GLUTEAL REGION

INTRODUCTION

• Gluteal = Rump (G)

• Extent: Iliac Crest To Gluteal Fold

• Natis or Buttock

• Hip

SKIN AND FASCIA

• Superficial fasciaThick, dense, well developed, laden with large quantities of fat that:– Gives the characteristic

convexity to the buttock

– Forms a thick cushion over the ischialtuberosity

• Deep fascia•Continuous with the deep fascia of the thigh (fascia lata).•At the lower border of the gluteus maximus, fascia latasplits to enclose the muscle•Above the gluteus maximus, the deep fascia continues as one layer covering the gluteus medius& gets attached to iliac crest•Laterally the fascia merges with the iliotibial tract

Fascia over gluteus medius

Tensor fascia lata

Gluteal fascia

Iliotibial tract

L1

L2

L3

S1

S2

S3

Branches from

posterior cutaneous

nerve of the thigh

Lateral cutaneous branch of iliohypogastric nerve

Lateral cutaneous nerve of the subcostal nerve T12

Branches from lateral

cutaneous nerves of the

thigh

1-The upper medial quadrantSupplied by

2-The upper lateral quadrantSupplied by

Anterior primary rami of

4-The lower lateral quadrant Supplied by

Anterior primary rami of

3-The lower medial quadrant Supplied by

Anterior primary rami of

Cutaneous innervations of gluteal region

UMUL

LMLL

• The gluteal region contains:

–Bones

– Ligaments

–Muscles

–Vessels

–Nerves

GLUTEAL REGION CONTAINS

BONES OF THE GLUTEAL REGION

• Posterior aspect of:

–Hip bone

– Femur

&

–Hip joint

LIGAMENTS OF THE GLUTEAL REGION

• 2 ligaments:

– Sacrospinous, connecting sacrum to ischial spine

– Sacrotuberous, connecting sacrum to ischial tuberosity

• Their main function is to:

– Stabilize the sacrum

– Prevent its posterior rotation at the sacroiliac joint

MUSCLES OF GLUTEAL REGION

•Gluteus maximus•Gluteus medius•Gluteus minimus•Tensor fascia lata•Piriformis•Superior Gemellus•Inferior Gemellus•Obturator internus•Quadratus femoris

Origin:

1- Ilium ( area behind the posterior

gluteal line)

2- Back of sacrum and coccyx

3- Back of sacrotuberous ligament

Insertion

1- The superficial three –fourths

are inserted into the iliotibial

tract

2- The lower deep part is inserted

into the gluteal tuberosity of

femur

GLUTEUS MAXIMUS

Actions

1- Extends thigh- main extensor

of the hip joint

2 - lateral rotation

3 - Abduction of thigh

3 - Plays an important role in

climbing upstairs and cycling

4- Supports the Extended knee

joint through Iliotibial tract

Innervation - Inferior

gluteal nerve, L5,S1,2

STRUCTURES UNDER THE COVER OF GLUTEUS MAXIMUS MUSCLE

A- Bony structures

1-Greater trochanter and bursa

2-Gluteal tuberosity

3-Ischial tuberosity and bursa

1- Sacrotuberous ligament

2- Scrospinous ligament

B- Ligaments

C- Muscles

1- Gluteus medius and minimus

2-Short Lateral rotator muscles (6)

3- origin of the hamstring muscles

D- Vessels

1- Superior gluteal vessels

2- inferior gluteal vessels

3- Internal pudendal vessels

E- Nerves

1- Superior and inferior gluteal nerve

2- Sciatic nerve

3- Pudendal nerve

4- Posterior cutaneous nerve of the thigh

5- Nerve to obturator internus

6- Nerve to quadratus femoris

Origin

Ilium ?

Insertion

Greater trochanter of femur

Actions

1-Abduction (main abductor

of the hip joint)

2-Medial rotation (anterior

fibers)

3-Both muscle contract

reflexly on each side

alternatively during

walking to prevent

tilting of the pelvis to

the unsupported side

Innervation

Superior gluteal nerve

(L4, 5 , S 1)

GLUTEUS MEDIUS & GLUTEUS MINIMUS

POWERFUL ABDUCTORS

1-Piriformis

2-Superior gemellus

3- Inferior gemellus

4- Obturator internus

5-Quadratus femoris

6 -Obturator externus

SHORT LATERAL ROTATOR MUSCLES

INNERVATIONS

VENTRAL RAMI S1 S2

N. TO OBTURATOR INTERNUS L5 S1 S2

N. TO QUADRATUS FEMORIS L4 L5 S1

POST. DIVISION OF OBTURATOR N. (L2 L3 L4)

OBTURATOR EXTERNUS

TENSOR FASCIA LATA

• Origin: Outer lip of iliac crest between anterior superior iliac spine & iliac tubercle

• Insertion: Into the iliotibialtract

• Nerve supply: Superior gluteal nerve (L4,5, S1)

• Action: Maintains the knee in extended position

Tensor fascia lata

Iliotibial tract

STRUCTURES PASSING THROUGH THE GREATER SCIATIC FORAMEN

Piriformis: an important landmark

Above the piriformis:Superior gluteal vessels & nerve

Below the piriformis:Inferior gluteal vessels & nerveSciatic nervePosterior cutaneous nerve of thighPudendalnerve & Internal pudendal vesselsNerve to obturator internusNerve to quadratus femoris

Structures passing through the lesser sciatic foramen

Entering:Pudendal nerve &Internal pudendal vessels

Exiting:Tendon of obturator internusNerve to obturator internus

NERVES OF GLUTEAL REGION

L 4

L 5

S 1

S 2

S 3

ANTERIOR POSTERIOR

N. TO QUADRATUS FEMORIS

SUPERIOR GLUTEAL N.

N. TO OBTURATOR INTERNUS

INFERIOR GLUTEAL N

SCIATIC NERVE TIBIAL PART

S 4

PUDENDAL NERVE

SCIATIC NERVECOMMON

PERONEAL PART

SACRAL PLEXUS

Superior Gluteal Nerve

(L4, 5 and S1)

a branch of the sacral plexus

leaves the pelvis through the greater

sciatic foramen above the piriformis

It divides into superior and

inferior branches

The superior branch supplies the

gluteus medius muscle

The inferior branch supplies the

gluteus minimus muscles and ends

by supplying the tensor fasciae latae

muscle.

Inferior Gluteal Nerve (L5, S1, S2)

a branch of the sacral plexus, leaves

the pelvis through the greater sciatic

foramen below the piriformis

It supplies the gluteus maximus

muscle

1-Superior Gluteal Artery

is a branch from the internal iliac artery

enters the gluteal region through the greater

sciatic foramen above the piriformis

It divides into superficial and deep branches.

The superficial branch supplies the gluteus

maximus & medius muscle

The deep branch take part in formation of

anastomosis.

2-Inferior Gluteal Artery

is a branch of the internal iliac artery

enters the gluteal region through the greater

sciatic foramen, below the piriformis

It divides into numerous branches that are

distributed throughout the gluteal region.

ARTERIES OF THE GLUTEAL REGION

Posterior view

Arterial supply to Femoral head

• Medial & lateral circumflex femoral arteries

• Superior and inferior gluteal arteries

TROCHANTERIC

ANASTOMOSIS

CRUCIATE ANASTOMOSIS

• Lies at the level of lesser trochanter

• between internal iliac and femoral arteries

• Formed by:– Descending branch of

inferior gluteal artery– Transverse branches of

medial and lateral circumflex arteries

– Ascending branch of first perforating artery

APPLIED ANATOMY

SAFE AREA FOR INTRAMUSCULAR INJECTION

• Intramuscular injection enables a large amount of a drug to be introduced at once but absorbed gradually.

• The injection site must be carefully selected to avoid injury to the underlying large vessels and nerves.

Outer upper quadrant of the buttock is the safe area for intramuscular injection to avoid injury to the underlying sciatic nerve

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TRENDELENBURG TEST

• To assesses whether the hip abductors (particularly gluteus medius) are functioning normally Observe patient from behind, ask him/her to stand on one foot and then the other

Negative test: Pelvis ‘tilts up’ on contralateral side

Positive test: Pelvis ‘sags’ on contralateral side

Positive test:

Pelvis ‘sags’ on contralateral side

BILATERAL

Waddling Gait

UNILATERAL

Lurching Gait