Anatomy of the Thigh

Angel A. Cayetano Jr, MD, FPOA, FPCS,

Organization of the Lower Limb
• Gluteal Region
• Thigh
• Knee
• Leg
• Ankle
• Foot
Skin of the Thigh
• Lateral cutaneous nerve
• Femoral branch of the genitofemoral nerve
• The ilioinguinal nerve
• Medial cutaneous nerve of the thigh
 Lateral cutaneous nerve

• Branch of the lumbar

plexus (L2 and 3)
• behind the lateral end of the
inguinal ligament
• the lateral aspect of the thigh
and knee
• the lower lateral quadrant of
the buttock
Femoral branch of the genitofemoral nerve

• -brach of lumbar plexus L1 and

2
• -enter the thigh- behind the
middle of the inguinal ligament
• small area of skin

• Genital branch
• cremaster muscle
The ilioinguinal nerve
• -lumbar plexus - (L1)
• -enter thigh= superficial
inguinal ring
• -root of the penis and
adjacent part of the scrotum
(or root of the clitoris
adjacent part of the labium
majus in the female)
• small skin area below the
medial part of the inguinal
ligament.
Medial cutaneous nerve of the thigh
• - branch of the femoral nerve
• - medial aspect of the thigh
Intermediate cutaneous nerve of the
thigh
• - femoral nerve
• - anterior aspect of the thigh
• - joins the patellar plexus
 Obturator nerve
• -anterior division
• - the medial aspect of the thigh
Superficial Veins
• Great saphenous veins
• Small saphenous veins
• situated beneath the
skin in the superficial
fascia
Great saphenous vein

• Drains medial end of the

dorsal venous arch of the
foot
• in front of the medial
malleolus
• + saphenous nerve -
medial side of the leg
Great saphenous vein

• - behind the knee 

medial side of the thigh
Great saphenous vein

• - It passes through the

lower part of the
saphenous opening in
the deep fascia
• -joins the femoral vein
about1.5 in. (4 cm)
below and lateral to the
pubic tubercle
 Great saphenous vein
❖numerous valves
❖connected to the small
saphenous vein (#1-2) @ back
of the knee
❖perforating veins – connects
with deep veins @ medial side
of the calf
Great saphenous vein
@At the saphenous opening in the
deep fascia it usually receives :
• Superficial circumflex iliac vein
• Superficial epigastric vein
• Superficial external pudendal
vein
Small saphenous vein
• Lateral part of the dorsal venous arch of
the foot
• behind the lateral malleolus in company
with the sural nerve
of the tendo calcaneus
• runs up the middle of the back of the leg
• ends in the popliteal vein
Mode of termination of the small
saphenous vein
• join the popliteal vein
• join the great saphenous vein
• split in two
• popliteal
• great saphenous vein
CLINICALNOTES
Veins of the Lower Limb

3 Groups:

1. Superficial
2. Deep
3. perforating
superficial veins
• great and small saphenous veins – just beneath the skin
• constant position of the great saphenous vein
• in front of the medial malleolus…for blood tranfusion
deep veins
• venae comitantes to the
anterior and posterior tibial
arteries
• the popliteal vein
• femoral veins
The perforating veins
• communicating vessels
• between the superficial and deep veins
• region of the ankle
• medial side of the lower part of the leg
• Valves
• Prevent the flow of blood from the deep to the superficial veins
Venous Pump of the Lower Limb
• valved venae comitantes
• Rest- pulsation from adjacent arteries
• Exercise – contraction of muscle
• Superficial- not subject to pressure changes
• Perforating veins- valves
• Prevent movement of blood from high to low pressure system
• @ relaxation- blood is sucked from superficial to deep
Varicose Veins
• larger diameter - elongated - tortuous
• Superficial veins
• Pain and discomfort
 Causes of Varicose Veins
• hereditary weakness of the vein
walls and incompetent valves
• elevated intraabdominal
pressure (pregnancy or tumor)
• thrombophlebitis of the deep
veins
=>superficial veins becoming
the main venous pathway for
the lower limb
 Inguinal Lymph Nodes

• superficial
• deep
Superficial Inguinal Lymph Nodes
• superficial fascia
• below the inguinal ligament
• a horizontal and a vertical group
 horizontal group
• just below and parallel to the inguinal ligament
• medial members = anterior abdominal wall below the
level of the umbilicus and from the perineum
• urethra, the external genitalia ( not the testes)
• lower half of the anal canal
• Lateral members = back below the level of the iliac
crests
vertical group
• along the terminal part
of the great saphenous
vein
• most of the superficial
lymph vessels of the
lower limb
Superficial to Deep LN
• The efferent lymph vessels from the
superficial inguinal nodes pass through the
saphenous opening in the deep fascia and
join the deep inguinal nodes.
Deep Inguinal
Lymph Nodes
• beneath the deep
fascia
• lie along the
medial side of the
femoral vein
 Deep Inguinal LN to Abdomen

• enter the abdomen - femoral canal

to lymph nodes along the external
iliac artery
Superficial Fascia of the Thigh

• membranous layer of the superficial fascia

• fatty layer of the superficial fascia
Superficial Fascia of the Thigh
• The membranous layer of the superficial fascia of the
anterior abdominal wall extends into the thigh and is
attached to the fascia lata below the inguinal
ligament
fatty layer of the superficial fascia
• extends into the thigh
• continues down over the lower limb without interruption
Membranous Layer of
Superficial Fascia
and the Extravasation of Urine
• membranous layer - potential closed space
continuous with the superficial perineal pouch via
the penis and scrotum
• Rupture of the penile urethra = urine @ scrotum,
perineum, penis  lower part of the anterior
abdominal wall deep to the membranous layer of
fascia
• excluded from the thigh
Deep Fascia (Fascia Lata)
• encloses the thigh
• upper end is attached to
the pelvis and the inguinal
ligament
• lateral aspect - iliotibial
tract
• above - iliac tubercle
• below - lateral condyle of
the tibia (Gerdy)
Iliotibial tract
• receives the insertion
• tensor fasciae latae
• gluteus maximus
• tensor fasciae latae = "the muscle that
stretches the band on the side."
Saphenous opening
• gap in the deep fascia
• below the inguinal ligament
• transmits -
• great saphenous vein
• branches of the femoral
artery,
• lymph vessels
• situated about 1.5 in. (4 cm)
below and lateral to the pubic
tubercle
• “Fossa ovalis”…also in the
heart
PUBIC TUBERCLE
• forward-
projecting tubercle on the
upper border of the
medial portion of
the superior ramus of the
pubis
Falciform margin
• lower lateral border of the opening
• lies anterior to the femoral vessels
• curves upward and medially laterally behind the
femoral vessels ->pectineal line of the superior ramus
of the pubis
• pectineal line- a ridge on the superior ramus of the
pubic bone
Cribriform fascia
• a deep, membranous, perforated part of the
superficial fascia of the thigh that covers the
saphenous opening
• loose connective tissue @ saphenous opening
• Synonym(s): fascia cribrosa, Hesselbach fascia
Fascial Compartment of the Thigh
Anterior Fascial Compartment
• Muscles: Sartorius, iliacus, psoas, pectineus, and
quadriceps femoris
• Blood supply: Femoral artery
• Nerve supply: Femoral nerve
SARTORIUS MUSCLE
• the longest muscle in the human
body
• Its upper portion forms the lateral
border of the femoral triangle.
• O:anterior superior iliac spine
• running obliquely =inferomedial
direction
• I: prox medial tibia (PES: +
gracilis and semitendinosus{SGT})
• sartorius (the tailor's muscle) = crossleggedFlexes, abducts,
• laterally rotates thigh at hip joint
• flexes and medially rotates leg at knee joint
iliopsoas muscle

• psoas minor is absent about 40% of the time

• appendix overlies the psoas major
PECTINEUS MUSCLE
• Latin word pecten, meaning
comb
• most anterior adductor of the hip
• adduct and medially rotate the
thigh
• primary function is hip flexion.
• Medial compartment- when the
function is emphasized
• Anterior compartment - when
the nerve is emphasized
Pes anserinus
• anteromedial surface of
the proximal extremity of
the tibia
• anterior to posterior:
sartorius, gracilis,
semitendinosus
• “SGT” FOT : F- femoral
nerve O- obturator nerve T-
tibial nerve
• Sartorius- help rotational
provide stability
Quadriceps Mechanism
• Extensor Mechanism:
Quads+ Quads tendon+
Patella + Patellar tendon
• lateral and upward pull
• vastus medialis - prevent the
patella from being pulled
laterally (plus lateral condyle
of the femur, which projects
forward)
 Quadriceps Femoris
• carefully examined when disease of the knee joint is suspected
• Measure the circumference
• vastus medialis muscle extends farther distally
• vastus medialis -first to atrophy /last to recover.
Femoral Triangle
• Superior: inguinal ligament
• Laterally: sartorius
• Medially: adductor longus
• floor : iliopsoas, pectineus, adductor longus
• roof - skin and fasciae of the thigh
Femoral Triangle
• Contents: term part of femoral nerve, femoral sheath,
femoral artery femoral vein ,deep inguinal lymph
nodes
Adductor (Subsartorial) Canal

• intermuscular cleft
• the middle third of the
thigh
• beneath the sartorius
muscle
• Above = apex of the
femoral triangle
• Below =opening in the
adductor magnus
Adductor (Subsartorial) Canal
• Triangular in Cross Section
• anteromedial wall – sartorius / fascia
• posterior wall - adductor longus
/magnus
• lateral wall - vastus medialis
Adductor (Subsartorial) Canal
• Term. of the femoral artery, the femoral vein
• deep lymph vessels, saphenous nerve
• nerve to the vastus medialis, terminal part of the
obturator nerve
 Femoral Sheath
• downward protrusion into the thigh of the fascial
envelope lining the abdominal walls
• anterior wall =fascia transversalis
• posterior wall =fascia iliaca
• surrounds the femoral vessels and lymphatics for
about 1 in. (2.5 cm) below the inguinal ligament
 Femoral Sheath- “NAVEL”
• femoral artery - lateral compartment
• femoral vein- intermediate compartment
• lymph vessels- medial compartment
• Separated by fibrous septum
femoral canal
• medial compartment for the lymph vessels
• 0.5 in. (1.3 cm) long
• upper opening is called the femoral ring
• femoral septum – closes the ring
Contents of the femoral canal
• fatty connective tissue
• efferent lymph vessels from the deep inguinal lymph nodes
• one of the deep inguinal lymph nodes
Femoral sheath
• adherent to the walls of the blood vessels
• part of the femoral sheath that forms the medially located femoral
canal -not adherent to the walls of the small lymph vessels
……………….. site that forms a potentially weak area in the abdomen
• femoral hernia - protrusion of peritoneum could be forced down the
femoral canal pushing the femoral septum before it
Femoral ring
• Anteriorly- the inguinal ligament
• Posteriorly - superior ramus of the pubis
• Medially - lacunar ligament
• Laterally- femoral vein.
• Lower end - closed
lacunar ligament
• connects the inguinal
ligament to the pectineal
ligament
The femoral ring
• close to the saphenous opening in the deep fascia of
the thigh
Femoral Hernia
• neck of the sac is narrow and lies at the femoral ring
• Tight canal= unable to expand
• irreducible hernia
• strangulated hernia
Differential diagnosis of a femoral
hernia
• Inguinal canal: above the medial end of the inguinal ligament.
• above and medial to the pubic tubercle.

• femoral hernia lies below and lateral to the pubic tubercle.

Differential diagnosis of a femoral
hernia
• Superficial inguinal lymph nodes:
• More than one lymph node is enlarged.
• Lymphadenitis
• Mucous membrane of the lower half of the anal canal: carcinoma?
Differential diagnosis of a femoral
hernia
•Great saphenous vein:
• a saphenous varix
• hernia and a varix increase in size when the
patient is asked to cough
Differential diagnosis of a femoral
hernia
• Psoas sheath: Tuberculous infection of a lumbar
vertebra
• extravasation of pus down the psoas sheath into the
thigh.
• swelling above and below the inguinal ligament,
Differential diagnosis of a femoral
hernia
• Femoral artery: aneurysm of the femoral artery

………expansile swelling along the course of the femoral

artery that fluctuates in time with the pulse
Blood Supply of the Anterior Compartment
of the Thigh: Femoral Artery

• from behind the

inguinal ligament, as a
continuation of the
external iliac artery
• between the ASIS
symphysis pubis
Femoral Artery
• descends almost
vertically toward the
adductor tubercle
• ends at the opening
in the adductor
magnus
• popliteal -popliteal
artery.
Relations of the Femoral Artery
Anteriorly
• upper part - covered
by skin and fascia
• lower part - passes
behind the sartorius
muscle
 Relations of the Femoral Artery
Posteriorly:
• Psoas ..hip joint
• Pectineus
• Adductor longus
……The femoral vein
intervenes between the
artery and the adductor
longus
Relations of the Femoral Artery
• Medially: It is related to the femoral vein in the upper
part of its course
Relations of the Femoral Artery
Laterally: The femoral nerve and its branches
Branches of the Femoral Artery
• superficial circumflex iliac
• superficial epigastric
• superficial external pudendal
• deep external pudendal
• profunda femoris artery
Branches of the Femoral Artery
• superficial circumflex iliac art
• region of the ASIS
Branches of the Femoral Artery
superficial epigastric artery
• crosses the inguinal ligament and runs to the region
of the umbilicus
Branches of the Femoral Artery
superficial / Deep external pudendal artery
• medially supply the skin of the scrotum or labium
majus
Branches of the Femoral Artery
profunda femoris artery
• (4 cm) below the inguinal ligament
• lateral side of the femoral artery
• enters the medial fascial compartment of the thigh
 Branches of the Femoral Artery
Profunda femoris artery
• ends by becoming the fourth perforating artery
Branches:
• medial femoral circumflex
• lateral femoral circumflex
• 3 perforating arteries
Branches of the Femoral Artery
Descending genicular artery
• near its termination
• knee joint
Femoral Artery Catheterization
• femoral triangle ->external and common iliac arteries
-> aorta
• inferior mesenteric, superior mesenteric, celiac, or
renal arteries
• Radiograph/ pressure records
 Femoral Vein
• enters the thigh by passing through the
• opening in the adductor magnus
• From politeal vien
• lateral side of the arteryposterior 
medial side
• intermediate compartment of the
femoral sheath behind inguinal
ligament ext iliac vein
Tributaries of the femoral vein
• great saphenous vein
• veins that correspond to the branches of the femoral
artery
• Superficial circumflex iliac vein
• superficial epigastric vein
• external pudendal veins
Femoral Vein Catheterization
• rapid access to a large vein
• femoral vein -medial side of the femoral artery -
below the inguinal ligament
Anatomy Femoral Vein Catheterization
1. local anesthetic-
genitofemoral nerve
2. femoral pulse – ASIS and
symphysis pubis . (Vien=
medial to artery)
3. two fingerbreadths below
the inguinal ligament
Lymph Nodes of the Anterior
Compartment
• deep inguinal lymph nodes= #3
• medial side of the femoral vein
• most superior= femoral canal
• receive all the lymph from the
superficial inguinal nodes via lymph
vessels that pass through the
cribriform fascia of the saphenous
opening
• deep structures of the lower limb
 Nerve Supply of the Anterior
Compartment of the Thigh
Femoral Nerve
• largest branch of the lumbar plexus
• Downward and laterally between the psoas and the
iliacus
• enters the thigh behind the inguinal ligament and lateral
to the femoral vessels and the femoral sheath
 Femoral Nerve
• 1.5 in. (4 cm) below the inguinal ligament - anterior
and posterior divisions
• supplies all the muscles of the anterior compartment
of the thigh
• Does not enter the thigh within the femoral sheath.
Anterior division
• Anterior cutaneous branches:
• intermediate femoral cutaneous nerve
• medial femoral cutaneous nerve
***Note: lateral femoral cutaneous nerve -lumbar plexus

Muscular :
Pectineus
Sartorius - arises in common with the intermediate cutaneous
Posterior Division
• cutaneous branch -saphenous nerve
• Muscular branches -quadriceps
Saphenous nerve
• crosses the femoral artery from its lateral to its medial
side
• medial side of the knee between the tendons of
sartorius and gracilis
Saphenous nerve

• then runs down the medial

side of the leg in company
with the great saphenous
vein
Saphenous nerve
• front of the medial malleolus and along the medial border of the foot
• terminates in the region of the ball of the big toe
Muscular branch of Posterior division of
the femoral nerve
• rectus femoris
• hip joint
• three vasti muscles
• knee joint
• Medial compartment of the thigh
• Posterior Compartment of the thigh
Medial Compartment of the Thigh
• Muscles: Gracilis, adductor longus, adductor brevis,
adductor magnus, and obturator externus
• Blood supply: Profunda femoris artery and obturator
artery
• Nerve supply: Obturator nerve
Muscles of the Medial Compartment
• Gracilis, adductor longus, adductor brevis, adductor magnus,
and obturator externus
Gracilis= spans 2 joints
 Adductor magnus
• Triangular
• adductor and hamstring
portions
• adductor hiatus- permits
the femoral vessels to
pass from the adductor
canal downward into the
popliteal space.
 Blood Supply of the Medial
Compartment
• Profunda Femoris Artery
• lateral side of the femoral artery
• 4 cm below inguinal ligament
• interval between the adductor longus and
adductor brevis and then lies on the
adductor magnus
• ends as the 4th perforating artery
Branches of Profunda Femoris Artery
• Medial femoral circumflex artery
• Lateral femoral circumflex artery
• Four perforating arteries
Medial femoral circumflex artery
• passes backward between the muscles that form the floor of the
femoral triangle
• floor : iliopsoas, pectineus, adductor longus
• formation of the cruciate anastomosis.
 cruciate anastomosis
• inferior gluteal artery
• larger of the two terminal
branches of the anterior trunk
of the internal iliac artery
• lateral and medial circumflex femoral
arteries
• first perforating artery of the profunda
femoris artery
 cruciate anastomosis
• clinical relevance:
• blockage between the femoral
artery and external iliac artery
• blood can reach the popliteal
artery
 Lateral femoral circumflex artery
• passes laterally between
the terminal branches of
the femoral nerve
 Four perforating arteries
• 3 branches
• 1 terminal branch
• run backward
• Anastomoses:
• one another
• inferior gluteal artery
• circumflex femoral arteries
• popliteal artery
 Obturator Artery
• branch of the internal iliac artery
• passes forward on the lateral wall of the pelvis
• accompanies the obturator nerve through the
obturator canal
• medial and lateral branches
Vein
• Profunda Femoris Vein
• drains into the femoral vein

• obturator vein
• drains into the internal iliac vein.
Nerve Supply of the Medial
Compartment of the Thigh
Obturator Nerve
• lumbar plexus (L2, 3,
and 4)
• medial border of the
psoas muscle within
the abdomen
• …lateral border-
femoral nerve
Obturator nerve

• ventral divisions of the second, third, and fourth lumbar

nerves
Obturator Nerve
• obturator foramen = anterior and posterior divisions
 Branches of Obturator Nerve
• anterior division gives muscular
branches
• passes downward
• in front of the obturator externus and
the adductor brevis
• Behind the pectineus and adductor
longus
Branches of Obturator Nerve
• anterior division gives muscular branches
• Gracilis, Adductor brevis/longus, pectineus.
• hip joint (articular branch)
• Femoral artery @ terminal branch (nervi vascularis-
sympathetic non myelinated- vasoconstrictor)..some
myelinated: sensory
• subsartorial plexus
• skin on the medial side of the thigh.
Branches of
• posterior division
Obturator Nerve
• knee joint (hip joint= anterior division)
• obturator externus
• adductor part of the adductor magnus
• occasionally to the adductor brevis.
The Back of the Thigh
Cutaneous Nerves
posterior cutaneous
nerve of the thigh
• sacral plexus
• lower border of the
gluteus maximus
muscle
• back of the thigh and
the upper part of the
leg
Superficial Veins
• medial and lateral aspects of the thigh and great
saphenous vein
• lower part of the back of the thigh join the small saphenous  vein in
the popliteal fossa.
Contents of the Posterior Fascial
Compartment of the Thigh

• Muscles: Biceps femoris, semitendinosus,

semimembranosus,
• small part of the adductor magnus (hamstring
muscles)
• Blood supply: Branches of the profunda femoris
artery
• Nerve supply: Sciatic nerve
• biceps femoris= sciatic nerve
• long head =tibial
• short head = common peroneal
• Hamstring/adductor magnus = tibial
portion of sciatic nerve
• Adductor = obturator nerve
• semimembranosus insertion =
oblique popliteal ligament=

**fibrous expansion upward and

laterally, which reinforces the capsule
on the back of the knee joint
Blood Supply of the Posterior
Compartment
• four perforating branches of the profunda femoris
• profunda femoris vein - drains the greater part of the blood
Nerve Supply of the Posterior
Compartment : Sciatic Nerve
• the sacral plexus (L4 and 5; S1,
2, and 3)
• Descends in midline of the
thigh
• overlapped by biceps femoris
and semimembranosus
 Sciatic Nerve
• posterior aspect of the
adductor magnus
• Divides= tibial and common
Peroneal @ lower third
 Sciatic Nerve
• Muscular branches =tibial component
• long head of the biceps femoris
• Semitendinosus
• Semimembranosus
• hamstring part of the adductor magnus
• Adductor portion- posterior division of the
obturator nerve
FEMUR
Femur
• fovea capitis-
obturator artery -
ligamentum teres
extracapsular arterieal ring

• at the base of the femoral neck

• posteriorly by large branch of MFCA
• anteriorly by smaller branches
of LFCA
***superior & inferior gluteal
artery have minor contributions
• Neck-shaft angle= 125°
• < 120 deg, coxa vara
• > 135 deg, coxa valga
• Version angle: 5-15’
Connecting the two trochanters are the intertrochanteric line anteriorly

*** iliofemoral ligament is attached

• Intertrochanteric crest posteriorly
= quadrate tubercle

• **that serves as a point of

insertion of the quadratus femoris
 femur
• Anterior- smooth
• Posterior- linea aspera
• Ridge for attachment of
intermuscular septa and muscles
• medial supracondylar ridge to the
adductor tubercle on the medial
condyle
• lateral supracondylar ridge
 femur
• gluteal tuberosity = posterior
surface of the shaft below the
greater trochanter

**attachment of the gluteus

maximus muscle.
 FEMUR
• popliteal surface
• Triangular portion on the
posterior distal end
 intercondylar notch
• lower end of the femur has
lateral and medial condyles
• separated posteriorly by the
intercondylar notch
• Above the condyles are the medial
and lateral epicondyles
• adductor tubercle= continuous with
the medial epicondyle

***insertion to the tendon of the

vertical fibers of adductor magnus
Fractures of the Shaft of the Femur
Proximal 3rd

proximal fragment
• flexed by the iliopsoas
• Abducted = the gluteus medius
and minimus
• laterally rotated by the gluteus
maximus,
• piriformis, obturator
internus, gemelli, quadratus
femoris
Proximal 3rd
Lower Fragment
• Adducted = adductor
• pulled upward =hamstrings and
quadriceps
• laterally rotated = adductors
• and the weight of the foot
Middle Third Femoral Fx
Distal fragment
• pulled upward = hamstrings and the
quadriceps
• rotated backward = pull of the two
heads of the gastrocnemius
 Distal Femoral Fractures

• same displacement M/3rd Fx

• may exert pressure on the popliteal artery
 Shentons line
imaginary line drawn along the
• inferior border of the superior pubic
ramus
• along the inferomedial border of the neck
of femur

** interrupted in DDH or fx
• lateral condyle broader in its antero-posterior and
transverse diameters
• medial condyle is the longer/ more distal
• Flabella - the lateral head of the gastrocnemius
muscle behind the lateral condyle of the femur
• present in humans in 10% to 30% of individuals
Surface Anatomy
• inguinal ligament = groin
• Laterally- ASIS
• Medial pubic tubercle
• SYMPHYSIS PUBIS
• cartilaginous joint = between the bodies of the pubic
bones
• upper margin of the symphysis pubis - lower part of
the anterior abdominal wall
• pubic tubercle - upper border of the pubis -medial end of the
inguinal ligament
• male - invaginating the scrotum
• female, it can be palpated through the lateral margin
of the labium majus
Femoral Triangle
• depression below the fold of the groin in the upper
part of the thigh
Femoral Triangle
• Base =inguinal ligament
• Lateral border =sartorius
• medial border= adductor longus muscle