THE ILIUM:

External surface of Ileum has three Gluteal lines for the Gluteus muscles, from superior to inferior in the following order:

Posterior Gluteal Line

Anterior Gluteal Line

Inferior Gluteal Line

THE FEMUR (N459):

Linea Aspera: Important ridge on the posterior surface of the femur, while the anterior surface is smooth. Hence this is a good way to tell the difference

between the two surfaces.

Greater and Less Trochanter:

Intertrochanteric Line connects them anteriorly.

Intertrochanteric Spine connects them posteriorly.

COLLATERAL CIRCULATION AROUND THE NECK OF THE FEMUR (N474a):

Lateral and Medial Circumflex Femoral Arteries -- supply the head and neck of the femur.

As well they supply the intertrochanteric region, regions between the greater and lesser trochanter.

INTERTROCHANTERIC FRACTURE: Fracture right across the intertrochanteric line, at the bottom of the neck.

You retain blood supply to the head and the neck of the femur, so this has a good chance of healing.

Head Blood Supply: Retinacular Arteries

Neck Blood Supply: Circumflex Femoral Arteries

SUBCAPITAL FRACTURE: Fracture right beneath the head, at the top of the neck.

You LOSE BLOOD SUPPLY TO THE HEAD, resulting in Avascular Necrosis (AVN) of the head of the femur! Bad news dude.

Cruciate Anastomosis: In a significant percentage of the population, anastomoses between the following vessels:

Inferior Gluteals

1st perforating branch of the Femoral Profunda artery

Medial and Lateral Femoral Circumflex.

In the event of a Femoral Artery Occlusion, there will still be some blood supply to the leg, because of this collateral circulation.

ISCHIAL SPINE: Is the bony protuberance that marks the separation between the Greater and Less Sciatic Foramina.

ANTERIOR COMPARTMENT OF THE THIGH:

Action = flexion of thigh and extension of leg.

Innervation = Femoral Nerve

POSTERIOR COMPARTMENT OF THE THIGH:

Action = Extension of thigh and flexion of leg

Innervation = Sciatic Nerve

CLINICAL -- WHERE TO GIVE A SHOT: The Upper Outer Quadrant, which is an intramuscular injection into the Gluteus Medius and Minimus.

The object: avoid the Sciatic nerve, which is in the lower medial quadrant.

CLINICAL -- PULLED HAMSTRINGS -- A common injury to this area.

Can occur at common origin (ischial tuberosity) or common tendon (medial condyle of tibia, or head of fibula for biceps femoris)

MEDIAL (ADDUCTOR) COMPARTMENT OF THE THIGH:

Action = Adduction of thigh

Innervation = Obturator Nerve

QUADRICEPS: These four muscles, which insert on the Quadriceps tendon on the Patella, have a crucial role in knee stability.

GAIT / WALKING / PELVIC TILT:

When walking, you have to tilt up your pelvis on the side of the body not planted. This involved contraction of Gluteus Minimus and Medius muscles.

Slightly Abducting the thigh and medially rotating it.

CLINICAL -- GLUTEAL GAIT: If you lose the superior gluteal nerve, you will no longer be able to list the hip. When walking, this looks like a gluteal gait.

To compensate for this, the leg swings out laterally so that the foot can move forward, so walking kind of looks like a shuffle.

This can be caused by loss of two different nerves:

Superior Gluteal Nerve (no abduction of thigh)

Obturator Nerve (no adduction of thigh)

SUPERIOR GLUTEALS (N473): The vein, artery, and nerve travel:

Superior to the Piriformis muscle.

Then between the gluteus minimus and medius muscles.

FASCIA LATA (N470, N464): The fascia on the thigh is very dense.

Superior Limit: The Inguinal Ligament and Iliac Crest, it is a continuation of the Transversus Abdominis.

Inferior Limit: It merges with the Iliotibial Tract, which is around the lateral of the leg.

ILIOTIBIAL TRACT (N464): Inserts onto the tibia, around the lateral aspect of the knee. It is continuous superomedially with the fascia lata.

When standing upright, it holds the knee in place.

GRACILIS MUSCLE: A GOOD SPARE PART. This weak adductor has a nice nerve and artery that are dispensable and can be grafted to other locations.

N.A.V.E.L.: The order of femoral vessels entering through the obturator foramen into the medial thigh, starting from the ASIS and working inferomedially to the

pubic tubercle.

N: Nerve

A: Artery

V: Vein -- the femoral nerve is not a part of the femoral sheath, while the others are.

E: Empty Space

L: Lacunar Ligament

FEMORAL TRIANGLE: Region of medial thigh, where the Femoral Sheath ends and lets out the Femoral Artery and Vein.

Floor of the Femoral Triangle is composed of the following muscles:

Iliopsoas

Pectineus

Adductor Longus

Borders of Femoral Triangle:

Sartorius: Inferior base of triangle

Inguinal Ligament: Superior limit of triangle

Adductor Longus: More or less the lateral limit

CLINICAL -- FEMORAL HERNIA: Abdominal contents can spill through the Femoral Sheath into the Femoral Triangle.

How to distinguish it from inguinal hernias: A femoral hernia is completely inferior to the inguinal ligament and lateral to the pubic tubercle.

Femoral Vessels (N470): Travel through the thigh between the anterior and medial compartments in the upper thigh.

Femoral Nerve: Enters the thigh by traveling just deep to the Inguinal Ligament, on the anterior surface of the Psoas Muscle. This creates a nerve-sandwich!

This entry-point is just medial to that of the lateral femoral cutaneous nerve.

Nerve Entrapment can occur between the Psoas Muscle and the Inguinal Ligament.

Lateral Femoral Cutaneous Nerve: Enters the thigh by traveling under the Inguinal Ligament at the very lateral aspect of the Inguinal Ligament.

Nerve Entrapment: Hence the nerve can get pinched, especially in overweight folks.

That would result in paresthesia in the lateral region of the thigh.

FEMORAL ARTERY (N471, N481): The continuation of the External Iliac Artery, beyond the Inguinal Ligament.

BRANCHES

Deep Femoral Artery -- goes around the posterior side of the knee and hugs the back of the knee joint.

Sends 3 Perforating Branches to posterior compartment.

Gives off Lateral Circumflex Artery that anastomoses both at the head of the femur and at the knee (via lateral superior genicular)

Popliteal Artery -- around posterior of knee, gives off three branches:

Anterior Tibial Artery -- main blood supply down anterior leg

Posterior Tibial Artery -- main blood supply down posterior leg.

Peroneal Artery -- it may play a significant role if one of the above is absent or damaged.

CLINICAL -- a knee injury around the back of the knee can injure the popliteal artery, but that usually doesn't happen because the popliteal is very

deep.

The Femoral Artery becomes the Popliteal after it has traveled through the Adductor Hiatus on the medial distal thigh.

At the same time it pierces the Adductor Magnus tendon.

CLINICAL -- FEMORAL CATHETER. The Femoral Artery lies halfway in-between the ASIS and the Pubic Tubercle, as it runs beneath the

Inguinal Ligament.

This is the location where you would put a catheter into the Femoral Artery. This is a common place to inject dye for arteriographs.

CLINICAL -- FEMORAL ARTERY OCCLUSION:

Commonly occurs at two points:

Just as the Femoral Artery enters the anterior thigh under the Inguinal Ligament., at the Femoral Triangle.

As the Femoral Artery goes through the Adductor Hiatus, going back into the Popliteal Fossa.

GLUTEAL MUSCLES: The order of muscles below the gluteus maximum and minimum, going from superior to inferior:

Piriformis

Sciatic Nerve comes out right below the Piriformis

Superior Gemellus

Obturator Internus

Inferior Gemellus

Quadratus Femoris