentially predisposing the hip joint to degenerative
detected radiographically (see arrow in Fig. 81.3). In some patients with arthritis (osteoarthrosis). Treatment may involve arthroscopic repair of
a cam deformity, extreme and repeated motions of the hip, typically the acetabular labrum and cartilage, as well as reshaping the area of the
involving combinations of flexion, medial rotation and adduction, can femoral head and neck responsible for the impingement. 1376.e1 | 1,889 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
Topography
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RETPAHC
circular and longitudinal. The circular fibres (zona orbicularis) are they are reinforced by the iliofemoral ligament. The capsule is also
internal and form a collar round the femoral neck; although partly strengthened inferiorly by the pubofemoral ligament, and posteriorly
blended with the pubofemoral and ischiofemoral ligaments, these by the ischiofemoral ligament. Externally the capsule is rough, covered
fibres are not directly attached to bone (see Fig. 81.4). Externally, lon- by muscles and tendons, and separated anteriorly from psoas major
gitudinal fibres are most numerous in the anterosuperior region, where and iliacus by a bursa. The capsular attachment to the femur lies
well distal to the growth plate of the femoral head both anteriorly
and posteriorly, and so the upper femoral epiphysis is entirely intrac-
Ilium apsular. The capsular attachment intersects the growth plate of the
greater trochanter on the superior surface of the base of the neck.
Ischial spine
Acetabular margin Iliocapsularis
Synovial membrane
Available with the Gray’s Anatomy e-book
Greater trochanter
Relations The joint capsule is surrounded by muscles (Fig. 81.5).
Anteriorly, lateral fibres of pectineus separate the capsule from the
femoral vein. Lateral to this, the tendon of psoas major, with iliacus
lateral to it, descends en route to the lesser trochanter, partly separated
from the capsule by a bursa. The femoral artery is anterior to the tendon
of psoas major, and the femoral nerve lies deep in a groove between
the tendon and iliacus. More laterally, the straight head of rectus femoris
crosses the joint with a deep layer of the iliotibial tract, which blends
with the capsule under the lateral border of the muscle. Superiorly, the
reflected head of rectus femoris contacts the capsule medially, while
Zona orbicularis gluteus minimus covers it laterally, being closely adherent. Inferiorly,
medial fibres of pectineus adjoin the capsule and, more posteriorly,
Ischial tuberosity
obturator externus spirals obliquely to its posterior aspect. Posteroinfe-
riorly, the capsule is covered by the tendon of obturator externus, sepa-
Lesser trochanter
rating it from quadratus femoris and accompanied by an ascending
branch of the medial circumflex femoral artery. Superior to this, the
tendon of obturator internus and the gemelli contact the joint capsule,
separating it from the sciatic nerve. The nerve to quadratus femoris is
Intertrochanteric crest
deep to the obturator internus tendon and descends medially on the
capsule. Superior to this, the posterior surface of the joint is crossed by
Fig. 81.4 Synovial cavity of the left hip joint (distended): posterior aspect. piriformis.
Gluteus medius
Anterior superior iliac spine
Tensor fasciae latae Gluteus minimus
Sartorius
Articular capsule
Rectus femoris, straight head
Acetabular labrum
Rectus femoris, reflected head
Iliacus
Piriformis
Ligament of head of femur
Obturator internus and gemelli
Psoas major tendon
Transverse acetabular ligament Gluteus maximus
Obturator externus
Pectineus
Medial circumflex femoral artery Sciatic nerve
Quadratus femoris
Obturator nerve, anterior division
Adductor longus
Adductor magnus, ischial fibres
Adductor brevis
Hamstrings
Obturator nerve, posterior division
Adductor magnus, pubic fibres
Gracilis
Fig. 81.5 Schematic dissection to display the structures surrounding the hip joint. The femoral head has been disarticulated and removed. | 1,890 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
18
RETPAHC
Hip
Iliocapsularis (also called iliacus minor or iliotrochantericus) is a little-
known but constant muscle that lies immediately deep to the tendon
of iliopsoas and overlies the anterior hip capsule (Babst et al 2011, Ward
et al 2000). Typically present as just a few strands of fibres, it originates
from the anteromedial hip capsule and anteroinferior iliac spine, and
is attached just distal to the lesser trochanter. Although the function of
the muscle is uncertain, it may draw the capsule taut as a way of redu-
cing its impingement during hip flexion.
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HiP
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NOiTCES
A Pubofemoral ligament Tendon of rectus femoris B Sacrospinous ligament
Obturator canal
Obturator membrane
Sacrotuberous
Reflected ligament
Tendon head
of rectus
femoris Straight
head
Descending Iliofemoral
part Iliofemoral ligament
Transverse ligament Neck
part of femur
Greater
trochanter
Ischiofemoral ligament
Lesser trochanter
Gluteal tuberosity
Greater trochanter
Lesser trochanter
Fig. 81.6 Ligaments of the hip joint. A, Anterior aspect; B, Posterior aspect. (With permission from Waschke J, Paulsen F (eds), Sobotta Atlas of Human
Anatomy, 15th ed, Elsevier, Urban & Fischer. Copyright 2013.)
Ligaments
The ligaments of the hip joint are the iliofemoral, pubof emoral,
ischiofemoral and transverse acetabular ligaments, and the ligament of
the head of the femur (Fig. 81.6). As the hip moves, the capsular liga-
ments wind and unwind, tightening around the hip, and affecting
Cut synovial membrane
stability, excursion and joint capacity (Fuss and Bacher 1991). Joint
capacity is maximal when the hip joint is held in a partially flexed and Synovial sleeve
abducted position; a patient with an effusion in the hip joint is there- around ligament
of head of femur
fore most comfortable when the joint is held in this position.
Obturator artery
Iliofemoral ligament The iliofemoral ligament is very strong and is
Pubic tubercle
shaped like an inverted Y, lying anteriorly and intimately blended with
the capsule. Its apex is attached between the anterior inferior iliac spine
Pubis
and acetabular margin, its base to the intertrochanteric line. It is com-
posed of a medially placed, thicker descending part and a laterally Acetabular branch of
placed, transverse part, which is typically distinguishable anteriorly. obturator artery
The obliquely disposed transverse part is attached to a tubercle at the Artery of ligament of
superolateral end of the intertrochanteric line, while the vertically head of femur
oriented descending part reaches the inferomedial end of the line. Ligament of head of femur
Obturator membrane
Pubofemoral ligament The pubofemoral ligament is triangular,
with a base that is attached to the iliopubic ramus, superior pubic Ischial tuberosity
ramus, obturator crest and membrane. It blends distally with the Fig. 81.7 Interior aspect of the hip joint to show the ligament of the head
capsule and deep surface of the descending part of the iliofemoral liga- of the femur. (With permission from Drake RL, Vogl AW, Mitchell A, et al
ment and has been described as consisting of multiple crura (Fuss and (eds), Gray’s Atlas of Anatomy, Elsevier, Churchill Livingstone. Copyright
Bacher 1991). 2008.)
Ischiofemoral ligament The ischiofemoral ligament thickens the
posterior aspect of the capsule. The central part spirals superolaterally
from the ischium, where it is attached posteroinferior to the acetabu- Ligament of the head of the femur The ligament of the head of
lum, then courses posterior to the femoral neck to attach distally to the the femur is a triangular and somewhat flattened band of connective
greater trochanter deep to the iliofemoral ligament. Some fibres blend tissue (see Fig. 81.5, Fig. 81.7). Its apex is attached anterosuperiorly in
with the zona orbicularis. Some of the more inferior fibres of the the fovea for the ligament of the head of the femur while its base is
ischiofemoral ligament embrace the posterior circumference of the attached principally to both edges of the acetabular notch, between
femoral neck. which it blends with the transverse acetabular ligament. It also receives
weaker contributions from the margins of the acetabular fossa, is
Transverse acetabular ligament The transverse acetabular liga- ensheathed by synovial membrane and varies in strength. Occasionally,
ment (see Fig. 80.4) is continuous peripherally with the labrum but the synovial sheath exists by itself in the absence of the ligament; rarely,
does not possess any cartilage cells. Its strong, flat fibres cross the both the ligament and sheath are absent.
acetabular notch, forming a foramen through which vessels and nerves Although the ligament of the head of the femur is known primarily
pass to enter the joint. for lending structural support to the blood vessels that travel to and | 1,892 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
Factors maintaining stability
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from the femoral head, speculation exists that it may also have a role closely by the acetabular labrum, which restrains it in the socket. In
in stabilizing the hip joint in utero. In the adult, it is mostly elongated addition, a ‘vacuum effect’ is present. The thick capsule is reinforced by
and assumed to be taut when the hip joint is semi-flexed, laterally the three major ligaments: iliofemoral, pubofemoral and ischiofemoral.
rotated, and adducted, the position where the capsular ligaments, as a The iliofemoral ligament is the strongest, and is progressively tightened
whole, offer least stability to the joint (Martin et al 2012). The degree when the femur extends to the line of the trunk. The pubofemoral and
to which the ligament of the head of the femur offers functional stabil- ischiofemoral ligaments also tighten when this happens and, as the
ity to the adult hip is uncertain, although it is likely to be secondary to joint approaches the close-packed position, resistance to an extending
that provided by the capsular ligaments and muscle activation. torque increases rapidly. The transverse acetabular ligament and liga-
Medical interest in the ligament of the head of the femur has ment of the head of the femur also contribute to stability. Only slight
increased with the advancing technology associated with medical separation of the articular surfaces can be achieved by strong traction
imaging and arthroscopic hip surgery (Botser et al 2011, Gray and Villar on the joint. To aid insertion of an arthroscope, a needle is first inserted
1997; Fig. 81.8). Free nerve endings have been identified within this into the joint to eliminate the suction effect; the joint will subsequently
ligament, suggesting that this structure may be a source of pain when open sufficiently with traction. Traumatic dislocation usually occurs
it is injured or degenerating (Leunig et al 2000). The afferent innerv- only when the joint is subjected to extreme force.
ation in the healthy state may serve as a source of proprioception or
protection of the joint (Bardakos and Villar 2009).
BIOMECHANICS OF THE HIP JOINT
Synovial membrane
The transition from quadrupedal to bipedal gait was a considerable bio-
mechanical milestone in the evolution of Homo sapiens. The biomech-
Starting from the femoral articular margin, the synovial membrane
anical features of the human lower limb, whose function is primarily
covers the intracapsular part of the femoral neck, and then passes to
to allow stance and bipedal propulsion, are very different from those of
the internal surface of the capsule to cover the acetabular labrum, the
the quadruped lower limb, and these differences are reflected in the
ligament of the head of femur and fat in the acetabular fossa. It is thin
anatomy and biomechanics of the human hip, knee, ankle and foot
on the deep surface of the iliofemoral ligament where it is compressed
joints.
against the femoral head, and sometimes is even absent here.
The acetabulum and femoral head form a multiaxial spheroidal
Bursae (‘ball and socket’) joint, which allows relatively unhindered motion in
three degrees of freedom, i.e. flexion/extension, abduction/adduction
and medial/lateral rotation. This articulation is innately limited in its
The hip joint may communicate with the subtendinous iliopectineal
capacity for translational motion in anteroposterior, transverse and
bursa through a circular aperture between the pubofemoral ligament
vertical directions.
and the descending part of the iliofemoral ligament. More distant
bursae are associated with the tendons of distal attachment of glutei Femur
medius and minimus at the greater trochanter, and between gluteus
maximus and vastus lateralis.
The femur is essentially a tubular structure with distortions that consist
of bows and twists. The most notable is the anterior bow in its mid
VASCULAR SUPPLY AND LYMPHATIC DRAINAGE portion, where the radius of curvature is relatively constant along the
length of the femoral shaft. In the coronal (frontal) plane, the femoral
neck is inclined obliquely to the shaft at an angle of about 135° (range
Articular arteries are branches from the obturator, medial circumflex
femoral, and superior and inferior gluteal arteries; they form the cruci- 120–140°; Fig. 81.10). Although the neck–shaft angle (collo–diaphyseal
angle; Mikulicz angle) and neck length are variable, the centre of the
ate and trochanteric anastomoses (see Fig. 80.18). There is a corre-
neck in the coronal plane is at the level of the apex of the greater tro-
sponding venous drainage.
chanter. In the axial (transverse) plane, the femoral neck is anteverted,
Lymphatics from the anterior aspect of the hip joint drain to the
i.e. rotated anteriorly relative to the posterior surfaces of the femoral
deep inguinal nodes, while those from the medial and posterior aspects
of the joint travel with the obturator and gluteal arteries, respectively,
condyles; in the adult, this angle is 10–15° (Fig. 81.11A). Excessive
anteversion may exist when this angle is significantly greater than
to reach the internal iliac nodes.
10–15° (Fig. 81.11B). At birth, the angle of anteversion is typically
about 35–40°. As the child develops, forces from muscles and gravity
INNERVATION cause the angle of anteversion to decrease gradually, approaching 15°
by young adulthood. Excessive anteversion usually persists beyond
The anterior capsule of the hip joint is innervated by the femoral,
obturator and accessory obturator (when present) nerves. The poste-
rior capsule is innervated by the sciatic and superior gluteal nerves, and
by the nerve to quadratus femoris (Birnbaum et al 1997, Gardner
1948).
Head B
Hip and groin pain
N
Greater trochanter
Pain emanating from the hip and groin has many possible causes. True
Neck
pain from the hip joint is typically felt deep in the crease of the groin.
NSA
Pain over the lateral aspect of the hip usually suggests a local problem
such as trochanteric bursitis. Pain in the buttock is only occasionally
derived from the hip joint; most frequently, it is referred from the Lesser trochanter
lumbosacral spine or may be caused by vascular claudication. Pain in
the groin may be associated with inguinal or femoral hernias. In the
younger age group, it afflicts those engaged in sports, especially running
ball sports; the pain is sometimes due to femoro-acetabular impinge-
ment or to hernia but most often is related to adductor longus tendinitis Shaft
(‘groin strain’). Attritional chronic overload of the anterior abdominal
wall at its attachments to the pubis and inguinal ligament, or of external
S
oblique at the superficial inguinal ring, is a common occurrence. Rarely,
problems may occur at the pubic symphysis.
Fig. 81.10 The neck–shaft angle (NSA) between the long axis of the
femoral shaft (S) and the axis of the femoral neck (N) is on average 135°
FACTORS MAINTAINING STABILITY
(range 125–140°). In addition, in most hips, a line nearly perpendicular to
S from the tip of the greater trochanter (B) passes through the centre of
The hip joint is normally very stable. The femoral head is closely fitted the femoral head. This approximation can be utilized in judging the
to the acetabulum in an area exceeding half a sphere, and is embraced position of the femoral osteotomy in hip arthroplasty. | 1,893 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
18
RETPAHC
Hip
The blood supply to the hip in the child is different from that in the the head of the femur. Any damage to these vessels (e.g. trauma, infec-
adult and this has very important implications clinically. Since the tion) can result in the devastating complication of avascular necrosis of
growth plate is avascular, the only blood supply to the femoral head is the femoral head. The growth plate represents a line of weakness and
conveyed through the retinacular vessels, which are mainly tributaries predisposes to fracture from injury. Acute injuries affecting the capital
of the medial circumflex femoral artery. These retinacular arteries enter epiphysis are uncommon. A more chronic fracture through the capital
the joint capsule in the trochanteric fossa and ascend the femoral neck epiphysis resulting in slipped capital femoral epiphysis, where the
on its outer aspect superiorly and posteriorly. They pass around the edge femoral head epiphysis displaces posteriorly off the femoral neck,
of the growth plate (physis) and enter the femoral head (Fig. 81.9). A occurs in pubescent adolescents, especially males (see Fig. 81.9 and
minor contribution to the vascular supply comes from the ligament of p. 1353).
Ligament of head of femur Fovea for ligament of head of femur Greater trochanter Fovea for ligament of head of femur Femoral head Transverse acetabular ligament
A B
Ligament of head of femur Acetabular fossa
Fig. 81.8 An intact ligament of the head of the femur in a left adult hip. A, T2-weighted fat-saturated MR arthrogram of the hip joint (coronal section).
(Courtesy of Michael O’Brien MD, Wisconsin Radiology Specialists, Milwaukee, WI, USA.) B, Photograph taken through an arthroscope of a slightly
distracted hip joint. (Courtesy of John T Heinrich MD, Milwaukee Orthopaedic Group Limited, Milwaukee, WI, USA.)
Fig. 81.9 Radiograph of the left hip of a 14-year-old boy. The yellow
arrow shows posterior displacement of the femoral head in the slipped
capital femoral epiphysis. The red arrow indicates the course of the
retinacular vessels along the posterior aspect of the femoral neck. The
blue arrow indicates the physis (growth plate). (Courtesy of Mr
Christopher Edward Bache.) 1379.e1 | 1,894 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
HiP
1380
9
NOiTCES
A the body passes posterior to a line joining the centres of the femoral
heads. The body therefore tends to incline posteriorly but this is coun-
terbalanced by ligamentous tension and congruence and compression
of the articular surfaces within the hip joints in the close-packed posi-
tion. Under increased loading of the trunk or leaning posteriorly, these
resistive but passive factors are assisted by active force produced by the
hip joint flexors. In swaying anteriorly at the ankles, or when the arms
are stretched forwards, and also in forward-bending at the hip, the line
of body weight moves anterior to the medial–lateral axis of rotation
through the hip joints. The posture adopted, or the rate of change of
posture, is largely controlled by the hamstrings, which, besides being
powerful flexors of the knee, are strong extensors of the hip. Gluteus
maximus becomes particularly active when the thigh is extended
15˚ against resistance, as in rising from a bending position or during
climbing.
Abduction is produced by glutei medius and minimus, assisted by
tensor fasciae latae, piriformis and sartorius. The motion is limited by
Normal anteversion adductor muscle tension, the pubofemoral ligament and the extreme
medial bands of the descending part of the iliofemoral ligament. The
B
abductor muscles, most notably glutei medius and minimus, are active
periodically at precise phases of the walking or running cycle to ensure
coronal plane stability of the pelvis.
Adduction is produced by adductors longus, brevis and magnus and
by gracilis assisted by pectineus, quadratus femoris and the inferior
fibres of gluteus maximus. The range of adduction is limited by the
increasing tension in the abductor muscles, the transverse part of the
iliofemoral ligament and the fascia lata of the thigh.
Medial rotation is produced by the anterior fibres of glutei minimus
and medius, and assisted by tensor fasciae latae and most adductor
muscles. The strength of medial rotation naturally increases as the hip
is flexed because this position increases the moment arm of most
medial rotator muscles (Delp et al 1999). Medial rotation is limited
by tension in lateral rotator muscles such as piriformis, the ischiofem-
35˚
oral ligament and the adjacent posterior joint capsule (Wagner et al
2012).
Excessive anteversion Lateral rotation is produced by gluteus maximus, obturator internus,
superior and inferior gemelli, quadratus femoris and piriformis, and it
Fig. 81.11 A, Superior view of a proximal femur with normal anteversion.
B, Superior view of a proximal femur with excessive anteversion. (With is assisted by obturator externus and sartorius. Lateral rotation, a
permission from Neumann D, Kinesiology of the Musculoskeletal System, stronger motion than medial rotation, is limited by tension in the
2nd ed, Elsevier, Mosby. Copyright 2010.) medial rotator muscles and the transverse part of the iliofemoral liga-
ment (Myers et al 2011).
Forces acting on the hip
childhood in cases of abnormal motor development, such as can be
seen with cerebral palsy.
The degree of anteversion affects many aspects of lower limb bio- In quiet upright standing, the femoral heads support the weight of the
mechanics, including the moment (lever) arms of the hip abductor and trunk, upper limbs and head. About two-thirds of body weight is
medial rotator muscles (the perpendicular distance from the centre of located above the hips, and so each femoral head normally accepts
rotation of the femur to the line of action of the resultant muscle force); about one-third of body weight. This force is compressive in nature, as
patellar tracking (the motion of the patella relative to the femur); and gravity pulls the acetabula against the femoral heads. When viewed in
foot orientation. the sagittal plane, minimal muscle forces suffice to maintain equilib-
rium as long as the weight of the upper body is directed over the femoral
Acetabulum heads. If the upper body leans anteriorly, shifting the upper body weight
vector anteriorly beyond the femoral heads and thereby producing a
hip flexion moment, posterior thigh muscles can counter such rotation.
The acetabulum consists of the confluence of the ilium, ischium and
As the capsular ligaments of the hip slacken in flexion, none of them
pubis at the triradiate cartilage. By itself, the acetabulum covers an area
is able to resist the forward lean.
slightly less than a hemisphere; it is deepened by the acetabular labrum.
During walking, hip joint compression force varies from one-third
The degree of acetabular anteversion is about 17° (16° males and 18°
of body weight, when both feet are on the ground, to some four times
females) (Reikeras et al 1983). In the coronal plane, the acetabular axis
body weight when the other foot is lifted. The large compression forces
is inclined inferiorly approximately 45° from the horizontal.
generated while walking originate primarily from two sources: gravity
and muscle activation. During the stance phase, gravity pulls the upper
MOVEMENTS body and acetabulum inferiorly on the femoral heads (as described
above for quiet standing). More significantly, each femoral head is
pushed superiorly against its socket as the foot strikes and then pushes
Available with the Gray’s Anatomy e-book against the ground. Although activation of muscles is responsible for a
greater portion of joint compression at the hip, the influences of gravity
Muscles producing hip joint movements
and of capsular tension (when the hip joint is extended) should not be
ignored.
Flexion is primarily produced by psoas major, iliacus and rectus femoris, As the lower limb is swinging anteriorly and free of contact with the
assisted by pectineus, tensor fasciae latae and sartorius. The adductors, ground, hip joint compression force is estimated to be at about 50%
particularly adductor longus and brevis, also assist, especially when the of body weight (Correa et al 2010). Such joint force is essentially myo-
hip is near full extension. Effective action of the hip flexor muscles genic. Consider, for example, a contracting iliopsoas pulling the femoral
requires strong synergistic activation of the abdominal muscles to sta- head against the acetabulum as it simultaneously advances the lower
bilize the pelvis. limb in walking.
Extension is produced by gluteus maximus, biceps femoris, semi- In contrast, during the stance phase of walking, hip joint forces may
tendinosus, semimembranosus and adductor magnus. The posterior reach four times body weight. These forces are mainly caused by the
fibres of gluteus medius assist with this action (Neumann 2010a). In pull of the hip abductor muscles (primarily gluteus medius, gluteus
the fully erect posture, a vertical line through the centre of gravity of minimus and tensor fasciae latae). This muscular action, essential to | 1,895 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
18
RETPAHC
Hip
Two terms can conveniently describe the kinematics (movements) at stationary femoral heads (compare Figs 81.12A and B). Depending on
the hip. Femoral-on-pelvic hip kinematics describes the rotation of the the accompanying trunk movement, the lumbar vertebrae will either
femur about a relatively fixed pelvis. Conversely, pelvic-on-femoral flex or extend in rhythm with the rotating pelvis. Consider, for example,
(hip) kinematics describes the rotation of the pelvis, and often the a short-arc anterior rotation (or tilt) of the pelvis over both femurs while
superimposed trunk, over a relatively fixed femur or set of femurs. the upper trunk remains stationary. During this motion, the lumbar
Regardless of whether the femur or the pelvis is the moving segment, vertebrae extend slightly towards greater lordosis. By comparison, rotat-
kinematics are described for all three cardinal planes on the assumption ing both the pelvis and the trunk over both femurs (as in reaching
that movements are initiated from the anatomical position. towards the ground with knees held extended), the pelvis and the tho-
Flexion and extension are motions that occur in the sagittal plane. racolumbar vertebrae both flex, thereby augmenting the overall forward
To appreciate the hip joint arthrokinematics that accompany the associ- motion of the body as a whole.
ated femoral-on-pelvic motions, the length and angulation of the Abduction and adduction of the hip joint occur in the coronal plane
femoral neck in relation to the shaft must be considered. As the hip about an anterior-to-posterior axis of rotation through the femoral
(femur) is flexed about 120° towards the anterior thoracic wall, or head. With the pelvis fixed, the femur abducts about 40° (Fig. 81.13A).
extended 10–20° beyond the plane of the trunk, the femoral head Conversely, pelvic-on-femoral (hip) motions that occur in the coronal
‘spins’ in the acetabulum about a side-to-side (medial–lateral) axis of
rotation. Conversely, from a pelvic-on-femoral perspective, the acetab-
ula rotate around a similar axis in flexion and extension relative to A
A Flexion
Slack iliofemoral Abduction
ligament
Pubofemoral ligament
Adductor brevis
Adductor longus
Gluteus
maximus
40˚
120˚
Inferior
capsule
B
Abduction
B
Intertransverse ligament
Flexion
(Anterior pelvic tilt) 30˚
Pubofemoral ligament
Slack iliofemoral
ligament Adductor brevis
30˚
Adductor longus
Biceps femoris
Fig. 81.12 Hip flexion shown from two kinematic perspectives, as
indicated by the green curved arrows. A, Femoral-on-pelvic flexion. Fig. 81.13 Hip abduction shown from two kinematic perspectives, as
B, Pelvic-on-femoral flexion. Note the directional-specific motion of the indicated by the green curved arrows. A, Femoral-on-pelvic abduction.
lumbar spine in B; this is a necessity, assuming the trunk remains upright. B, Pelvic-on-femoral abduction. Note the directional-specific motion of
Tissues that are elongated or pulled taut are indicated by orange arrows; the lumbar spine in B; this is a necessity, assuming the trunk remains
tissues slackened are indicated by blue wavy arrows. In all cases, upright. Tissues that are elongated or pulled taut are indicated by orange
muscles are assumed to be inactive but stretched. The red circle arrows. In all cases, muscles are assumed to be inactive but stretched.
indicates the axis of rotation at the hip. (With permission from Neumann The red circle indicates the axis of rotation at the hip. (With permission
D, Kinesiology of the Musculoskeletal System, 2nd ed, Elsevier, Mosby. from Neumann D, Kinesiology of the Musculoskeletal System, 2nd ed,
Copyright 2010.) Elsevier, Mosby. Copyright 2010.) 1380.e1 | 1,896 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |
9
NOiTCES
HiP
Adduction
Intertransverse
ligament Tensor fasciae latae
25˚ and iliotibial tract
Gluteus medius
Erector spinae
Transversospinalis
Gluteus medius
(posterior fibres)
Piriformis
Obturator internus
Quadratus femoris
Gluteus maximus
Fig. 81.14 Hip adduction shown from a pelvic-on-femoral perspective, as
indicated by the green curved arrow. Note the directional-specific motion
of the lumbar spine; this is a necessity, assuming the trunk remains
upright. Tissues that are elongated or pulled taut are indicated by orange
arrows. In all cases, muscles are assumed to be inactive but stretched. Fig. 81.15 The right lateral rotator muscles of the hip contract to produce
The red circle indicates the axis of rotation at the hip. (With permission lateral rotation of the right hip, from a pelvic-on-femoral perspective.
from Neumann D, Kinesiology of the Musculoskeletal System, 2nd ed, Back extensor muscles are also shown active, rotating the lower trunk
Elsevier, Mosby. Copyright 2010.) to the left. (With permission from Neumann D, Kinesiology of the
Musculoskeletal System, 2nd ed, Elsevier, Mosby. Copyright 2010.)
plane are best described assuming a person is bearing weight firmly on fixed, the femur rotates medially about 35°. The extended hip rotates
one lower limb, referred to hereafter as the ‘support’ hip. Abduction at laterally about 45°. Transverse plane movements of the hip joint from
the support hip occurs by raising the contralateral side of the pelvis a a pelvic-on-femoral perspective, as explained above, are best described
few degrees (Fig. 81.13B). Marked tightness in hip adductor muscles or assuming a person is bearing weight over a given ‘support’ hip. Con-
medial capsule of the hip on the support hip can limit this pelvic sider, for example, running and rapidly changing directions while one
motion. Adduction at the support hip occurs by lowering the contra- lower limb is securely planted on the ground. During lateral rotation
lateral side of the pelvis (Fig. 81.14). Assuming that the trunk remains of the support hip, the iliac crest located contralateral to the support
nearly stationary during these short-arc pelvic-on-femoral motions, the limb rotates posteriorly in the transverse plane, an action driven strongly
lumbar spine laterally bends slightly as a way to offset undesired tho- by gluteus maximus (Fig. 81.15). Conversely, pelvic-on-femoral (hip)
racic motion. The lumbar vertebrae, therefore, act to decouple motion medial rotation occurs as the contralateral iliac crest region rotates
of the pelvis (moving on the femur) from undesired motions between anteriorly.
the thorax and pelvis (Neumann 2010b). This decoupling function of As stated above, the axis of rotation for transverse plane motions at
the lumbar vertebrae is especially useful during walking as a way of the hip joint occurs about a vertical axis of rotation. The slight anterior
partially fixing the spatial orientation of the upper thorax, as well as the bowing for the femoral shaft, coupled with the natural angle between
associated craniocervical region and the embedded senses of vision and the femoral shaft and neck, means that this axis is not intramedullary;
equilibrium. This kinematic linkage between the spine, pelvis and rather it passes just posterior and slightly medial to the shaft. The posi-
femur exists in essentially all hip motions to varying degrees, and is an tion of this ‘mechanical’ (versus medullary) axis becomes biomechani-
essential characteristic of normal walking. cally relevant when considering the actions and moment arms of certain
Medial and lateral rotation of the hip joint occurs in the transverse hip muscles, most notably for adductor muscles that also function as
(horizontal) plane about a vertical axis of rotation. With the pelvis medial rotators.
1380.e2 | 1,897 | Gray's Anatomy | temp.pdf | https://archive.org/download/GraysAnatomy41E2015PDF/Grays%20Anatomy-41%20E%20%282015%29%20%5BPDF%5D.pdf | PDFPlumberTextLoader |