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Anatomy of Anterior thigh
 

Anatomy of Anterior thigh

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Anatomy of Anterior thigh Anatomy of Anterior thigh Presentation Transcript

  • MOB TCD Anterior Thigh Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin
  • MOB TCD Cutaneous Supply
  • MOB TCD Thigh • Anterior muscle group: supplied by femoral nerve • Sartorius • Quadriceps: rectus femoris, vastus medialis, vastus intermedius and vastus lateralis • Pectineus
  • MOB TCD Thigh • 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
  • MOB TCD Femoral 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
  • MOB TCD Quadriceps 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
  • MOB TCD Rectus 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
  • MOB TCD Vastus 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
  • MOB TCD Vastus 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
  • MOB TCD Vastus 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
  • MOB TCD Quadriceps • 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
  • MOB TCD Quadriceps 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
  • MOB TCD Weak 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
  • MOB TCD Abnormal 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
  • MOB TCD The 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
  • MOB TCD The Q-angle • Functionally, on standing, the normal angle is 10–15° • With the knee at 90°of flexion, an angle of 6°is normal, while greater than 10°is 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
  • MOB TCD Osgood 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
  • MOB TCD Sartorius • 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
  • MOB TCD Sartorius • 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
  • MOB TCD Adductor 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
  • MOB TCD Adductor Origins lateral medial inferior
  • MOB TCD Adductor 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
  • MOB TCD Adductor 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
  • MOB TCD Adductor 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
  • MOB TCD Gracilis • 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
  • MOB TCD Gracilis • 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
  • MOB TCD The 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
  • MOB TCD Adductors • 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
  • MOB TCD Adductor Muscle - Tendon Strain Common in soccer is adductor muscletendon strain. Be aware of: • • • • • • Rectus Femoris Sartorius Rectus Abdominus Pectineus Adductor Magnus Gracilis
  • MOB TCD Adductors • 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
  • MOB TCD Pectineus • 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)
  • MOB TCD Pectineus • 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
  • MOB TCD Psoas 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
  • MOB TCD Psoas Minor • • • • • • Minor Origin T12 –L1 Insertion Arcuate line Iliopubic eminence
  • MOB TCD Psoas 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 attached to the transverse processes of the lumbar vertebrae • Medial Arcuate Ligament is a thickening of fascia over the Psoas
  • MOB TCD Psoas • Flexes the hip when acting from above • Lumbar plexus is formed inside the substance of psoas • A strain of the psoas muscle may be the cause of chronic groin pain, and you must take care not to mistake it for an adductor strain
  • MOB TCD Psoas  Psoas bursa, between psoas and capsule of hip joint, may communicate with the synovial membrane of the joint  Psoas abscess will present in the groin
  • MOB TCD The Iliopsoas • The iliacus • Origin: iliac fossa and iliac crest • Inserted into the lateral aspect of the psoas and into the femur below the lesser trochanter • Nerve L2,3 • The iliopsoas is an active postural or stabilising muscle of the hip which helps to prevent hyperextension of the hip while standing • Acting from above, the iliopsoas flexes the hip and may be either a medial or a lateral rotator; acting from below, psoas flexes spine
  • MOB TCD The Iliopsoas • In walking, the iliopsoas is used to start swinging the leg forwards • On level ground the leg moves forwards like a pendulum to complete the swing • Stronger contraction of the iliopsoas is required when running or walking up a hill • When climbing stairs, the iliopsoas lifts the leg and places the foot on the stair above
  • MOB TCD The Iliopsoas • When preparing to stand from sitting, the iliopsoas pulls the trunk forwards as the femur is fixed • The trunk leans forwards and, before standing upright, the centre of gravity of the trunk moves over the feet • In sitting up from lying, the iliopsoas pulls on the pelvis and the lower vertebrae in order to pull the trunk up Tyldesley & Grieve, 1989
  • MOB TCD The Iliopsoas • Running with the legs lifted high, helps to develop the iliopsoas • The iliopsoas is also used in the downbeat of freestyle swimming • The iliopsoas is the main muscle involved in straight leg sit-ups • These, however, should never be done as they put stress on the lumbar vertebrae and do nothing for the abdominal muscles
  • “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”