COURSE: GROSS ANATOMY

COURSE CODE: ANA 211

GLUTEAL REGION
 Gluteal region
 It is the transitional region between the trunk and
the free lower limb.

 It includes two parts of the lower limb: the rounded,

prominent posterior region ( buttocks), and the
lateral, usually less prominent hip (coxa) or hip
region.

 The gluteal region is bounded superiorly by the

iliac crest, medially by the intergluteal (natal) cleft,
and inferiorly by the skin fold (groove) underlying
the buttock, the gluteal fold (sulcus glutealis). The
gluteal muscles constitute the bulk of this region.
 Surface Landmarks

 Buttocks separated at midline by the natal cleft.

 Gluteal folds; Transverse skin folds at the inferior aspect of the region

 Ischial tuberosity: a large bony prominence which lies deep to the lower border of gluteus
maximus.

 Greater trochanter of femur: a large bony prominence situated on the side of the hip.

 Iliac crest is a thick curved bony ridge felt in the groove in the lower margin of the waist.

 Posterior superior iliac spine lies in the floor of a dimple about 5 cm from the median
plane.

 Sacrum lies posteriorly between the two hip bones.

 Coccyx lies just behind the anus which is slightly mobile under pressure.
Surface Landmarks
 Fascia
 Superficial fascia: It is heavily laden with fat
(more in females) and is tough and stringy over
the ischial tuberosity where it forms an efficient
cushion for supporting the body weight in the
sitting posture. It contains cutaneous nerves,
vessels and lymphatics.

 Deep fascia: The deep fascia above and in

front of the gluteus maximus, i.e. over the
gluteus Medius is thick, dense, opaque and
pearly white. Over the gluteus maximus,
however, it is thin and transparent. The deep
fascia splits and encloses the gluteus maximus
muscle.
 Gluteal Ligaments

 The parts of the bony pelvis (hip bones, sacrum, and

coccyx) are bound together by dense ligaments.

 The sacrotuberous and sacrospinous ligaments convert

the sciatic notches in the hip bones into the greater and
lesser sciatic foramina.

 The sacrotuberous: Is a long and strong ligament

extending between the medial margin of ischial tuberosity
and the posterior iliac spines. It forms the posteriorlateral
boundary of the outlet of the pelvis.

 Sacrospinous ligaments: Is a short, thick, triangular band

situated deep to the sacrotuberous ligament. It is attached:
 Laterally to the ischial spine
 Medially to the sacrococcygeal junction
 Sciatic Foramina
These are two foramina of the gluteal region, which provide a path for entrance and
exit of structures to and from pelvis.

 The sacrotuberous and sacrospinous ligaments convert the sciatic notches into
foramina.

 The greater sciatic foramen is the passageway for structures entering or leaving
the pelvis (e.g., sciatic nerve), whereas the lesser sciatic foramen is the
passageway for structures entering or leaving the perineum (e.g., pudendal
nerve).

 The greater sciatic foramen (major conduit of neurovascular structures) is the

door through which all lower limb arteries and nerves leave the pelvis and enter
the gluteal region.
 Structures Related to Greater Sciatic Foramina

 The greater sciatic foramen is bounded anterosuperiorly by the greater sciatic

notch, posteriorly by the sacrotuberous ligament and inferiorly by the
sacrospinous ligament and ischial spine.

Structures passing through the greater sciatic foramen (Gate of gluteal region)

A. It is partly filled by the emerging piriformis (key muscle of the region).

B. Above the piriformis are the superior gluteal vessels and nerve leaving the pelvis.

C. Below the piriformis are the inferior gluteal vessels and nerve, internal pudendal
vessels and pudendal nerve, sciatic and posterior femoral cutaneous nerves and
the nerves to obturator internus and quadratus femoris all leave the pelvis.
 Structures Related to Lesser Sciatic Foramina

 The lesser sciatic foramen is an opening between the pelvis and the
back of the thigh.

 It is bounded anteriorly by the ischial body, superiorly by its spine and

sacrospinous ligament, and posteriorly by the sacrotuberous ligament.

Structures passing through the lesser sciatic foramen

 It transmits the tendon of obturator internus, the nerve to obturator

internus, and the internal pudendal vessels and pudendal nerve.
 Muscles of the Gluteal Region
 The gluteal muscles have a common compartment but are organized into
superficial and deep layers:

 The superficial layer consists of the three large glutei (maximus, medius, and
minimus) and the tensor of the fascia lata.

 The deep layer consists of smaller muscles (piriformis, obturator internus, externus
gemelli, and quadratus femoris) covered by the inferior half of the gluteus
maximus.

Gluteus Maximus

The gluteus maximus is the most superficial gluteal muscle. It is the largest,
heaviest, and most coarsely fibered muscle of the body. The gluteus maximus covers
all of the other gluteal muscles except for the anterosuperior third of the gluteus
 Muscles of the Gluteal Region
Gluteus Maximus

Origin
Ilium posterior to posterior gluteal line; dorsal surface of sacrum and coccyx; sacrotuberous ligament.

Insertion
Most fibers end in iliotibial tract, which inserts into lateral condyle of tibia; some fibers insert on gluteal
tuberosity.

Nerve supply
Inferior gluteal nerve (L5, S1, S2).

Actions

 Chief extensor of the thigh at the hip joint.

 Assist in lateral rotation of the thigh.
 Abduction of the thigh (by its upper fibres)
 Along with the tensor fasciae latea the muscle stabilizes the knee through the iliotibial tract.
 Muscles of the Gluteal Region
Gluteus medius and minimus

They are smaller gluteal muscles and are fan shaped, and their fibers converge in the same manner
toward essentially the same target. They share the same actions and nerve supply and are supplied
by the same blood vessel, the superior gluteal artery.

Origin

Gluteus medius: External surface of ilium between anterior and posterior gluteal lines
Gluteus minimus: External surface of ilium between anterior and inferior gluteal lines

Insertion

Gluteus medius: Lateral surface of greater trochanter of femur

Gluteus minimus: Anterior surface of greater trochanter of femur

Nerve Supply
Superior gluteal nerve (L5, S1)
 Muscles of the Gluteal Region
Gluteus medius and minimus

Actions

 They are powerful abductors of the thigh.

 Their anterior fibers are medial rotators of the thigh.
 Their most important action is to maintain the balance of the body when
opposite foot is off the ground as in walking and running.
 They do this by preventing the opposite side of the pelvis from tilting
downwards under the influence of gravity.
 Gluteal Bursae
 Gluteal bursae separate the gluteus maximus from adjacent structures. Bursae are membranous sacs
lined by a synovial membrane containing a capillary layer of slippery fluid resembling egg white.

 Bursae are located in areas subject to friction; their purpose is to reduce friction and permit free
movement. Usually three bursae are associated with the gluteus maximus:

1. The trochanteric bursa separates superior fibers of the gluteus maximus from the greater
trochanter. The trochanteric bursa is commonly the largest of the bursae formed in relation to bony
prominences and is present at birth. Other such bursae appear to form as a result of postnatal
movement.

2. The ischial bursa separates the inferior part of the gluteus maximus from the ischial tuberosity; it is
often absent.

3. The gluteofemoral bursa separates the iliotibial tract from the superior part of the proximal
attachment of the vastus lateralis, a thigh muscle.
Gluteal Bursae
 Muscles of the Gluteal Region
Tensor of fascia lata

The tensor of the fascia lata is a fusiform muscle approximately 15 cm long that is enclosed between two
layers of fascia lata.

Origin
Anterior superior iliac spine; anterior part of iliac crest

Insertion
Iliotibial tract, which attaches to lateral condyle of tibia

Nerve supply
Superior gluteal nerve (L5, S1)

Actions
 Lateral rotator of the thigh at the hip joint
 Abductor and medial rotator of thigh and extensor of knee joint.
 Muscles of the Gluteal Region
Piriformis

The narrow, pear-shaped piriformis is located partly on the posterior wall of the lesser pelvis and partly
posterior to the hip joint.

Origin
Anterior surface of sacrum; sacrotuberous ligament

Insertion
Superior border of greater trochanter of femur

Nerve supply
Branches of anterior rami of S1, S2

Actions
 Laterally rotate extended thigh and abduct flexed thigh; steady femoral head in acetabulum
 Muscles of the Gluteal Region
Obturator internus

It is a fan-shaped flattened belly that lies in the pelvis and the tendon in the gluteal region

Origin
Pelvic surface of obturator membrane and surrounding bones.

Insertion
Medial surface of greater trochanter (trochanteric fossa) of femur.

Nerve supply
Nerve to obturator internus (L5, S1)

Actions
 Laterally rotate extended thigh and abduct flexed thigh; steady femoral head in acetabulum
 Muscles of the Gluteal Region
Obturator Externus

It is triangular in shape that covers the outer surface of the anterior wall of the pelvis.

Origin
Outer surface of the obturator membrane and outer surface of the bony margins of obturator foramen.

Insertion
Trochanteric fossa (on medial side of the greater trochanter).

Nerve supply
Posterior division of obturator nerve (L2, L3, l4)

Actions
 Laterally rotate extended thigh and abduct flexed thigh; steady femoral head in acetabulum
 Muscles of the Gluteal Region
Superior and inferior gemelli

It is triangular in shape that covers the outer surface of the anterior wall of the pelvis.

Origin
Superior: ischial spine Inferior: ischial tuberosity.

Insertion
Trochanteric fossa (on medial side of the greater trochanter).

Nerve supply
Superior: Nerve to obturator internus (L5, S1, S2), Inferior: Nerve to quadratus femoris (L4, L5, S1)

Actions
 Laterally rotate extended thigh and abduct flexed thigh; steady femoral head in acetabulum
 Muscles of the Gluteal Region
Quadratus Femoris

Is a short, flat quadrangular muscle located inferior to the obturator internus and gemelli. True to its name,
the quadratus femoris is a rectangular muscle.

Origin
Lateral border of ischial tuberosity

Insertion
Quadrate tubercle on intertrochanteric crest of femur and area inferior to it.

Nerve supply
Nerve to quadratus femoris (L5, S1)

Actions
It is a strong lateral rotator of the thigh.
Steady femoral head in acetabulum
 Arteries of Gluteal Region
The arteries of the gluteal region arise, directly or indirectly, from the internal iliac arteries, but the
patterns of origin of the arteries varies.

 Superior gluteal artery

The largest branch of the posterior division of the internal iliac artery.

Course
 The superior gluteal artery leaves the pelvis through the greater sciatic foramen, superior to the
piriformis, and divides immediately into superficial and deep branches.

Distribution
 The superficial branch supplies the gluteus maximus and skin over the proximal attachment of
this muscle.

 The deep branch supplies the gluteus medius, gluteus minimus, and tensor of the fascia lata.

 The superior gluteal artery anastomoses with the inferior gluteal and medial circumflex femoral
arteries.
 Arteries of Gluteal Region
 Inferior gluteal artery
The inferior gluteal artery arises from the anterior division of the
internal iliac artery

Course
Enters gluteal region through greater sciatic foramen inferior to
piriformis; descends on medial side of sciatic nerve;
anastomoses with superior gluteal artery and participates in
cruciate anastomosis of thigh, involving first perforating artery
of deep femoral and medial and lateral circumflex arteries.

Distribution
Supplies gluteus maximus, obturator internus, quadratus femoris,
and superior parts of hamstrings
 Arteries of Gluteal Region

 Internal Pudendal artery

It arises from the anterior division of the internal iliac artery and lies anterior to the
inferior gluteal artery.

Course
Enters gluteal region through greater sciatic foramen and has a very short course in the
gluteal region. descends posterior to ischial spine; enters perineum through lesser sciatic
foramen.

Distribution
Supplies external genitalia and muscles in perineal region; does not supply gluteal region

Others are the arteries involved in the trochanteric anastomosis and Cruciate anastomosis
 Veins of Gluteal Region

The gluteal veins are tributaries of the internal iliac veins that drain
blood from the gluteal region.

 The superior and inferior gluteal veins accompany the

corresponding arteries through the greater sciatic foramen,
superior and inferior to the piriformis, respectively.

 The internal pudendal veins accompany the internal pudendal

arteries and join to form a single vein that enters the internal iliac
vein.
 Lymphatic Drainage of the Gluteal Region

 Lymph from the deep tissues of the buttocks follows the gluteal
vessels to the superior and inferior gluteal lymph nodes and
from them to the internal, external, and common iliac lymph
nodes and from them to the lateral aortic lumbar (caval/lymph)
nodes.

 Lymph from the superficial tissues of the gluteal region enters

the superficial inguinal lymph nodes, which also receive lymph
from the thigh.
 Nerves of the Gluteal Region

Clunial (Superficial Gluteal) Nerves

 The skin of the gluteal region is richly innervated by

superior, middle, and inferior clunial nerves (L. clunes,
buttocks). These superficial nerves supply the skin over the
iliac crest, between the posterior superior iliac spines and
over the iliac tubercles. Consequently, these nerves are
vulnerable to injury when bone is taken from the ilium for
grafting.
 Deep Nerves of the Gluteal Region

The following are the deep nerves to the gluteal region

 Superior gluteal nerve

 Inferior gluteal nerve
 Sciatic nerve
 Posterior cutaneous nerve of the thigh
 Nerve to quadratus femoris
 Sciatic Nerve
 Pudendal nerve
 Nerve to the obturator internus
 Clinicals
Gluteal Muscles

 Intramuscular injections are given in the anterosuperior quadrant of the

gluteal region (in the glutei medius and minimus to avoid injury to large
vessels and nerves which passes through the lower part of this region).

 When the gluteus maximus is paralyzed as in muscular dystrophy, the

patent cant stand up from a sitting posture without support.

 When the glutei medius and minimus (of right side) are paralyzed, the
patient cannot walk normally. He/she bends waddles on the right side or
paralyzed side to clear the opposite foot i.e. left off the ground. This is
known as lurching gait (Trendelenburg) ; when bilateral, it is called the
waddling gait.
 Clinicals
Ischial Bursitis

 Recurrent microtrauma resulting from repeated stress (e.g., as from cycling, rowing, or other
activities involving repetitive hip extension while seated) may overwhelm the ischial bursa's
ability to dissipate applied stress. The recurrent trauma results in inflammation of the bursa
(ischial bursitis).

Trochanteric Bursitis

 Inflammation of the trochanteric bursae, or trochanteric bursitis, may result from repetitive
actions such as climbing stairs while carrying heavy objects or running on a steeply elevated
treadmill.
 These movements involve the gluteus maximus which causes deep diffuse pain in the lateral
thigh region.
 This type of friction bursitis is characterized by point tenderness over the great trochanter;
however, the pain radiates along the iliotibial tract that extends from the iliac tubercle to the
tibia.
 Assignment
Briefly discuss on the following
a) Trochanteric anastomosis
b) Cruciate anastomosis

Write in a tabular form the Origin, Course and Distribution of the following nerves:

1. Superior gluteal nerve

2. Inferior gluteal nerve
3. Sciatic nerve
4. Posterior cutaneous nerve of the thigh
5. Nerve to quadratus femoris
6. Sciatic Nerve
7. Pudendal nerve
8. Nerve to the obturator internus
Thanks