Anatomy of Anterior thigh

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  • Anatomy of Anterior thigh

    1. 1. MOB TCD Anterior Thigh Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin
    2. 2. MOB TCD Cutaneous Supply
    3. 3. MOB TCD Thigh • Anterior muscle group: supplied by femoral nerve • Sartorius • Quadriceps: rectus femoris, vastus medialis, vastus intermedius and vastus lateralis • Pectineus
    4. 4. 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
    5. 5. 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
    6. 6. 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
    7. 7. 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
    8. 8. 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
    9. 9. 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
    10. 10. 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
    11. 11. 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
    12. 12. 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
    13. 13. 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
    14. 14. 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
    15. 15. 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
    16. 16. 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
    17. 17. 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
    18. 18. 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
    19. 19. 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
    20. 20. 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
    21. 21. MOB TCD Adductor Origins lateral medial inferior
    22. 22. 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
    23. 23. 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
    24. 24. 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
    25. 25. 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
    26. 26. 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
    27. 27. 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
    28. 28. 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
    29. 29. 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
    30. 30. 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
    31. 31. 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)
    32. 32. 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
    33. 33. 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
    34. 34. MOB TCD Psoas Minor • • • • • • Minor Origin T12 –L1 Insertion Arcuate line Iliopubic eminence
    35. 35. 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
    36. 36. 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
    37. 37. 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
    38. 38. 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
    39. 39. 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
    40. 40. 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
    41. 41. 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
    42. 42. “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”

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