Xie-Xie Dr. Xiaoming Zhang, Professor Dr. Ji-cheng Li, and Professor Dr. Lizhong Du

Xie-XieXie-Xie

Dr. Xiaoming Zhang,Dr. Xiaoming Zhang,

Professor Dr. Ji-cheng Li, Professor Dr. Ji-cheng Li,

andand

Professor Dr. Lizhong DuProfessor Dr. Lizhong Du

• Teaching ObjectivesTeaching Objectives

Gluteal RegionGluteal Region

• Discuss the functional and clinical Discuss the functional and clinical importance of the gluteal regionimportance of the gluteal region

• Illustrate the muscles, nerve supply, and Illustrate the muscles, nerve supply, and vasculature of the gluteal region, in the vasculature of the gluteal region, in the context of their clinical importancecontext of their clinical importance

• Functional and clinical importance of the Functional and clinical importance of the gluteal region?gluteal region?

Gluteal RegionGluteal Region

• LocomotionLocomotion

• Site for intramuscular injectionSite for intramuscular injection

• Site for nerve injurySite for nerve injury

• Gateway for neurovascular structures to Gateway for neurovascular structures to the perineumthe perineum

• LocationLocation

• Posterior region of the Posterior region of the os coxae (pelvic bone os coxae (pelvic bone or hip bone)or hip bone)

Overview of the Gluteal RegionOverview of the Gluteal Region

Overview of the Gluteal RegionOverview of the Gluteal Region

• ContentsContents• Gluteal muscles (three)Gluteal muscles (three)• Nerves for the gluteal musclesNerves for the gluteal muscles• Nerves for the lower limb, including the Nerves for the lower limb, including the

sciatic nerve (largest nerve in the body), sciatic nerve (largest nerve in the body), and the perineumand the perineum

• Vessels to the gluteal muscles and Vessels to the gluteal muscles and perineumperineum

• Gluteus maximusGluteus maximus

• Gluteus mediusGluteus medius

• Gluteus minimusGluteus minimus

• PiriformisPiriformis

• Superior gemellusSuperior gemellus

• Obturator internusObturator internus

• Inferior gemellusInferior gemellus

• Quadratus femorisQuadratus femoris

Muscles of the Gluteal RegionMuscles of the Gluteal Region

Gluteus maximus

Gluteus medius

• Deep musclesDeep muscles

• Gluteus minimusGluteus minimus

• PiriformisPiriformis

• Superior gemellusSuperior gemellus

• Obturator internusObturator internus

• Inferior gemellusInferior gemellus

• Quadratus femoris Quadratus femoris 

Muscles of the Gluteal RegionMuscles of the Gluteal Region

1. Gluteus maximus 1. Gluteus maximus (cut) (cut)

2. Gluteus medius 2. Gluteus medius (cut)(cut)

3. Gluteus minimus3. Gluteus minimus

Muscles of the Gluteal RegionMuscles of the Gluteal Region

• Deep musclesDeep muscles

4. Piriformis4. Piriformis

5. Superior 5. Superior gemellusgemellus

6. Obturator 6. Obturator internusinternus

7. Inferior 7. Inferior gemellusgemellus

8. Quadratus 8. Quadratus femoris femoris 

Muscles of the Gluteal RegionMuscles of the Gluteal Region

Muscle Muscle Proximal Proximal attachmentattachment

DistalDistal

attachmentattachment

ActionAction InnervationInnervation

Gluteus maximus Gluteus maximus Ilium behind the Ilium behind the posterior gluteal posterior gluteal line, sacrum, line, sacrum, coccyx, and coccyx, and sacrotuberous sacrotuberous ligament ligament

Iliotibial tract and Iliotibial tract and gluteal tuberosity gluteal tuberosity of the femur of the femur

Powerfully Powerfully extends the flexed extends the flexed femur at the hip femur at the hip joint; laterally joint; laterally stabilizes the hip stabilizes the hip and knee jointsand knee joints

Inferior gluteal n. Inferior gluteal n. [L5,S1,S2] [L5,S1,S2]

Gluteus medius Gluteus medius Ilium between the Ilium between the anterior and anterior and posterior gluteal posterior gluteal lines lines

Greater trochanterGreater trochanter Abduct the femur Abduct the femur at the hip joint; at the hip joint; hold the pelvis hold the pelvis secure over the secure over the stance leg; stance leg; prevent pelvic prevent pelvic drop on the drop on the opposite swing opposite swing side during side during walking; hip walking; hip internal rotation internal rotation

Superior gluteal n. Superior gluteal n. [L4,L5,S1][L4,L5,S1]

Gluteus minimus Gluteus minimus Ilium between the Ilium between the anterior and anterior and inferior gluteal inferior gluteal lines lines

Muscles of the Gluteal RegionMuscles of the Gluteal Region

Muscle Muscle Proximal Proximal attachmentattachment

DistalDistal

attachmentattachment

ActionAction InnervationInnervation

Piriformis Piriformis Anterior surface of Anterior surface of the sacrum the sacrum

Greater trochanterGreater trochanter Laterally rotate the Laterally rotate the hip joint hip joint

N. to piriformisN. to piriformis

[S1,S2] [S1,S2]

Superior gemellus Superior gemellus Ischial spine Ischial spine Superior gluteal n. Superior gluteal n. [L4,L5,S1] [L4,L5,S1]

Obturator internusObturator internus Deep surface of Deep surface of the obturator the obturator membrane and membrane and surrounding bonesurrounding bone

Nerve to the Nerve to the obturator internus obturator internus and sup. gemellus and sup. gemellus [L5,S1,S2][L5,S1,S2]

Inferior gemellusInferior gemellus Ischial tuberosityIschial tuberosity Nerve to the inf. Nerve to the inf. gemellus and gemellus and quadratus femoris quadratus femoris [L4,L5,S1][L4,L5,S1]

Quadratus femorisQuadratus femoris Lateral aspect of Lateral aspect of the ischium, just the ischium, just anterior to the anterior to the ischial tuberosityischial tuberosity

Intertrochanteric Intertrochanteric crestcrest

Nerve to the inf. Nerve to the inf. gemellus and gemellus and quadratus femoris quadratus femoris [L4,L5,S1][L4,L5,S1]

Muscles of the Gluteal RegionMuscles of the Gluteal Region

• Functional and clinical importance of the Functional and clinical importance of the gluteal regiongluteal region

Gluteal RegionGluteal Region

• LocomotionLocomotion

• Site for intramuscular injectionSite for intramuscular injection

Gluteal RegionGluteal Region- Locomotion -- Locomotion -

• Gluteus medius and Gluteus medius and minimus are key musclesminimus are key muscles

• Hold the pelvis secure Hold the pelvis secure over the stance legover the stance leg

• Prevent pelvic drop on Prevent pelvic drop on the opposite swing-side the opposite swing-side during walkingduring walking

Gluteal RegionGluteal Region- Site of Intramuscular Injection -- Site of Intramuscular Injection -

Safe area for injectionsSafe area for injections

Gluteal RegionGluteal Region- Site of Intramuscular Injection -- Site of Intramuscular Injection -

Tubercle of the iliac crest

Anterior superior iliac spine

Safe area (Gluteus medius)

Location of the sciatic nerve

Gluteal RegionGluteal Region

• Sciatic nerveSciatic nerve

• Largest nerve in the bodyLargest nerve in the body

• Located deep to the Located deep to the gluteus maximus and gluteus maximus and piriformis* musclespiriformis* muscles

* >87% of cadavers* >87% of cadavers

• Spinal segments L4-S3Spinal segments L4-S3

Sciatic NerveSciatic Nerve

Sciatic NerveSciatic Nerve

Superior Gluteal NerveSuperior Gluteal Nerve

• Functional and clinical importance of the Functional and clinical importance of the gluteal regiongluteal region

Gluteal RegionGluteal Region

• LocomotionLocomotion

• Site for intramuscular injectionSite for intramuscular injection

• Site for nerve injurySite for nerve injury

Gluteal RegionGluteal Region- Injury -- Injury -

• Injury to the Injury to the superior gluteal superior gluteal nervenerve• Gluteus Gluteus

medius limp medius limp and gluteal and gluteal gategate

• Superior gluteal a and vSuperior gluteal a and v• Inferior gluteal a and vInferior gluteal a and v

Gluteal VesselsGluteal Vessels

• Internal pudendal a and vInternal pudendal a and v

Gluteal VesselsGluteal Vessels

Internal pudendal a

PerineumPerineum- Today’s Word & Intellectual Challenge -- Today’s Word & Intellectual Challenge -

• The region that closes the pelvic outletThe region that closes the pelvic outlet

• Divided into two spaces (triangles)Divided into two spaces (triangles)• Ischioanal (Anal) triangleIschioanal (Anal) triangle• Urogenital (UG) triangleUrogenital (UG) triangle

• Means “modest or private”Means “modest or private”

• Relevant to the gluteal regionRelevant to the gluteal region• Thoroughfare for the internal pudendal Thoroughfare for the internal pudendal

a and v, and pudendal na and v, and pudendal n

Abdominopelvic RegionAbdominopelvic Region

PerineumPerineum

Perineum – 2 TrianglesPerineum – 2 Triangles

Sacrotuberous ligament

CoccyxCoccyx Gluteus max m.Gluteus max m.

Ext. anal sphincter m.Ext. anal sphincter m.

Levator ani m.Levator ani m.

Sacrotuberous lig.Sacrotuberous lig.

Ischial tuberosityIschial tuberosity

ScrotumScrotum

Int. pudendal a.Int. pudendal a.Pudendal n.Pudendal n.

Park City, Utah, USAPark City, Utah, USA

Jeremy Ranch (my home’s backyard)Jeremy Ranch (my home’s backyard)

Wild Wild moosemoose

Thank you!Thank you!