Gluteal region and thigh

Dr Yasrul Izad Abu Bakar

Faculty of Medicine, UniSZA

Strictly for educational

purposes only
 Learning outcome
1. List the muscles in gluteal region and thigh.

2. State their nerve supply and main actions.

3. Describe the distribution and branches of the major

vessels of gluteal region and thigh.

4. Describe the distribution and branches of the nerves of

gluteal region and thigh.

5. Discuss the clinical aspects.

6. Describe the boundaries & contents of Femoral triangle &

Adductor canal
Gluteal region
 Gluteal
• Gluteal is
posterolateral
region between the
iliac crest and the
gluteal fold

Iliac crest

Gluteal fold
Hip bone – revision
PSIS Iliac crest

Ilium

ASIS

AIIS

Pubis
Ischium

Ischial Pubic Obturator

tuberosity symphysis foramen
 Revision – Hip bone
Iliac crest

ASIS ASIS

PSIS
AIIS
PIIS
Greater sciatic Acetabulum
ischial
notch
spine
Lesser sciatic
notch
Obturator
foramen Ischial
tuberosity

Medial view Lateral view

 Revision – Hip bone

Sacrospinous
Greater sciatic ligament
foramen
Sacrotuberous
Lesser sciatic ligament
foramen

Pectineal line
 Gluteal muscles
• The muscles of
gluteal region are
organized into two
groups

1. Superficial group
(larger muscles)

2. Deep group
(small muscles)
 Superficial group of gluteal muscles
Action:
• Mainly extend & abduct
the hip joint

• Include:
1. Gluteus maximus
2. Gluteus medius
3. Gluteus minimus
4. Tensor of fasciae latae
(also extend knee)
 Gluteus maximus
Gluteus maximus
• Largest gluteal muscle
• Quadrangular in shape

• Origin: ilium, sacrum, coccyx

• Insertion: iliotibial tract
(tendinous thickening of fascia lata)

Innervation:
• Inferior gluteal nerve

Action:
• Extends hip joint
• Also stabilizes knee & hip
joints
Iliotibial tract
 Gluteus Medius & Gluteus
medius
Minimus
• Fan-shaped muscle beneath the Gluteus maximus
gluteus maximus

• Origin: Ilium Gluteus

minimus
• Insertion: greater trochanter

Innervation:
• Superior gluteal nerve

Action:
• Abduct hip joint

(*Clinical importance: reduce pelvic

drop during walking)
Gluteus Gluteus
medius minimus
 Tensor Of Fasciae Latae
• The most anterior of
superficial group

• Origin: Ilium Tensor

• Insertion: iliotibial tract of
fasciae
latae
Innervation:
• Superior gluteal nerve

Action:
• Abducts hip joint
• Stabilizes knee in extension
 Deep group of gluteal muscles
Mainly lateral rotators of the thigh at hip
joint (all inserted at greater trochanter of femur)
Also abduct thigh (except quadratus femoris)
They also stabilize the hip joint by fixed the
femoral head in the acetabulum.

Include:
1. Piriformis
2. Obturator internus
3. Superior gemelli
4. Inferior gemelli
5. Quadratus femoris
 Piriformis Gluteus medius

• Most superior deep group of

muscles (lies below & parallel the gluteus
medius)

Piriformis
• Origin: 2-4th sacrum
• Insertion: greater trochanter

Innervation:
• Nerve to piriformis

Action:
• Lateral rotators of thigh
• Abducts thigh at hip joint

*Important landmark because it

divides the greater sciatic foramen
 Gemellus superior (GS) &
Obturator internus (OI)
Gemellus
Origin: superior
• Ischial spine (GS)
• Obturator membrane (OI)
Insertion: greater trochanter Obturator
internus
Innervation: Nerve to obturator internus

Action:
• Lateral rotators of thigh
• Abduct thigh at hip joint

* Gemelli = twins
 Gemellus inferior (GI) & quadratus
femoris (QF)
• Triangular shaped (GI)
• Quadrilateral shaped, most inferior of
deep group muscles (QF)

• Origin: ischial tuberosity

• Insertion: greater trochanter
Gemellus Quadratus
inferior femoris
Innervation:
• Nerve to quadratus femoris

Action:
• Lateral rotators of thigh
• Abducts thigh at hip joint (only GI)
 Greater
trochanter
Muscles of Gluteal region - summary

Gluteus
Gluteus medius
maximus
Gluteus
minimus

SG
OI
IG

QF
 Muscles of gluteal region
Muscles of the gluteal
region of mainly:

1. Extensors (E)
Superficial
group
2. Abductors (A)
Deep
3. Rotators (R) group

of the hip joint

 Gluteal muscles: summary
Muscle Nerve Main Action
Gluteus maximus Inferior gluteal Extensor hip joint
(L5, S1, S2)

Gluteus medius
Gluteus minimus Superior gluteal Abductor hip joint
Tensor fascia lata (L4, L5, S1)

Piriformis Nerve to piriformis

Superior gemellus Nerve to Lateral
Obturator internus obturator internus rotators
of thigh
Inferior gemellus Nerve to
Quadratus femoris quadratus femoris
 Gluteal region – arteries
• 2 arteries enter the
gluteal region from the
pelvic cavity through the
greater sciatic foramen Superior gluteal a.

1. Superior gluteal artery

2. Inferior gluteal artery

Inferior gluteal a.
 Gluteal arteries
1. Superior gluteal artery:
From ant. trunk of internal
iliac artery

2. Inferior gluteal artery:

From post. trunk of internal
iliac artery

• They supply structures in

the gluteal region and
posterior thigh

• Have important collateral

anastomoses* with
branches of the femoral
artery
 Nerve of gluteal region
• Nerves enter gluteal region:

1) Superior gluteal nerve

2) Inferior gluteal nerve
3) Nerve to obturator internus
4) Nerve to quadratus femoris
5) Nerve to piriformis
6) Sciatic nerve
7) Posterior cutaneous nerve of
thigh
8) Pudendal nerve All nerves are branches of the sacral
plexus and enter the gluteal through the
greater sciatic foramen
 *Sacral Plexus
• Formed by L4, L5 and S1, S2, S3 nerves

• Supply:
1) the gluteal region
 Superior gluteal nerves
 Inferior gluteal nerves
 Nerve to obturator internus
 Nerve to quadratus femoris
 Nerve to piriformis

2) the perineum
 pudendal nerve

3) the thigh
 sciatic nerve
 Posterior cutaneous nerve of thigh
*Sacral plexus
 Piriformis: important landmark
• Piriformis is important landmark for nerves Superior gluteal
nerve
and blood vessels leaving pelvis through
greater sciatic foramen

Above piriformis:
– Superior gluteal vessels and nerve

Below piriformis:
– Inferior gluteal vessels and nerve
– Sciatic nerve
– Posterior cutaneous nerve of thigh
Inferior gluteal
– Nerve to quadratus femoris nerve
– Nerve to obturator internus
– Pudendal nerve
 Nerves Of Gluteal Region
superior gluteal nerve
inferior gluteal nerve

nerve to obturator internus

pudendal nerve

sciatic nerve
posterior cutaneous
nerve of thigh
 Clinical importance:
Trendelenburg Test
Positive Trendelenburg test:
Indicate injury to superior
gluteal nerve

A. The pelvis during normal

gait.

B. A positive Trendelenburg
test

• Also positive in fracture of

greater trochanter & hip
dislocation
 Clinical importance:
Gluteal Intramuscular injection
The safe area for
intragluteal injections
is_________________.

a) Upper medial quadrant

b) Upper lateral quadrant
c) Lower medial quadrant
d) Lower lateral quadrant
 Clinical importance:
Gluteal Intramuscular injection
Intramuscular injection at
gluteal region:

• The safe area for

intragluteal injections is
at the upper lateral
quadrant.
Thigh
 Introduction – thigh
Inguinal
ligament
• Posteriorly: The thigh is
between the gluteal fold
and the knee
Gluteal
fold
• Anteriorly: The thigh is
between the inguinal
ligament and the knee joint
Knee joint
 Greater
trochanter Head
Neck

Lesser
Femur: trochanter

revision

Shaft
(body)
Adductor
tubercle

Lateral Medial
epicondyle epicondyle
Lateral condyle Medial condyle
 Trochanteric
fossa

Medial lip
of linea
aspera
Femur: Lateral lip
of linea
revision aspera

linea
Adductor aspera
tubercle

Intercondylar fossa
 Muscles Of The Thigh
Separated into 3
compartments:
1. Anterior Medial
intermuscular
septum
2. Medial Fascia lata

3. Posterior Lateral
Anterior
intermuscular
septum
Medial
Organised by:
Posterior
i. Fascia lata (deep fascia that invests
the thigh)
ii. Fascial intermuscular Posterior

septae intermuscular
septum
 Anterior thigh muscles
(flexors of thigh) illiopsoas

• Flexors of the hip

Rectus Sartorius
femoris
• Include:
1. Sartorius Vastus
2. Quadriceps femoris medialis
(Rectus femoris, Vastus
medialis, Vastus intermedius
& Vastus lateralis) Vastus
3. Illiopsoas (iliacus & psoas lateralis
major)
4. Pectineus*
 Anterior view:
superficial
Sartorius dissection

• Origin: ASIS
Sartorius
• Insertion: Head of tibia
(medial)

Innervation: Femoral nerve

Action
• Flexes thigh at hip joint and
flexes the leg at the knee
joint
• Cross legged sitting (Bersila)
 Anterior
view:
Quadriceps femoris superficial
dissection

• Consists of:
1. Rectus femoris
2. Vastus medialis (VM), Vastus Rectus
intermedialis (VI) & Vastus femoris
lateralis (VL)
Vastus
medialis
Origin: (VM)

• lateral lip of linea aspera (VL)

• shaft of femur (VI)
• medial lip of linea aspera (VM) Vastus
• AIIS (Rectus femoris*) lateralis
(VL)

Insertion: tibial tuberosity

 Anterior view:
deeper dissection
Quadriceps femoris
Innervation: Femoral
nerve
Vastus
intermedius
(VI)
Action:
• Flexes the thigh at the
hip joint (*Rectus femoris only)
• Extensor of knee joint
 Iliopsoas Psoas minor

• Iliopsoas is a functional
unit of muscles that
consists of
1. Psoas major and
minor
2. Iliacus

• Chief flexor of the thigh

Psoas major
Psoas minor is absent in almost
Illiacus
40% of subjects
 Iliopsoas
Origin:
• Psoas major- lumbar
vertebrae
• Iliacus - iliac fossa

Insertion:
• lesser trochanter

Innervation: Lumbar plexus

• PM - Anterior rami (L1 - L3)
• Illiacus - Femoral nerve
Psoas major (PM)
Illiacus
Action: Flexor of thigh
 Anterior view:
deeper dissection
Pectineus* Pectineus

• Origin: Pectineal line

• Insertion: medial lip of linea
aspera

Nerve: Femoral nerve

Actions: Flexes and adducts* thigh

at hip joint

*transitional muscle of anterior &

medial compartment
 Medial thigh muscles
(adductors of thigh)
• Its main action is to adduct the thigh at the
hip joint

• Comprise of 5 muscles:
1. gracilis
2. adductor longus
3. adductor brevis
4. adductor magnus
5. obturator externus

• All muscles:
• cross the hip joint
• Origin – pubis (except hamstring part of
adductor magnus & obturator externus)
• *only gracilis reaches beyond the knee
 Anterior view:
deeper dissection
Gracilis
• The most superficial medial thigh
muscles
• Descends vertically in medial side
of thigh

• Origin: pubis
• Insertion: medial tibia
Gracilis

Innervation: Obturator nerve

Actions: Adducts thigh at hip joint

and flexes leg at knee joint
 Adductor longus &
adductor brevis
• Origin: pubis
• Insertion: linea
aspera
Adductor
brevis
Nerve: Obturator Adductor
nerve longus

Action: adduct thigh Anterior view:

deeper dissection
 Adductor longus & adductor brevis
Anterior
view:
deepest
Pectineus
dissection

Adductor Adductor
brevis magnus

Adductor
longus
 Anterior view:
deepest
Adductor magnus dissection

• The largest & deepest medial thigh

muscles
Adductor
part
(adductor
• Triangular in shape magnus)

• Consists of 2 parts:
Hamstring
part
1. Adductor part (adductor
2. Hamstring part magnus)

(the 2 parts differ in their

attachments, nerve supplies & main
actions)
 Anterior view:
Adductor magnus deepest
dissection

1) Adductor part
• Origin: ischiopubic ramus
• Insertion: linea aspera
• Nerve: Obturator nerve Adductor
• Action: adduction & flexes thigh part

2) Hamstring part
• Origin : ischial tuberosity
• Insertion: adductor tubercle of femur Hamstring
• Nerve: tibial part of sciatic nerve part
• Action: adduction & extends thigh
 A circular gap between adductor and hamstring part is
called adductor hiatus Adductor
 Adductor hiatus allows femoral artery/vein to pass between hiatus
thigh and popliteal fossa
 Pectineus
Obturator externus
iliopsoas
Obturator
• Flat, fan-shaped externus
• Deeply placed in superior part of
thigh

• Origin: obturator membrane Anterior

• Insertion: trochanteric fossa of view:
femur deepest
dissection

Nerve: Obturator nerve

Action: laterally rotates thigh

(collectively adducts thigh with other medial thigh
muscles)
 Posterior view:
superficial dissection
Posterior thigh muscles
• Include of 3 long muscles:
1. Biceps femoris
Semitendinosus
2. Semitendinosus
3. Semimembranosus Semimembranosus

• Semimembranosus, semitendinosus &

biceps femoris (long head) are
collectively called ‘Hamstring muscle’ Biceps
femoris

The word ham originally referred to the fat and muscle

behind the knee. String refers to tendons, and thus, the
hamstrings are the string-like tendons felt on either side of
the back of the knee
 Semitendinosus Posterior view:
superficial dissection
Hamstrings Biceps
femoris

Shares common features

(tie):

• Innervation: tibial
division of sciatic nerve

• Origin – ischial
Semimembranosus
tuberosity

• Action as a group:
extend thigh & flex leg
(2 joints involved)
Posterior view: deep
dissection
 Posterior view:
Posterior thigh muscles superficial dissection

Muscle Origin Insertion

Semi Ischial Tibia Biceps
membranosus tuberosity (medial) femoris
(long head)
Semitendinosus
Semi Ischial Tibia
tendinosus tuberosity (medial)

long head: Semimembranosus

Ischial
Biceps tuberosity Fibula
femoris Biceps
(lateral head) femoris
*short head: (short
head)
Linea aspera
 Posterior view: deepest
Posterior thigh muscles dissection

Muscle Nerve Action

Semi
membranosus Tibial Extend
division of thigh & flex Semitendinous
Semi Biceps
sciatic nerve leg femoris
tendinosus (short
head)
Biceps femoris *Biceps
long head femoris
also
laterally
Biceps femoris Common rotates
*Short head fibular leg in
Biceps
division of knee femoris
sciatic nerve flexed Semimembranous (long
position head)
Thigh: Innervation & blood supply

• Each compartment of thigh has its own

muscles, nerve & arteries
 Innervation of thigh muscles
In general:

• the anterior Compartment Nerve

compartment is
innervated by the femoral
nerve Anterior Femoral
(L2 – L4)
• the medial compartment Medial Obturator
by the obturator nerve (L2 – L4)
Posterior Tibial part of
• the posterior sciatic
compartment by the tibial
part of the sciatic nerve. (L4 –S3)
 Femoral nerve
Course:
• Originates from lumbar plexus (L2 – L4)
Femoral
nerve
• Enters the femoral triangle by passing
under the inguinal ligament

• Supplies iliacus & pectineus

• Divides into branches:

1. Numerous motor nerves (ant. thigh
muscles)
2. Anterior cutaneous branches (skin on
ant. thigh & knee)
3. Saphenous nerve (skin on medial knee,
leg & foot)
 Obturator nerve
Course:
• Originates from lumbar plexus (L2-L4)

• Descends in the middle part of psoas Obturator

muscle and then enter the pelvis nerve

• Passing through the obturator canal to

enter the medial compartment of
thigh

• Supplies medial thigh muscles & medial

thigh skin
 Sciatic nerve
• It is the thickest nerve in the
body

• Originates from lumbosacral

plexus (L4 - S3)

• It leaves the pelvis via the

greater sciatic foramen below
piriformis muscle (but did not
supplies the gluteal)

• Then enters & supplies the

posterior thigh muscles

• Divides at superior border of

popliteal fossa into
1. Tibial nerve Common
Tibial fibular
2. Common fibular nerve division
division
 *Lumbar & sacral plexus

L1
Iliohypogastric n.

Ilioinguinal n. L2

Genitofemoral n.
L3
Lateral cutaneous
nerve of thigh
L4

Femoral L5
nerve

Obturator nerve Sacral plexus

Lumbosacral
trunk
 Lumbar Plexus: Branches & relation to psoas
major
In relation to psoas major:

Between psoas major and iliacus

Femoral nerve (L2 - L4)

Medial to psoas major: IH

II
1. Obturator nerve (L2 - L4)
2. Lumbosacral trunk (L4, L5) GF
GF
LCNOT
ObN
FN
Anterior: LST
Genitofemoral nerve (L1, 2) ObN
Lateral:
1. Iliohypogastric nerve (L1)
2. Ilioinguinal nerve (L1)
3. Lateral cutaneous nerve of thigh (L2,L3)
 Thigh: arteries
• 3 arteries enter the
thigh: Femoral
artery
1. Femoral artery (chief
artery to lower limb)

2. Obturator artery

3. Inferior gluteal artery

 External

1. Femoral artery iliac

artery

Course:
Femoral
• Continuation of external iliac artery
artery

• Passes under inguinal ligament to

enter femoral triangle* (relatively
superficial & useful for clinical procedures e.g.
cardiac angiography) Adductor
hiatus

• Enters adductor canal* at the apex

of femoral triangle

• Change its name to popliteal artery

once passed through adductor Clinical importance: Femoral artery
hiatus is palpable just inferior to the
midpoint of inguinal ligament
 1. Femoral artery Deep
femoral a.

• Branches: Lateral
1. Deep artery of thigh circumflex
femoral a.
(profunda femoris artery) – largest Medial
circumflex
branch & chief artery of thigh femoral a.
Perforating
arteries
femoral a.
2. Medial circumflex
femoral artery

3. Lateral circumflex
femoral artery
 2. Obturator artery
Course:
• Branch of the internal iliac
artery in the pelvic cavity

• Enters the medial

compartment of thigh
through the obturator canal

• Supply adjacent muscles

and anastomose with the
inferior gluteal and medial
circumflex femoral arteries
 Collateral anastomosis
• Inferior gluteal artery/obturator artery - Internal
iliac artery
• Medial circumflex artery
External
• Lateral circumflex artery
iliac artery
• Perforating artery

When external iliac artery or femoral artery are

obstructed, this anastomosis supplies blood to
lower limb
 Venous drainage of thigh
• The lower limb has superficial and deep veins

1. the superficial veins are in the

subcutaneous tissue

2. the deep veins are deep to fascia lata and

accompany the arteries (similar names)

• Both veins are interconnected

• Valves are more numerous in deep veins
 Superficial veins in thigh
Superficial veins of lower limb:

1. Great saphenous vein (largest)

2. Small saphenous vein

 Great saphenous veins
• The great saphenous vein is
formed by venous arch on Saphenous
dorsal foot opening

• Ascends along medial side of

LL to the proximal thigh
Great

• Empties into the femoral vein saphenous

vein
through the saphenous
opening.

Saphenous opening:
- a gap in fascia lata, 4 cm inferolateral to pubic tubercle
Small saphenous vein
• The small saphenous vein
arises on the lateral side of
the foot Small
saphenous
vein

• Empties into popliteal vein

Clinical Importance
• The femoral triangle is a
subfascial space in the
anterosuperior third of
the thigh

• It appears as a triangular
depression inferior to the
inguinal ligament when
the thigh is flexed,
abducted & laterally
rotated
The femoral triangle is bounded

1. Superiorly by inguinal ligament

(which forms the base of the
femoral triangle)

2. Medially by the adductor longus

muscle

3. Laterally by the sartorius

The apex is where the medial

border of the sartorius crosses the
lateral border of the adductor
longus
• From lateral to medial
1. Femoral nerve & its branches
2. Femoral sheath
Femoral sheath
3. Femoral artery & its branches
4. Femoral vein & its proximal Femoral nerve
tributaries (e.g., the great saphenous Femoral artery
vein) Femoral vein
5. Deep inguinal lymph Deep inguinal lymph nodes
nodes (Cloquet node)

*femoral vessels are vulnerable

to traumatic injury in anterior
thigh wound (due to its relative
superficial position)
• The adductor canal
(subsartorial canal) is a
intermuscular tunnel
occupying the distal 2/3
of the medial aspect of
the thigh

• It starts at the apex of

the femoral triangle
• Boundaries:

o anteriorly and laterally

AL
by the vastus medialis

o posteriorly by the
adductor longus and
adductor magnus VM

o medially by the
sartorius, which
forming roof of the
canal
Provides an intermuscular
passage for

1. the femoral artery and

vein (with branches &
tributaries)
Femoral
vessels
2. the saphenous nerve
Saphenous
nerve
into the popliteal fossa via
the adductor hiatus
 Self study
What is?

• Piriformis syndrome
• Sciatica
• Compartment syndrome
• Drainage of Cloquet nodes
• Differential diagnosis for femoral triangle
swelling
 References
• Clinically Oriented Anatomy. 6th edition. 2010.
Keith L. Moore & Arthur F. Dalley. Lippincott
Williams & Wilkins.

• Gray’s anatomy for students. 2nd edition. 2010.

Richard L. Drake, A. Wayne Vogl & Adam W. M.
Mitchell. Churchill Livingstone Elsevier.

• Atlas of Human Anatomy. 5th edition. 2010. Frank

H. Netter. Saunders Elsevier.

78
 Thank you

yasrulizadh@unisza.edu.my
Ext: 5557