Anatomy of Anterior thigh

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  • 1.MOB TCDAnterior Thigh Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin

2. MOB TCDCutaneous Supply 3. MOB TCDThigh Anterior muscle group: supplied by femoral nerve Sartorius Quadriceps: rectus femoris, vastus medialis, vastus intermedius and vastus lateralis Pectineus 4. MOB TCDThigh Medial or adductor group: adductor longus, adductor brevis, adductor portion adductor magnus and gracillis are supplied by the obturator nerve Posterior group: hamstring, semimembranosus, semitendinosus, biceps femoris, adductor magnus, below femoral hiatus Supplied by sciatic nerve 5. MOB TCDFemoral Sheath Anterior wall formed by transversalis fascia Posterior by fascia iliaca Three compartments Medial, short, is the femoral canal, contains lymph gland Opens into abdomen via femoral ring, site of femoral hernia Middle compartment contains femoral vein Lateral, femoral artery and femoral branch of genitofemoral nerve Femoral nerve is outside sheath 6. MOB TCDQuadriceps Femoris Rectus femoris Vastus medialis Vastus intermedius Vastus lateralis Forms the anterior portion of the capsule of the knee joint The largest muscle group in the body Wastes rapidly if there is an effusion, particularly the oblique portion of the vastus medialis 7. MOB TCDRectus Femoris Tendinous origin from the upper part of the anterior inferior iliac spine (epiphysis) and the groove above the acetabulum The most superficial portion of the quadriceps The most frequently strained The only portion of the quadriceps that crosses two joints Flexes hip, extends knee Femoral nerve 8. MOB TCDVastus Medialis Vastus medialis arises from the lower half of the trochanteric line The spiral line The medial lip of the linea aspera The oblique (horizontal) fibres arise from the lower portion of the adductor magnus, helping to stabilise the patella Separate branch from femoral nerve 9. MOB TCDVastus Lateralis Arises from the upper half of the inter-trochanteric line The root of the greatertrochanter The lateral lip of the gluteal tuberosity The lateral lip of the linea aspera The oblique portion of the muscle arises from the iliotibial band Separate nerve supply Helps to stabilise the patella Lateralis is a common site for muscle biopsies and for injections 10. MOB TCDVastus Intermedius Arises from the upper two thirds of the anterior and lateral aspect of the shaft of the femur It is the deepest portion of the quadriceps and is a common site (with vastus lateralis) for myositis ossificans, after a direct blow to the thigh The articularis genu is inserted into the upper part of the suprapatellar bursa 11. MOB TCDQuadriceps The rectus femoris forms the most superficial lamina of the quadriceps, passes anterior to the patella To form the anterior part of the patellar ligament The fibres of the medialis and the lateralis decussate cross in an X-shape and lie in a plane posterior to the rectus femoris Some of these fibres form the retinacular fibres Their oblique portions are inserted into the sides of the patella 12. MOB TCDQuadriceps Femoris The vastus intermedius is the most posterior lamina, forms the main part of the patellar ligament It is the most powerful extensor The patellar ligament is inserted into the smooth upper portion of the tibial tuberosity The quadriceps are the extensors of the knee Only the rectus femoris portion arises above the hip joint, and therefore is also a flexor of the hip 13. MOB TCDWeak Vastus Medialis Obliquus Lower most fibres of vastus medialis Partly arise from the adductor magnus Straightens the pull on the quads tendon and patella Controls patella tracking during flexion/extension of the knee Fibres atrophy quickly after knee injury (within 24 hours) 10-15 ml of effusion inhibit VMO VMO rehabilitation strength and timing of contraction 14. MOB TCDAbnormal Lower Limb Biomechanics Anatomical anomalies Femoral torsion Genu valgum Increased Q angle High (Alta) patella Tibial torsion Overpronation Q angles males 140 and females 170 > 200 greater problems 15. MOB TCDThe Q-angle The Q-angle is the angle formed by a line drawn from the anterior superior iliac spine to the centre of the patella And a line drawn upwards from the attachment of the patellar ligament to the tibial tubercle passing through this point 16. MOB TCDThe Q-angle Functionally, on standing, the normal angle is 1015 With the knee at 90of flexion, an angle of 6is normal, while greater than 10is abnormal Contraction of the quadriceps tends to displace the patella laterally in the femoral groove The oblique fibres of the vastus medialis and the bony prominence of the lateral femoral condyle resist this 17. MOB TCDOsgood Schlatter In young athletes, the patellar ligament is stronger than the bone Which can lead to a traction apophysitis of the tibial tuberosity, Osgood Schlatter disease Jumpers knee is a lesion at the apex of the patella and the ligament 18. MOB TCDSartorius Sartorius arises from anterior superior illiac spine Forms lateral boundary of femoral triangle Crosses adductor longus at apex Lies anterior to femoral artery Posterior to adductor longus lies the profunda artery Knife injury at apex can injury both arteries and the main blood supply to lower limb Sartorius lies on roof of subsartorial canal which contains femoral artery 19. MOB TCDSartorius Inserted into upper third of medial surface of tibia Anterior to gracillis and semitendinosus, as part of the pes anserinum Separated by tibial intertendinous bursa Supplied by femoral nerve 20. MOB TCDAdductor Muscles Adductor longus Adductor brevis Portion of adductor Magnus Gracilis Supplied by obturator Nerve L2,3,4 Act with lower abdominals to stabilise the pelvis 21. MOB TCDAdductor Originslateralmedialinferior 22. MOB TCDAdductor Longus Tendinous origin, pubic body, has a variable shape Inserted into medial lip of linea aspera Most frequently torn at proximal musculo-tendinous junction, which varies Or may tear at teno-periosteal junction Site of junction varies, medial or lateral, may be longer in some Anterior division obturator nerve 23. MOB TCDAdductor Brevis Origin lower portion of body of pubis Inferior pubic ramus Inserted into lower half of the pectineal line Upper half of the linea aspera Deep to adductor longus Separates two divisions of obturator nerve Anterior division supplies it 24. MOB TCDAdductor Magnus Triangular area of ischial tuberosity Ramus of ischium and inferior ramus of pubis Inserted into medial lip of gluteal tuberosity Lateral lip of linea aspera Medial supracondylar line Adductor tubercle Hiatus for popliteal vessels Origin of oblique fibres of vastus medialis Post division obturator nerve Sciatic nerve below hiatus for femoral vessels 25. MOB TCDGracilis Gracilis is the weakest, most medial and superficial of the adductors Gracilis is the only one that crosses the knee joint It arises from a thin aponeurosis, lower half of the body and the inferior ramus of the pubis and part of the ramus of the ischium. It is strap like above It ends in a rounded tendon, inserted into the upper portion of the medial surface of the tibia between the sartorius and the semitendinosus 26. MOB TCDGracilis Gracilis is separated from sartorius and the semitendinosus by the tibial intertendinous bursa (pes anserinum) Gracilis is usually supplied by the anterior division of the obturator nerve, L2, 3, 4 It adducts the hip and flexes and medially rotates the leg 27. MOB TCDThe Tibial Intertendinous Bursa Inflammation of the tibial intertendinous bursa Must be differentiated from injury to the lower attachment of the medial collateral ligament of the knee 28. MOB TCDAdductors The adductors adduct the femur and help to stabilise and counteract the rotation of the pelvis, particularly during the double support When the anterior limb is flexed and the posterior limb is extended Carlsoo, 1972 29. MOB TCDAdductor Muscle - Tendon Strain Common in soccer is adductor muscletendon strain. Be aware of: Rectus Femoris Sartorius Rectus Abdominus Pectineus Adductor Magnus Gracilis 30. MOB TCDAdductors If the hip is flexed, the adductors rotate the hip medially When the hip is extended the adductors can laterally rotate They can also flex the extended hip and extend the flexed hip At the beginning of the swing phase of walking they work synergistically with the iliopsoas At the end of the swing phase, they work with the hamstrings, which contract to prevent further hip flexion 31. MOB TCDPectineus The pectineus muscle is a short flat muscle, which forms part of the floor of the femoral triangle It arises from the anterior aspect of the superior ramus of the pubic bone and the fascia covering it It is inserted into the upper half of a line drawn from the lesser trochanter to the linea aspera and lies posterior to the femoral sheat It is supplied by a branch from the femoral nerve or the accessory obturator (L2, 3) 32. MOB TCDPectineus The pectineus is mainly a flexor of the thigh and a weak adductor There may occasionally be some fusion between the adductor longus and brevis or with the pectineus Doubling of the origin of the adductor longus or brevis may also take place 33. MOB TCDPsoas Major Origin Intervertebral discs, adjoining bodies of T12-L5 vertebrae Medial half, anterior aspect of five lumbar transverse processes Fibrous arches on the sides of the bodies of the four upper four lumbar vertebrae, over four lumbar arteries Inserted into the lesser trochanter of femur Nerve L2,3,4 34. MOB TCDPsoas Minor Minor Origin T12 L1 Insertion Arcuate line Iliopubic eminence 35. MOB TCDPsoas Major Muscle and Fascia The psoas is covered by fascia which is attached medially to the lumbar vertebrae To the fibrous arches Medially along the brim of the pelvis to the arcuate and pectineal lines Laterally, the fascia is atta