Gluteal region - JU Medicine · 1-Superior Gluteal Artery A branch from the internal iliac artery Enters the gluteal region through the greater sciatic foramen above the piriformis

Gluteal region

Dr. Heba Kalbouneh

Associate Professor of Anatomy and Histology

Skin of the Buttock (Gluteal region) Iliohypogastric nerve

Subcostal nerve

L5

L4

L3

L2

L1

Ilio-inguinal nerve

Ilio-hypogastric nerve

L1

Subcostal nerve

T12

1-Superficial fascia; is thick especially in women.

It contributes to the prominence of the buttock.

2-Deep fascia; continuous with the deep fascia of the

thigh (fascia lata).

Fascia of the Buttock (Gluteal region)

Glu

teu

s M

axim

us

Posterior view

Posterior gluteal line

Inferior gluteal line

Anterior gluteal line

Greater sciatic foramen

Lessor sciatic foramen

Posterior view

Gluteus

maximus

Insertion:

1-The superficial three –fourths are

inserted into the iliotibial tract

2-The deep one fourth is inserted into the

gluteal tuberosity of femur

Origin:

1-Ilium (area behind the

posterior gluteal line)

2-Back of sacrum and coccyx

3-Back of sacrotuberous

ligament

Gluteus maximus

Iliotibial

tract

Action:

1-Extends thigh, some lateral

rotation

(Main extensor of hip joint)

2-Plays an important role in

climbing upstairs and cycling

Powerful extensor of flexed

femur at hip joint

3-Supports the extended knee

joint through iliotibial tract

Nerve supply:

Inferior gluteal nerve (L5;S1,2)

Facts about Gluteus

Maximus

Gluteus maximus gait

Lurching gait (gluteus maximus) characterized by posterior leaning of the trunk at heel strike

in order to keep the hip extended during stance phase

https://www.youtube.com/watch?v=krm2Fm26S54

Gluteus medius

Gluteus minimus

Origin: Ilium ?

Insertion: Greater trochanter of femur

Action:

1-Abduction (main abductors of the hip joint)

2-Medial rotation (anterior fibers)

3-Both muscle contract reflexly on each side alternatively during

walking to prevent tilting of the pelvis to the unsupported side

Nerve supply: Superior gluteal nerve (L4, L5, S1)

Medius

Minimus

Posterior view

During walking, the glutei medius and minimus of the stance limb tilt the pelvis so

that the swinging limb can clear the ground

Stance Swing

During walking, the glutei medius and minimus of the stance limb tilt the pelvis so

that the swinging limb can clear the ground

When standing on one leg, the abductors of the hip on this side (gluteus medius and minimus

and tensor fascia lata) maintain fixation at the hip joint

If, however, there is any defect in these muscles or lever mechanism

of the hip joint, the weight of the body in these circumstances forces

the pelvis to tilt downwards on the opposite side.

Trendelenburg’s test

The normal pelvis (right) tilts

downwards

Left Right

Injury to the superior gluteal nerve

On one side causes Lurching gait

Both sides Waddling gait

Positive Trendelenburg’s test

Note

Other conditions also my cause lurching and waddling gates such as:

Clinical Notes

During the stance phase, the weakened abductor muscles allow the pelvis to tilt down on the

opposite side. The pelvis sags on the opposite side of the lesioned superior gluteal nerve.

https://www.youtube.com/watch?v=Rz7V1i8kYGU

Lurching gait (gluteus medius and minimus)

To compensate, the trunk lurches to the weakened side to

attempt to maintain a level pelvis throughout the gait

cycle

Tensor fascia

lata

Origin:

Iliac crest

Insertion:

Iliotibial tract

Action:

Assist gluteus maximus in

extending the knee joint

Nerve supply:

Superior gluteal nerve

Tensor fascia lata

Iliotibial

tract

Tensor

fascia

latae Gluteus

maximus

Iliotibial

tract

The two muscles are inserted on

iliotibial tract

Tense the iliotibial tract and help extend

the knee

This reduces the amount of muscle

energy required to keep the joint

extended when standing

Short Lateral rotator muscles

1- Piriformis

2- Obturator internus

3- Superior gemellus

4- Inferior gemellus

5-Quadratus femoris

6- Obturator externus

Muscle Origin Insertion Nerve supply

Piriformis Anterior surface of

sacrum

Upper border of

greater trochanter

(medial side)

First and second

sacral nerves

Obturator internus Inner surface of

obturator

membrane and

surrounding bone

Medial side of

greater trochanter

Nerve to obturator

internus (L5 S1)

Sacral plexus

Superior gemellus Ischial spine Medial side of

greater trochanter

Nerve to obturator

internus (L5 S1)

Sacral plexus

Inferior gemellus Ischial tuberosity

(Upper aspect)

Medial side of

greater trochanter

Nerve to quadratus

femoris (L5 S1)

Sacral plexus

Quadratus femoris Lateral border of

ischial tuberosity

Intertrochanteric

crest (quadrate

tubercle)

Nerve to quadratus

femoris (L5 S1)

Sacral plexus

Obturator internus

Piriformis

Inferior gemellus

Quadratus femoris

Superior gemellus

Posterior view

Obturator internus

Piriformis

Inferior gemellus

Quadratus femoris

Superior gemellus

Gluteus Medius

Gluteus Minimus

Posterior view

Obturator internus

Posterior view

Posterior view

Origin: Outer surface of obturator membrane and

surrounding bone

Insertion: Medial surface of greater trochanter

Nerve supply: Obturator nerve

Action: Laterally rotates thigh at hip joint

Obturator externus

Obturator membrane

o Piriformis: fills the foramen almost

completely leaving some structures to pass

either above or below it.

Structures passing above Piriformis

muscle:

o Superior gluteal nerve and vessels

Structures passing below Piriformis

muscle:

o Inferior gluteal nerve and vessels

o Sciatic nerve

o Posterior cutaneous nerve of the thigh

o Nerve to quadratus femoris

o Pudendal nerve

o Internal pudendal vessels

o Nerve to obturator internus

o Tendon of obturator internus

o Nerve to obturator internus

o Pudendal nerve

o Internal pudendal vessels

Structures passing through the greater sciatic foramen:

Structures passing through the lesser sciatic foramen:

Piriformis fills the greater

sciatic foramen almost

completely leaving some

structures to pass either

above or below it.

Piriformis passes through

the greater sciatic foramen.

Obturator internus passes

through the lesser sciatic

foramen.

Posterior view

Piriformis

Inferior gluteal

vessels and nerve

Superior gluteal

vessels and nerve

Obturator internus and

nerve to obturator internus

Internal pudendal vessels

and pudendal nerve

Sciatic nerve

Posterior cutaneous

nerve of the thigh

Posterior view

Obturator internus and

nerve to obturator internus

Internal pudendal vessels

and pudendal nerve

Structures passing

through the lesser

sciatic foramen:

Superior Gluteal Nerve (L4, L5,

S1)

A branch of the sacral plexus

Leaves the pelvis through the

greater sciatic foramen above the

piriformis

Supplies the gluteus medius,

minimus, tensor fascia lata

Inferior Gluteal Nerve (L5, S1, S2)

A branch of the sacral plexus,

leaves the pelvis through the greater

sciatic foramen below the piriformis

Supplies the gluteus maximus

1-Superior Gluteal Artery

A branch from the internal

iliac artery

Enters the gluteal region

through the greater sciatic

foramen above the

piriformis

2-Inferior Gluteal Artery

A branch of the internal

iliac artery

Enters the gluteal region

through the greater sciatic

foramen below the

piriformis

Arteries of the Gluteal Region

Note

Superior gluteal artery

Inferior gluteal artery

Obturator artery

(from the internal iliac artery)

Medial femoral circumflex artery

Lateral femoral circumflex artery

(From Profunda femoris- femoral artery-

External iliac artery)

Provides a connection between the internal

iliac and the external iliac arteries

Supply the hip joint

The muscles of the gluteal region are acting on the hip joint as different functional

groups

Gluteus maximus

Acts as the main extensor of the hip joint

Gluteus medius and minimus

Act as the main abductors of the hip joint while

their anterior fibers act as medial rotators on the hip joint

Short Lateral rotator muscles

Act as lateral rotators on the hip joint

Muscles of the Anterior and medial compartments of the thigh

The muscles of the gluteal region, therefore, extend, abduct and rotate the hip joint

medially and laterally

Leaving adduction and flexion to other groups of muscles, which ? Why?

Intramuscular

(IM) injection

Clinical Notes

The great thickness of

gluteus maximus muscle

makes it ideal for

intramuscular injections.

To avoid injury to the

underlying sciatic nerve,

the injection should be

given well forward on

The upper outer quadrant

of the buttock

However, the upper lateral quadrant, most likely to

be made by the

Gluteus medius muscle rather than the gluteus

maximus muscle.

The gluteus maximus covers the posterior part

only of the

Gluteus medius while the anterior part (which

makes the upper lateral quadrant)

is covered by skin and fascia only

Therefore, the intramuscular injection will be

injected into the gluteus medius muscle rather

than gluteus maximus muscle

A better surface marking for the safe area of

buttock injections can be defined as that area

which lies under the outstretched hand when

the thumb and thenar eminence are placed

along the iliac crest with the tip of the thumb

touching the ASIS

STRUCTURES UNDER THE COVER OF GLUTEUS MAXIMUS MUSCLE

Bony structures:

Ischial tuberosity and bursa

Greater trochanter and bursa

Ligaments:

Sacrospinous

Sacrotuberous

Muscles:

Gluteus medius and minimus

Short lateral rotators

Origin of hamstring muscles

Vessels:

Superior gluteal

Inferior gluteal

Internal pudendal

Nerves:

Superior gluteal nerve

Inferior gluteal nerve

Sciatic nerve

Posterior cutanous nerve of thigh

Pudendal nerve

Nerve to obturator internus

Nerve to quadratus femoris

Bursa

Bursa

Sacrotuberous

ligament

Sacrospinous

ligament

Ischial tuberosity

Greater trochanter