1.For the students of Gulf Medical University, Ajman, BPTDr. Seyed Morteza Mahmoudi, MBBS Gulf Medical University, Ajman

2. Contents Gluteal region and boundaries Cutaneous innervation Muscles of gluteal region Arteries of gluteal region Nerves of gluteal region 3. Gluteal region The transitional area between the trunk and thelower extremity. Anatomically it is part of the trunk. Functionally it is part of the lower extremity. The gluteal region includes the rounded, posterior buttocks and the laterally placed hip region. 4. Boundaries Superiorly: iliac crest (at L4), Medially: intergluteal cleft, Laterally: Greater trochanter, Inferiorly: gluteal fold The gluteal muscles form the prominent majorityof the gluteal region. 5. SUPERFICIAL FASCIA Cutaneous Nerves Upper-outer quadrant: Lateral branch of subcostal nerve. Lateral branches of iliohypogastric nerve Upper-inner quadrant: Posterior primary rami of L1,2,3 Posterior primary rami of S1,2,3 Lower-outer quadrant: Posterior divisions of lateral cutaneous nerve of thigh Lower-medial quadrant: Perforating cutaneous branches of S 2,3 Gluteal branches of posterior cutaneous nerve of thigh. 6. Muscles of the Gluteal Region 7. Muscles of the Gluteal Region Gluteus maximus: Largest muscle responsible for the prominence of the buttocks OriginOuter surface of ilium behind posterior gluteal line Posterior surface of sacrum, coccyx and sacrotuberous ligament. Insertion 75% of fibres into ilio-tibial tract 25%(deep) into gluteal tuberosity. 8. Nerve- inferior gluteal nerve. ActionExtensor & lateral rotator of thigh at hip joint.Helps to maintain extension at knee through the ilio-tibial tract Paralysis of muscle inability to raise the trunk from sitting or stooping positions 3 bursae are related to this muscle- trochanteric , ischial & gluteofemoral (v.lateralis) 9. Iliotibial tract & Tensor fascia lata 10. Muscles of the Gluteal RegionTensor fascia lata Arises from anterior part of iliac crest, ASIS and notch below and inserts into the iliotibial tract. Nerve: Superior gluteal nerve Action: Assists gluteus maximus in keeping knee in extended position 11. Muscles of the Gluteal Region 12. Gluteus medius Posterior part covered by gluteus maximusOrigin Outer surface of ilium b/w iliac crest above & posterior gluteal line behind and middle gluteal line below.Insertion Lateral surface of greater trochanterNerve superior gluteal nerve Action With G minimus and tensor fascia lata -powerful abductor at hip. Anterior fibres medially rotate the thigh Walking and running Holds opposite side of pelvis horizontally when foot is off the ground. 13. Muscles of the Gluteal Region 14. Gluteus minimus Origin Outer surface of ilium b/w middle & inferior gluteal lines Insertion - Anterior surface of greater trochanterNerve-superior gluteal nerve Action With G minimus and tensor fascia lata -powerful abductor at hip. Anterior fibres medially rotate the thigh 15. Trendelenburg test----used to assess hipstability. The patient is asked to stand unassisted on each leg in turn, whilst the examiner's fingers are placed on the anterior superior iliac spines. The foot on the contralateral side is elevated from the floor by bending at the knee. In normal function, the hip is held stable by gluteus medius acting as an abductor in the supporting leg. If the pelvis drops on the unsupported side - positive Trendelenburg sign The hip on which the patient is standing is painful or has a weak or mechanically-disadvantaged gluteus medius. 16. A positive Trendelenburg test is found in: Any condition that brings the origin and insertion of gluteus medius together: subluxation or dislocation of the hipcoxa vara (defect of head of femur)greater trochanter fracturesslipped upper femoral epiphysisabductor paralysis or weakness e.g.: polio root lesionpost-operative nerve damage muscle-wasting disease Any painful hip disorder which results in gluteal inhibition 17. Short Lateral Rotators of Thigh 18. Short Lateral Rotators of Thigh Piriformis Key muscle of gluteal region Origin Pelvic surface of sacrum 2nd,3rd & 4th pieces Sacrotuberous ligament Insertion Upper border of greater trochanter Leaves the pelvis through greater sciatic foramen and separates gleuteal vessels and nerves to superior and inferior Nerve S1 2 anterior rami 19. Short Lateral Rotators of ThighObturator Internus Origin: from pelvic surfaces of Body of ischium Ischial tuberosity Ischio-pubic ramus Obturator membrane & fascia. Insertion: tendon passes out of the pelvis through the lesser sciatic foramen and enters gluteal region >> upper border of greater trochanter. One of muscle in pelvis other in perineum Tendon in gluteal regionNerve: Nerve to obturator internus L5 S1 2 20. Short Lateral Rotators of Thigh Gamellus superior Origin-spine of ischium Insertion-tendon of OBT int Nerve- to OBT internus Gamellus inferior Origin-ischial tuberosity Insertion-tendon of OBT internus Nerve-to Quadratus femorisQuadratus femoris Origin-ischial tuberosity Insertion-quadrate tubercle Nerve-sacral plexus 21. Arteries of Gluteal Region Superior gluteal-from internal iliac posterior division above piriformis Inferior gluteal-from internal iliac anterior division-below piriformis Trochanteric anastomosis- main supply to head of femur. Retinacular nutrient arteries pass along neck of femur to head. Formation 1. Superior gluteal A 2. Inferior gluteal A 3. Medial Circumflex A 4. Lateral circumflex ACruciate anastomosis 1. 2. 3.Inferior gluteal MCF and LCF 1st perforating branch of PFA 22. Superior gluteal artery Branch from posterior division of the internal iliac artery Leaves the pelvis by passing through the greatersciatic foramen above the piriformis muscle 23. INFERIOR GLUTEAL ARTERY Arises from anterior division of Internal iliac artery. Leaves the pelvis by passing through the greatersciatic foramen below the piriformis muscle 24. Sacral plexus Formed by the 4th & 5th lumbar ventral rami (lumbosacral trunk) and S1234 Forms on the ventral surface of the piriformis muscleThe sacral plexus supplies innervation to the pelvic muscles, gluteal muscles, and perineal muscles. It also forms the sciatic nerve. 25. Sciatic nerve (L4, L5, SI, S2, S3) Is the largest branch of the sacral plexus and the largest nerve in body Consists of two separate nerves, the common peroneal nerve and the tibial nerve Leaves the pelvis through the greater sciatic foramen below the piriformis muscle 26. Superior gluteal nerve (L4, L5, S1) Leaves the pelvis through the greater sciatic foramen above the piriformis muscle with the superior gluteal artery and vein In the gluteal region supplies the gluteus medius, the gluteus minimus, the tensor fasciae latae, and the hip joint 27. Inferior gluteal nerve (L5, S1, S2) Leaves the pelvis through the greater sciatic foramen below the piriformis muscle with the inferior gluteal artery and vein In the gluteal region supplies the gluteus maximus muscle 28. Posterior femorai cutaneous nerve (SI, S2, S3) Leaves the pelvis through the greater sciatic foramen inferior to the piriformis In the gluteal region descends on the posterior surface of the sciatic nerve Supplies the skin of the buttocks, posterior thigh, popliteal fossa, and external genitalia 29. Nerve to the obturator internus (L5, S1, S2) Leaves the pelvis throughthe greater sciatic foramen below the piriformis muscle In the gluteal region descends on the superior gemellus muscle to pass below the ischial spine and enter the lesser sciatic foramen Supplies the superior gemellus and obturator internus muscles 30. Nerve to the quadratus femoris (L4, L5, SI) Leaves the pelvis through the greater sciatic foramen below the piriformis muscle and deep to the sciatic nerve In the gluteal region runs anterior to the superior and inferior gemellus and obturator internus muscles Supplies the inferior gemellus and quadratus femoris muscles 31. Pudendal nerve (S2, S3, S4) Leaves the pelvis through the greater sciatic foramen inferior to the piriformis muscle along with the internal pudendal artery and vein In the gluteal region descends posterior to the ischial spine and enters the lesser sciatic foramen Is distributed to the perineum and has no branches in the gluteal region 32. Structures under cover Gluteus Maximus 1. 2. 3. 4. 5. 6. 7. 8.Gluteus medius and minimis Piriformis Superior gamellus and inferior Gamellus Tendon of obturator internus Quadratus femoris Adductor magnus-pubic fibres Origin of hamstrings Structures through greater sciatic foramen a. Above piriformis- superior gluteal vessels and nerves b. Below piriformisSciatic n; posterior femoral cutaneous nerves Inferior gluteal vessels & nerves PIN structures Nerve to OBT internus Nerve to quadratus femoris 10. Cruciate anastamosis 11. Bursae-ischial, tronchanteric,ilial & gluteo-femoral