The Thigh II Dr Fadel Naim Orthopedic Surgeon

The Thigh II Dr. Fadel Naim Orthopedic Surgeon IUG DR FADEL NAIM IUG

CONTENTS OF THE MEDIAL FASCIAL COMPARTMENT OF THE THIGH p Muscles: n n n p • Blood supply: n n p Gracilis Adductor longus Adductor brevis Adductor magnus Obturator externus Profunda femoris artery Obturator artery • Nerve supply: n Obturator nerve DR FADEL NAIM IUG

DR FADEL NAIM IUG

Gracilis p p p Long and strap like Lies on the medial side of the thigh and the knee Origin: n n p Insertion: n n n p The fibers pass downward along the medial side of the thigh Attached to the upper part of the medial surface of the shaft of the tibia Close to that of the sartorius and the semitendinosus muscles. Nerve supply: n p The outer surface of the inferior ramus of the pubis The ramus of the ischium Obturator nerve. • Action: Adducts the thigh at the hip joint DR FADEL NAIM n Flexes the leg at the knee joint IUG n

Adductor Longus p p p Triangular The most anterior of the three adductor muscles Origin: n p Insertion: n n p The muscle fibers diverge as they pass downward and laterally Attached to the linea aspera Nerve supply: n p From the front of the body of the pubis below and medial to the pubic tubercle Obturator nerve. • Action: n n Adducts the thigh at the hip joint Assists in lateral rotation DR FADEL NAIM IUG

Adductor Brevis p p lies posterior to the pectineus and the adductor longus. Origin: n p Insertion: n n p The muscle fibers diverge as they pass downward and laterally attached to the linea aspera Nerve supply: n p From the outer surface of the inferior ramus of the pubis Obturator nerve. Action: n n Adducts the thigh at the hip joint Assists in lateral rotation DR FADEL NAIM IUG

Adductor Magnus p p p A large, triangular muscle Consisting of adductor and hamstring portions Origin: n n p p Insertion: In the adductor portion: n n p p p The fibers that arise from the ischial tuberosity are inserted below on the adductor tubercle on the medial condyle of the femur. Nerve supply: The adductor portion: the obturator nerve The hamstring portion: the sciatic nerve. Action: The adductor portion n n p The muscle fibers diverge as they pass downward and laterally Attached to the posterior surface of the shaft of the femur. In the hamstring portion n p From the outer surface of the inferior ramus of the pubis From the ramus of the ischium and the ischial tuberosity. Adducts the thigh at the hip joint Assists in lateral rotation. The hamstring portion DR FADEL n NAIM Extends IUG the thigh at the hip joint.

Adductor Hiatus A gap is in the attachment of this muscle to the femur p Permits the femoral vessels to pass from the adductor canal downward into the popliteal space p DR FADEL NAIM IUG

Obturator Externus p p A deeply placed, triangular muscle. Origin: n n p • Insertion: n n p The muscle fibers converge as they pass laterally at first below and then behind the hip joint Inserted onto the medial surface of the greater trochanter. • Nerve supply: n p From the outer surface of the obturator membrane The pubic and ischial rami. Obturator nerve. • Action: n Laterally rotates the thigh at the hip joint. DR FADEL NAIM IUG

Muscle Origin Insertion Nerve Supply Nerve Action Roots Gracilis Inferior ramus of pubis, ramus of ischium Upper part of shaft of tibia on medial surface Obturator nerve L 2, 3, 4 L 2, 3, 4 Adducts thigh at hip joint; flexes leg at knee joint Adductor longus Body of pubis, medial to pubic tubercle Posterior surface Obturator of shaft of femur nerve (linea aspera) L 2, 3, 4 L 2, 3, 4 Adducts thigh at hip joint and assists in lateral rotation Adductor brevis Inferior ramus of pubis Posterior surface Obturator of shaft of femur nerve (linea aspera) L 2, 3, 4 L 2, 3, 4 Adducts thigh at hip joint and assists in lateral rotation Adductor magnus Inferior ramus of pubis, ramus of ischium, ischial tuberosity Posterior surface of shaft of femur, adductor tubercle of femur Adductor portion: obturator nerve Hamstring portion: sciatic nerve L 2, 3 & 4 Adducts thigh at hip joint and assists in lateral rotation; hamstring portion extends thigh at hip join Obturator externus Outer surface of obturator membrane and pubic and ischial rami Medial surface of greater trochanter Obturator nerve DR FADEL NAIM IUG L 3, 4 Laterally rotates thigh at hip joint

Blood Supply of the Medial Fascial Compartment of the Thigh p Profunda femoris artery n n n A large artery that arises from the lateral side of the femoral artery in the femoral triangle, about 1. 5 in. (4 cm) below the inguinal ligament It descends in the interval between the adductor longus and adductor brevis and then lies on the adductor magnus Ends as the fourth perforating artery DR FADEL NAIM IUG

Branches Profunda Femoris Artery Medial femoral circumflex artery: n n n This passes backward between the muscles that form the floor of the femoral triangle Gives off muscular branches in the medial fascial compartment of the thigh It takes part in the formation of the cruciate anastomosis. Lateral femoral circumflex artery: n n n This passes laterally between the terminal branches of the femoral nerve It breaks up into branches that supply the muscles of the region Takes part in the formation of the cruciate anastomosis. Four perforating arteries: n n Three of these arise as branches of the profunda femoris artery The fourth perforating artery is the terminal part of the profunda artery The perforating arteries run backward, piercing the various muscle layers as they go. Terminate by anastomosing with: 1. 2. 3. DR FADEL NAIM 4. IUG One another The inferior gluteal artery The circumflex femoral arteries The muscular branches of the popliteal artery

DR FADEL NAIM IUG

Profunda Femoris Vein The profunda femoris vein receives tributaries that correspond to the branches of the artery. p It drains into the femoral vein p DR FADEL NAIM IUG

Obturator Artery p p p A branch of the internal iliac artery Passes forward on the lateral wall of the pelvis Accompanies the obturator nerve through the obturator canal On entering the medial fascial compartment of the thigh, it divides into medial and lateral branches, which pass around the margin of the outer surface of the obturator membrane. It gives off muscular branches and an articular branch to the hip joint. DR FADEL NAIM IUG

Obturator Vein The obturator vein receives tributaries that correspond to the branches of the artery p It drains into the internal iliac vein p DR FADEL NAIM IUG

ADDUCTOR MUSCLES AND CEREBRAL PALSY p In patients with cerebral palsy who have marked spasticity of the adductor group of muscles n It is common practice to Perform a tenotomy of the adductor longus tendon p Divide the anterior division of the obturator nerve. p In addition, in some severe cases the posterior division of the obturator nerve is crushed. n This operation overcomes the spasm of the adductor group of muscles and permits slow recovery of the muscles supplied by the posterior division of the DR FADEL NAIM n IUG

Superficial Veins Many small veins curve around the medial and lateral aspects of the thigh and ultimately drain into the great saphenous vein p Veins from the lower part of the back of the thigh join the small saphenous vein in the popliteal fossa. DR FADEL NAIM p IUG

Lymph Vessels p Lymph from the skin and superficial fascia on the back of the thigh drains upward and forward into the vertical group of superficial inguinal lymph nodes DR FADEL NAIM IUG

CONTENTS OF THE POSTERIOR FASCIAL COMPARTMENT OF THE THIGH p Muscles: n n p Blood supply: n p Biceps femoris Semitendinosus Semimembranosus a small part of the adductor magnus (hamstring muscles). Branches of the profunda femoris artery. Nerve supply: n Sciatic nerve. DR FADEL NAIM IUG

DR FADEL NAIM IUG

Biceps Femoris p Origin: n The long head p n The short head p p The two heads unite just above the knee joint The common tendon is inserted into the head of the fibula. Nerve supply: p p p The linea aspera The lateral supracondylar ridge of the shaft of the femur. Insertion: p p The ischial tuberosity The long head is supplied by the tibial part of the sciatic The short head is supplied by the common peroneal part of the sciatic. Action: p p DR FADEL NAIM IUG Flexes and laterally rotates the leg at the knee joint The long head also extends the thigh at the hip joint.

Semitendinosus p Origin: n p Insertion: n p By a long tendon into the upper part of the medial surface of the shaft of the tibia. Nerve supply: n p From the ischial tuberosity The tibial portion of the sciatic. Action: n n Flexes and medially rotates the leg at the knee joint Extends the thigh at the hip joint. DR FADEL NAIM IUG

Semimembranos us p Origin: n p From the ischial tuberosity Insertion: n n Into the posteromedial surface of the medial condyle of the tibia. The oblique popliteal ligament: p p Nerve supply: n p A fibrous expansion upward and laterally, which reinforces the capsule on the back of the knee joint The tibial portion of the sciatic. Action: n n Flexes and medially rotates the leg at the knee joint It also extends the thigh at the hip joint. DR FADEL NAIM IUG

Pes Anserinus DR FADEL NAIM IUG

Adductor Magnus (Hamstring Portion) p Origin: n n p p Insertion: In the hamstring portion n p the fibers that arise from the ischial tuberosity are inserted below on the adductor tubercle on the medial condyle of the femur Nerve supply: n p From the outer surface of the inferior ramus of the pubis from the ramus of the ischium and the ischial tuberosity. The tibial portion of the sciatic Action: n Extends the thigh at the hip joint. DR FADEL NAIM IUG

DR FADEL NAIM IUG

Blood Supply of the Posterior Compartment of the Thigh The four perforating branches of the profunda femoris artery provide a rich blood supply to this compartment p The profunda femoris vein drains the greater part of the blood from the compartment p DR FADEL NAIM IUG

Hip Joint p p p The articulation between the hemispherical head of the femur and the cup-shaped acetabulum of the hip bone The articular surface of the acetabulum is horseshoe shaped and is deficient inferiorly at the acetabular notch. The cavity of the acetabulum is deepened by the presence of a fibrocartilaginous rim called the acetabular labrum. The labrum bridges across the acetabular notch and is here called the transverse acetabular ligament The articular surfaces are covered with hyaline cartilage. The hip joint is a synovial ball-and-socket joint. DR FADEL NAIM IUG

DR FADEL NAIM IUG

CAPSULE p p p The capsule encloses the joint Attached to the acetabular labrum medially Laterally n To the intertrochanteric line of the femur in front p some of its fibers, accompanied by blood vessels, are reflected upward along the neck as bands called retinacula. § These blood vessels supply the head and neck of the femur. n Halfway along the posterior aspect of the neck of the bone behind. DR FADEL NAIM IUG

DR FADEL NAIM IUG

LIGAMENTS p The iliofemoral ligament: n n A strong, inverted vshaped ligament Its base is attached to the anterior inferior iliac spine above Below, the two limbs of the Y are attached to the upper and lower parts of the intertrochanteric line of the femur. Prevents overextension during standing. DR FADEL NAIM IUG

LIGAMENTS p The pubofemoral ligament n n Triangular The base of the ligament is attached to the superior ramus of the pubis The apex is attached below to the lower part of the intertrochanteric line. This ligament limits extension and abduction. DR FADEL NAIM IUG

LIGAMENTS p The ischiofemoral ligament n n n Spiral shaped Attached to the body of the ischium near the acetabular margin The fibers pass upward and laterally Attached to the greater trochanter This ligament limits extension. DR FADEL NAIM IUG

LIGAMENTS p The transverse acetabular ligament n n p formed by the acetabular labrum as it bridges the acetabular notch converts the notch into a tunnel through which the blood vessels and nerves enter the joint. The ligament of the head of the femur flat and triangular n It is attached by its apex to the pit on the head of the femur (fovea capitis) n its base to the transverse ligament and the margins of the acetabular notch. n It lies within the joint and is ensheathed by DR FADEL NAIMsynovial membrane n IUG

DR FADEL NAIM IUG

SYNOVIAL MEMBRANE The synovial membrane lines the capsule p Attached to the margins of the articular surfaces p It covers the portion of the neck of the femur that lies within the capsule. p It ensheathes the ligament of the head of the femur p Covers the pad of fat contained in the acetabular fossa p DR FADEL NAIM IUG

SYNOVIAL MEMBRANE p A pouch of synovial membrane frequently protrudes through the gap in the anterior wall of the capsule, between the femoral and iliofemoral ligaments, and forms bursa beneath the psoas tendon DR FADEL NAIM IUG

NERVE SUPPLY Femoral nerve p Obturator nerve p Sciatic nerve p The nerve to quadratus femoris p DR FADEL NAIM IUG

Movements Of The Hip Joint p p p A wide range of movement, but less so the shoulder joint Some of the movement has been scarified to provide strength and stability. The strength of the joint depends largely on: n n p The shape of the bones taking part in the articulation The strong ligaments. When the knee is flexed n Flexion is limited by p p the anterior surface of the thigh coming into contact with the anterior abdominal wall. When the knee is extended n Flexion is limited by p DR FADEL NAIM IUG the tension of the hamstring group of muscles.

p Extension is limited by the tension of n n n p Abduction is limited by the tension of n p n Contact with the opposite limb The tension in the ligament of the head of the femur Lateral rotation is limited by n n p The pubofemoral ligament Adduction is limited by n p The iliofemoral ligament Pubofemoral ligament Ischiofemoral ligament The tension in the iliofemoral ligament Pubofemoral ligament Medial rotation is limited by n The ischiofemoral ligament DR FADEL NAIM IUG

Movements Of The Hip Joint p p p p p Flexion Extension Abduction Adduction Lateral rotation. Medial rotation. Circumduction is a combination of the previous movements. The extensor group of muscles is more powerful than the flexor group The lateral rotators are more powerful than the medial rotators. DR FADEL NAIM IUG

DR FADEL NAIM IUG

Important Relations p Anteriorly: n n p Posteriorly: n n n p The obturator internus the gemelli The quadratus femoris muscles separate the joint from the sciatic nerve Superiorly: n n p Iliopsoas Pectineus Rectus femoris muscles. The iliopsoas and pectineus separate the femoral Vessels and nerve from the joint Piriformis gluteus minimus Inferiorly: Obturator externus tendon n NAIM DR FADEL IUG

REFERRED PAIN FROM THE HIP JOINT p p The femoral nerve not only supplies the hip joint but also supplies the skin of the front and medial side of the thigh. Pain originating in the hip joint may be referred to the front and medial side of the thigh The posterior division of the obturator nerve supplies both the hip and knee joints. Hip joint disease sometimes gives rise to pain in the knee joint. DR FADEL NAIM IUG

CONGENITAL DISLOCATION OF THE HIP p p p The stability of the hip joint depends on the ball-an dsocket arrangement of the articular surfaces and the strong ligaments In congenital dislocation of the hip the upper lip of the acetabulum fails to develop adequately The head of the femur rides up out of the acetabulum onto the gluteal surface of the ilium. DR FADEL NAIM IUG

p Previously known as congenital dislocation of the hip implying a condition that existed at birth p Developmental encompasses embryonic, fetal and infantile periods p Includes congenital dislocation and developmental hip problems including: Subluxation p Dislocation p Dysplasia p DR FADEL NAIM IUG

DR FADEL NAIM IUG

DR FADEL NAIM IUG

TRAUMATIC DISLOCATION OF THE HIP p p p Rare because of its strength Usually caused by motor vehicle accidents Joint is flexed and adducted. The head of the femur is displaced posteriorly out of the acetabulum Rest on the gluteal surface of the ilium (posterior dislocation) The sciatic nerve is prone to injury in posterior dislocations DR FADEL NAIM IUG

TRAUMATIC DISLOCATION OF THE HIP DR FADEL NAIM IUG

Hip Joint Stability Normal Gait p The stability of the hip joint when a person stands on one leg with the foot of the opposite leg raised above the ground depends on three factors: The gluteus medius and minimus must be functioning normally. 2. The head of the femur must be located normally within the acetabulum. 3. The neck of the femur must be intact and must have a normal angle with the shaft of the femur. 1. DR FADEL NAIM IUG

Hip Joint Stability Normal Gait p A positive trendelenburg's sign n p p p If anyone of these factors is defective, then the pelvis will sink downward on the opposite, unsupported side. Normally, when walking, a person alternately contracts the gluteus medius and minimus By this means he or she is able to raise the pelvis allowing the leg to be flexed at the hip joint and moved forward The leg is raised clear of the ground before it is thrust forward in taking the forward step. DR FADEL NAIM IUG

Dipping and Waddling Gait p p p A patient with a right-sided congenital dislocation of the hip, when asked to stand on the right leg and raise the opposite leg clear of the ground, will exhibit a positive Trendelenburg's sign, and the unsupported side of the pelvis will sink below the horizontal If the patient is asked to walk, he or she will show the characteristic "dipping" gait. In patients with bilateral congenital dislocation of the hip, the gait is typically "waddling“ in nature. DR FADEL NAIM IUG

ARTHRITIS OF THE HIP JOINT p p p A patient with an inflamed hip joint will place the femur in the position that gives minimum discomfort The position in which the joint cavity has the greatest capacity to contain the increased amount of synovial fluid secreted. The hip joint is partially: n n n Flexed Abducted Externally rotated. DR FADEL NAIM IUG

Osteoarthritis Of the Hip Joint Coxarthrosis p p The most common disease of the hip joint in the adult Causes: n Pain p In the hip joint itself or referred to the knee § (the obturator nerve supplies both joints) n Stiffness p n Caused by the pain and reflex spasm of the surrounding muscles. Deformity p Produced initially by muscle spasm and later by muscle contracture. § Flexion § Adduction § External rotation DR FADEL NAIM IUG

DR FADEL NAIM IUG