GLUTEAL REGION

Its boundaries are superiorly iliac crest and inferiorly the fold of the buttock.

Areas to consider
(i) Skin and fascia
(ii) Bones
(iii) Ligaments
(iv) Foramina
(v) Nerves
(vi) Arteries
(vii) Muscles

Skin
The skin of the buttock is thick. The fold of the buttock is the transverse
crease of the hip joint.

Fascia
Superficial
Characteristic shape of the buttock is largely due to the pad of adipose
tissue. It is thick particularly in women. The quantity of fat decreases as the
fascia continues with the neighbouring regions of the back, lateral and
anterior aspect of abdomen and the thigh. Small nerves and blood vessels
reach the skin through the superficial fascia after piercing the deep fascia.

Deep
Lower limb is invested in a sheath of deep fascia composed of rather
substantial and inelastic connective tissue membrane. It forms a more or
less continuous stocking known as fascia lata over the thigh.

Fascia lata extends into the hip and gluteal regions to attach to bony
prominence and ligaments associated with the pelvis. On the lateral surface
of the thigh, the fascia is thickened to form a strong, wide band the iliotibial
tract which is attached above to the tubercle of the iliac crest. A substantial
part of gluteus maximus, as well as tensor fasciae lata, insert into the tract,
which then descends along the lateral aspect of the thigh and inserts on the
lateral condyle of the tibia.

Ligaments of the gluteal region

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The function of the two important ligaments:
 To stabilize the sacrum and prevent its rotation at the sacroiliac joint by
the weight of the vertebral column.
 They oppose upward tilting of the lower part of the sacrum under
downward thrust at its upper end (vide infra).
 They also convert the sciatic notches into foramina.

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The sacrotuberous ligament is broadly attached by its base to the posterior
iliac spine, to the lower transverse sacral tubercles and the lateral margins of
the lower sacrum and upper coccyx. Its oblique fibres descend laterally,
converging to form a thick, narrow band which widens again below and is
attached to the ischial tuberosity’s medial margin.

The sacrospinous ligament is strong and triangular shaped. It is attached

by its base to the lateral part of the sacrum and coccyx and by its apex to the
spine of the schium. Its anterior surface is muscular and constitutes the
coccygeus; the ligament is often regarded as a degenerate part of the muscle.

Foramena of the gluteal region

The greater sciatic foramen is formed by the greater sciatic notch of the
hip bone and the sacrotuberous and inferiorly by the sacrospinous ligament
and ischial spine. It provides exit from the pelvis into the gluteal region of
the following:
 Piriformis
 Sciatic nerve
 Posterior cutaneous nerve of the thigh
 Superior and inferior gluteal nerves
 Superior and inferior gluteal arteries and veins
 Internal pudendal vessels
 Pudendal nerve
 Nerves to obturator internus and quadratus femoris

The lesser sciatic foramen is formed by lesser sciatic notch and the
sacrospinous ligament and the sacrotuberous ligaments. It provides entrance
into the perineum from the gluteal region. The following structures pass thru
the foramen.
 Tendon of obturator internus
 Nerve to obturator internus
 Internal pudendal vessels
 Pudendal nerve.

Structures in the gluteal region

Nerves
Nerves of the buttock are branches of the sacral plexus. Both the plexus and
the internal iliac vessels are located in the pelvic cavity. They leave and

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enter the pelvis with the piriformis muscles. Those for which distribution is
primarily confined to the buttock are the superior and inferior gluteal nerves
and the two small nerves to the obturator internus and quadratus femoris.
Those that pass through the buttock to another distribution are internal
pudendal nerve, pudendal nerve, posterior cutaneous nerve of the thigh, and
sciatic nerve.

Sciatic nerve is the largest nerve in the body and is formed in the pelvis on
the anterior surface of the piriformis, it emerges in the buttock below the
priformis. Here it is located half way between the ischial tuberosity and
greater trochanter. It does not supply any structures in the buttock, but its
upper branches to the hamstring muscles may arise at or above the level of
the ischial tuberosity.

Blood vessels
The vessels of the region are branches of the internal iliac artery or
tributaries of the internal iliac vein. Both the plexus and the internal iliac
vessels are located in the pelvic cavity and vessels leave and enter the pelvis
with the piriformis muscles. Those for which distribution is primarily
confined to the buttock are the superior and inferior gluteal vessels. Those
that pass through the buttock to another distribution are internal pudendal
vessels
Superior gluteal artery enters the buttock above the piriformis.

Inferior gluteal artery enters the buttock below the piriformis muscle. The
artery gives off other muscular twigs and un-named anastomotic branches
that join the cruciate anastomosis. The arteria comitans nervei ischiadici is a
small branch of the inferior gluteal artery. As its name implies, it
accompanies, the sciatic nerve, and is the remnant of the axial artery of the
developing lower limb.

Of the vessels that pass through the buttock without supplying structures in
it, internal pudendal vessels are the most medial and have the shortest course
in the buttock. The internal pudendal artery is a branch of the internal iliac.
They serve the perineum. They leave the pelvis with the piriformis, appear
in the buttock at the lower margin of the muscle and descend, crossing the
posterior surface of the superior gemellus and, deep to it, the spine of the
ischium. To reach the perineum, they artery pass medially through the lesser
sciatic foramen. The internal pudental vein runs with the artery and nerve.

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Trochanteric anastomosis forms at the head of the femur by
1. Superior gluteal
2. Inferior gluteal
3. Medial femoral circumflex
4. Lateral femoral circumflex

Cruciate Anastomosis formed at the level of lesser trochanter. It connects

internal iliac and femoral arteries. Formed by
1. Medial femoral circumflex
2. Lateral femoral circumflex
3. 1st perforating branch of profunda artery
4. Inferior gluteal

Lymphatics drain to the lateral group of inguinal lymph nodes

Muscles
Gluteus region contains the chief abductor and extensor muscles of the hip
joint. It also has a group which contributes to rotation of the femur.

Most superficial: Gluteus maximus posterioly and tensor fascia latae

anteriorly
Deep layer gluteus medius and gluteus minimis
Deepest layer five short muscles: Piriformis, obturator internus, two
gemelli and quadratus femoris

Gluteus maximus
It is the largest single muscle in the body and the most powerful extensor of
the hip. It has a wide area of origin. Only the deep fibers of the lower half of
this thick, quadrangular muscle insert into the gluteal tuberosity of the
femur; the remaining and far greater number insert into the iliotibial tract.
Gluteus maximus covers most of the muscles and all nerves and vessels
Action:
Gluteus maximus is called into action only during rapid and powerful
extension or when resistance has to be overcome. In the normal gait cycle,
hip extension is achieved primarily by the hamstring muscles that arise from
the gluteal tuberosity. Where the muscles is definitely required is for hip

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extension in such action as climbing, going upstairs, or getting up from a
squatting position. The gluteus maximus can extent the femur not only
through its bony attachment but also through the iliotibial tract.

Gluteus Medius and Minimus

These two fan-shaped muscles are the chief abductors of the hip. They
originate on the lateral surface of the ilium, the minimus anterior and deep to
the medius, and insert by separate tendons into the greater trochanter.

Gluteus minimus arises from the ilium between the anterior and inferior
gluteal lines and inserts in front of the gluteus medius on the upper and
anterior surface of the greater tochanter.

Action
During walking, the two abductors on one side alternate with those of the
other side. The contraction occurs on the side of the stance leg, its purpose
being to prevent the pelvis from sagging on the opposite side. During
clinical evaluation, the efficiency of the abductors may be tested by
observing the level of the two anterior and posterior superior iliac spines
while the subject is standing on one leg. If the abductors are weak, the
anterior and posterior superior iliac spines will sag on the opposite side.
This maneuver is known as the Trendelenburg test. The test is positive
when the pelvis tilts downward on the unsupported side, signifying
weakness of the abductors.

Tensor fasciae lata

It assists gluteus maximus muscle in maintaining the knee in the extension
position.

Short Rotators
Numerous muscles, including those discussed in the foregoing, have a
rotatory action on the femoral shaft, but only a few function primarily as
rotators.

Piriformis arises from the anterior surface of the lateral mass of the 2nd, 3rd
and 4th sacral segments. The pyramid-shaped muscle exits the pelvis
through the greater sciatic foramen and inserts on the summit of the greater
trochanter. The sacral plexus is formed largely on the pelvic surface of the
piriformis, and the branches of the plexus emerge in the gluteal region along
the superior and inferior margins of the muscle.

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Obturator internus has an extensive area of origin from the medial surface
of the obturator membrane and part of the coxal bone that surrounds it. The
muscle tapers posteriorly to a narrow belly and tendon, and makes a sharp
turn around the sciatic notch to head toward its insertion just above the
trochanteric fossa.

Superior and inferior gemellus arises from the ischial spine, and the
inferior gemellus from the ischial tuberosity. They insert into the tendon of
the obturator internus.
Quadratus femoris arises form the ischial tuberosity and inserts on the
quadrate tubercle and adjoining parts of the intertrochanteric crest.

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