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vastus intermedius
Attachments Vastus intermedius arises from the anterior and lateral
Piriformis Iliopsoas
surfaces of the upper two-thirds of the femoral shaft, and from the lower
part of the lateral intermuscular septum. Its fibres end on the anterior
surface of the muscle in an aponeurosis that forms the deep part of the Pectineus Rectus femoris
quadriceps femoris tendon and is attached to the lateral border of the
patella and the lateral condyle of the tibia. Adductor longus Iliopectineal bursa
Vastus intermedius appears to be inseparable from vastus medialis. Gluteus medius
However, when rectus femoris is reflected, a narrow cleft can be seen
extending upwards from the medial border of the patella between the Iliopsoas
Adductor brevis
two muscles, sometimes as far as the lower part of the intertrochanteric
line; proximal to this, the two muscles are frequently fused. Obturator externus Lesser trochanter
Quadratus femoris
Relations Vastus intermedius is almost completely covered by the Pectineus
other components of quadriceps femoris, except laterally, where a small
part becomes superficial behind vastus lateralis. Adductor brevis
Adductor magnus
Vascular supply Vastus intermedius receives a lateral artery of Vastus lateralis
supply, which arises from the ‘artery of the quadriceps’, and a medial
artery that arises directly from the profunda femoris artery. Arteries to Adductor longus
the other components of quadriceps femoris may also contribute. There
is an anastomotic network deep to the muscle that supplies the supra-
patellar bursa and articularis genus, and may form a collateral pathway Gracilis Vastus medialis
when the femoral artery is blocked.
articularis genus Adductor hiatus
Articularis genus is a small muscle, usually distinct from vastus inter-
medius but occasionally blending with it. It consists of several muscular Vastus intermedius
bundles that arise from the anterior surface of the lower part of the
femoral shaft and are attached to a proximal reflection of the synovial
membrane of the knee joint. It is visible during knee arthroscopy when


viewed looking superiorly from within the suprapatellar bursa (see Femur
Commentary 9.3).
innervation of quadriceps femoris
Quadriceps femoris and articularis genus are supplied by the femoral
nerve, L2, 3 and 4.
actions of quadriceps femoris Sartorius
Quadriceps femoris extends the knee. Rectus femoris helps to flex the Gracilis Tendons of
thigh on the pelvis; if the thigh is fixed, it helps to flex the pelvis on Semitendinosus
Anserine bursa
the thigh. Rectus femoris can flex the hip and extend the knee simulta-
neously. Electromyographic studies indicate that the three vasti are not
equally active in different phases of extension or rotation. There is little
Fig. 80.29 The adductor muscles of the thigh, anterior aspect. (With
or no activity in quadriceps femoris during standing. Rectus femoris
permission from Waschke J, Paulsen F (eds), Sobotta Atlas of Human
pulls the patella along the line of the mechanical axis of the lower limb
Anatomy, 15th ed, Elsevier, Urban & Fischer. Copyright 2013.)
(i.e. the line connecting the centres of the hip, knee and ankle) because
its attachment is anterior to the hip joint. The remaining muscles in the
group are attached to the shaft of the femur and their pull is lateral as Gracilis
well as proximal. An extremely important dynamic function of vastus Attachments Gracilis (see Figs 80.2, 80.29) is the most superficial of
medialis obliquus is to counter this lateral vector on the patella during the adductor group. It is thin and flat, broad above, and narrow and
knee motion. Other static factors that help are the depth of the femoral tapering below. It arises by a thin aponeurosis from the medial margins
patellar surface, the buttressing effect of the lateral femoral condyle in of the lower half of the body of the pubis, the whole of the inferior
the groove, and the restraining action of the medial patellofemoral liga- pubic ramus, and the adjoining part of the ischial ramus. The fibres


ment. Inadequacy of vastus medialis obliquus is a factor in producing descend vertically into a rounded tendon, often harvested as a knee
patellar instability and pain. Strengthening of this muscle to improve ligament graft, which passes across the medial condyle of the femur
patellar ‘tracking’ on the femur is an important part of physiotherapy posterior to the tendon of sartorius. It then curves around the medial
regimens for patellofemoral problems. condyle of the tibia, where it fans out and is attached to the upper part
Articularis genus retracts the synovial suprapatellar bursa proximally of the medial surface of the tibia, just below the condyle, forming part
during extension of the leg, presumably to prevent interposition of of the pes anserinus (see Fig. 80.28). A few fibres from the lower part
redundant synovial folds between patella and femur. of the tendon continue into the deep fascia of the lower leg. Often there
is a slip that blends with the tendon of the medial head of gastrocne-
Testing The quadriceps femoris is tested by extending the knee against mius. Unless divided, this can lead to problems during surgical harvest-
resistance, in the supine position with the hip flexed. ing of the gracilis tendon.
Adductor compartment Relations The muscle is covered medially by the fascia lata through-
out most of its length. Deep to gracilis lie adductor brevis and adductor
The muscles of the adductor compartment – gracilis, pectineus, adduc- magnus. The tibial attachment is immediately proximal to that of semi-
tor longus, adductor brevis, and adductor magnus (Fig. 80.29) – have tendinosus, and the tendon of sartorius, with which it is partly blended,
evolved, as their nerve supply suggests, from both flexor and extensor overlaps its upper edge. It is separated from the tibial collateral ligament
columns. All five muscles cross the hip joint but only gracilis reaches of the knee joint by the anserine bursa.
beyond the knee. They are known collectively as the adductors of the
thigh, although their actions are more complex than this, e.g. acting Vascular supply The arterial supply to gracilis enters via its lateral


from below they have important roles in balancing the trunk on the surface. The main pedicle arises from the ‘artery to the adductors’, a
lower limb during walking. branch of the profunda femoris artery, and enters at the junction of the
Their blood supply is derived from the profunda femoris artery, upper and middle thirds of the muscle. The gracilis musculocutaneous
medial circumflex femoral, femoral and obturator arteries. The pro- flap is based on this pedicle. A less important artery enters the distal
funda femoris artery (or sometimes the first perforator) supplies a large third of the muscle from the femoral artery. There is a minor proximal
branch, the ‘artery of the adductor muscles’. supply from the medial circumflex femoral artery.


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Innervation Gracilis is innervated by the obturator nerve, L2 and 3. Actions The actions of the named adductors as a group are discussed
below, after each muscle has been described.
Actions Gracilis flexes the leg and rotates it medially. It may also act
as an adductor of the thigh. When the foot is fixed, gracilis rotates the Testing Adductor brevis is tested in the same way as adductor
femur and pelvis laterally on the tibia, and helps balance the trunk longus.
during walking.
Adductor magnus
Testing While palpating over the tendon posteromedially at the Attachments Adductor magnus (see Figs 80.2, 80.25A, 80.29, 80.30),
flexed knee, the knee is actively further flexed and the leg actively
a massive triangular muscle, arises from a small part of the inferior
rotated medially. Gracilis can also be tested with the other adductors
ramus of the pubis, from the conjoined ischial ramus, and from the
of the hip.
inferolateral aspect of the ischial tuberosity. The short, horizontal fibres
Adductor longus from the pubic ramus are inserted into the medial margin of the gluteal
tuberosity of the femur, medial to gluteus maximus; this part of the
Attachments Adductor longus (see Figs 80.2, 80.22), the most ant-
muscle, in a plane anterior to the rest, is sometimes called adductor
erior of the three adductors, is a large, fan-shaped muscle that lies in
minimus. The fibres from the ischial ramus fan out downwards and
the same plane as pectineus. It arises by a narrow tendon with a flat-
laterally, to insert via a broad aponeurosis into the linea aspera and the
tened (sometimes C-shaped) cross-section, which is attached to the
proximal part of the medial supracondylar line. The medial part of the
front of the pubis in the angle between the crest and the symphysis. It


muscle, composed mainly of fibres from the ischial tuberosity, is a thick
expands into a broad fleshy belly that descends posterolaterally and
mass that descends almost vertically, and ends in the lower third of the
inserts by an aponeurosis into the linea aspera in the middle third of
thigh in a rounded tendon, which can be palpated proximal to its
the femur, between vastus medialis and adductors magnus and brevis,
attachment to the adductor tubercle on the medial condyle of the
usually blending with all of them. Its proximal attachment is vulnerable
femur. The tendon is connected by a fibrous expansion to the medial
to overload from sporting activity: this is one cause of sport-related
supracondylar line.
groin pain.
The long, linear attachment of the muscle is interrupted by a series
Adductor longus is occasionally double.
of osseo-aponeurotic openings, bridged by tendinous arches attached
to the bone. The upper four are small and transmit the perforating
Relations Anterior to adductor longus are the spermatic cord, fascia
branches and the termination of the profunda femoris artery. The
lata (which separates it from the long saphenous vein) and, near its
lowest is large and allows the femoral vessels to cross to the popliteal
attachment, the femoral artery and vein and sartorius. Posterior to it are
fossa.
adductor brevis and adductor magnus, the anterior branch of the obtu-
The vertical, ischiocondylar part of the muscle varies in its degree of
rator nerve and, near its attachment, the deep artery and vein of the
separation from the rest. The upper border of adductor magnus may
thigh. Lateral and medial to adductor longus are, respectively, pectineus
fuse with quadratus femoris.
and gracilis.
Relations Anteriorly lie pectineus, adductor brevis and adductor
Vascular supply The main supply to adductor longus is to the
longus, the femoral and deep femoral vessels, and the posterior branch
central part of the muscle from the ‘artery to the adductors’, a branch
of the obturator nerve. A bursa separates the proximal part of the muscle


of the profunda femoris artery. There is an additional proximal supply
from the lesser trochanter of the femur. Posteriorly are the sciatic nerve,
from the medial circumflex femoral artery, and a more distal supply
gluteus maximus, biceps femoris, semitendinosus and semimembrano-
from the femoral artery and sometimes the descending genicular
sus. The superior border is parallel with quadratus femoris, and the
artery.
transverse branch of the medial circumflex femoral artery passes
between the muscles. The medial border is related to gracilis, sartorius
Innervation Adductor longus is innervated by the anterior division of
and the fascia lata.
the obturator nerve, L2, 3 and 4.
Vascular supply As expected from its position, adductor magnus is
Actions The actions of the named adductors as a group are discussed
supplied from both its anterior and its posterior aspects. The contribu-
below, after each muscle has been described.
tion from the anterior compartment is the more important. The pro-
funda femoris artery, obturator artery and femoral artery all contribute;
Testing The adductors are tested as a group by adduction of the thigh
the main supply comes directly from the distal part of the profunda
against resistance, in the supine position and with the knee extended.
femoris artery. Distally, there may be contributions from the femoral
Adductor brevis and descending genicular arteries. Posteriorly, there are branches from
the medial circumflex femoral, the first and second perforating and the
Attachments Adductor brevis (see Fig. 80.2A; Fig. 80.25B) lies pos-
popliteal vessels.
terior to pectineus and adductor longus. It arises by a narrow attach-
ment from the external aspect of the body and inferior ramus of the
Innervation Adductor magnus is composite and is doubly innervated
pubis, between gracilis and obturator externus. Like adductor longus, it
by the obturator nerve and by the tibial division of the sciatic nerve (L2,
is somewhat triangular, and expands as it descends posterolaterally to
3 and 4), which supplies the ischiocondylar part. Both nerves are


insert via an aponeurosis into the femur, along a line from the lesser
derived from anterior divisions in the lumbosacral plexus, indicating a
trochanter to the linea aspera, and on the upper part of the linea imme-
primitive flexor origin for both parts of the muscle.
diately behind pectineus and the upper part of adductor longus.
Adductor brevis often has two or three separate parts, or may be
Actions of the adductors
integrated into adductor magnus.
Extensive or forcible adduction of the femur is not often required.
Relations Anteriorly lie pectineus, adductor longus, the profunda Although the adductors can act in this way, they more commonly act
femoris artery and the anterior branch of the obturator nerve; posteri- as synergists in the complex patterns of gait activity, and to some degree
orly are adductor magnus and the posterior branch of the obturator as controllers of posture. They are active during flexion and extension
nerve. The upper border of adductor brevis is related to the medial of the knee. Adductors magnus and longus are probably medial rotators
circumflex femoral artery, obturator externus, and the conjoined tendon of the thigh. The adductors are inactive during adduction of the
of psoas major and iliacus. Its lower border is related to gracilis and abducted thigh in the erect posture (when gravity assists), but active in
adductor magnus. The second perforating artery, or first and second other postures, such as the supine position, or during adduction of the
perforating arteries, pierces it near its femoral attachment. flexed thigh when standing. They are also active during flexion (longus)
and extension (magnus) of the thigh at the hip joint. In symmetrical
Vascular supply The vascular supply to adductor brevis is variable. easy standing their activity is minimal.
Usually the main supply is directly from the profunda femoris artery
distally and from the ‘artery to the adductors’ more proximally. There Testing of the adductors The adductors are usually tested as a
is an additional proximal supply from the medial circumflex femoral group by adduction of the thigh against resistance, in the supine posi-


artery. The deep surface receives branches from the obturator artery. tion with the knee extended. The tendon of adductor magnus can be
felt just proximal to the adductor tubercle on the medial condyle of the
Innervation Adductor brevis is innervated by the obturator nerve, L2 femur. Clinical testing of the other actions mentioned above is not
and 3. feasible for the individual muscles.


Muscles
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Iliac crest Fig. 80.30 The posterior thigh and
gluteal regions with associated
neurovascular structures. (With
Gluteus medius Gluteus maximus permission from Netter, FH, Atlas of
Human Anatomy, 5th ed, Elsevier,
Saunders. Copyright 2011.)
Gluteus minimus
Superior gluteal artery and nerve
Tensor fasciae latae
Piriformis
Gemellus superior
Inferior gluteal artery and nerve
Gemellus inferior
Nerve to obturator internus
Gluteus medius
Ischial tuberosity
Greater trochanter of femur
Pudendal nerve
Quadratus femoris
Obturator internus
Medial femoral circumflex artery Inferior clunial nerves
Sciatic nerve
Perineal branches of posterior
Gluteus maximus femoral cutaneous nerve
Adductor magnus
First perforating artery Adductor magnus
(from profunda femoris artery)
Muscular branches of sciatic nerve
Gracilis
Vastus lateralis and iliotibial tract
Second and third perforating arteries
(from profunda femoris artery)
Semitendinosus (retracted)
Semimembranosus
Fourth perforating artery
(from profunda femoris artery)
Long head (retracted)
Biceps femoris
Short head
Popliteal artery and vein
Adductor hiatus
Superior medial genicular artery
Tibial nerve
Plantaris Medial epicondyle of femur
Common fibular (peroneal nerve)
Gastrocnemius (lateral head) Gastrocnemius (medial head)
Small saphenous vein
Pectineus lat erally, to psoas major and the medial circumflex femoral vessels; and
Attachments Pectineus (see Fig. 80.22) is a flat, quadrangular medially, to the lateral margin of adductor longus.
muscle in the femoral triangle. It may also be considered as part of the
anterior compartment of the thigh. It arises from the pecten pubis, from Vascular supply The main arterial supply to pectineus is derived
the bone anterior to it between the iliopubic ramus and the pubic from the medial circumflex femoral artery, which enters the superficial


tubercle, and from the fascia on its own anterior surface. The fibres surface of the muscle. There may be a branch from the femoral artery
descend, initially posteromedially and then posterolaterally, to be more proximally, and a deep supply from the obturator artery.
attached along a line from the lesser trochanter to the linea aspera.
Proximally, it may be partially or wholly attached to the capsule of the Innervation Pectineus is innervated by the femoral nerve, L2 and 3, and
hip joint. the accessory obturator nerve, L3 (when present). Occasionally, it receives
a branch from the obturator nerve. The muscle may be incompletely
Relations Pectineus is related anteriorly to the deep lamina of the divided into dorsal and ventral layers, which are supplied by the obtura-
fascia lata, which separates it from the femoral vessels and long saphen- tor and femoral (or rarely, accessory obturator) nerves, respectively.
ous vein; posteriorly, to the capsule of the hip joint, adductor brevis,
obturator externus and the anterior branch of the obturator nerve; Actions Pectineus adducts the thigh and flexes it on the pelvis.


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Testing The action of pectineus cannot be tested clinically in Semimembranosus
isolation. Attachments Semimembranosus (see Figs 80.2, 80.30), so named
because of the flattened form of its upper attachment, is posteromedial
Adductor canal
in the thigh. It arises by a long, flat tendon from a superolateral impres-
The adductor canal (Hunter’s canal; subsartorial canal) is a trough- sion on the ischial tuberosity (see Fig. 80.5). Inferomedially, the tendi-
shaped intermuscular tunnel occupying the distal two-thirds of the nous fibres intermingle to some extent with those of biceps femoris and
medial aspect of the thigh (see Fig. 80.2B). It starts at the apex of the semitendinosus. The tendon receives, from the ischial tuberosity and
femoral triangle and extends distally as far as the distal attachment of ramus, two fibrous expansions that flank adductor magnus. It then
the tendon of adductor magnus. It is triangular in section and is broadens and descends deep to semitendinosus and the long head of
bounded anterolaterally by vastus medialis; posteromedially by adduc- biceps femoris. Muscle fibres arise from the tendon at about mid-thigh
tor longus; and distal to adductor longus, by adductor magnus. Its and converge to a second aponeurosis on the posterior aspect of the
anteromedial boundary (often referred to as the roof) is a strong and lower part of the muscle, which tapers to the heavy, rounded tendon of
dense fascia that extends from the medial surface of vastus medialis to the distal attachment. The tendon divides at the level of the knee into
the medial edge of the adductors longus and magnus, overlapping in five components. The main one is attached to a tubercle (sometimes
its stride the femoral vessels in the adductor canal. This fascia, on called the tuberculum tendinis) on the posterior aspect of the medial


account of being overlain by sartorius, is termed the subsartorial fascia. tibial condyle. The others are: a series of slips to the medial margin of
The adductor canal contains the femoral artery and vein, the descend- the tibia, immediately behind the tibial collateral ligament; a thin
ing genicular and muscular branches of the femoral artery and their fibrous expansion to the fascia over popliteus; a cord-like tendon to the
corresponding venous tributaries, the saphenous nerve, and the nerve inferior lip and adjacent part of the groove on the back of the medial
to vastus medialis (until it enters its muscle). The femoral vessels pass tibial condyle, deep to the tibial collateral ligament; and a strong expan-
from the adductor canal into the popliteal fossa via the adductor hiatus, sion that passes obliquely upwards to the femoral intercondylar line
an opening in the tendon of adductor magnus adjacent to the femoral and lateral femoral condyle, and forms much of the oblique popliteal
shaft, two-thirds of the way down the adductor canal. ligament of the knee joint.
Semimembranosus varies considerably in size and may be absent. It
Posterior compartment may be double, and arise mainly from the sacrotuberous ligament. Slips
to the femur or to adductor magnus may occur.
The posterior thigh muscles, biceps femoris, semitendinosus and semi-
membranosus, are colloquially termed the ‘hamstrings’. They cross both Relations Semimembranosus overlaps the popliteal vessels and is
hip and knee joints, and integrate extension at the hip with flexion at itself partly overlapped by semitendinosus throughout its extent (see
the knee. As the muscles span the back of the knee, they form the Fig. 80.2). Its deep surface lies on adductor magnus. The sciatic nerve
proximal lateral and medial margins of the popliteal fossa. The actions lies laterally and surprisingly close to the surface. The distal end of the
of these muscles and their clinical anatomy will be considered as a muscle partially overlies the medial head of gastrocnemius before
group after they have been described individually. passing anteromedially to it. An important bursa lies between the semi-


The muscles of the posterior compartment (see Figs 80.2, 80.25A, membranosus tendon and gastrocnemius, and often communicates
80.27) receive their blood supply from the perforating branches of the with the knee joint and with a smaller bursa between the tendon and
profunda femoris artery, most importantly through the first perforator the posterior tibial margin.
given off from this artery. This vessel has important anastomoses with
the inferior gluteal artery (on or within semitendinosus) and with the Vascular supply Semimembranosus is supplied from the perforat-
medial circumflex femoral artery, while the third perforator anastomo- ing arteries, usually from all, though predominantly from the first.
ses with the superior medial genicular artery within the short head of Sometimes the predominant artery arises from the fourth perforator. A
biceps femoris. This anastomotic chain forms an important collateral branch of the femoral or popliteal artery supplies the distal part of the
arterial pathway when the femoral artery is blocked. muscle, and there may be a contribution from the inferior gluteal artery
at the proximal attachment.
Semitendinosus
Attachments Semitendinosus (see Figs 80.2B, 80.30), notable for the Innervation Semimembranosus is innervated by the sciatic nerve, L5,
length of its tendon, lies posteromedial in the thigh. It arises from an S1 and 2, through its tibial division.
inferomedial impression on the upper area of the ischial tuberosity (see
Fig. 80.5), by a tendon it shares with the long head of biceps femoris, Biceps femoris
and from an aponeurosis connecting the adjacent surfaces of the two Attachments Biceps femoris (see Figs 80.2, 80.30) occupies a
muscles for 7.5 cm from their common origin. The belly is fusiform posterolateral position in the thigh. It has two proximal attachments.
and ends a little below mid-thigh in a long, rounded tendon that runs One, the long head, arises from an inferomedial impression on the


on the posterior surface of semimembranosus. The tendon curves upper area of the ischial tuberosity (see Fig. 80.5), via a tendon that it
around the medial condyle of the tibia, passes over the tibial collateral shares with semitendinosus, and from the lower part of the sacrotuber-
ligament (from which it is separated by the anserine bursa), and inserts ous ligament. The other, the short head, arises from the lateral lip of
into the upper part of the medial surface of the tibia behind the attach- the linea aspera, between adductor magnus and vastus lateralis. This
ment of sartorius and distal to that of gracilis (see Fig. 80.28). At its attachment extends proximally almost to gluteus maximus and distally
termination, it is united with the tendon of gracilis and gives off a along the lateral supracondylar line to within 5 cm of the lateral femoral
prolongation to the deep fascia of the leg and to the medial head of condyle, and from the lateral intermuscular septum. The long head
gastrocnemius. A tendinous intersection is usually present near the forms a fusiform belly that descends laterally across the sciatic nerve.
midpoint of the muscle, which may also receive a muscular slip from The fibres end in an aponeurosis that covers the posterior surface of the
the long head of biceps femoris. These connections with the medial muscle. This aponeurosis receives on its deep surface the fibres of the
head of gastrocnemius and biceps femoris can cause difficulty when short head, and gradually narrows to a tendon (the lateral hamstring).
harvesting the tendon surgically for a graft. The main part of the tendon splits round the fibular collateral ligament
and is attached to the head of the fibula. The remainder splits into three
Relations Semitendinosus lies on semimembranosus throughout its laminae. The intermediate lamina fuses with the fibular collateral liga-
length. The relations of the distal part of the muscle are described above ment, while the others pass superficial and deep to the ligament to
and with the pes anserinus. attach to the lateral condyle of the tibia.
The short head may be absent. Additional slips may arise from the


Vascular supply The two main arteries of supply to semitendinosus ischial tuberosity, linea aspera or medial supracondylar line.
are superior and inferior. The superior is derived from either the medial
circumflex femoral artery or the first perforating artery. The inferior and Relations Proximally, biceps femoris is covered by gluteus maximus,
larger branch arises from the first perforator distal to the origin of the but elsewhere it lies relatively superficially. Deep to it lie semimem-
superior branch. An accessory supply at the ischial attachment is derived branosus proximally, and the sciatic nerve, adductor magnus and the
from the inferior gluteal artery, and at the tibial attachment from the lateral head of gastrocnemius more distally. Semitendinosus and semi-
inferior medial genicular artery. membranosus lie medially. A bursa may lie between the tendon and
the fibular collateral ligament. The common fibular nerve descends
Innervation Semitendinosus is innervated by the sciatic nerve, L5, S1 along the medial border of the tendon of biceps femoris, separating it
and 2, through its tibial division (see Fig. 80.30). distally from the lateral head of gastrocnemius.


vascular supply and lymphatic drainage
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As a guide during surgery, it is safest to find a nerve proximally and ARTERIES
dissect it free distally. The common fibular nerve is found emerging
posterior to the biceps femoris tendon, which is a useful guide to locat- Gluteal vessels
ing the nerve and avoiding iatrogenic injury. The nerve is adherent to
the tendon; if part of the fibular head or the attachment of the tendon
The superior and inferior gluteal arteries (see Fig. 80.30) are described
of biceps femoris, usually with the insertion of the fibular collateral
on pages 1226 and 1227, respectively.
ligament, is avulsed, then the tendon will exert proximal traction on
the nerve, which may contribute to common fibular nerve traction
Arteria comitans nervi ischiadici
injury. When the lateral meniscus is sutured arthroscopically, care must
(artery to sciatic nerve)
be taken that all needle passages are anterior to biceps femoris. A proxi-
mal fibular fracture may result in the nerve being trapped in the fracture
line. The arteria comitans nervi ischiadici is a direct or indirect branch of the
internal iliac artery, and runs on the surface of, or within, the sciatic
Vascular supply The long head of biceps femoris is supplied by the nerve. It represents the primitive axial artery of the lower limb. The
first and second perforating arteries. There are accessory supplies at the artery is usually a very small vessel; occasionally, it persists as a large
ischial attachment from the inferior gluteal and medial circumflex vessel, in which case the femoral artery is correspondingly reduced in
femoral arteries, and in the distal quarter from the superior lateral size. The artery may participate in collateral circulatory pathways.
genicular artery. The short head is supplied superiorly by the second or
third perforating artery and inferiorly by the superior lateral genicular Femoral artery
artery.
The femoral artery (see Figs 78.4, 80.2–80.3; Figs 80.31–80.32) is a


Innervation Biceps femoris is innervated by the sciatic nerve, L5, S1 continuation of the external iliac artery (Benninger 2014). It begins
and 2: the long head through the tibial division and the short head behind the inguinal ligament, midway between the anterior superior
through the common fibular division, a distribution that reflects the
composite derivation from flexor and extensor musculature.
Actions of posterior thigh muscles
External iliac Inguinal ligament
Acting from above, the posterior thigh muscles flex the knee. Acting artery and vein
from below, they extend the hip joint, pulling the trunk upright from Lateral femoral
a stooping posture against the influence of gravity, biceps femoris being Internal iliac cutaneous nerve
artery
the main agent. When the knee is semi-flexed, biceps femoris can act
as a lateral rotator and semimembranosus and semitendinosus as Femoral nerve
medial rotators of the lower leg on the thigh at the knee. When the hip
Iliopsoas
is extended, biceps femoris is a lateral rotator and semimembranosus
Pectineus
and semitendinosus are medial rotators of the thigh. As is the case with Femoral nerve
quadriceps femoris, the adductors and gluteus maximus, the hamstrings Long Profunda femoris
saphenous vein
are quiescent in easy symmetrical standing. However, any action that artery
takes the centre of gravity in front of a transverse axis through the hip Femoral artery
joints, e.g. forward reaching, forward sway at the ankle joints or forward
Tensor fasciae latae
bending at the hips, is immediately accompanied by strong contraction
of the hamstrings. This is in marked contrast to gluteus maximus, which Femoral vein
contracts only when there is a call for powerful extension at the hip
joint.
When the knee is flexed against resistance, the tendon of biceps Adductor longus
femoris can be felt lateral to the popliteal fossa. Medial to the fossa, the
Rectus femoris
tendons of gracilis (which is the more medial) and semitendinosus
stand out sharply. The semimembranosus tendon is just palpable in the
Gracilis


interval between them (and also by deep pressure from a ‘pincer’ grip
beyond their margins). There is some evidence that semimembranosus,
semitendinosus and biceps femoris, although they cross both hip and
knee joints, may produce movement at one of these joints without Sartorius
resisting antagonists at the other. Usually, however, each of these
muscles contracts as a whole, and whether or not movement takes place
at hip or knee is determined by other muscles that act as fixators of
these joints.
Testing The posterior thigh muscles are tested clinically by active knee Vastus lateralis
flexion against resistance in the supine or prone position. In the prone
position, the individual hamstring tendons can be identified more
easily.
When relaxed, these muscles show considerable variation in length; Vastus medialis
in some individuals, the muscles are so short as to impose a serious
limitation on flexion of the trunk at the hip joints when the knees are
kept extended. Movements such as stooping must then be accom-
plished by flexing the vertebral column or squatting. Perhaps the need
for more stress on the lumbar spine accounts for the occurrence of
Articular branch
hamstring tightness in adolescents who develop spondylolysis. These
(descending genicular artery)
muscles are prone to tearing, which may be related to the relative com-
plexity of muscles that cross two joints, or to the fact that they are
subject to large forces including eccentric contractions. Patellar anastomosis
VASCULAR SUPPLY AND LYMPHATIC DRAINAGE
Patellar ligament
Iliac vessels and external iliac arteries
and veins
Fig. 80.31 The left femoral triangle. (With permission from Waschke J,
The iliac vessels are described on page 1224, and the external iliac arter- Paulsen F (eds), Sobotta Atlas of Human Anatomy, 15th ed, Elsevier,
ies and veins on pages 1227 and 1228, respectively. Urban & Fischer. Copyright 2013.)


Pelvic girdle, gluteal region and thigh
1368
9
noitceS
Femoral artery Obturator nerve
Lateral femoral
Obturator nerve cutaneous nerve Long saphenous External iliac vein
Acetabular branch of vein External iliac artery
obturator artery Medial circumflex Femoral nerve
femoral artery
Anterior branch of Femoral nerve lliacus
obturator artery
Obturator nerve Profunda femoris
Iliopsoas
Obturator nerve artery
Obturator artery Ascending
Medial circumflex
branch
femoral artery Lateral circumflex
Femoral vein Lateral
femoral artery
Pectineus circumflex
Profunda
femoral
Profunda femoris vein
artery
femoris artery
Adductor brevis
Sartorius Adductor Descending
longus branch
Descending branch
Femoral vein of lateral circumflex Muscular branches
Perforating artery of femoral nerve
femoral artery
Femoral artery Rectus femoris
Cutaneous branch of
obturator nerve Rectus femoris Adductor longus
Perforating artery
Saphenous nerve
Femoral vein
Anteromedial Muscular branch of Gracilis
intermuscular septum femoral nerve Vastus lateralis
(subsartorial fascia) Adductor magnus
Muscular branch
Gracilis Femoral artery of femoral nerve
Adductor hiatus
Rectus femoris
Descending
Saphenous nerve
genicular artery, Vastus medialis
saphenous branch
Sartorius Vastus medialis Saphenous nerve
Sartorius
Articular branch of
descending
genicular artery
Descending genicular artery,
articular branches
Superior medial
genicular artery
Popliteal
artery
Genicular anastomosis
Inferior medial
genicular artery
Fig. 80.32 The neurovascular structures of the anteromedial thigh. (With Fig. 80.33 The neurovascular structures of the anterior thigh. This is a
permission from Waschke J, Paulsen F (eds), Sobotta Atlas of Human deeper dissection than is shown in Figure 80.32. (With permission from


Anatomy, 15th ed, Elsevier, Urban & Fischer. Copyright 2013.) Waschke J, Paulsen F (eds), Sobotta Atlas of Human Anatomy, 15th ed,
Elsevier, Urban & Fischer. Copyright 2013.)
iliac spine and the pubic symphysis, descends along the anteromedial
part of the thigh in the femoral triangle, enters and passes through the to the medial side. Posteriorly, the posterior wall of the femoral sheath
adductor (subsartorial) canal, and becomes the popliteal artery as it separates the artery from the tendons of psoas, pectineus and adductor
passes through an opening in adductor magnus near the junction of longus. The artery is separated from the hip joint by the tendon of psoas
the middle and distal thirds of the thigh. Its first 3 or 4 cm are enclosed, major, from pectineus by the femoral vein and deep femoral vessels,
with the femoral vein, in the femoral sheath. The femoral artery gives and from adductor longus by the femoral vein. Proximally, the nerve
off several branches in the proximal thigh, including the superficial to pectineus passes medially behind the artery. The femoral nerve lies
epigastric, superficial circumflex iliac, superficial external pudendal, lateral to the artery, outside the femoral sheath. The femoral vein is
deep external pudendal and the profunda femoris artery. It gives off the medial to the artery in the proximal part of the triangle and becomes
descending genicular artery within the adductor canal. posterior distally at the apex.
Rarely, the femoral artery divides, distal to the origin of the profunda Within the adductor canal, the artery is covered by skin, subcutan-
femoris artery, into two trunks that reunite near the adductor opening. eous tissue, deep fascia, sartorius and the fibrous roof (subsartorial
The inferior gluteal artery, accompanying the sciatic nerve to the pop- fascia) of the canal. The saphenous nerve lies at first lateral, then ant-
liteal fossa and representing a persistence of the original axial artery, erior and finally medial to the artery. Adductor longus and adductor


may replace it. The external iliac artery is then small, ending as the deep magnus are posterior, vastus medialis and its nerve are anterolateral,
artery of the thigh. and the femoral vein is also posterior proximally but it becomes lateral
distally (see Figs 80.31–80.32; Fig. 80.33).
Relations
Compression of the femoral artery is most effective just distal to the
Anterior to the artery in the femoral triangle are the skin, subcutaneous inguinal ligament, where it is superficial and separated from the bone
tissue, superficial inguinal lymph nodes, fascia lata, femoral sheath, (iliopubic ramus) only by the psoas tendon. For this reason, arterial
superficial circumflex iliac vein (crossing in the subcutaneous tissue) injury proximal to the inguinal ligament, such as laceration by a knife,
and the femoral branch of the genitofemoral nerve (which is at first cannot be controlled simply by compression. Gaining proximal control
lateral and then anterior). Near the apex of the triangle, the medial of bleeding involves major exposure of the more proximal arteries as a
femoral cutaneous nerve crosses in front of the artery from the lateral life-saving manœuvre.


vascular supply and lymphatic drainage
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Branches Lateral circumflex femoral artery The lateral circumflex femoral
The branches of the femoral artery include the superficial epigastric, artery (see Figs 80.32–80.33) is a laterally running branch given off near
superficial circumflex iliac, superficial external pudendal, deep external the root of the profunda femoris artery. It passes between the divisions
pudendal arteries, muscular branches, the profunda femoris artery and of the femoral nerve, posterior to sartorius and rectus femoris, and
the descending genicular artery (see Fig. 78.4). divides into ascending, transverse and descending branches. The ascend-
ing branch ascends along the intertrochanteric line, under tensor fasciae
Superficial epigastric artery latae, lateral to the hip joint. It anastomoses with the superior gluteal
The superficial epigastric artery arises anteriorly from the femoral artery and deep circumflex iliac arteries, supplying the greater trochanter, and,
approximately 1 cm distal to the inguinal ligament, and traverses the with branches of the medial circumflex femoral, forms an anastomotic
cribriform fascia to ascend anterior to the ligament and run in the ring round the femoral neck, from which the femoral neck and head
abdominal subcutaneous tissue almost to the umbilicus. It supplies are supplied. The ascending branch forms the pedicle of the tensor
the superficial inguinal lymph nodes, subcutaneous tissue and skin, and fasciae latae musculocutaneous flap. The descending branch descends
anastomoses with branches of the inferior epigastric artery and its con- posterior to rectus femoris, along the anterior border of vastus lateralis,
tralateral fellow. which it supplies; a long branch descends in vastus lateralis to the knee,
anastomosing with the superior lateral genicular branch of the popliteal
Superficial circumflex iliac artery artery, accompanied by the nerve to vastus lateralis. The fasciocutaneous
The superficial circumflex iliac artery is the smallest superficial branch perforators that arise from the descending branch supply the antero-


of the femoral artery and arises near or with the superficial epigastric lateral thigh fasciocutaneous flap. The transverse branch, the smallest,
artery. It usually emerges through the fascia lata, lateral to the saphen- passes laterally anterior to vastus intermedius and pierces vastus latera-
ous opening, and turns laterally distal to the inguinal ligament towards lis to wind round the femur, just distal to the greater trochanter. It
the anterior superior iliac spine. It supplies the skin, subcutaneous anastomoses with the medial circumflex, inferior gluteal and first per-
tissue and superficial inguinal lymph nodes, anastomosing with the forating arteries, forming a cruciate anastomosis.
deep circumflex iliac, superior gluteal and lateral circumflex femoral The lateral circumflex femoral artery may arise from the femoral
arteries. artery or as a common trunk with the profunda femoris artery and the
The superficial circumflex iliac artery is the basis for the important medial circumflex femoral artery. The ascending and descending
axial-pattern pedicled groin skin flap. Free flaps based on the vessel may branches may occasionally arise separately (Siddharth et al 1985).
also be raised.
Medial circumflex femoral artery The medial circumflex femoral
Superficial external pudendal artery artery (see Figs 80.32–80.33) usually originates from the posteromedial
The superficial external pudendal artery arises medially from the aspect of the profunda femoris artery, but sometimes originates from
femoral artery, close to the preceding branches. Emerging from the the femoral artery itself or as a common trunk with either the profunda
cribriform fascia, it passes medially, usually deep to the long saphenous femoris artery or the lateral circumflex femoral artery or both (Sid-
vein, across the spermatic cord (or round ligament) to supply the lower dharth et al 1985). It supplies the adductor muscles and curves medi-
abdominal, penile, scrotal or labial skin, and anastomoses with ally round the femur between pectineus and psoas major and then
branches of the internal pudendal artery. obturator externus and adductor brevis, finally appearing between


quadratus femoris and the upper border of adductor magnus, dividing
deep external pudendal artery into transverse and ascending branches. The transverse branch takes
The deep external pudendal artery passes medially across pectineus and part in the cruciate anastomosis. The ascending branch ascends on the
anterior or posterior to adductor longus, covered by fascia lata, which tendon of obturator externus, anterior to quadratus femoris, to the
it pierces to supply the skin of the perineum and scrotum or labium trochanteric fossa, where it anastomoses with branches of the gluteal
majus. Its branches anastomose with the posterior scrotal or labial and lateral circumflex femoral arteries. An acetabular branch at the
branches of the internal pudendal artery. proximal edge of adductor brevis enters the hip joint under the trans-
verse acetabular ligament with one from the obturator artery. It supplies
Muscular branches
the fat in the fossa and reaches the femoral head along its ligament. For
These branches supply sartorius, vastus medialis and the adductors. details of the blood supply of the proximal end of the femur, consult
Crock (1996).
Profunda femoris artery (deep artery of the thigh)
The profunda femoris artery (see Figs 80.2B, 80.25, 80.32–80.33) is a Perforating arteries The perforating arteries (see Fig. 80.25) perfo-
large branch that arises posterolaterally from the femoral artery about rate the femoral attachment of adductor magnus to reach the flexor
3.5 cm distal to the inguinal ligament. At first lateral to the femoral aspect of the thigh. There are three perforating branches, and the ter-
artery, it spirals posterior to this and the femoral vein to reach the minal part of the profunda femoris artery itself becomes the fourth
medial side of the femur. It passes between pectineus and adductor perforator. They pass close to the linea aspera under small tendinous
longus, then between the latter and adductor brevis, before it descends arches and give off muscular, cutaneous and anastomotic branches.


between adductor longus and adductor magnus. It pierces adductor Diminished, they pass deep to the short head of biceps femoris (the
magnus and anastomoses with the upper muscular branches of the first usually through the attachment of gluteus maximus), traverse the
popliteal artery. This terminal part is sometimes named the fourth lateral intermuscular septum and enter vastus lateralis. The first arises
perforating artery. proximal, the second anterior, and the third distal to adductor brevis.
The profunda femoris artery is the main supply to the adductor, The first perforating artery passes back between pectineus and adductor
extensor and flexor muscles, and also anastomoses with the internal brevis (sometimes through the latter), pierces adductor magnus near
and external iliac arteries above and with the popliteal artery below. the linea aspera to supply adductor brevis, adductor magnus, biceps
It is a major collateral artery of the lower limb in patients with femoro- femoris and gluteus maximus, and anastomoses with the inferior
popliteal arterial occlusive disease (see Fig. 80.33) (Shakeri et al gluteal, medial and lateral circumflex femoral and second perforating
2010). arteries. The larger second perforating artery, often arising with the first,
The profunda femoris artery sometimes arises from the posterior pierces the attachments of adductor brevis and magnus, divides into
aspect of the femoral artery, and more rarely from the medial aspect. If the ascending and descending branches supplying the posterior thigh
it arises posteriorly, it may cross anterior to the femoral vein and then muscles and anastomoses with the first and third perforating arteries.
pass backwards around its medial side. The femoral nutrient artery usually arises from it. When two nutrient
arteries exist, they usually arise from the first and third perforators. The
Relations third perforating artery starts distal to adductor brevis, pierces the
Posteriorly, in proximodistal order, lie iliacus, pectineus, adductor attachment of adductor magnus and divides into branches to the pos-
brevis and adductor magnus. Anteriorly, the femoral and deep femoral terior thigh muscles. It anastomoses proximally with the perforating


veins, and distally, adductor longus, separate the profunda femoris arteries, and distally with the end of the profunda femoris artery and
artery from the femoral artery. Laterally, vastus medialis separates the muscular branches of the popliteal. The femoral nutrient artery may
proximal part of the artery from the femur. arise from it. Side branches of the diaphysial nutrient and other
branches of the profunda femoris artery provide subsidiary cortical
Branches arteries.
The profunda femoris artery gives off the lateral and medial circumflex The perforating arteries form a double chain of anastomoses,
arteries in the proximal thigh, and perforating and muscular branches initially in the adductor muscles and subsequently near the linea
more distally. aspera.


Pelvic girdle, gluteal region and thigh
1370
9
noitceS
Muscular branches Numerous muscular branches arise from the Perforator flaps in the hip and thigh
profunda femoris artery. Some end in the adductors, and others pierce
adductor magnus, supply the flexors and anastomose with the medial Gluteal region
circumflex femoral artery and superior muscular branches of the pop-
The gluteal region of the lower limb has an average of 21 perforators,
liteal artery. The profunda femoris artery is thus the main supply to the
which arise from three main source arteries: namely, the superior and
thigh muscles.
inferior gluteal and the internal pudendal arteries (see Fig. 78.7). The
descending genicular artery flaps based on these perforators are used as free flaps for breast recon-
struction and as local flaps for covering defects in the sacral and perineal
The descending genicular artery (see Figs 82.1, 80.32–80.33), the distal
region.
branch of the femoral artery, arises just proximal to the adductor
opening and immediately supplies a saphenous branch. It then descends Hip and thigh region
in vastus medialis, anterior to the tendon of adductor magnus, to
The hip and thigh region has six source arteries and an average of 50
the medial side of the knee, where it anastomoses with the superior
arterial perforators. The thigh can be divided into four areas: antero-
medial genicular artery. Muscular branches supply vastus medialis and
medial; anterolateral and trochanteric; posteromedial; and posterola-
adductor magnus, and give off articular branches that anastomose
teral. The perforators that supply the anteromedial thigh are derived
round the knee joint. One articular branch crosses above the femoral
from the femoral artery, and those for the anterolateral thigh are derived
patellar surface, forming an arch with the superior lateral genicular
from branches of the lateral circumflex femoral artery. Perforators that
artery and supplying the knee joint. The saphenous branch (saphe nous
supply the skin over the posteromedial and posterolateral thigh regions


artery) emerges distally through the roof of the adductor canal to
are derived from the profunda femoris artery and the popliteal arteries.
accompany the saphenous nerve to the medial side of the knee. It passes
Skin flaps based on the superficial circumflex iliac, superficial external
between sartorius and gracilis, and supplies the skin of the proximome-
pudendal and superficial inferior epigastric arteries have been used as
dial area of the leg; it anastomoses with the inferior medial genicular
local flaps, tube pedicles and free tissue transfers. Other popular skin
artery.
flaps are TFL (tensor fasciae latae) perforator flaps, ALT (anterolateral
thigh) and AMT (anteromedial thigh) flaps, gracilis perforator flap and
Arterial anastomoses around the hip
posterior thigh flaps.
In the fetus, a peri-acetabular vascular circle formed by the superior and
inferior gluteal, internal pudendal and obturator arteries reduces the VEINS
risk of bony necrosis of this region in children. However, there is a zone
at the anterior portion of the acetabulum where the blood supply is Femoral vein
less abundant (Damsin et al 1992).
Anastomoses on the back of the thigh The femoral vein accompanies its artery, beginning at the adductor
opening as the continuation of the popliteal vein, and ending posterior
An important chain of anastomoses extends on the back of the
to the inguinal ligament as the external iliac vein (see Figs 78.8, 80.1–
thigh from the gluteal region to the popliteal fossa. It is formed in
80.3, 80.31). The vein is posterolateral to the femoral artery in the distal
proximodistal order by anastomoses between the gluteal arteries and
adductor canal. More proximally in the canal, and in the distal femoral
terminal branches of the medial circumflex femoral artery; the circum-
triangle (i.e. at its apex), the vein lies posterior to the artery and proxi-
flex femoral arteries and the first perforating artery; the perforating
mally, at the base of the triangle, the vein lies medial to the artery. The


arteries themselves; and between the fourth perforating artery and the
vein occupies the middle compartment of the femoral sheath, between
superior muscular branches of the popliteal artery (see Fig. 80.18). The
the femoral artery and femoral canal; fat in the canal permits expansion
trochanteric and cruciate anastomoses are the proximal elements of this
of the vein.
chain.
The femoral vein has numerous muscular tributaries. The profunda
femoris vein (deep vein of the thigh, deep femoral vein) joins the
trochanteric anastomosis
femoral vein posteriorly 4–12 cm distal to the inguinal ligament, and
The so-called trochanteric anastomosis lies near the trochanteric fossa
the long saphenous vein then enters anteriorly. Veins accompanying the
of the femur and is an anastomosis between the ascending branch of
superficial epigastric, superficial circumflex iliac and external pudendal
the medial circumflex femoral artery and descending branches of the
arteries join the long saphenous vein before it enters the saphenous
superior and inferior gluteal arteries (see Fig. 80.18). The lateral cir-
opening. Lateral and medial circumflex femoral veins are usually tribu-
cumflex femoral artery and the first perforating artery from the pro-
taries of the femoral vein. There are usually four or five valves in the
funda femoris artery may also contribute, creating an extracapsular
femoral vein; the two most constant are just distal to the entry of pro-
‘arterial ring of the femoral neck’ (Crock 1996). Branches from this
funda femoris and near the inguinal ligament.
ring, the retinacular vessels, pierce the capsule and ascend along the
femoral neck to give the main blood supply to the head of the Profunda femoris vein (Deep vein of the thigh)
femur.
Profunda femoris lies anterior to its artery and receives tributaries cor-
responding to the branches of the artery. Through these tributaries it
cruciate anastomosis
connects distally with the popliteal vein and proximally with the infe-


The cruciate anastomosis lies at the level of the lesser trochanter,
rior gluteal veins. It sometimes drains the medial and lateral circumflex
near the lower edge of the femoral attachment of quadratus femoris,
femoral veins and has a valve just before it empties into the femoral
and is an anastomosis between the transverse branches of the medial
vein.
and lateral circumflex femoral arteries, a descending branch of the
inferior gluteal artery and an ascending branch from the first perforating Long saphenous vein
artery. The long saphenous vein (great saphenous vein) (see Fig. 78.9A), the
longest vein in the body, starts distally as a continuation of the medial
Collateral circulation in proximal femoral
marginal vein of the foot, and ends in the femoral vein a short dis-
artery occlusion
tance distal to the inguinal ligament. It ascends immediately anterior
After occlusion of the femoral artery proximal to the origin of the pro- to the tibial malleolus, crosses the distal third of the medial surface of
funda femoris artery, five main anastomotic channels are available. the tibia obliquely in an anteroposterior direction to reach its medial
These are between branches of the superior and inferior gluteal arteries, border, and then ascends a little behind the border to the knee. Proxi-
the medial and lateral circumflex femoral arteries and the first perforat- mally, it is posteromedial to the medial tibial and femoral condyles
ing branch of the profunda femoris artery; the obturator branch of the (lying the breadth of the subject’s hand posterior to the medial edge
internal iliac artery and the medial circumflex femoral artery; the inter- of the patella), and then ascends the medial aspect of the thigh. It
nal pudendal branch of the internal iliac artery and the superficial and passes through the saphenous opening and finally opens into the
deep external pudendal branches of the femoral artery; a deep circum- femoral vein. The ‘centre’ of the opening is often said to be 2.5–3.5 cm


flex iliac branch of the external iliac artery, the lateral circumflex femoral inferolateral to the pubic tubercle, and the vein is then represented
branch of the deep artery of the thigh and the superficial circumflex by a line drawn from this point to the adductor tubercle. However,
iliac branch of the femoral artery; and the inferior gluteal branch of the the saphenous opening varies greatly in size and disposition so that
internal iliac artery and perforating branches of the profunda femoris this ‘centre’ is not a reliable surface marking for the saphenofemoral
artery. junction.


innervation
1371
08
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In its course through the thigh, the long saphenous vein is accom- nodes along the termination of the long saphenous vein. They receive
panied by the medial branches of the anterior cutaneous branches of all the superficial vessels of the lower limb, except those from the pos-
the femoral nerve. At the knee, the saphenous branch of the descending terolateral calf. All superficial inguinal nodes drain to the external iliac
genicular artery (the saphenous artery) and, in the leg and foot, the nodes, some via the femoral canal and others anterior or lateral to the
saphenous nerve all lie anterior to the vein. The vein is often duplicated, femoral vessels. Numerous vessels interconnect individual nodes.
especially distal to the knee. It has 10–20 valves, which are more numer- Superficial inguinal nodes are frequently enlarged in disease or
ous in the leg than in the thigh. One is present just before the vein injury in their region of drainage. Thus the proximal inguinal nodes are
pierces the cribriform fascia, another at its junction with the femoral almost invariably affected in malignant or infective disease of the
vein. In almost its entire extent the vein lies in subcutaneous tissue, but prepuce, penis, labia majora, scrotum, perineum, anus and lower
it has many connections with the deep veins, especially in the leg. vagina, or in diseases affecting the skin and superficial structures in
these regions, in the infra-umbilical part of the abdominal wall or in
tributaries the gluteal region. The distal group is implicated only in disease or
At the ankle, the long saphenous vein drains the sole by medial mar- injury of the limb.
ginal veins. In the leg, it often connects with the short saphenous vein
and with deep veins via perforating veins. Just distal to the knee, it Deep inguinal nodes
usually receives three large tributaries from the front of the leg, the tibial
malleolar region (connecting with some of the ‘perforating’ veins) and The deep inguinal nodes vary from one to three, and are situated medial


the calf (communicating with the short saphenous vein). The tributary to the femoral vein. One lies just distal to the saphenofemoral junction,
draining the tibial malleolar region is formed distally from a fine another in the femoral canal, and the most proximal node lies laterally
network or ‘corona’ of delicate veins over the medial malleolus, and in the femoral ring. The middle node is the most inconstant and the
then ascends the medial aspect of the calf as the posterior arch vein proximal node is often absent. All receive deep lymphatics that accom-
(Dodd and Cockett 1976). This vein was first illustrated by Leonardo pany the femoral vessels, lymph vessels from the glans penis or clitoris
da Vinci, whose name is sometimes given to it. It connects with poste- and a few efferents from the superficial inguinal nodes. Their own
rior tibial venae comitantes by a series of perforating (communicating) efferents traverse the femoral canal to the external iliac nodes.
veins. There are usually three, equally spaced between the medial malle-
olus and the mid-calf. More than three such perforators are uncommon,
and an arch vein perforator above mid-calf is only very rarely found. INNERVATION
Above the posterior crural arch vein, perforating veins join the long
saphenous vein or one of its main tributaries at two main sites. The first LUMBAR PLEXUS AND BRANCHES
is at a level in the upper calf indicated by its name, the tibial tubercle
perforator; the second is in the lower/intermediate third of the thigh, The lumbar plexus is formed by the first three and most of the fourth
where it perforates the deep fascia roof of the subsartorial canal to join lumbar ventral rami (see Fig. 62.15). The iliohypogastric, ilioinguinal
the femoral vein. and genitofemoral nerves are described on pages 1094–1096.
In the thigh, the long saphenous vein receives many tributaries.
Some open independently, while others converge to form large named Lateral femoral cutaneous nerve
channels that frequently pass towards the basal half of the femoral
triangle before joining the long saphenous near its termination. These


The lateral femoral cutaneous nerve (lateral cutaneous nerve of the
may be grouped as follows: one or more large posteromedial tributaries,
thigh) arises from the dorsal branches of the second and third lumbar
one or more large anterolateral tributaries, and four or more peri-
ventral rami and emerges from the lateral border of psoas major, cross-
inguinal veins. The posteromedial vein of the thigh, large and some-
ing iliacus obliquely towards the anterior superior iliac spine. It supplies
times double, drains a large superficial region indicated by its name; it
the parietal peritoneum in the iliac fossa. The right nerve passes poste-
has (as have the other tributaries) radiological and surgical significance.
rolateral to the caecum, separated from it by the fascia iliaca and peri-
One of its lower radicles is often continuous with the short saphenous
toneum; the left passes behind the lower part of the descending colon.
vein. The posteromedial vein is sometimes named the accessory saph-
Both pass behind or through the inguinal ligament, variably medial to
enous vein, though some restrict the term accessory to a lower (more
the anterior superior iliac spine (commonly 1 cm) and anterior to or
distal) posteromedial tributary when two (or more) are present. Another
through sartorius into the thigh, where they divide into anterior and
large vessel, the anterolateral vein of the thigh (anterior femoral cutan-
posterior branches. The anterior branch becomes superficial approxi-
eous vein), usually commences from an anterior network of veins in
mately 10 cm distal to the anterior superior iliac spine and supplies the
the distal thigh and crosses the apex and distal half of the femoral tri-
skin of the anterior and lateral thigh as far distally as the knee. It con-
angle to reach the long saphenous vein. As the latter traverses the
nects terminally with the cutaneous branches of the anterior division
saphenous opening, it is joined by the superficial epigastric, superficial
of the femoral nerve and the infrapatellar branch of the saphenous
circumflex iliac and superficial external pudendal veins. Their mode of


nerve, forming the peripatellar plexus. The posterior branch pierces the
union varies. Superficial epigastric and circumflex iliac veins drain the
fascia lata higher than the anterior, and divides to supply the skin on
inferior abdominal wall, the latter also receiving tributaries from the
the lateral surface from the greater trochanter to about mid-thigh. It
proximolateral region of the thigh. The superficial epigastric or the
may also supply skin of the gluteal region.
femoral vein may connect with the lateral thoracic veins by means of a
thoracoepigastric vein that runs superficially on the anterolateral aspect lesions of the lateral femoral cutaneous nerve
of the trunk. This vein connects the inferior and superior caval areas of The lateral femoral cutaneous nerve may become entrapped at three
drainage and may be dilated and visible in cases of inferior caval sites along its course: close to the vertebral column; within the abdomi-
obstruction. Superficial external pudendal veins drain part of the nal cavity as the nerve travels across the pelvis; and as it leaves the pelvis.
scrotum/labia; one is joined by the superficial dorsal vein of the penis/ This last site is where the nerve is most commonly damaged, and
clitoris. The deep external pudendal veins join the long saphenous vein entrapment is thought to occur as the nerve passes through or deep to
at the saphenous opening. the inguinal ligament just medial to the anterior superior iliac spine.
The long saphenous vein is often harvested for grafts used in both The angulation of the nerve as it crosses the iliac crest means that it is
peripheral and coronary arterial surgery. vulnerable to compression during movement, e.g. hip extension may
increase angulation and tension on the nerve.
Injury produces an area of impaired sensation, often with pain and
LYMPHATIC DRAINAGE
paraesthesia on the anterolateral aspect of the thigh (meralgia paraes-
thetica) in the distal cutaneous distribution of the nerve. This area does
Superficial inguinal nodes
not extend across the midline anteriorly, it does not extend below the
knee and it does not extend behind the hamstring tendons laterally.


The superficial inguinal nodes form proximal and distal groups. The Symptoms may be exacerbated when wearing tight belts or tight-waisted
proximal group usually consists of five or six nodes just distal to the clothes or as a result of a recent weight gain or pregnancy. Exceptionally,
inguinal ligament. Its lateral members receive afferent vessels from the posterior branch of the lateral femoral cutaneous nerve, which sup-
the gluteal region and the adjoining infra-umbilical anterior abdominal plies a thin strip from the greater trochanter of the femur down about
wall. Medial members receive superficial vessels from the external geni- two-thirds of the way to the knee, may be affected separately. This
talia (including the inferior vagina), inferior anal canal and perianal branch leaves the main trunk of the nerve, usually distal to the inguinal
region, adjoining abdominal wall, umbilicus and vessels accompanying ligament, and it then turns laterally to pierce tensor fasciae latae, where
the round ligament. The distal group usually consists of four or five it may become entrapped.


Pelvic girdle, gluteal region and thigh
1372
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noitceS
Femoral nerve lesions of the femoral nerve
The main trunk of the femoral nerve is not subject to an entrapment
The femoral nerve is the largest branch of the lumbar plexus and arises neuropathy, but it may be compressed by retroperitoneal tumours or
from the dorsal branches (posterior divisions) of the second to fourth retroperitoneal haemorrhage in patients on anticoagulants or with a
lumbar ventral rami (see Figs 78.11A, 80.31–80.33). It descends through bleeding diathesis. A localized lesion of the femoral nerve may occur
psoas major, emerging low on its lateral border, and then passes in diabetes mellitus (one of the forms of diabetic amyotrophy). The
between psoas and iliacus, deep to the iliac fascia. Passing behind the most striking feature of femoral neuropathy is wasting and weakness of
inguinal ligament into the thigh, it is split into anterior and posterior quadriceps femoris, which results in considerable difficulty in walking
divisions by the lateral circumflex femoral artery. Behind the inguinal and a tendency for the leg to collapse. Pain and paraesthesia may occur
ligament, it is separated from the femoral artery by part of psoas major. on the anterior and medial aspect of the thigh, extending down the
In the abdomen, the nerve supplies small branches to iliacus and medial aspect of the leg in the distribution of the saphenous branch of
pectineus and a branch to the proximal part of the femoral artery; the the femoral nerve.
latter branch sometimes arises in the thigh.
Obturator nerve
nerve to pectineus
The nerve to pectineus branches from the medial side of the femoral The obturator nerve arises from the ventral branches of the second to
nerve near the inguinal ligament. It passes behind the femoral sheath fourth lumbar ventral rami. The branch from the third is the largest
and enters the anterior aspect of the muscle. while that from the second is often very small. The nerve descends in
psoas major, emerging from its medial border at the pelvic brim to pass


anterior division of the femoral nerve behind the common iliac vessels and lateral to the internal iliac vessels.
The anterior division of the femoral nerve supplies intermediate and It then descends forwards along the lateral wall of the lesser pelvis on
medial femoral cutaneous nerves and branches to sartorius. obturator internus, anterosuperior to the obturator vessels, to the obtu-
rator foramen, entering the thigh by its upper part. Near the foramen,
Medial femoral cutaneous nerve of the thigh The medial it divides into anterior and posterior branches, separated at first by part
of obturator externus and lower down by adductor brevis.
femoral cutaneous nerve (medial cutaneous nerve of the thigh) is at
first lateral to the femoral artery. It crosses ant erior to the artery at the anterior branch
apex of the femoral triangle and divides into anterior and posterior
The anterior branch (see Fig. 80.33) leaves the pelvis anterior to obtur-
branches. Before doing so, it sends a few rami through the fascia lata
ator externus, descending in front of adductor brevis, behind pectineus
to supply the skin of the medial side of the thigh, near the long saphe-
and adductor longus. At the lower border of adductor longus it com-
nous vein; one ramus emerges via the saphe nous opening, while
municates with the medial cutaneous and saphenous branches of the
another becomes subcutaneous about mid-thigh. The anterior branch
femoral nerve, to form a subsartorial plexus that supplies the skin on
descends on sartorius, perforates the fascia lata beyond mid-thigh, and
the medial side of the thigh (see below). It descends on, and supplies,
divides into a branch that supplies the skin as low as the medial side
the femoral artery. Near the obturator foramen, the anterior branch
of the knee, and another that runs lateral to the former and connects
supplies the hip joint. Behind pectineus it supplies adductor longus,
with the infrapatellar branch of the saphenous nerve. The posterior
gracilis, usually adductor brevis and often pectineus, and connects with
branch descends along the posterior border of sartorius to the knee,


the accessory obturator nerve (when present). Occasionally, the com-
pierces the fascia lata, connects with the saphenous nerve and gives off
municating branch to the femoral medial cutaneous and saphenous
several cutaneous rami, some as far as the medial side of the leg. The
branches continues as a cutaneous branch to the thigh and leg. When
nerve contributes to the subsartorial plexus (see below).
this occurs, the nerve emerges from behind the distal border of adductor
longus to descend along the posterior margin of sartorius to the knee,
Intermediate cutaneous nerve of the thigh The intermediate where it pierces the deep fascia and connects with the saphenous nerve
femoral cutaneous nerve (intermediate cutaneous nerve of the thigh) to supply the skin halfway down the medial side of the leg.
usually pierces the fascia lata some 8 cm below the inguinal ligament,
either as two branches or as one trunk that quickly divides into two. Subsartorial nerve plexus The medial cutaneous nerve of the
These descend on the front of the thigh, supplying the skin as far as the thigh forms a subsartorial plexus with branches of the saphenous and
knee and ending in the peripatellar plexus. The lateral branch of the obturator nerves, deep to the fascia lata, at the lower border of adductor
intermediate cutaneous nerve communicates with the femoral branch longus. When the communicating branch of the obturator nerve is large
of the genitofemoral nerve, frequently piercing sartorius and sometimes and reaches the leg, the posterior branch of the medial cutaneous nerve
supplying it. is small, and ends in the plexus from which it gives rise to a few cutan-
eous filaments.
Nerve to sartorius The main nerve to sartorius arises from the
Posterior branch
femoral nerve in common with the intermediate cutaneous nerve of the
thigh. The posterior branch pierces obturator externus anteriorly, supplies it
and passes behind adductor brevis to the front of adductor magnus,
Posterior division of the femoral nerve dividing into branches to this and adductor brevis when the latter is
not supplied by the anterior division. It usually sends an articular fila-
The branches of the posterior division of the femoral nerve are the


ment to the knee joint, which either perforates adductor magnus dis-
saphenous nerve and branches to quadriceps femoris and the knee joint.
tally or traverses its opening with the femoral artery to enter the
popliteal fossa. Within the fossa, the nerve descends on the popliteal
Saphenous nerve See page 1399.
artery to the back of the knee, pierces its oblique posterior ligament and
supplies the articular capsule. It gives filaments to the popliteal artery.
Muscular branches The muscular branches of the posterior divi-
sion of the femoral nerve supply quadriceps femoris. A branch to rectus lesions of the obturator nerve
femoris enters its proximal posterior surface and also supplies the hip Isolated lesions of the obturator nerve are extremely rare, but may
joint. A larger branch to vastus lateralis forms a neurovascular bundle occasionally occur as a result of direct trauma (sometimes during par-
with the descending branch of the lateral circumflex femoral artery in turition) or in anterior dislocations of the hip. The nerve may also be
its distal part and also supplies the knee joint. A branch to vastus damaged by an obturator hernia, or be involved together with the
medialis descends through the proximal part of the adductor canal, femoral nerve in retroperitoneal lesions that occur close to the origins
lateral to the saphenous nerve and femoral vessels, and enters the of the lumbar plexus. Compression of the nerve by herniated bowel
muscle at about its midpoint, sending a long articular filament distally loops at the obturator foramen can result in pain referred to the hip,
along the muscle to the knee. Two or three branches to vastus inter- medial thigh and knee, the so-called Howship–Romberg sign. A more
medius enter its anterior surface about mid-thigh; a small branch from distal nerve entrapment syndrome causing chronic medial thigh pain
one of these descends through the muscle to supply articularis genus has been described in athletes with large adductor muscles.
and the knee joint.
Accessory obturator nerve
vascular branches
Vascular branches of the femoral nerve supply the femoral artery and Occasionally present, the accessory obturator nerve is small and arises
its branches. from the ventral branches of the third and fourth lumbar ventral rami.


innervation
1373
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retPahc
Table 80.1 The branches of the sacral plexus
Ventral divisions Dorsal divisions
Nerve to quadratus femoris and gemellus L4, 5, S1
inferior
Nerve to obturator internus and gemellus L5, S1, 2
superior
Greater sciatic foramen
Nerve to piriformis (L5), S1, 2
Superior gluteal L4, 5, S1 Sciatic nerve
Posterior femoral
Inferior gluteal L5, S1, 2
cutaneous nerve
Posterior femoral cutaneous S2, 3 S1, 2
Tibial (sciatic) L4, 5, S1, 2, 3
Common fibular (sciatic) L4, 5, S1, 2 Inferior clunial nerves
Perforating cutaneous S2, 3 Perineal branches of
Common fibular nerve posterior femoral cutaneous nerve
Pudendal S2, 3, 4
Tibial nerve
Branches to levator ani, coccygeus and S4
external anal sphincter Adductor magnus
(also partially supplied
by obturator nerve)
It descends along the medial border of psoas major, crosses the superior Long head of
pubic ramus behind pectineus and divides into branches; one branch biceps femoris
enters the deep surface of pectineus, another supplies the hip joint, and
a third connects with the anterior branch of the obturator nerve. Some-
times the accessory obturator nerve is very small and only supplies
pectineus. Any branch may be absent and others may occur; an addi-
tional branch sometimes supplies adductor longus. Semitendinosus
Short head of
biceps femoris
SACRAL PLEXUS AND BRANCHES
Long head of
The branches of the sacral plexus (see Fig. 78.11B) are shown in biceps femoris
Table 80.1.
Semimembranosus
Sciatic nerve Tibial nerve Articular branch
The sciatic nerve is 2 cm wide at its origin and is the thickest nerve in Plantaris


the body. It leaves the pelvis via the greater sciatic foramen below piri-
formis and descends between the greater trochanter and ischial tuberos- Lateral sural
ity, along the back of the thigh, dividing into the tibial and common cutaneous nerve
fibular nerves at a varying level proximal to the knee (Fig. 80.34; see Medial sural cutaneous nerve
Fig. 78.11B). Superiorly, it lies deep to gluteus maximus, resting first on
the posterior ischial surface with the nerve to quadratus femoris between Sural communicating
them. It then crosses posterior to obturator internus, the gemelli and branch
quadratus femoris, separated by the latter from obturator externus and
the hip joint. It is accompanied medially by the posterior femoral cuta-
neous nerve and the inferior gluteal artery. More distally, it lies behind Gastrocnemius
adductor magnus and is crossed posteriorly by the long head of biceps
femoris. Its course corresponds to a line drawn from just medial to the
midpoint between the ischial tuberosity and greater trochanter to the
apex of the popliteal fossa. Sural nerve
Articular branches arise proximally to supply the hip joint through
its posterior capsule; these are sometimes derived directly from the
sacral plexus. Muscular branches are distributed to biceps femoris,
semitendinosus, semimembranosus and the ischial part of adductor Soleus
magnus.
The point of division of the sciatic nerve into its tibial and common
fibular components is very variable. The common site is at the junction
of the middle and lower thirds of the thigh, near the apex of the pop-
liteal fossa, but the division may occur at any level above this point
Lateral calcaneal branches Tibial nerve
and, rarely, may occur below it.
Medial calcaneal branches
Blood supply to the sciatic nerve
In the gluteal region, the sciatic nerve is supplied by the inferior gluteal Lateral dorsal cutaneous nerve
Medial and lateral plantar nerves
artery and cruciate anastomosis (the medial and lateral circumflex
femoral arteries, inferior gluteal artery and the first perforating branch


of the profunda femoris artery) (see Fig. 80.30). On rare occasions, it
is supplied by branches from the superior gluteal or internal pudendal
arteries, which reach the nerve on its medial side. Lower in the thigh,
arterial branches derived from the perforating branches of the profunda
femoris artery or the anastomotic chain between them or, occasionally,
from the popliteal artery, enter the nerve on its lateral or anterolateral
side (Sunderland 1945). The numerous arterial branches to the sciatic
nerve anastomose with each other to form extraneural and intraneural Fig. 80.34 The sciatic nerve and its branches, posterior view.
arterial chains (Sunderland 1945, Ugrenovic et al 2013).
lesions of the sciatic nerve
The sciatic nerve supplies the knee flexors and all the muscles below
the knee, which means that a complete palsy of the sciatic nerve results
in a flail foot and severe difficulty in walking. Fortunately, complete


Pelvic girdle, gluteal region and thigh
1374
9
noitceS
sciatic nerve palsy is very rare. The nerve is vulnerable in posterior dis- Nerve to obturator internus
location of the hip. As it leaves the pelvis, it passes either behind piri-
formis or sometimes through the muscle, and at that point it may very
The nerve to obturator internus arises from the ventral branches of the
rarely become entrapped or tethered; the piriformis syndrome is a
fifth lumbar and first and second sacral ventral rami. It leaves the pelvis
controversial condition in which an anomalous relationship between
via the greater sciatic foramen below piriformis, supplies a branch to
piriformis and the sciatic nerve is thought to cause pain in the buttocks
the upper posterior surface of gemellus superior, crosses the ischial
and along the course of the sciatic nerve. External compression over the
spine lateral to the internal pudendal vessels, re-enters the pelvis via the
buttock, e.g. in patients who lie immobile on a hard surface for a con-
lesser sciatic foramen, and enters the pelvic surface of obturator
siderable length of time, can injure the nerve. However, the most
internus.
common cause of serious sciatic nerve injury (and of the resulting major
medicolegal claims) is iatrogenic (Dillow et al 2013). The nerve may
Posterior femoral cutaneous nerve (posterior
be damaged in misplaced therapeutic injections into gluteus maximus.
cutaneous nerve of the thigh)
Sciatic nerve palsy occurs after total hip replacement or similar surgery
in 1% of cases, and may be caused by sharp injury, burning from bone
cement, traction from instruments, manipulation of the hip, inadvert- The posterior femoral cutaneous nerve (posterior cutaneous nerve
ent lengthening of the femur, or haematoma surrounding the nerve. For of the thigh) arises from the dorsal branches of the first and second,
some reason, possibly anatomical, the common fibular component of and the ventral branches of the second and third sacral rami. It leaves
the sciatic nerve is more usually affected; the patient has a foot drop the pelvis via the greater sciatic foramen below piriformis and descends


and a high-stepping gait. under gluteus maximus with the inferior gluteal vessels, lying posterior
or medial to the sciatic nerve (see Fig. 80.30). It descends in the back
Inferior gluteal nerve of the thigh superficial to the long head of biceps femoris, deep to the
fascia lata. It pierces the deep fascia behind the knee and accompanies
the short saphenous vein to mid-calf, its terminal twigs connecting with
The inferior gluteal nerve arises from the dorsal branches of the fifth
the sural nerve. Its branches are cutaneous and are distributed to the
lumbar and first and second sacral ventral rami. It leaves the pelvis via
gluteal region, perineum, posterior thigh and proximal posterior leg.
the greater sciatic foramen below piriformis, and divides into branches
Three or four gluteal branches (inferior clunial nerves) curl round
that enter the deep surface of gluteus maximus (see Fig. 80.30).
the lower border of gluteus maximus to supply the skin over the infero-
lateral portion of the muscle. The perineal branch supplies the supero-
Superior gluteal nerve
medial skin in the thigh, curves forwards across the hamstrings below
the ischial tuberosity, pierces the fascia lata and then runs in the super-
The superior gluteal nerve arises from the dorsal branches of the fourth ficial perineal fascia to the scrotal or labial skin. It communicates with
and fifth lumbar and first sacral ventral rami. Accompanied by the the inferior rectal and posterior scrotal or labial branches of the perineal
superior gluteal vessels, the nerve leaves the pelvis via the greater sciatic nerve, and gives numerous branches to the skin of the back and medial
foramen above piriformis, and divides into superior and inferior side of the thigh, the popliteal fossa and the proximal part of the back
branches (see Fig. 80.30). The superior branch accompanies the upper of the leg. One study found the perineal branch of the posterior cutane-
branch of the deep division of the superior gluteal artery to supply ous nerve of the thigh in about one-half of specimens (Tubbs et al


gluteus medius and occasionally gluteus minimus. The inferior branch 2009).
runs with the lower ramus of the deep division of the superior gluteal
artery across gluteus minimus, supplies the glutei medius and minimus, Nerve to piriformis
and ends in tensor fasciae latae.
The nerve to piriformis usually arises from the dorsal branches of the
Pudendal nerve
first and second sacral ventral rami (sometimes only the second) and
enters the anterior surface of piriformis.
See Figure 62.15 and pages 1230 and 1236.
Visceral and pelvic muscular branches
Perforating cutaneous nerve
of sacral plexus
The perforating cutaneous nerve usually arises from the posterior
Visceral branches of the sacral plexus are described on page 1229. Pelvic
aspects of the second and third sacral ventral spinal rami. It pierces the
muscular branches are described on page 1221.
sacrotuberous ligament, curves round the inferior border of gluteus
maximus and supplies the skin over the inferomedial aspect of this
muscle. The nerve may arise from the pudendal nerve or it may be
absent, in which case it may be replaced either by a branch from the
posterior femoral cutaneous nerve or from the third and fourth, or Bonus e-book images
fourth and fifth, sacral ventral rami.
Nerve to quadratus femoris
Fig. 80.20 An ultrasound image of a 4-week-old baby taken in the
lateral position and demonstrating the cartilaginous femoral head
The nerve to quadratus femoris arises from the ventral branches of the and edge of the acetabulum.
fourth lumbar to the first sacral ventral rami. It leaves the pelvis via the
greater sciatic foramen below piriformis, descends on the ischium deep Fig. 80.21 A radiograph of the pelvis of a 9-month-old infant
to the sciatic nerve, the gemelli and the tendon of obturator internus, showing the centre of ossification of the femoral epiphysis.
and supplies gemellus inferior, quadratus femoris and the hip joint.
KEY REFERENCES


Dixon AF 1910 The architecture of the cancellous tissue forming the upper An analysis of over 8000 femora representing 100 human groups, which
end of the femur. J Anat Physiol 44:223–30. found a markedly lower average femoral neck-shaft angle of 127°.
A neglected and original work with far-reaching implications for the
Holm NJ 1980 The internal stress pattern of the os coxae. Acta Orthop Scand
understanding of femoral structure.
51:421–8.
Finnegan M 1978 Non-metric variation of the infracranial skeleton. J Anat Biomechanical information, relevant to the function of the hip and pelvis.
125:33–7.
Scheuer L, Black S 2004 The Juvenile Skeleton. London: Elsevier, Academic
A reference text for forensic and osteo-archaeological work.
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Gilligan I, Chandraphak S, Mahakkanukrauh P 2013 Femoral neck-shaft An invaluable reference to the skeleton of the juvenile. Relevant to the fields
angle in humans: variation relating to climate, clothing, lifestyle, sex, of anthropology, archaeology, anatomy, skeletal biology and forensic science.
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62–5.
Tubbs RS, Miller J, Loukas M et al 2009 Surgical and anatomical landmarks
An original study emphasizing the significance of the profunda femoris
for the perineal branch of the posterior femoral cutaneous nerve: impli-
artery as a collateral artery of the lower limb.
cations in perineal pain syndromes. Laboratory investigation. J Neuro-
Siddharth P, Smith NL, Mason RA et al 1985 Variational anatomy of the surg 111:332–5.
deep femoral artery. Anat Rec 212:206–9. A recent and original study on the perineal branch of the posterior femoral
A detailed study of the variations in the origin of the deep femoral artery cutaneous nerve.
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Whitehouse WJ 1977 Cancellous bone in the anterior part of the iliac crest.
Sunderland S 1945 Blood supply of the sciatic nerve and its popliteal divi- Calcif Tissue Res 23:67–76.
sions in man. Arch Neurol Psych 54:283–9. Detailed information on the internal structure of a site that is commonly
A neglected and original work with detailed information on the blood supply used for marrow biopsy.
of the sciatic nerve.
Taylor GI, Razaboni RM (eds) 1994 Michael Salmon: Anatomic Studies.
Book 1, Arteries of the Muscles of the Extremities and the Trunk.
St Louis: Quality Medical Publishing.


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Edinburgh: Elsevier, Churchill Livingstone.
Shakeri A, Tubbs RS, Shoja MM et al 2010 Analysis of the profunda femoris
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hood. Surg Radiol Anat 4:215–21. A neglected and original work with detailed information on the blood supply
Delaere O, Kok V, Nyssen-Behets C et al 1992 Ossification of the human of the sciatic nerve.
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Taylor GI, Razaboni RM (eds) 1994 Michael Salmon: Anatomic Studies.
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end of the femur. J Anat Physiol 44:223–30. St Louis: Quality Medical Publishing.
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Dodd H, Cockett FB 1976 The Pathology and Surgery of the Veins of the Trueta J 1957 The normal vascular anatomy of the femoral head during
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Emans JB, Ciarlo M, Callahan M et al 2005 Prediction of thoracic dimen- cations in perineal pain syndromes. Laboratory investigation. J Neuro-
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Whitehouse WJ 1977 Cancellous bone in the anterior part of the iliac crest.


Holm NJ 1980 The internal stress pattern of the os coxae. Acta Orthop Scand Calcif Tissue Res 23:67–76.
51:421–8. Detailed information on the internal structure of a site that is commonly
Biomechanical information, relevant to the function of the hip and pelvis. used for marrow biopsy.
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192–201.
1375.e1


CHAPTER
81
Hip
ligament. The acetabular labrum is triangular in section, attached by its
TOPOGRAPHY
base to the acetabular margin and blending with adjacent articular
cartilage; its acute free edge projects beyond the acetabular margin. The
The hip joint is a synovial joint of ball-and-socket (multiaxial spheroi- diameter of the acetabular cavity is constricted by the labral rim, which
dal) type between the head of the femur and the cup-shaped (cotyloid) embraces the femoral head, thereby contributing to the stability of the
acetabulum; its centre lies a little inferior to the middle one-third of the articulation. The acetabular labrum increases the surface area for joint
inguinal ligament. contact as well as sealing the joint, allowing optimal intra-articular
distribution of synovial fluid (Ferguson et al 2003, Cadet et al 2012). It
Articular surfaces thus facilitates nutrition of the articular cartilage and helps to reduce
intra-articular friction (Safran et al 2011, Song et al 2012). Nerve
endings found within the labrum suggest this structure may be a source
The femoral head can be landmarked from the surface roughly 2–4 cm
of proprioception or, when injured, of pain (Kim and Azuma 1995). A
superior to an approximate midpoint of a line joining the superior
torn acetabular labrum can be detected using MRI, to identify the site
margin of the greater trochanter to the pubic tubercle. The articular
and severity of the lesion (Fig. 81.2).
surfaces of the femoral head and the acetabulum are reciprocally curved
but neither coextensive nor completely congruent (Fig. 81.1; see Fig.
80.16). The close-packed position of the hip joint is one of full exten- Acetabular labrum and impingement injury
sion, with slight abduction and medial rotation (see also Table 5.4).
This position winds up most of the joint’s capsular ligaments, which Available with the Gray’s Anatomy e-book
can provide an important element of articular stability. The femoral
head is covered by articular cartilage, except over the rough pit where
Fibrous capsule


the ligament of the head of the femur is attached. Anteriorly, the carti-
lage extends laterally over a small area on the adjoining neck. Articular
cartilage is, generally, thicker centrally than peripherally. Cartilage thick- The fibrous capsule of the hip joint is strong and dense (Fig. 81.4). It
ness is maximal anterosuperiorly in the acetabulum and anterolaterally is attached superiorly to the acetabular margin 5–6 mm medial to the
on the femoral head, the two areas that correspond to the principal labral attachment, anteriorly to the outer labral aspect and, near the
load-bearing areas within the joint. The acetabular articular surface, the acetabular notch, to the transverse acetabular ligament and the adjacent
lunate surface, is an incomplete ring, broadest anterosuperiorly where rim of the obturator foramen. From its acetabular attachment, it extends
the pressure of body weight falls in the erect posture, and narrowest in laterally to surround the femoral head and neck, and is attached ante-
its pubic region. It is deficient inferiorly opposite the acetabular notch. riorly to the intertrochanteric line, superiorly to the base of the femoral
The lunate surface is covered by articular cartilage, which is thickest neck, posteriorly 1 cm superomedial to the intertrochanteric crest, and
where the surface is broadest. The acetabular fossa, the central non- inferiorly to the femoral neck near the lesser trochanter. Anteriorly,
articular area in the floor of the acetabulum, is devoid of cartilage but many fibres ascend along the neck as longitudinal retinacula, contain-
contains fibroelastic fat largely covered by synovial membrane. The ing blood vessels for both the femoral head and the neck. The capsule
acetabular labrum, a fibrocartilaginous rim attached to the acetabular is thicker anterosuperiorly, where maximal stress occurs, particularly
margin, serves to deepen the acetabulum and bridges the acetabular while standing with the hip extended. Posteroinferiorly, it is relatively
notch by attaching to the peripheral edge of the transverse acetabular thin and loosely attached. The capsule as a whole has two sets of fibres,


Fig. 81.1A Anteroposterior radiograph of an adult female
pelvis. 1, sacral promontory; 2, margin of anterior sacral
foramen; 3, linea terminalis; 4, fovea for ligament of head;
10 5, lesser trochanter of left femur; 6, left ischial tuberosity;
7, left obturator foramen; 8, coccyx; 9, left anterior
inferior iliac spine; 10, gas in sigmoid colon.
1 (B, continued online)
2
3 9
8
4
7
6
5
A
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