KIN 191AAdvanced Assessment of Lower Extremity Injuries

THE PELVIS AND THIGH

ANATOMY

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INTRODUCTIONINTRODUCTION

BONY ANATOMYBONY ANATOMY ARTICULATIONS AND LIGAMENTOUS ARTICULATIONS AND LIGAMENTOUS

ANATOMYANATOMY MUSCULAR ANATOMYMUSCULAR ANATOMY BURSAESBURSAES VASCULAR/NEURO ANATOMYVASCULAR/NEURO ANATOMY

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BONY ANATOMYBONY ANATOMY Anterior & lateral portion of the pelvic Anterior & lateral portion of the pelvic

formed by two innominate bonesformed by two innominate bones Each consisting ofEach consisting of

• IliumIlium• IschiumIschium• PubisPubis

Posterior junction of the pelvis girdle is Posterior junction of the pelvis girdle is formed by the sacrumformed by the sacrum Fixates the spinal column to the pelvisFixates the spinal column to the pelvis Sacrum (4~5 fused segments)Sacrum (4~5 fused segments)

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Pubis

Ischium

Ilium

Articular Surface

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ASIS

AIISPIIS

PSIS

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Iliac Crest Iliac Tuberosity

77Ischial Tuberosity

Ischial Spine

Ramos of Ischium

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S. Ramos of Pubis

Ischium

Ilium

Pubic Tubercle

I. Ramos of Pubis

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AcetabulumAcetabulum Downwardly and outwardly directed Downwardly and outwardly directed

depressiondepression Accepts the femoral head within its fossaAccepts the femoral head within its fossa

Superior wall (ilium)Superior wall (ilium) Inferior wall (ischium)Inferior wall (ischium) Internal, medial wall (pubis)Internal, medial wall (pubis)

Lateral Aspect of the PelvicLateral Aspect of the Pelvic

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Ligamentum teresLigamentum teres• Centered within fossaCentered within fossa

LabrumLabrum• A thick ring of fibrocartilageA thick ring of fibrocartilage• Lines the outer rim of the acetabulum Lines the outer rim of the acetabulum • Deepens the articular areaDeepens the articular area• Thicker and stronger superiorly than inferiorlyThicker and stronger superiorly than inferiorly

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Rim of Acetabulum

Acetabulum NotchAcetabulum Lunate Surface

Acetabulum Fossa

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A 180 degree arc in diameterA 180 degree arc in diameter Thickly covered with hyaline cartilageThickly covered with hyaline cartilage

Except a central depression that accepts the Except a central depression that accepts the ligamentum teresligamentum teres

Connected to the femur’s shaft by the femoral Connected to the femur’s shaft by the femoral neckneck

Frontal plane: angled at approximately 125˚Frontal plane: angled at approximately 125˚ Known as the “angle of inclination”Known as the “angle of inclination” Slightly decreased in womenSlightly decreased in women

Transverse plane: between femoral head and Transverse plane: between femoral head and shaft is the “angle of torsion”shaft is the “angle of torsion” Normally 15˚Normally 15˚

Femoral HeadFemoral Head

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Trochanters are the attachment sites for Trochanters are the attachment sites for many of the pelvic and hip musclesmany of the pelvic and hip muscles

Greater trochanterGreater trochanter Projects laterallyProjects laterally

Lesser trochanterLesser trochanter Projects mediallyProjects medially

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Median Sacral Crest

Cornua

Coccygeal Cornua

Transverse Process

Articular Surface

HiatusI.

L.

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Dorsal Sacrum Foramina Transverse Tubercles

1st Coccygeal Vertebra

Fused 2nd -4th Vertebrae

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ARTICULATIONS AND ARTICULATIONS AND LIAGAMENTOUS ANATOMYLIAGAMENTOUS ANATOMY

Pubic symphysisPubic symphysis Articulates anteriorlyArticulates anteriorly Relatively immobile jointRelatively immobile joint Fibrocartilaginous interpubic diskFibrocartilaginous interpubic disk Subtle distraction, compression, rotation Subtle distraction, compression, rotation

motionmotion

Coxofemoral jointCoxofemoral joint Ball-and-socket jointBall-and-socket joint 3 degrees of freedom3 degrees of freedom

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Sacroiliac (SI) jointSacroiliac (SI) joint Posteriorly, each ilium articulates with the Posteriorly, each ilium articulates with the

sacrumsacrum Very strong joint with limited mobility – Very strong joint with limited mobility –

irregular shapes contribute to stabilityirregular shapes contribute to stability Anterior (ventral) and posterior (dorsal) Anterior (ventral) and posterior (dorsal)

sacroiliac ligamentssacroiliac ligaments Sacrotuberous ligament – sacrum to ischial Sacrotuberous ligament – sacrum to ischial

tuberositytuberosity Sacrospinous ligament – ischial spine to Sacrospinous ligament – ischial spine to

sacrum/coccyxsacrum/coccyx

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Originates from AIISOriginates from AIIS One band inserting on the distal aspect of One band inserting on the distal aspect of

the anterior intertrochanter linethe anterior intertrochanter line Other band inserting on the proximal aspect Other band inserting on the proximal aspect

of the anterior intertrochanter line and the of the anterior intertrochanter line and the femoral neckfemoral neck

Limiting hyperextensionLimiting hyperextension Superior fibers (limits adduction)Superior fibers (limits adduction) Inferior fibers (limits abduction)Inferior fibers (limits abduction)

Iliofemoral Ligament Iliofemoral Ligament (Y ligament of bigelow)(Y ligament of bigelow)

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Iliofemoral Ligament

Ingunial Ligament

Pubofemoral Ligament

Ischiofemoral Ligament

Sacrotuberous Ligament

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Pubofemoral LigamentPubofemoral Ligament

Emerging from the pubic ramusEmerging from the pubic ramus Inserting on the anterior aspect of the Inserting on the anterior aspect of the

intertrochanteric fossaintertrochanteric fossa LimitsLimits

AbductionAbduction hyperextensionhyperextension

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Ischiofemoral LigamentIschiofemoral Ligament

Triangular ligamentTriangular ligament From posterior acetabulum rim with From posterior acetabulum rim with

upwardly spiraling fibers attaching to the upwardly spiraling fibers attaching to the joint capsule and the inner surface of the joint capsule and the inner surface of the greater trochantergreater trochanter

LimitsLimits ExtensionExtension

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Inguinal LigamentInguinal Ligament

Originates from ASISOriginates from ASIS Inserts at the pubic symphysisInserts at the pubic symphysis

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Ligamentum TeresLigamentum Teres

Known as the “ligament of the head of the Known as the “ligament of the head of the femur”femur”

Serves as a conduit for the medial and Serves as a conduit for the medial and lateral circumflex arterieslateral circumflex arteries

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Ischiofemoral L.

Transverse Acetabulum Ligament

Pubofemoral L.

Iliofemoral L.Ligamentum Teres

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MUSCULAR ANATOMYMUSCULAR ANATOMY Anterior MusculatureAnterior Musculature Medial MusculatureMedial Musculature Lateral MusculatureLateral Musculature Posterior musculaturePosterior musculature

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Anterior MusculatureAnterior Musculature QuadricepsQuadriceps

Rectus femorisRectus femoris Vastus medialis, lateralis, intermediusVastus medialis, lateralis, intermedius

SartoriusSartorius IliopsoasIliopsoas

IliacusIliacus Psoas major/minorPsoas major/minor

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Rectus FemorisRectus Femoris

O: O: AIISAIIS I: I: Tibial tuberosity Tibial tuberosity

via infrapatellar via infrapatellar tendontendon

N: N: FemoralFemoral A:A: Knee extension, Knee extension,

hip flexion hip flexion

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Vasti MusclesVasti Muscles O: O: VL – VL – Greater trochanter, Greater trochanter,

lateral lip of linealateral lip of linea aspera aspera

VI – VI – Anterolateral upper 2/3 Anterolateral upper 2/3 of femur, of femur, lateral liplateral lip of of linea aspera linea aspera VM –VM – Distal intertrochanteric Distal intertrochanteric line, medial line, medial lip of lip of linea linea asperaaspera

I: I: Tibial tuberosity via Tibial tuberosity via infrapatellar infrapatellar tendontendon

N: N: FemoralFemoral A: A: Knee extensionKnee extension

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SartoriusSartorius

O: O: ASISASIS I: I: Anteromedial tibial Anteromedial tibial

flare (pes anserine)flare (pes anserine) N: N: FemoralFemoral A:A: Hip flexion,Hip flexion,

Hip abduction,Hip abduction,Hip external rotationHip external rotationKnee flexionKnee flexion

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IliopsoasIliopsoas IliacusIliacus

O: O: IIliacliac fossa/crestfossa/crest I: I: L Lesser trochanteresser trochanter N: L1-L4N: L1-L4 A: Hip flexion, lateral rotationA: Hip flexion, lateral rotation

Psoas major/minorPsoas major/minor O: O: TTransverse processes T12-L5ransverse processes T12-L5/T12-L1/T12-L1 I: I: L Lesser trochanteresser trochanter/Pectineal line of the /Pectineal line of the

pubis pubis N:N: L1-L4L1-L4 A: Hip flexion, lateral rotationA: Hip flexion, lateral rotation Anterior pelvic tilt/Posterior pelvic tiltAnterior pelvic tilt/Posterior pelvic tilt

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Medial MusculatureMedial Musculature

PectineusPectineus Adductor longusAdductor longus GracilisGracilis Adductor Adductor brevis (deep to adductor longus)brevis (deep to adductor longus) Adductor Adductor magnus (deepest)magnus (deepest)

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PectineusPectineus

O: O: SSuperior pubic uperior pubic symphysissymphysis

I: I: PPectineal line of ectineal line of femurfemur

N: N: OObturatorbturator A: A: Hip adduction, flexionHip adduction, flexion

Anterior pelvic tiltAnterior pelvic tilt

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Adductor LongusAdductor Longus

O: O: PPubic symphysisubic symphysis I: I: MMedial 1/3 of linea edial 1/3 of linea

asperaaspera N: N: OObturatorbturator A:A: Hip adduction, flexionHip adduction, flexion

Anterior pelvic tiltAnterior pelvic tilt

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GracilisGracilis

O: O: Anterior body of pubisAnterior body of pubis I: I: Pes anserine tendonPes anserine tendon N: N: OObturatorbturator A: A: Hip adduction, flexionHip adduction, flexion

Knee flexionKnee flexion

Anterior pelvic tiltAnterior pelvic tilt

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Adductor BrevisAdductor Brevis O: O: PPubic ramusubic ramus I: I: Proximal 1/3Proximal 1/3 linea linea

asperaaspera N: N: OObturatorbturator A: A: Hip adduction, flexionHip adduction, flexion

Anterior pelvic tiltAnterior pelvic tilt

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Adductor MagnusAdductor Magnus O: O: IInferior pubic ramus, isnferior pubic ramus, iscchical hical

ramus, ischial tuberosityramus, ischial tuberosity I: I: GGluteal tuberosity to luteal tuberosity to

adductor adductor tubercletubercle N: N: OObturator, tibial and common bturator, tibial and common

peronealperoneal A:A: Hip adduction, extensionHip adduction, extension

Posterior pelvic tiltPosterior pelvic tilt

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Lateral MusculatureLateral Musculature

Tensor fascia lataeTensor fascia latae Gluteus medius/minimusGluteus medius/minimus External rotatorsExternal rotators (superior to inferior) (superior to inferior)

PiriformisPiriformis Superior Superior GemellusGemellus Obturator internusObturator internus Inferior Inferior Gemellus Gemellus Obturator externusObturator externus Quadratus femorisQuadratus femoris

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Tensor Fascia Latae (TFL)Tensor Fascia Latae (TFL)

O: O: SSuperior ilium uperior ilium posterolaterallyposterolaterally

I: I: GGreater trochanterreater trochanter N: N: SSuperior glutealuperior gluteal A: A: Hip flexion, abduction, Hip flexion, abduction,

medial rotationmedial rotation

Anterior pelvic tiltAnterior pelvic tilt

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Gluteus MediusGluteus Medius

O: O: SSuperior ilium uperior ilium posterolaterallyposterolaterally

I: I: GGreater trochanterreater trochanter N: N: SSuperior glutealuperior gluteal A:A: Hip abductionHip abduction

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Gluteus MinimusGluteus Minimus

O: O: LLower portion of ower portion of iliumilium

I: I: GGreater trochanterreater trochanter N: N: SSuperior glutealuperior gluteal A:A: Hip abductionHip abduction

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External Hip RotatorsExternal Hip Rotators

PiriformisPiriformis Superior Superior GemellusGemellus Obturator internusObturator internus Inferior Inferior Gemellus Gemellus Obturator externusObturator externus Quadratus femorisQuadratus femoris

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Posterior MusculaturePosterior Musculature

Gluteus maximusGluteus maximus

HamstringsHamstrings Biceps femorisBiceps femoris SemimembranosusSemimembranosus SemitendinosusSemitendinosus

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Gluteus MaximusGluteus Maximus

O: O: PPosterior ilium,osterior ilium, sacrum and sacrum and coccyxcoccyx

I: I: GGluteal tuberosity of femurluteal tuberosity of femur N: N: IInferior glutealnferior gluteal A:A: Hip extension, lateral Hip extension, lateral

rotationrotation

Hip abduction (upper Hip abduction (upper 1/3)1/3)

Hip addction (lower 2/3)Hip addction (lower 2/3)

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BURSAEBURSAE

Trochanteric bursaTrochanteric bursa Gluteus maximus passes over the greater Gluteus maximus passes over the greater

trochantertrochanter Gluteofemoral bursaGluteofemoral bursa

Separates the gluteus maximus from the Separates the gluteus maximus from the origin of the vastus lateralisorigin of the vastus lateralis

Ischial bursaIschial bursa Serves as a weight bearing structure when Serves as a weight bearing structure when

seated, cushioning the ischial tuberosityseated, cushioning the ischial tuberosity

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VASCULAR/NEUROVASCULAR/NEUROANATOMYANATOMY

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Femoral TriangleFemoral Triangle

BordersBorders Superiorly – inguinal ligamentSuperiorly – inguinal ligament Laterally – sartoriusLaterally – sartorius Medially – adductor longusMedially – adductor longus

ContentsContents NAVEL (lateral to medial)NAVEL (lateral to medial) Femoral Nerve, Artery, Vein, (Femoral Nerve, Artery, Vein, (EEmpty space), mpty space),

LLymphatic channelymphatic channel

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Femoral TriangleFemoral Triangle

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Femoral ArteryFemoral Artery Has deep branch Has deep branch

of the femoral of the femoral arteryartery

Terminates at Terminates at popliteal fossa as popliteal fossa as popliteal arterypopliteal artery

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Dermatomes and MyotomesDermatomes and Myotomes L1L1

Dermatome: Back, greater Dermatome: Back, greater trochanter and grointrochanter and groin

Myotome: hip flexionMyotome: hip flexion L2: L2:

Dermatome: Back, anterior Dermatome: Back, anterior superior thighsuperior thigh

Myotome: hip flexion & Myotome: hip flexion & adduction adduction

L3L3 Dermatome: Anterior medial Dermatome: Anterior medial

thigh,back, upper glutealthigh,back, upper gluteal Myotome: Knee extensionMyotome: Knee extension

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Obturator NerveObturator Nerve

Dermoatome: None (mDermoatome: None (medial thigh)edial thigh) MMyotome:yotome: H Hip adductionip adduction

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Superior/InferiorSuperior/Inferior Gluteal Gluteal NerveNervess

Superior Gluteal NerveSuperior Gluteal Nerve Dermatome: NoneDermatome: None MMyotome:yotome: HHip aip abbductionduction

Inferior Gluteal NerveInferior Gluteal Nerve Dermatome: NoneDermatome: None MMyotome:yotome: H Hip ip extensionextension

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Additional Additional NeuroanatomyNeuroanatomy

Lumbar plexusLumbar plexus Sacral plexusSacral plexus

Nerve roots named for spinal segment Nerve roots named for spinal segment superior to corresponding nerve root levelsuperior to corresponding nerve root level L4 nerve root exits spinal column below 4L4 nerve root exits spinal column below 4 thth

lumbar vertebraelumbar vertebrae

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Lumbar PlexusLumbar Plexus

Primarily arises from L2, L3, L4 nerve Primarily arises from L2, L3, L4 nerve rootsroots

Posterior (dorsal) branches combine to Posterior (dorsal) branches combine to form femoral nerveform femoral nerve Femoral nerve – posterior division of L2-L4Femoral nerve – posterior division of L2-L4

Anterior (ventral) branches combine to Anterior (ventral) branches combine to form obturator nerveform obturator nerve Obturator nerve – anterior division of L2-L4Obturator nerve – anterior division of L2-L4

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Lumbar PlexusLumbar Plexus

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Sacral PlexusSacral Plexus

Primarily arises from anterior branches of Primarily arises from anterior branches of L4 and L5 as well as S1 through S3L4 and L5 as well as S1 through S3

Anterior (ventral) branches of L4-S3 Anterior (ventral) branches of L4-S3 combine to form tibial nervecombine to form tibial nerve Tibial nerve – anterior division of L4-S3Tibial nerve – anterior division of L4-S3

Posterior (dorsal) branches of L4-S2 Posterior (dorsal) branches of L4-S2 combine to form common peroneal nervecombine to form common peroneal nerve Common peroneal nerve – posterior division Common peroneal nerve – posterior division

of L4-S2of L4-S2

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Sacral PlexusSacral Plexus

Posterior (dorsal) branches of L4-S1 Posterior (dorsal) branches of L4-S1 combine to form superior gluteal nervecombine to form superior gluteal nerve Superior gluteal nerve – posterior division of Superior gluteal nerve – posterior division of

L4-S1L4-S1 Posterior (dorsal) branches of L5-S2 Posterior (dorsal) branches of L5-S2

combine to form inferior gluteal nervecombine to form inferior gluteal nerve Inferior gluteal nerve – posterior division ofInferior gluteal nerve – posterior division of

L5-S2L5-S2

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Sacral PlexusSacral Plexus