The Muscles and FasciÃ¦ of the Thigh

Anatomy > Gray's Anatomy of the Human Body > IV. Myology > 8b. The Muscles and Fasciæ of the Thigh

Henry Gray (1821–1865). Anatomy of the Human Body. 1918. 8b. The Muscles and Fasciæ of the Thigh 1. [[The Anterior Femoral Muscles (Fig. 430)]] Sartorius. Quadriceps femoris. Rectus femoris. Vastus lateralis. Vastus medialis. Vastus intermedius. Articularis genu. Superficial Fascia—The superficial fascia forms a continuous layer over the whole of the thigh; it consists of areolar tissue containing in its meshes much fat, and may be separated into two or more layers, between which are found the superficial vessels and nerves. It varies in thickness in different parts of the limb; in the groin it is thick, and the two layers are separated from one another by the superficial inguinal lymph glands, the great saphenous vein, and several smaller vessels. The superficial layer is continuous above with the superficial fascia of the abdomen. The deep layer of the superficial fascia is a very thin, fibrous stratum, best marked on the medial side of the great saphenous vein and below the inguinal ligament. It is placed beneath the subcutaneous vessels and nerves and upon the surface of the fascia lata. It is intimately adherent to the fascia lata a little below the inguinal ligament. It covers the fossa ovalis (saphenous opening), being closely united to its circumference, and is connected to the sheath of the femoral vessels. The portion of fascia covering this fossa is perforated by the great saphenous vein and by numerous blood and lymphatic vessels, hence it has been termed the fascia cribrosa the openings for these vessels having been likened to the holes in a sieve. A large subcutaneous bursa is found in the superficial fascia over the patella. Deep Fascia—The deep fascia of the thigh is named, from its great extent, the fascia lata it constitutes an investment for the whole of this region of the limb, but varies in thickness in different parts. Thus, it is thicker in the upper and lateral part of the thigh, where it receives a fibrous expansion from the Glutæus maximus, and where the Tensor fasciæ latæ is inserted between its layers; it is very thin behind and at the upper and medial part, where it covers the Adductor muscles, and again becomes stronger around the knee, receiving fibrous expansions from the tendon of the Biceps femoris laterally, from the Sartorius medially, and from the Quadriceps femoris in front. The fascia lata is attached, above and behind, to the back of the sacrum and coccyx; laterally, to the iliac crest; in front, to the inguinal ligament, and to the superior ramus of the pubis; and medially, to the inferior ramus of the pubis, to the inferior ramus and tuberosity of the ischium, and to the lower border of the sacrotuberous ligament. From its attachment to the iliac crest it passes down over the Glutæus medius to the upper border of the Glutæus maximus, where it splits into two layers, one passing superficial to and the other beneath this muscle; at the lower border of the muscle the two layers reunite. Laterally, the fascia lata receives the greater part of the tendon of insertion of the Glutæus maximus, and becomes proportionately thickened. The portion of the fascia lata attached to the front part of the iliac crest, and corresponding to the origin of the Tensor fasciæ latæ, extends down the lateral side of the thigh as two layers, one superficial to and the other beneath this muscle; at the lower end of the muscle these two layers unite and form a strong band, having first received the insertion of the muscle. This band is continued downward, under the name of the iliotibial band (tractus iliotibialis) and is attached to the lateral condyle of the tibia. The part of the iliotibial band which lies beneath the Tensor fasciæ latæ is prolonged upward to join the lateral part of the capsule of the hip-joint. Below, the fasciæ lata is attached to all the prominent points around the knee-joint, viz., the condyles of the femur and tibia, and the head of the fibula. On either side of the patella it is strengthened by transverse fibers from the lower parts of the Vasti, which are attached to and support this bone. Of these the lateral are the stronger, and are continuous with the iliotibial band. The deep surface of the fascia lata gives off two strong intermuscular septa, which are attached to the whole length of the linea aspera and its prolongations above and below; the lateral and stronger one, which extends from the insertion of the Glutæus maximus to the lateral condyle, separates the Vastus lateralis in front from the short head of the Biceps femoris behind, and gives partial origin to these muscles; the medial and thinner one separates the Vastus medialis from the Adductores and Pectineus. Besides these there are numerous smaller septa, separating the individual muscles, and enclosing each in a distinct sheath. The Fossa Ovalis ([[saphenous opening) (Fig. 431)]]—At the upper and medial part of the thigh, a little below the medial end of the inguinal ligament, is a large oval-shaped aperture in the fascia lata; it transmits the great saphenous vein, and other, smaller vessels, and is termed the fossa ovalis The fascia cribrosa, which is pierced by the structures passing through the opening, closes the aperture and must be removed to expose it. The fascia lata in this part of the thigh is described as consisting of a superficial and a deep portion.

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FIG. 431– The fossa ovalis. (Picture From the Classic Gray's Anatomy) The superficial portion of the fascia lata is the part on the lateral side of the fossa ovalis. It is attached, laterally to the crest and anterior superior spine of the ilium, to the whole length of the inguinal ligament, and to the pectineal line in conjunction with the lacunar ligament. From the tubercle of the pubis it is reflected downward and lateralward, as an arched margin, the falciform margin forming the lateral boundary of the fossa ovalis; this margin overlies and is adherent to the anterior layer of the sheath of the femoral vessels: to its edge is attached the fascia cribrosa. The upward and medial prolongation of the falciform margin is named the superior cornu its downward and medial prolongation, the inferior cornu The latter is well-defined, and is continuous behind the great saphenous vein with the pectineal fascia. The deep portion is situated on the medial side of the fossa ovalis, and at the lower margin of the fossa is continuous with the superficial portion; traced upward, it covers the Pectineus, Adductor longus, and Gracilis, and, passing behind the sheath of the femoral vessels, to which it is closely united, is continuous with the iliopectineal fascia, and is attached to the pectineal line. From this description it may be observed that the superficial portion of the fascia lata lies in front of the femoral vessels, and the deep portion behind them, so that an apparent aperture exists between the two, through which the great saphenous passes to join the femoral vein. The Sartorius the longest muscle in the body, is narrow and ribbon-like; it arises by tendinous fibers from the anterior superior iliac spine and the upper half of the notch below it. It passes obliquely across the upper and anterior part of the thigh, from the lateral to the medial side of the limb, then descends vertically, as far as the medial side of the knee, passing behind the medial condyle of the femur to end in a tendon. This curves obliquely forward and expands into a broad aponeurosis, which is inserted in front of the Gracilis and Semitendinous, into the upper part of the medial surface of the body of the tibia, nearly as far forward as the anterior crest. The upper part of the aponeurosis is curved backward over the upper edge of the tendon of the Gracilis so as to be inserted behind it. An offset, from its upper margin, blends with the capsule of the knee-joint, and another from its lower border, with the fascia on the medial side of the leg. Variations—Slips of origin from the outer end of the inguinal ligament, the notch of the ilium, the ilio-pectineal line or the pubis occur. The muscle may be split into two parts, and one part may be inserted into the fascia lata, the femur, the ligament of the patella or the tendon of the Semitendinosus. The tendon of insertion may end in the fascia lata, the capsule of the knee-joint, or the fascia of the leg. The muscle may be absent. The Quadriceps femoris (Quadriceps extensor) includes the four remaining muscles on the front of the thigh. It is the great extensor muscle of the leg, forming a large fleshy mass which covers the front and sides of the femur. It is subdivided into separate portions, which have received distinctive names. One occupying the middle of the thigh, and connected above with the ilium, is called from its straight course the Rectus femoris The other three lie in immediate connection with the body of the femur, which they cover from the trochanters to the condyles. The portion on the lateral side of the femur is termed the Vastus lateralis that covering the medial side, the Vastus medialis and that in front, the Vastus intermedius The Rectus femoris is situated in the middle of the front of the thigh; it is fusiform in shape, and its superficial fibers are arranged in a bipenniform manner, the deep fibers running straight down to the deep aponeurosis. It arises by two tendons: one, the anterior or straight, from the anterior inferior iliac spine; the other, the posterior or reflected, from a groove above the brim of the acetabulum. The two unite at an acute angle, and spread into an aponeurosis which is prolonged downward on the anterior surface of the muscle, and from this the muscular fibers arise. The muscle ends in a broad and thick aponeurosis which occupies the lower two-thirds of its posterior surface, and, gradually becoming narrowed into a flattened tendon, is inserted into the base of the patella. The Vastus lateralis (Vastus externus) is the largest part of the Quadriceps femoris. It arises by a broad aponeurosis, which is attached to the upper part of the intertrochanteric line, to the anterior and inferior borders of the greater trochanter, to the lateral lip of the gluteal tuberosity, and to the upper half of the lateral lip of the linea aspera; this aponeurosis covers the upper three-fourths of the muscle, and from its deep surface many fibers take origin. A few additional fibers arise from the tendon of the Glutæus maximus, and from the lateral intermuscular septum between the Vastus lateralis and short head of the Biceps femoris. The fibers form a large fleshy mass, which is attached to a strong aponeurosis, placed on the deep surface of the lower part of the muscle: this aponeurosis becomes contracted and thickened into a flat tendon inserted into the lateral border of the patella, blending with the Quadriceps femoris tendon, and giving an expansion to the capsule of the knee-joint. The Vastus medialis and Vastus intermedius appear to be inseparably united, but when the Rectus femoris has been reflected a narrow interval will be observed extending upward from the medial border of the patella between the two muscles, and the separation may be continued as far as the lower part of the intertrochanteric line, where, however, the two muscles are frequently continuous. The Vastus medialis (Vastus internus) arises from the lower half of the intertrochanteric line, the medial lip of the linea aspera, the upper part of the medial supracondylar line, the tendons of the Adductor longus and the Adductor magnus and the medial intermuscular septum. Its fibers are directed downward and forward, and are chiefly attached to an aponeurosis which lies on the deep surface of the muscle and is inserted into the medial border of the patella and the Quadriceps femoris tendon, an expansion being sent to the capsule of the knee-joint. 13 The Vastus intermedius (Crureus) arises from the front and lateral surfaces of the body of the femur in its upper two-thirds and from the lower part of the lateral intermuscular septum. Its fibers end in a superficial aponeurosis, which forms the deep part of the Quadriceps femoris tendon. 14 The tendons of the different portions of the Quadriceps unite at the lower part of the thigh, so as to form a single strong tendon, which is inserted into the base of the patella, some few fibers passing over it to blend with the ligamentum patellæ. More properly, the patella may be regarded as a sesamoid bone, developed in the tendon of the Quadriceps; and the ligamentum patellæ, which is continued from the apex of the patella to the tuberosity of the tibia, as the proper tendon of insertion of the muscle, the medial and lateral patellar retinacula (see p. 338) being expansions from its borders. A bursa, which usually communicates with the cavity of the knee-joint, is situated between the femur and the portion of the Quadriceps tendon above the patella; another is interposed between the tendon and the upper part of the front of the tibia; and a third, the prepatellar bursa is placed over the patella itself. 15 The Articularis genu (Subcrureus) is a small muscle, usually distinct from the Vastus intermedius, but occasionally blended with it; it arises from the anterior surface of the lower part of the body of the femur, and is inserted into the upper part of the synovial membrane of the knee-joint. It sometimes consists of several separate muscular bundles. 16 Nerves—The muscles of this region are supplied by the second, third, and fourth lumbar nerves, through the femoral nerve. 17 Actions—The Sartorius flexes the leg upon the thigh, and, continuing to act, flexes the thigh upon the pelvis; it next abducts and rotates the thigh outward. When the knee is bent, the Sartorius assists the Semitendinosus, Semimembranosus, and Popliteus in rotating the tibia inward. Taking its fixed point from the leg, it flexes the pelvis upon the thigh, and, if one muscle acts, assists in rotating the pelvis. The Quadriceps femoris extends the leg upon the thigh. The Rectus femoris assists the Psoas major and Iliacus in supporting the pelvis and trunk upon the femur. It also assists in flexing the thigh on the pelvis, or if the thigh be fixed it will flex the pelvis. The Vastus medialis draws the patella medialward as well as upward. 18 2. [[The Medial Femoral Muscles Gracilis. Adductor longus. Adductor magnus. Pectineus. Adductor brevis. The Gracilis' (Fig. 430) is the most superficial muscle on the medial side of the thigh. It is thin and flattened, broad above, narrow and tapering below. It arises by a thin aponeurosis from the anterior margins of the lower half of the symphysis pubis and the upper half of the pubic arch. The fibers run vertically downward, and end in a rounded tendon, which passes behind the medial condyle of the femur, curves around the medial condyle of the tibia, where it becomes flattened, and is inserted into the upper part of the medial surface of the body of the tibia, below the condyle. A few of the fibers of the lower part of the tendon are prolonged into the deep fascia of the leg. At its insertion the tendon is situated immediately above that of the Semitendinosus, and its upper edge is overlapped by the tendon of the Sartorius, with which it is in part blended. It is separated from the tibial collateral ligament of the knee-joint, by a bursa common to it and the tendon of the Semitendinosus. 19''

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FIG. 432– Cross-section through the middle of the thigh. (Eycleshymer and Schoemaker.) (Picture From the Classic Gray's Anatomy) The Pectineus (Fig. 430) is a flat, quadrangular muscle, situated at the anterior part of the upper and medial aspect of the thigh. It arises from the pectineal line, and to a slight extent from the surface of bone in front of it, between the iliopectineal eminence and tubercle of the pubis, and from the fascia covering the anterior surface of the muscle; the fibers pass downward, backward, and lateralward, to be inserted into a rough line leading from the lesser trochanter to the linea aspera. 20 The Adductor longus (Fig. 433), the most superficial of the three Adductores, is a triangular muscle, lying in the same plane as the Pectineus. It arises by a flat, narrow tendon, from the front of the pubis, at the angle of junction of the crest with the symphysis; and soon expands into a broad fleshy belly. This passes downward, backward, and lateralward, and is inserted by an aponeurosis, into the linea aspera, between the Vastus medialis and the Adductor magnus, with both of which it is usually blended. 21 The Adductor brevis (Fig. 433) is situated immediately behind the two preceding muscles. It is somewhat triangular in form, and arises by a narrow origin from the outer surfaces of the superior and inferior rami of the pubis, between the Gracilis and Obturator externus. Its fibers, passing backward, lateralward, and downward, are inserted by an aponeurosis, into the line leading from the lesser trochanter to the linea aspera and into the upper part of the linea aspera, immediately behind the Pectineus and upper part of the Adductor longus. 22 The Adductor magnus (Fig. 433) is a large triangular muscle, situated on the medial side of the thigh. It arises from a small part of the inferior ramus of the pubis, from the inferior ramus of the ischium, and from the outer margin of the inferior part of the tuberosity of the ischium. Those fibers which arise from the ramus of the pubis are short, horizontal in direction, and are inserted into the rough line leading from the greater trochanter to the linea aspera, medial to the Glutæus maximus; those from the ramus of the ischium are directed downward and lateralward with different degrees of obliquity, to be inserted by means of a broad aponeurosis, into the linea aspera and the upper part of its medial prolongation below. The medial portion of the muscle, composed principally of the fibers arising from the tuberosity of the ischium, forms a thick fleshy mass consisting of coarse bundles which descend almost vertically, and end about the lower third of the thigh in a rounded tendon which is inserted into the adductor tubercle on the medial condyle of the femur, and is connected by a fibrous expansion to the line leading upward from the tubercle to the linea aspera. At the insertion of the muscle, there is a series of osseoaponeurotic openings, formed by tendinous arches attached to the bone. The upper four openings are small, and give passage to the perforating branches of the profunda femoris artery. The lowest is of large size, and transmits the femoral vessels to the popliteal fossa. 23

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FIG. 433– Deep muscles of the medial femoral region. (Picture From the Classic Gray's Anatomy) Variations—The Pectineus is sometimes divided into an outer part supplied by the femoral nerve and an inner part supplied by the obturator nerve. The muscle may be attached to or inserted into the capsule of the hip-joint. The Adductor longus may be double, may extend to the knee, or be more or less united with the Pectineus The Adductor brevis may be divided into two or three parts, or it may be united to the Adductor magnus. The Adductor magnus may be more or less segmented, the anterior and superior portion is often described as a separate muscle, the Adductor minimus The muscle may be fused with the Quadratus femoris. 24 Nerves—The three Adductores and the Gracilis are supplied by the third and fourth lumbar nerves through the obturator nerve; the Adductor magnus receiving an additional branch from the sacral plexus through the sciatic. The Pectineus is supplied by the second, third, and fourth lumbar nerves through the femoral nerve, and by the third lumbar through the accessory obturator when this latter exists. Occasionally it receives a branch from the obturator nerve. 86 25 Actions—The Pectineus and three Adductores adduct the thigh powerfully; they are especially used in horse exercise, the sides of the saddle being grasped between the knees by the contraction of these muscles. In consequence of the obliquity of their insertions into the linea aspera, they rotate the thigh outward, assisting the external Rotators, and when the limb has been abducted, they draw it medialward, carrying the thigh across that of the opposite side. The Pectineus and Adductores brevis and longus assist the Psoas major and Iliacus in flexing the thigh upon the pelvis. In progression, all these muscles assist in drawing forward the lower limb. The Gracilis assists the Sartorius in flexing the leg and rotating it inward; it is also an adductor of the thigh. If the lower extremities be fixed, these muscles, taking their fixed points below, may act upon the pelvis, serving to maintain the body in an erect posture; or, if their action be continued, flex the pelvis forward upon the femur. 26 3. [[The Muscles of the Gluteal Region (Fig. 434)]] Glutæus maximus. Obturator internus. Glutæus medius. Gemellus superior. Glutæus minimus. Gemellus inferior. Tensor fasciæ latæ. Quadratus femoris. Piriformis. Obturator externus. The Glutæus maximus the most superficial muscle in the gluteal region, is a broad and thick fleshy mass of a quadrilateral shape, and forms the prominence of the nates. Its large size is one of the most characteristic features of the muscular system in man, connected as it is with the power he has of maintaining the trunk in the erect posture. The muscle is remarkably coarse in structure, being made up of fasciculi lying parallel with one another and collected together into large bundles separated by fibrous septa. It arises from the posterior gluteal line of the ilium, and the rough portion of bone including the crest, immediately above and behind it; from the posterior surface of the lower part of the sacrum and the side of the coccyx; from the aponeurosis of the Sacrospinalis, the sacrotuberous ligament, and the fascia (gluteal aponeurosis) covering the Glutæus medius. The fibers are directed obliquely downward and lateralward; those forming the upper and larger portion of the muscle, together with the superficial fibers of the lower portion, end in a thick tendinous lamina, which passes across the greater trochanter, and is inserted into the iliotibial band of the fascia lata; the deeper fibers of the lower portion of the muscle are inserted into the gluteal tuberosity between the Vastus lateralis and Adductor magnus. 27 Bursæ—Three bursæ are usually found in relation with the deep surface of this muscle. One of these, of large size, and generally multilocular, separates it from the greater trochanter; a second, often wanting, is situated on the tuberosity of the ischium; a third is found between the tendon of the muscle and that of the Vastus lateralis. 28 The Glutæus medius is a broad, thick, radiating muscle, situated on the outer surface of the pelvis. Its posterior third is covered by the Glutæus maximus, its anterior two-thirds by the gluteal aponeurosis, which separates it from the superficial fascia and integument. It arises from the outer surface of the ilium between the iliac crest and posterior gluteal line above, and the anterior gluteal line below; it also arises from the gluteal aponeurosis covering its outer surface. The fibers converge to a strong flattened tendon, which is inserted into the oblique ridge which runs downward and forward on the lateral surface of the greater trochanter. A bursa separates the tendon of the muscle from the surface of the trochanter over which it glides. 29 Variations—The posterior border may be more or less closely united to the Piriformis, or some of the fibers end on its tendon. 30 The Glutæus minimus the smallest of the three Glutæi, is placed immediately beneath the preceding. It is fan-shaped, arising from the outer surface of the ilium, between the anterior and inferior gluteal lines, and behind, from the margin of the greater sciatic notch. The fibers converge to the deep surface of a radiated aponeurosis, and this ends in a tendon which is inserted into an impression on the anterior border of the greater trochanter, and gives an expansion to the capsule of the hip-joint. A bursa is interposed between the tendon and the greater trochanter. Between the Glutæus medius and Glutæus minimus are the deep branches of the superior gluteal vessels and the superior gluteal nerve. The deep surface of the Glutæus minimus is in relation with the reflected tendon of the Rectus femoris and the capsule of the hip-joint. 31 Variations—The muscle may be divided into an anterior and a posterior part, or it may send slips to the Piriformis, the Gemellus superior or the outer part of the origin of the Vastus lateralis. 32

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FIG. 434– Muscles of the gluteal and posterior femoral regions. (Picture From the Classic Gray's Anatomy) The Tensor fasciæ latæ (Tensor fasciæ femoris) arises from the anterior part of the outer lip of the iliac crest; from the outer surface of the anterior superior iliac spine, and part of the outer border of the notch below it, between the Glutæus medius and Sartorius; and from the deep surface of the fascia lata. It is inserted between the two layers of the iliotibial band of the fascia lata about the junction of the middle and upper thirds of the thigh. 33 The Piriformis is a flat muscle, pyramidal in shape, lying almost parallel with the posterior margin of the Glutæus medius. It is situated partly within the pelvis against its posterior wall, and partly at the back of the hip-joint. It arises from the front of the sacrum by three fleshy digitations, attached to the portions of bone between the first, second, third, and fourth anterior sacral foramina, and to the grooves leading from the foramina: a few fibers also arise from the margin of the greater sciatic foramen, and from the anterior surface of the sacrotuberous ligament. The muscle passes out of the pelvis through the greater sciatic foramen, the upper part of which it fills, and is inserted by a rounded tendon into the upper border of the greater trochanter behind, but often partly blended with, the common tendon of the Obturator internus and Gemelli. 34 Variations—It is frequently pierced by the common peroneal nerve and thus divided more or less into two parts. It may be united with the Glutæus medius, or send fibers to the Glutæus minimus or receive fibers from the Gemellus superior. It may have only one or two sacral attachments or be inserted in to the capsule of the hip-joint. It may be absent. 35

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FIG. 435– The obturator membrane. (Picture From the Classic Gray's Anatomy) Obturator Membrane (Fig. 435)—The obturator membrane is a thin fibrous sheet, which almost completely closes the obturator foramen. Its fibers are arranged in interlacing bundles mainly transverse in direction; the uppermost bundle is attached to the obturator tubercles and completes the obturator canal for the passage of the obturator vessels and nerve. The membrane is attached to the sharp margin of the obturator foramen except at its lower lateral angle, where it is fixed to the pelvic surface of the inferior ramus of the ischium, i. e within the margin. Both obturator muscles are connected with this membrane. 36 The Obturator internus is situated partly within the lesser pelvis, and partly at the back of the hip-joint. It arises from the inner surface of the antero-lateral wall of the pelvis, where it surrounds the greater part of the obturator foramen, being attached to the inferior rami of the pubis and ischium, and at the side to the inner surface of the hip bone below and behind the pelvic brim, reaching from the upper part of the greater sciatic foramen above and behind to the obturator foramen below and in front. It also arises from the pelvic surface of the obturator membrane except in the posterior part, from the tendinous arch which completes the canal for the passage of the obturator vessels and nerve, and to a slight extent from the obturator fascia, which covers the muscle. The fibers converge rapidly toward the lesser sciatic foramen, and end in four or five tendinous bands, which are found on the deep surface of the muscle; these bands are reflected at a right angle over the grooved surface of the ischium between its spine and tuberosity. This bony surface is covered by smooth cartilage, which is separated from the tendon by a bursa, and presents one or more ridges corresponding with the furrows between the tendinous bands. These bands leave the pelvis through the lesser sciatic foramen and unite into a single flattened tendon, which passes horizontally across the capsule of the hip-joint, and, after receiving the attachments of the Gemelli, is inserted into the forepart of the medial surface of the greater trochanter above the trochanteric fossa. A bursa, narrow and elongated in form, is usually found between the tendon and the capsule of the hip-joint; it occasionally communicates with the bursa between the tendon and the ischium. 37 The Gemelli are two small muscular fasciculi, accessories to the tendon of the Obturator internus which is received into a groove between them. 38 The Gemellus superior the smaller of the two, arises from the outer surface of the spine of the ischium, blends with the upper part of the tendon of the Obturator internus, and is inserted with it into the medial surface of the greater trochanter. It is sometimes wanting. 39 The Gemellus inferior arises from the upper part of the tuberosity of the ischium, immediately below the groove for the Obturator internus tendon. It blends with the lower part of the tendon of the Obturator internus, and is inserted with it it into the medial surface of the greater trochanter. Rarely absent. 40 The Quadratus femoris is a flat, quadrilateral muscle, between the Gemellus inferior and the upper margin of the Adductor magnus; it is separated from the latter by the terminal branches of the medial femoral circumflex vessels. It arises from the upper part of the external border of the tuberosity of the ischium, and is inserted into the upper part of the linea quadrata—that is, the line which extends vertically downward from the intertrochanteric crest. A bursa is often found between the front of this muscle and the lesser trochanter. Sometimes absent. 41 The Obturator externus (Fig. 436) is a flat, triangular muscle, which covers the outer surface of the anterior wall of the pelvis. It arises from the margin of bone immediately around the medial side of the obturator foramen, viz., from the rami of the pubis, and the inferior ramus of the ischium; it also arises from the medial two-thirds of the outer surface of the obturator membrane, and from the tendinous arch which completes the canal for the passage of the obturator vessels and nerves. The fibers springing from the pubic arch extend on to the inner surface of the bone, where they obtain a narrow origin between the margin of the foramen and the attachment of the obturator membrane. The fibers converge and pass backward, lateralward, and upward, and end in a tendon which runs across the back of the neck of the femur and lower part of the capsule of the hipjoint and is inserted into the trochanteric fossa of the femur. The obturator vessels lie between the muscle and the obturator membrane; the anterior branch of the obturator nerve reaches the thigh by passing in front of the muscle, and the posterior branch by piercing it. 42 Nerves—The Glutæus maximus is supplied by the fifth lumbar and first and second sacra nerves through the inferior gluteal nerve; the Glutæi medius and minimus and the Tensor fasciæ latæ by the fourth and fifth lumbar and first sacral nerves through the superior gluteal; the Piriformis is supplied by the first and second sacral nerves; the Gemellus inferior and Quadratus femoris by the last lumbar and first sacral nerves; the Gemellus superior and Obturator internus by the first, second, and third sacral nerves, and the Obturator externus by the third and fourth lumbar nerves through the obturator. 43

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FIG. 436– The Obturator externus. (Picture From the Classic Gray's Anatomy) Actions—When the Glutæus maximus takes its fixed point from the pelvis, it extends the femur and brings the bent thigh into a line with the body. Taking its fixed point from below, it acts upon the pelvis, supporting it and the trunk upon the head of the femur; this is especially obvious in standing on one leg. Its most powerful action is to cause the body to regain the erect position after stooping, by drawing the pelvis backward, being assisted in this action by the Biceps femoris, Semitendinosus, and Semimembranosus. The Glutæus maximus is a tensor of the fascia lata, and by its connection with the iliotibial band steadies the femur on the articular surfaces of the tibia during standing, when the Extensor muscles are relaxed. The lower part of the muscle also acts as an adductor and external rotator of the limb. The Glutæi medius and minimus abduct the thigh, when the limb is extended, and are principally called into action in supporting the body on one limb, in conjunction with the Tensor fasciæ latæ. Their anterior fibers, by drawing the greater trochanter forward, rotate the thigh inward, in which action they are also assisted by the Tensor fasciæ latæ. The Tensor fasciæ latæ is a tensor of the fascia lata; continuing its action, the oblique direction of its fibers enables it to abduct the thigh and to rotate it inward. In the erect posture, acting from below, it will serve to steady the pelvis upon the head of the femur; and by means of the iliotibial band it steadies the condyles of the femur on the articular surfaces of the tibia, and assists the Glutæus maximus in supporting the knee in the extended position. The remaining muscles are powerful external rotators of the thigh. In the sitting posture, when the thigh is flexed upon the pelvis, their action as rotators ceases, and they become abductors, with the exception of the Obturator externus, which still rotates the femur outward. 44 4. The Posterior Femoral Muscles (Hamstring Muscles) (Fig. 434). 45 Biceps femoris. Semitendinosus. Semimembranosus. The Biceps femoris (Biceps) is situated on the posterior and lateral aspect of the thigh. It has two heads of origin; one, the long head arises from the lower and inner impression on the back part of the tuberosity of the ischium, by a tendon common to it and the Semitendinosus, and from the lower part of the sacrotuberous ligament; the other, the short head arises from the lateral lip of the linea aspera, between the Adductor magnus and Vastus lateralis, extending up almost as high as the insertion of the Glutæus maximus; from the lateral prolongation of the linea aspera to within 5 cm. of the lateral condyle; and from the lateral intermuscular septum. The fibers of the long head form a fusiform belly, which passes obliquely downward and lateralward across the sciatic nerve to end in an aponeurosis which covers the posterior surface of the muscle, and receives the fibers of the short head; this aponeurosis becomes gradually contracted into a tendon, which is inserted into the lateral side of the head of the fibula, and by a small slip into the lateral condyle of the tibia. At its insertion the tendon divides into two portions, which embrace the fibular collateral ligament of the knee-joint. From the posterior border of the tendon a thin expansion is given off to the fascia of the leg. The tendon of insertion of this muscle forms the lateral hamstring; the common personeal nerve descends along its medial border. 46 Variations—The short head may be absent; additional heads may arise from the ischial tuberosity, the linea aspera, the medial supracondylar ridge of the femur or from various other parts. A slip may pass to the Gastrocnemius. 47 The Semitendinosus remarkable for the great length of its tendon of insertion, is situated at the posterior and medial aspect of the thigh. It arises from the lower and medial impression on the tuberosity of the ischium, by a tendon common to it and the long head of the Biceps femoris; it also arises from an aponeurosis which connects the adjacent surfaces of the two muscles to the extent of about 7.5 cm. from their origin. The muscle is fusiform and ends a little below the middle of the thigh in a long round tendon which lies along the medial side of the popliteal fossa; it then curves around the medial condyle of the tibia and passes over the tibial collateral ligament of the knee-joint, from which it is separated by a bursa, and is inserted into the upper part of the medial surface of the body of the tibia, nearly as far forward as its anterior crest. At its insertion it gives off from its lower border a prolongation to the deep fascia of the leg and lies behind the tendon of the Sartorius, and below that of the Gracilis, to which it is united. A tendinous intersection is usually observed about the middle of the muscle. 48 The Semimembranosus so called from its membranous tendon of origin, is situated at the back and medial side of the thigh. It arises by a thick tendon from the upper and outer impression on the tuberosity of the ischium, above and lateral to the Biceps femoris and Semitendinosus. The tendon of origin expands into an aponeurosis, which covers the upper part of the anterior surface of the muscle; from this aponeurosis muscular fibers arise, and converge to another aponeurosis which covers the lower part of the posterior surface of the muscle and contracts into the tendon of insertion. It is inserted mainly into the horizontal groove on the posterior medial aspect of the medial condyle of the tibia. The tendon of insertion gives off certain fibrous expansions: one, of considerable size, passes upward and lateralward to be inserted into the back part of the lateral condyle of the femur, forming part of the oblique popliteal ligament of the knee-joint; a second is continued downward to the fascia which covers the Popliteus muscle; while a few fibers join the tibial collateral ligament of the joint and the fascia of the leg. The muscle overlaps the upper part of the popliteal vessels. 49 Variations—It may be reduced or absent, or double, arising mainly from the sacrotuberous ligament and giving a slip to the femur or Adductor magnus. 50 The tendons of insertion of the two preceding muscles form the medial hamstrings. 51 Nerves—The muscles of this region are supplied by the fourth and fifth lumbar and the first, second, and third sacral nerves; the nerve to the short head of the Biceps femoris is derived from the common peroneal, the other muscles are supplied through the tibial nerve. 52 Actions—The hamstring muscles flex the leg upon the thigh. When the knee is semiflexed, the Biceps femoris in consequence of its oblique direction rotates the leg slightly outward; and the Semitendinosus, and to a slight extent the Semimembranosus, rotate the leg inward, assisting the Popliteus. Taking their fixed point from below, these muscles serve to support the pelvis upon the head of the femur, and to draw the trunk directly backward, as in raising it from the stooping position or in feats of strength, when the body is thrown backward in the form of an arch. As already indicated on page 285, complete flexion of the hip cannot be effected unless the knee-joint is also flexed, on account of the shortness of the hamstring muscles. 53 Note 86 The Pectineus may consist of two incompletely separated strata; the lateral or dorsal stratum, which is constant, is supplied by a branch from the femoral nerve, or in the absence of this branch by the accessory obturator nerve; the medial or ventral stratum, when present, is supplied by the obturator nerve.—A. M. Paterson, Journal of Anatomy and Physiology, xxvi, 43.

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