gluteal region

1. Gluteal region

2. Skin and fascia of the gluteal region

3. 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 quadrant
Supplied by
2-The upper lateral quadrant
Supplied 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 Innervation of the gluteal region
A) Skin of the Buttock (Gluteal region)

4. 1- Superficial fascia; is thick especially in women .
It contributes to the prominence of the buttock.
2- Deep fascia; contentious with the deep
fascia of the thigh (fascia lata).
B) Fascia of the Buttock (Gluteal region)
 Is a strong fibrous sheet that surrounds the whole
of the thigh like a tight trousers.
 Thin on its medial side while it is getting thicker
on its lateral side to form the iliotibial tract.
Iliotibial tract
Is a strong wide band (thickening of the deep
fascia (fascia lata)) on the lateral side of the
thigh) attached above to the tubercle of ilium
and below to the lateral condyle of tibia.
Receives the insertion of tensor fascia latae
and GM muscles.
Fascia lata

5. Muscles of the gluteal region

6. • Gluteus maximus
 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

7.  Actions
1- Extends thigh, some lateral rotation (main
extensor of the hip joint)
2-Plays an important role in climbing
upstairs and cycling
3- Supports the Extended knee joint through
Iliotibial tract
 Innervation - Inferior gluteal nerve,
L5;S1,2

8. 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

9. Bursae Related to Gluteus Maximus
 Gluteofemoral Bursa:
lies between gluteus
maximus tendon and
vastus lateralis
 Trochanteric Bursa:
lies between gluteus
maximus tendon and
greater trochanter
 Ischial Bursa: lies
between gluteus
maximus & ischial
tuberosity

10. T e n s o r f a s c i a e l a t a e
Origin
Iliac crest
Insertion
Iliotibial tract
Action
Assist gluteus maximus in extending the
knee joint
Nerve supply
Superior gluteal nerve L4,5

11. • Gluteus medius
• Gluteus minimus
 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

12. 1-Piriformis
2-Quadratus femoris
3-Obturator internus
4-Superior gemellus
5-Obturator externus
6-Inferior gemellus
Short Lateral rotator muscles

13. Read these muscles from this slide which can be found on page (566) Snell 8th edition
Muscle Origin Insertion Nerve supply
Short lateral rotator muscles of the hip joint
They have common function; lateral rotation of the thigh at hip joint.
Make sure that you know where to find it on the femur

14. A) Structures passing through the greater sciatic
foramen:
1- Piriformis: fills the foramen almost completely
leaving some structures to pass either above or below it.
Structures passing above Piriformis muscle:
1- Superior gluteal nerve and vessels
Structures passing below Piriformis muscle:
1-inferior gluteal nerve
2-inferior gluteal vessels
3-sciatic nerve
4-posterior cutaneous nerve of the thigh
5-nerve to quadratus femoris
6-pudendal nerve
7-internal pudendal vessels
9-nerve to obturator internus
B) Structures passing through the lesser sciatic foramen:
1- tendon of obturator internus
2-pudendal nerve
3-internal pudendal vessels
4-nerve to obturator internus

15. Bursae Related to Gluteus Maximus
 Gluteofemoral Bursa:
lies between gluteus
maximus tendon and
vastus lateralis
 Trochanteric Bursa:
lies between gluteus
maximus tendon and
greater trochanter
 Ischial Bursa: lies
between gluteus
maximus & ischial
tuberosity

16. 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 medius, 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

17. NERVES

1. Sciatic nerve.

2. Posterior cutaneous
nerve of thigh.

3. Superior and Inferior
Gluteal nerves.

4. Nerve to Quadratus
Femoris.

5. Nerve to Obturator
Internus.

6. Pudendal nerve.

18. SCIATIC NERVE

It is the largest
nerve in the body.

It is the larger of
the two terminal
branches of the
sacral plexus.

It is flat and broad
near its origin and
becomes rounded
downwards.

19. SCIATIC NERVE

It is composed of two
components :

(a) Tibial nerve :

It arises from the ventral
divisions of all components
of the sacral plexus.

(b) Common peroneal
verve :

It arises from the dorsal
divisions of all components
of the sacral plexus.

20. COURSE

It leaves the pelvis
through the lower part of
the GSF below the
piriformis.

As it descends it lies on:

1.Root of ischial spine.

2.Gemelli.

3.Obturator internus.

4.Quadratus femoris.

5.Adductor magnus.

21. COURSE

It is related posteriorly to :

1.Posterior cutaneous nerve
of the thigh.

2.Gluteus maximus.

It enters the back of the
thigh by passing deep to the
long head of biceps femoris.

Branches :

Usually it has No branches in
the gluteal region.

22. TERMINATION

About the middle of
the thigh it divides
into its terminal
branches :Tibial and
Common Peroneal.

23. POSTERIOR CUTANEOUS N. OF
THE THIGH

ORIGIN :

Sacral plexus.

COURSE :

It leaves the pelvis through
the lower part of the GSF
below piriformis.

It descends on the posterior
surface of the sciatic nerve
till the popliteal fossa.

24. POSTERIOR CUTANEOUS N. OF
THE THIGH

BRANCHES :

1. Gluteal : to the lower
medial quadrant of the
buttock.

2. Perineal : to the skin
of the back of scrotum (or
labia majora).

3. Cutaneous : to the
back of the thigh and
upper leg.

25. SUPERIOR GLUTEAL NERVE

ORIGIN :

From the sacral
plexus (L4,5 & S1).

COURSE :

It leaves the pelvis
through the upper
part of the greater
sciatic foramen above
piriformis.

It passes between
gluteus medius and
minimus.

26. SUPERIOR GLUTEAL NERVE

BRANCHES

It gives motor supply
to:

1. Gluteus medius.

2. Gluteus minimus.

3. Tensor fascia latae.

27. INFERIOR GLUTEAL NERVE

Origin:

Sacral plexus (L5, S1 &S2).

Course :

It leaves the pelvis through
the lower part of the (GSF)
below piriformis.

Branches:

It gives motor supply to :

Gluteus maximus.

28. NERVE TO QUADRATUS
FEMORISN

It arises from the sacral
plexus.

It leaves the pelvis
through the lower part of
the GSF below piriformis.

It supplies :

(1) Quadratus femoris.

(2) Inferior gemillus.

29. PUDENDAL N. & N. TO
OBTURATOR INTERNUS

Both arise from the
sacral plexus.

They Leave the pelvis
through the lower part of
GSF below piriformis.

They reenter the pelvis
through the LSF with the
pudendal vessels by
crossing the ischial spine.

30. PUDENDAL N. & N. TO
OBTURATOR INTERNUS

Nerve to obturator
internus

Supplies :

1. Obturator internus.

2. Superior gemellus.

Pudendal Neve

Supplies the structures
in the perineum.

31. SUPERIOR & INFERIOR
GLUTEAL ARTERIES

They arise from the internal
iliac artery.

They leave the pelvis through
the GSF above and below the
piriformis muscle respectively
in company with the
corresponding nerves.

They distribute into many
branches and share in the
anastomoses in the gluteal
region and back of the thigh.

32. TROCHANTERIC ANASTOMOSIS

Position :

Near the trochanteric fossa.

Arteries sharing :

(1) Superior gluteal.

(2) Inferior gluteal.

(3) Medial circumflex femoral.

(4) Lateral circumflex femoral.

Function :

It is the main source of
arterial supply of the head
of the femur.

33. Trochanteric Anastomosis
 Is the main supply to the head &
neck of femur
 Provides a connection between
internal iliac and femoral arteries
 Lies near the trochanteric fossa,
branches run along the femoral
neck beneath the reticular fibers of
the capsule
 Formed by:
 Descending branches of
superior and inferior gluteal
arteries &
 Ascending branches of lateral
and medial circumflex arteries

34. Posterior view
Arterial supply to Femoral
head
•
Medial & lateral femoral
circumflex arteries
•
Superior and inferior
gluteal arteries
•
Post. obdurator artery
via artery of femoral
ligament
TROCHANTERIC
ANASTOMOSIS

35. CRUCIATE ANASTOMOSIS

Position :

On the upper part of the back
of the thigh.

Arteries sharing :

(1) Inferior gluteal.

(2) Medial circumflex femoral.

(3) Lateral circumflex femoral.

(4) First perforating.

Function :

It provides connection between
internal iliac and femoral
arteries.

36. Cruciate Anastomosis
 Lies at the level of lesser
trochanter
 Provides a connection 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

37. 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 muscle
The deep branch supplies the glutei
medius and minimus.
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

38. The Cruciate Anastomosis
The cruciate anastomosis is situated at the level of
the lesser trochanter of the femur and, together
with the trochanteric anastomosis, provides a
connection between the internal iliac and the
femoral arteries
Branches from the internal iliac artery (superior and inferior gluteal arteries) anastomosis
With branches from the femoral artery to form
1-The Trochanteric Anastomosis 2-The Cruciate Anastomosis
The trochanteric anastomosis :
provides the main blood supply to
THE HEAD OF THE
FEMUR
The nutrient arteries pass
along the femoral neck
beneath the capsule
The following arteries take part in the
anastomosis:
A) The superior gluteal artery, the
inferior gluteal artery and the
obturator artery (from the internal
iliac artery)
B) The medial femoral circumflex
artery, and the lateral femoral
circumflex artery (from the femoral
artery)

39. The muscles of the gluteal region are acting on the hip joint
as different functional groups
Gluteus maximus
Acts as the main extensor of the hip joint
Gluteus medius and minimus
They act as the main abductors of the hip joint while
their anterior fibers act as medial rotators on the hip joint
Short Lateral rotator muscles
They act as lateral rotators on the hip joint
The muscles of the gluteal region, therefore, extend, abduct and rotate the hip joint
medially and laterally
Leaving adduction and flexion to other groups of muscles, which ? Why?

40. When standing on
one leg, the abductors of the hip on this side (gluteus medius and minimus
and tensor fasciae latae) maintain fixation at the hip joint
If, however, there is any defect in these muscles or lever mechanism
of the hip joint, the weight of the body in these circumstances forces
the pelvis to tilt downwards on the opposite side.
Trendelenburg’s test
The stability of the hip in the standing position depends on
two factors:
1- The strength of the surrounding muscles
2-The integrity of the lever system of
the femoral neck and head within the intact hip joint
The positive Trendelenburg test is seen if:
A- The hip abductors are paralysed (e.g. poliomyelitis) nerve injury
B-Congenital dislocation of the hip
C-The head of the femur has been destroyed by disease or
removed operatively (pseudarthrosis),
D-There is an un-united fracture of the femoral neck
E-There is a very severe degree of coxa vara

41. 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

42.  Problems that could lead to a positive
Trendelenburg test:
 Fracture neck of femur
 Dislocation of hip joint
 Coxa Vara
 Nonfunctioning gluteus medius and minimus
due to:
 Neurological damage (L4 – 5 disc herniation)
 Any disease affecting muscles (myopathy)

43. 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

44. Positive Trendelenburg's sign
 If right gluteus
medius and
minimus muscles
are paralyzed, the
unsupported left
side of the pelvis
falls (sags)
instead of rising;
normally, the
pelvis rises.

45. Injury to the superior gluteal nerve
On one side causes Lurching gait
Both sides Waddling gait
Positive Trendelenburg’s test
Clinical Notes
Gluteus Medius and Minimus and Poliomyelitis
The gluteus medius and minimus muscles may be paralyzed when
poliomyelitis involves the lower lumbar and sacral segments of the
spinal cord.
They are supplied by the superior gluteal nerve (L4 and 5 and S1)
Paralysis of these muscles seriously interferes with the ability of the
patient to tilt the pelvis when walking.
The test indicates
‘a defect in
the osseo-muscular
stability
of the hip joint’

46. Clinical Notes
The great thickness of
gluteus maximus muscle
makes it ideal for
intramuscular injections.
To avoid injury to the
underlying sciatic nerve,
the injection should be
given well forward on
the upper outer quadrant
of the buttock.

47. However, the upper lateral quadrant,
most likely to be made by the
Gluteus medius muscle rather than the
gluteus maximus muscle .
The gluteus maximus covers the
posterior part only of the
Gluteus medius while the anterior part
(which makes the upper lateral
quadrant)
is covered by skin and fascia only
Therefore, the intramuscular injection
will be injected into the gluteus medius
muscle rather than gluteus maximus
muscle