Gluteal region Extends from the iliac crest above to the gluteal fold below. The superficial fascia...

Gluteal region Extends from the iliac crest above to the

gluteal fold below.

The superficial fascia is thick dense and

fatty, the deep fascia is thick over the

anterior border of gluteus maximus while

elsewhere is thin. It continuous below with

the fascia lata and attached to the iliac

crest above.

Gluteal region

Cutaneous nerves of the gluteal region

• 1- lateral cutaneous branches from subcostal (T12) and

iliohypogastric nerve(L1) supply the upper lateral

quadrant of the buttock.

• 2-The lower lateral quadrant is supplied by the lateral

cutaneous nerve of the thigh(L2,L3).

• 3- The lower medial quadrant supplied by the posterior

cutaneous nerve of the thigh which curve over the lower

border of gluteus maximus (inferior cluneal nerve).

• 4- The upper medial quadrant supplied by the lateral

cutaneous branches from dorsal rami L1-L3 (superior

cluneal nerves) and the lateral cutaneous branches of

the dorsal rami of S1-S3 (middle cluneal nerves)

• The perforating cutaneous nerve (S2,3) of the sacral

plexus, pierces the sacrotuberous ligament and gluteus

maximus mid way between coccyx and ischial tuberosity.

Cutaneous nerves of the gluteal region

• Sacrotuberous ligament:

• It is a strong band passes upwards from the

medial side of the ischial tuberosity to the margins

of the sacrum and coccyx and to both posterior

iliac spines. The lateral edge of the ligament forms

the posteromedial border of the greater and lesser

sciatic notches.

Sacrotuberous ligament

• Sacrospinous ligament:

• This is a thick triangular band it passes

from the the ischial spine to the margin of

coccyx and last piece of the sacrum deep

to the sacrotuberous ligament.

Sacrospinous ligament

• Sciatic foramina

• The greater sciatic foramen: bounded by the

greater sciatic notch of the hip bone the

sacrotuberous ligament and the sacrospinous

ligament, it transmit structures from the pelvis to

the gluteal region.

• The lesser sciatic foramen: bounded by

the lesser sciatic notch and the

sacrospinous and sacrotuberous

ligaments, it transmits structures between

the gluteal region and the perineum.

Structures which enter the gluteal region from the pelvis

• 1- Remain in the gluteal region these include;

the gluteal vessels and nerves and the piriformis

muscle.

• 2- Descend from the gluteal region into the back

of the thigh include; the sciatic nerve, the

posterior cutanous of the thigh and branches of

the inferior gluteal vessels.

• 3- Turn forwards through the lesser sciatic

foramen into the perineum include; the

internal pudendal vessels, pudendal nerve

and nerve to obturator internus muscle.

Muscles of the gluteal region

• The large muscles include: Gluteus maximus, medius and minimus.

• The small muscles include: piriformis, obturator internus, superior and inferior gemelli and quadratus femoris.

Large muscles of the gluteal region

Small muscles of gluteal region

Piriformis muscle• it is a land mark muscle in the gluteal region. It is

conical muscle arise in the pelvis from the pelvic

surface of the middle three pieces of the sacrum, It

passes through the greater sciatic foramen to be

inserted in the upper border of the greater trochanter

of the femur.

• Nerve supply from the first and second sacral

nerves.

Gluteal vessels

• Include • Inferior gluteal artery • Superior gluteal artery

Inferior gluteal artery:

it is a branch of the internal iliac artery emerges

from the pelvis below piriformis muscle

accompany the inferior gluteal nerve supply the

gluteus maximus and gives cutaneous branches

to the buttock and the back of the thigh, it also

give a slender companion artery to the sciatic

nerve.

Superior gluteal artery arise from the internal iliac artery accompany the

superior gluteal nerve, it enters the gluteal region

above the piriformis muscle. It divided into

• Superficial branch passes between the gluteus

medius and piriformis.

• Deep branch follow the superior gluteal nerve

supply the gluteus medius, minimus and the hip

joint.

Inferior and superior gluteal artery

Nerves of the gluteal region

• Inferior gluteal nerve (L5 S1 S2): it is a branch

from the sacral plexus enter the gluteal region

with the posterior cutanous nerve of the thigh

inferior to the piriformis m. supply gluteus

maximus m.

• Superior gluteal nerve (L4 L5 S1): it is a

branch from the sacral plexus enters the

gluteal region above the piriformis m.

divided into numbers of branches supply

the glueus medius , minimus and tensor

fasciae lata m.

Sciatic nerve (L4 L5 S1 S2 S3)• it is the thickest nerve in the body arise from the sacral

plexus, pass inferior to the piriformis m through the

greater sciatic foramen, deep to the gluteus maximus m.

in the upper part of its course it descends over:

• 1- ischial wall of the acetabulum.

• 2- Obturator internus m. and the 2 gemelli ms.

• 3- Quadratus femoris m.

• It leaves the buttock by passing deep to the long

head of the biceps femoris, it supply the

hamstring ms and gives articular branch to the

hip joint. the sciatic nerve then descends on the

posterior surface of the adductor magnus m. at

the lower third of the thigh it divided into medial

branch (tibial nerve) and lateral branch (common

peroneal nerve).

Sciatic nerve

Anastomosis between branches from the internal and external iliac arteries

• 1- between medial circumflex femoral artery

and:

• a- obturator artery.

• b- Both gluteal arteries.

• c- Lateral circumflex artery.

• d- perforating branches of the profunda artery.

• 2- Between The superior gluteal artery and

• a- lateral circumflex artery.

• b- Superficial circumflex iliac artery.

• 3- between internal pudendal artery, deep

and superficial external pudendal arteries of

the femoral artery.

The back of the thigh(the posterior compartment)

• The muscles of the back of the thigh are the

hamstring muscles which are extensors of the

hip joint and flexors of the knee joint, all arise

from the ischial tuberosity except the short head

of the biceps m. and all are inserted in the bones

of the leg.

• These muscles include: biceps femoris,

semitendinosus and semimembranosus.

All supplied by the sciatic nerve.

• Cutaneous supply of the back of the thigh is the

posterior cutanous nerve of the thigh. which is a

branch of the sacral plexus enters the thigh inferior to the

piriformis muscle through the greater sciatic foramen. it

descend through the posterior midline of the thigh giving

small branches from both sides to the skin of the back of

the thigh and the popliteal fossa, it pierce the fascia lata

and ends as a cutaneous branches over the calf.

• The blood supply of the posterior compartment are the

perforating branches from the profunda femoris artery.

Posterior cutaneous nerve of the thigh

The popliteal fossa

• It lies behind the knee, the lower 1/3 of the

femur and the upper part of the tibia. It is

diamond in shape.

• The superficial fascia of the fossa contain

little fat, while the deep fascia is thin, strong

and firmly attached to the tendons.

Boundaries• Upper lateral --------- biceps femoris m.

• Upper medial--------- semimembranosus and semitendinosus

ms.

• Lower lateral and medial--------- the 2 heads of the

gastrocnemius m.

• The anterior wall is the popliteal surface of the femur, the

posterior capsule of the knee joint and the fascia of the

popliteus m.

• The posterior wall is the deep fascia of the fossa.

The popliteal fossa

Contents of the fossa

• These include:• 1- The popliteal vessels.• 2- Branches of the sciatic nerve, the tibial

and common peroneal nerves.• 3- Popliteal lymph nodes.• 4- Posterior cutaneous nerve of the thigh.

Contents of the fossa

The popliteal vesselsThese are the direct continuation of the femoral vessels enter the fossa through the adductor hiatus. They lie anterior to the tibial nerve, the common peroneal nerve pass laterally accompany the tendons of the biceps muscle. The popliteal artery ends at the lower border of the popliteus muscle by dividing into anterior and posterior tibial arteries. it lies aganist the posterior part of the capsule of the knee joint, then it lies posterior to popliteus muscle in the upper part of the leg.

• The popliteal artery: begin at the adductor hiatus and ends at the lower border of the popliteus m. where it divided into anterior and posterior tibial arteries. The popliteal artery is anterior to the semimembranosus m. Popliteal vein, tibial nerve, the heads of the gastrocnemius and plantaris ms.

The popliteal artery

• Branches: • 1- muscular branches to the hamstring ms. And

to the muscles of the calf.• 2- Articular branches these are the lateral and

medial superior and inferior genicular and middle genicular arteries to the knee joint correspond to the genicular branches from the tibial and common peroneal nerves. they anastomosed with the branches from the lateral circumflex femoral, descending genicular arteries, and the recurrent branches of the anterior tibial artery

The popliteal vein

• formed by the union of the anterior tibial, the posterior tibial and the peroneal veins at the lower border of the popliteus muscle, it lies superficial to the artery and between it and the tibial nerve. it receive tributaries correspond to the branches of the popliteal artery and the lesser saphenous vein. it become the femoral vein at the adductor hiatus.

• Tibial nerve (L4 L5 S1 S2 S3).• It is the largest of the two terminal branches of

the sciatic nerve, it begins above the popliteal fossa descends vertically in the fossa, Lying first on the lateral side of the popliteal artery then posterior to it and finally medial to it then it pass between the two heads of the gastrocnemius muscle and under the soleus muscle. It supply the muscles of the back of the thigh and leg, the sole of the foot, the skin of the lateral and lower half of the back of the leg and sole of the foot.

Tibial nerve

• Branches in the popliteal fossa:• 1- sural nerve: it is a cutaneous branch descend in the

groove between the two heads of the gastrocnemius m. it pierce the deep fascia about the middle of the back of the leg join the peroneal communicating branch from the peroneal nerve, supply the skin of the lower posterior part of the leg and the skin of the lateral side of the dorsum of the foot. It accompany the small saphenous vein.

• 2- Muscular branches to the gastrocnemius, plantaris, soleus and popliteus ms.

• 3- Articular branches, it gives superomedial, inferomedial and middle genicular branches to the knee joint, accompanied the corresponding branches from the popliteal artery

• Common peroneal nerve (L4 L5 S1 S2)• It is smaller than tibial nerve runs follow

the tendon of biceps femoris m. along the upper lateral border of the popliteal fossa to the back of the head of the fibula, then curves forwards along the neck of the fibula deep to the peroneus longus m. here it divides into deep and superficial branches.

• Branches in the popliteal fossa:• 1- cutaneous branches, these include the

peroneal communicating branch which arise in the upper part of the popliteal fossa descend on the posterolateral side of the calf to join the sural nerve about the middle of the back of the leg, it supply the proximal 2/3 of the posterolateral part of the leg.

• Lateral cutaneous nerve of the calf arise on the lateral head of the gastrocnemius m. supply the lateral side of the leg.