The Thigh ‘This region of the lower limb lies between the gluteal, abdominal, and perineal regions proximally and the knee region distally. It contains most of the femur, which connects the hip and knee. The remaining thigh muscles are organized into three compartments by intermuscular septa that pass deeply between the muscle groups from the inner surface of the fascia lata to the linea aspera of the femur. The compartments are anterior or extensor, medial or adductor, and posterior or flexor, Generally, the anterior group is innervated by the femoral nerve, the medial group by the ‘obturator nerve, and the posterior group by the tibial portion of the sciatic nerve.* The Deep Fascia of the Thigh This is the wide deep fascia of the thigh. It is attached above to the inguinal ligament and bony ‘margins of the pelvis and below to the tibial condyles, head of fibula and patella. Three fascial septa pass from the deep surface of the fascia lata to insert onto the linea aspera of the femur ‘and consequently divide the thigh into three compartments. On the lateral side, the fascia lata is condensed to form the iliotibial tract. The tract is attached above to the iliac crest and receives the insertions of the tensor fasciae latae and three quarters of gluteus maximus. These muscles ‘are also enveloped in deep fascia. The iliotibial tract inserts into the lateral condyle of the tibia The saphenous opening is a gap in the deep fascia which is filled with loose connective tissue - ‘the cribriform fascia. The lateral border of the opening, the falciform margin curves in front of .e femoral vessels whereas on the medial side, it curves behind to attach to the iliopectineal The great saphenous vein pierces the cribriform fascia to drain into the femoral artery and are also transmitted through the saphenous opening. _ Anterior Compartment of the Thigh ‘The anterior compartment of the thigh contains the anterior thigh muscles. They are flexors of _ the hip and extensors of the knee. They include: 1) Pectineus 2) tiopsoas 3) Sartorius 4) Quadriceps femoris Pectineus This is a flat quadrangular muscle it is located in the anterior part of the superomedial aspect of the thigh. It often appears to be composed of a superficial and deep layers it adducts and flexes the thigh and assists in medial rotation of the thigh. ‘ iopsoasThisis the chief flexor of the thigh, itis the most powerful flexor of the hip with the longest range ttisa relatively hidden muscle with most of its mass located in the posterior wall of the abdomen and greater pelvis. It has a broad lateral part; the Iliacus which arises from the iliac fossa and a ong medial part, the psoas major which arises from the lumbar vertebrae. It is the only muscle attached to the vertebral column, pelvis and femur. The iliopsoas is in a unique position and therefore produces both movement and stability. However, it can also Perpetuate and even contribute to deformity and disability when it is malformed. Sartorius (Tailors Muscle) The Sartorius is a narrow strap or ribbon-like muscle and is the longest muscle in the body. It asses obliquely in a lateral to medial direction, across the superoanterior part of the thigh. The Sartorius ies superficially inside the anterior compartment, within its fascial sheath, The Sartorius descends inferiorly as far as the side of the knee. The satorius acts across two joints, it flexes the hip joint, and participates in flexion of the knee joint. It also weakly abducts the thigh and laterally rotates it. The actions of the Sartorius are weak and therefore is mainly a synergist, acting with other muscles that produce these movements. Quadriceps Femoris This forms the main bulk of the anterior thigh muscles and collectively constitutes the largest and ‘one of the most powerful muscles in the body. It covers almost all the anterior aspect and sides ofthe femur. The quadriceps femoris consists of four parts namely i) Rectus femoris ii) Vastus lateralis iii) _Vastus intermedius iv) Vastus mediali Collectively, the quadriceps acts on two joints, capable of producing action at both the hip and “the knee. The tendons of the four parts of the quadriceps unite in the distal portion of the thigh _ to form a single strong, broad quadriceps tendon. The patellar ligament, attached to the [Link] ity, is the continuation of the quadriceps tendon in which the patella is embedded, The fend lateral vasti muscles also attach independently to the patella and form aponeuroses, and lateral patellar retinacula. isis afusiform muscle, it runs straight down the thigh, attaching to the hip bone rectus femoris crosses two joints, and hence is Capable of flexing the thigh at the ‘extending the leg at the knee joint. This muscle is the only part of the quadriceps hip joint. vastus muscles, indicate their position around the femoral shaft ponent of the quadriceps lies on the lateral side of the thigh ‘medial side of the thigh. aVastu: . is intermedius: lies deep to the rectus femoris, between the vastus medialis and the vastus lateralis, The smal, flat articular muscle of the knjee is derivative of the vastus intermedius and usually Consists of a valuable number of muscular slips that attach superiorly to the inferior part of the anterior aspect of the femur and inferiorly to the synovial membrane of the knee joint and wall of the suprapatellar bursa. Muscle Proximal Attachment Distal Attachment Innervation ‘Main Action Pectineus | Superior ramus of pubis Pectineal line of femur, just inferior Femoral nerve (L2, L3); may receive a branch from ‘Adducts and flexes | thigh; assists with medial rotation of thigh E Act conjointly in | flexing thigh at hip jopectineal arch to lesser trochanter obturator nerve Wiopsoas Psoas major | Sides of 112-15 Lesser trochanter | Anterior rami of vertebrae and discs of femur lumbar nerves (L1, | between them; 12,13) transverse processes of all lumbar vertebrae | Sides of 112-11 Pectinealline, | Anterior rami of vertebrae and iliopectineal lumbar nerves (L1, | intervertebral disc ‘eminence via 2) liac crest, iliac fossa, ala ‘of sacrum, and anterior Tendon of psoas major, lesser trochanter, and femur distal to it Femoral nerve (L2, 3) joint and in stabilizing this joint rior superior iliac superior part Superior part of medial surface of tibia Femoral nerve (L2, 13) Flexes, abducts, and laterally | rotates thigh at hip joint; flexes leg at knee joint,‘The medial thigh muscles, also known as the adductor group of muscles are found in the medial compartment of the thigh and they collectively adduct the thigh. They include: Adductor longus Adductor brevis Adductor magnus Gracilis Obturator externus ‘large fan-shaped muscle, itis the most anteriorly placed of the adductor group inferior to the pubic crest ment: middle third of linear aspera of femur ‘obturator nerve, branch of anterior division (12, 13 & 14) cts the thigh “short adductor muscle largely covered by jeus and adductor longus muscles Proximal attachment: body & inferior ramus of pubis attachment: pectineal line and proximal part of linear aspera of femur vations : obturator nerve (L2, L3, & 14), branch of anterior division # Aducts thigh and to some extent flexes it. y the adductor longus, it lies deep to the st muscle in the adductor group. It is a composite, triangular muscle that has mstring parts, the two parts differ in their attachme: ints, nerve supply, and main inear aspera, medial supracondylar line 18 Part: adductor tubercle of femur @bturstor nerve (12, 13, and L4) branches of posterior division lamstring part: Tibial part of sciatic nerve (L4) part: Flexes thighThis is a long straplike muscle that lies along the medial side of the thigh and knee. It is the most superficial of the adductor group and is the weakest member. It is the only one of the group to cross the knee joint. Proximal attachment: body & inferior ramus of pubis Distal attachment: superior part of medial surface of tibia Innervations: obturator nerve (L2 & L3) Action: Adducts thigh, flexes leg and helps rotate it medially ‘Obturator Externus This is a flat relatively small fan shaped muscle, deeply placed in the superomedial part of the thigh. It extends from the external surface of the obturator membrane and surrounding bone of the pelvis to the posterior aspect of the greater trochanter, passing under the head and neck of the femur. Proximal attachment: margins of obturator foramen and obturator membrane Distal attachment: trochanteric fossa of femur Innervations: obturator nerve (L3, L4) Action: laterally rotates thigh: steadies head of femur in acetabulum. “Muscle Proximal Distal Innervation Main Action | ‘Attachment Attachment | Anterior inferior | Via common Femoral nerve Extend leg at iliac spine and tendinous (L2, 13, L4) knee joint; ilium superior to | (quadriceps rectus femoris acetabulum tendon) and also steadies independent hip joint and poppet attachments to helps iliopsoas trochanter and | base of patella; flex thigh | lateral lip of ine2 | indirectly via aoffemur | stellar ligament to ti tuberosity; medial and lateral vasti alsoVastus | Anterior and | attach to tibia intermedius | lateral surfaces of | and patella via | shaft of femur | aponeuroses (medial and [lateral patellar yacula) | POSTERIOR THIGH MUSCLES There are three muscles in the posterior aspect of the thigh and they are known as the hamstrings Semitendinosus Semimembranosus Biceps femoris (long head) ‘These muscles span the hip and knee joints, arise from the ischial tuberosity deep to the gleutus ‘maximus, and innervated by the tibial division of the sciatic nerve. ‘The hamstrings are extensors of the thigh and flexors of the leg especially during walking, Both actions cannot be performed fully at the same time. When the thighs and legs are fixed, the hamstrings can help to extend the trunk. ‘Semitendinosus ‘This is a semitendinous muscle, it has a fusiform belly and a long, cord-like tendon that begins approximately two thirds of the way down the thigh and attaches to the medial surface of erior part of the tibia. jal attachment: ischial tuberosity ment: medial surface of superior part of tibia ons: tibial division of sciatic nerve (LS, $1 & 52) d thigh, flex leg and rotates it medially when the knee is flexed; when thigh and leg yese muscles can extend trunk. ‘named so because of the flattened membranous form of its proximal tuberosity. The tendon of the Semimembranosus forms around the cends to the posterior part of the medial tibial condyle. osity rt of medial condyle of tibia; reflected attachment forms oblique tic nerve (L5, $1 & $2)Extend thigh; Ne igh; flex leg and rotate it medially when knee is flexed; when thigh and leg are yese muscles can extend trunk Femoris $a fusiform Muscle that has two heads, a long and a short. In the inferior part of the thigh, ‘head becomes tendinous and is joined by the short head. The rounded tendon attaches head of the fibula and can easily be seen and felt as it passes the knee, especially when flexed against resistance. Posteriorly, the long head of the biceps Femoris crosses and ‘protection for the sciatic nerve after it descends from the gluteal region into the ‘aspect of the thigh. jattachment: long head: ischial tuberosity. bis Short head: linear aspera and lateral supracondylar line of femur rent; lateral side of head of fibula; tendon is split at this site by fibular collateral jknee Jong head: tibial division of sciatic nerve (LS, $1 and $2) Short head: common fibular division of sciatic nerve (L5, $1, & S2) Jeg and rotates it laterally when knee is flexed; extends thigh, when starting to Proximal Distal Attachment Attachment Innervation Main Action Body of pubis | Middle third of | Obturator ‘Adducts thigh inferior to pubic | linea aspera of | nerve, branch of crest femur anterior division c @ | Adducts thigh; inferior ramus of | and proximal | (t - | to some extent pubis part of linea aspera of femur x Body and Pectineal line ‘Adductor part: inferior ramus of, pubis, ramus of ischium Hamstringsischial adductor tibial part of tuberosity tubercle of ic nerve (L4) femur Gracilis Body and Superior part of | Obturator nerve | Adducts thigh; inferior ramus of | medial surface of | (12, 13) flexes leg; helps pubis | tibia rotate it | | medially ‘Obturator Margins of Trochanteric | Obturator nerve | Laterally rotates externus obturator fossa of femur | (L3, La) thigh; steadies foramen and head of femur in obturator acetabulum membrane Femoral Triangle This isa triangular depression inferior to the inguinal ligament when the thigh is flexed, abducted, and laterally rotated. Boundaries Superiorly: the inguinal ligament (forms the base of the triangle) Medially: the adductor longus Laterally: the Sartorius The apex is formed where the lateral boThis is an opening between the aponeurotic distal attachment of the adductor part of the adductor magnus and tendinous distal attachment of the hamstring part. It transmits the femoral artery and vein from the adductor canal in the thigh to the popliteal fossa posterior to the knee Femoral nerve (L2-L4) This is the largest branch of the lumbar plexus Origin: it originates from the posterior divisions of the anterior primary rami of L2, L3 & L4 Course: it courses from within the psoas major and descends posterolaterally through the pelvis to approximately the midpoint of the inguinal ligament. At this point it lies on illacus, which it supplies and is situated immediately lateral to the femoral sheath. It branches within the femoral triangle only a short distance beyond the inguinal ligament. The lateral circumflex femoral artery passes through these branches to divide them into superficial and deep divisions Superficial division: this consists of medial and intermediate cutaneous branches, (which supply the skin over the anterior and medial aspects of the thigh) and two muscular branches which supply Sartorius and pectineus Deep division: this consists of four muscular branches which supply the components of quadriceps femoris and one cutaneus nerve-the saphenous nerve. The saphenous nerve is the only branch to extend beyond the knee. It pierces the deep fascia overlying the adductor canal and descends through the leg accompanied by the great saphenous vein to supply the skin over the medial aspect of the leg and foot. The Femoral Sheath This is a funnel shaped fascial tube 3-4cm that passes deep to the inguinal ligament lining the vascular lacuna of the subinguinal space. Itis formed by an inferior prolongation of transversalis & iliopsoas fascia from the abdomen. It terminates inferiorly by blending with the adventitia of the femoral vessels and creates the femoral canal medial to them. The femoral sheath does not enclose the femoral nerve, its medial wall is pierced by the great saphenous vein and lymphatic vessels. The femoral sheath allows the femoral artery and vein to glide deep to the inguinal ligament during movements of the hip joint. ‘The femoral sheath is subdivided into three compartments by vertical septa of extraperitoneal connective tissue. 1) Lateral compartment for the femoral artery 2) Intermediate compartment for the femoral vein 3) Medial compartment, which constitutes the femoral canal Femoral CanalThis is the smallest of the three compartments. It is short (app. 1.25cm) and conical and lies between the medial edge of the femoral sheath and the femoral vein The Femoral Canal 1) Extends distally to the level of the proximal edge of the saphenous opening, 2) Allows the femoral vein to expand during increased veinous returns from the lower limb. 3) Contains loose connective tissues, fat, | lymph node (Cloquet nodes) The base of the femoral canal is formed by the oval femoral ring lymphatic vessels and sometimes a deep inguinal 4) The Femoral Ring [Thisisan opening atthe abdominal end (base) ofthe femoral canal itis oval inshape and is closed by extraperitoneal fatty tissue that forms a transversely oriented femoral septum. The septum is Pierced by lymphatic vessels connecting the inguinal and external iliac lymph nodes Boundaries taterally the vertical septum between the femoral canal and the femoral vein. Posteriorly: the superior ramus of the pubis covered by the pectineus and its fascia Medially: the lacunar ligament Anteriorly: the medial part of the inguinal ligament. Femoral Artery This is the continuation of the ‘external iliac artery and is the chief artery to the lower limb. It Fenmences behind the inguinal ligament at the mid inguinal point. Inthe groin, the femoral sein lies immediately medial to the artery and both are enclosed inthe femoral sheath The femoral ‘nerve lies Immediately lateral to the femoral sheath. The femoral artery descends the thigh to ‘Pass under Sartorius and then through the adductor canal to become the popliteal artery. rt of the femoral triangle: four branches are given off which of the lower abdominal wall and perineum. artery of the thigh): this is the largest branch of the femoral ral side of the femoral artery, 4cm below the inguinal rise to medial and lateral circumflex femoral branchesadductor longus in the medial compartment of the thigh and gives rise to four perforating branches. These circle the femur posteriorly, Perforating and supplying all muscles in their path, The profunda and perforating branches ultimately anastomose with the genicular branches of the popliteal artery. 3) Obturator artery: the obturator artery helps the deep artery of the thigh supply the adductor muscles via anterior and posterior branches which anastomose. The posterior branch gives off an acetabular branch that supplies the head of the femur. Femoral vein: this is the continuation of the popliteal vein proximal to the adductor hiatus, the femoral vein lies posterolateral and then posterior to the femoral artery as it ascends through the adductor canal, The femoral vein enters the femoral sheath lateral to the femoral canal and ends posterior to the inguinal ligament, where it becomes the external iliac vein.