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surface of the vastus lateralis, reaches the posterior part of
the thigh, and inosculates with the medial femoral circumflex
artery and the first perforating artery. The descending branch
gives twigs to the vastus intermedius and rectus femoris,
and one long branch, which may be traced distally, amid
the fibres of the vastus lateralis, to the knee, where it
anastomoses with the lateral superior genicular artery.

Dissection. Divide the ilio-tibial tract of the fascia lata,
distal to the tensor fasciae latae, in order to obtain a better demon-
stration of the limits of the lateral intermuscular septum and a
better view of the vastus lateralis muscle. Take hold of the
distal part of the ilio-tibial tract and pull it laterally, at the
same time push the vastus lateralis medially, then the strong
fibrous lateral intermuscular septum will be seen passing towards
the linea aspera on the back of the femur.

Intermuscular Septa. There are three intermuscular
septa of the thigh: lateral, medial, and posterior (p. 235).
The lateral is strong, the other two are both weak. Only
the lateral and medial are to be examined at present.

The lateral intermuscular septum is a fibrous partition
interposed between the vastus lateralis and intermedius
anteriorly, and the popliteal fossa and the short head of the
biceps femoris posteriorly. It springs from the deep surface
of the ilio-tibial tract, and its deep border is attached to the
lateral supracondylar ridge and to the lateral lip of the linea
aspera of the femur. Parts of the vastus intermedius and
vastus lateralis arise from its anterior surface, and some of the
fibres of the short head of the biceps femoris spring from its
posterior surface. Immediately proximal to the lateral
condyle of the femur it is pierced by the lateral superior
genicular artery and nerve. The medial intermuscular septum,
which is thin in comparison with the lateral septum, should
now be examined. It is interposed between the adductors
and the vastus medialis. Its distal part, which is most
distinct, passes laterally, from the fascia lata on the medial
side of the thigh, behind the posterior border of the sartorius
and behind the saphenous nerve, to the medial supracondylar
ridge, and it lies in front of the distal part of the adductor
magnus. Its proximal part is the thin layer of fascia on the
anterior surfaces of the adductors magnus and longus, which
is continuous above with the pectineal fascia.

M. Quadriceps Femoris. The quadriceps femoris muscle



262



THE INFERIOR EXTREMITY



Obturator interims
Piriformis /



is composed of four portions : the rectus femoris, which is
placed in the anterior part of the thigh, and is quite
distinct from the others, except at its insertion ; the vastus
lateralis, the vastus intermedius, and the vastus median's,
which clothe the body of the femur on its lateral, anterior,
and medial aspects, and are more or less blended with
each other.

M. Rectus Femoris. The rectus femoris muscle arises by
two tendinous heads of origin, which were exposed when

the dissection was
carried deeply in
the interval be-
tween the iliacus
and tensor of the
fascia lata (p. 250).
The anterior or
straight head springs
from the anterior
inferior spine of the
ilium (Fig. 116);
the posterior or
reflected head arises,
under cover of the
glutaeus minimus, from a
marked impression on the
lateral surface of the ilium,
immediately above the upper
part of the rim of the

FIG. 117. Anterior Aspect of Proximal acetabulum (Fig. 1 1 6). It
Portion of Femur with Attachments , j , ., .', ,,

of Muscles mapped out. 1S connected both with the

capsule of the hip joint and
the deep lamina of the ilio-tibial tract of the fascia lata.

At the present stage of dissection only the anterior part of the reflected
head is visible ; the posterior part will be seen when the gluteal region is
dissected.

The two heads of origin of the rectus femoris join at a
right angle, immediately beyond the margin of the acetabulum,
and form a strong, flattened tendon, which, gives place to
a fusiform, fleshy belly. The tendon of origin spreads out on
the anterior surface of the proximal part of the muscle in the
form of an aponeurosis. About three inches proximal to the
knee joint the rectus femoris ends in a strong tendon of




Ilio-psoas



THE THIGH 263

insertion, which is prolonged for some distance proximally,
on its deep surface, in the form of an aponeurosis. As it
nears the knee the tendon of the rectus femoris joins the
other tendons of the quadriceps, and forms with them a
common tendon which is inserted into the proximal border
of the patella. The rectus femoris is supplied by the femora?
nerve.

M. Vastus Lateralis. The lateral vastus muscle forms
the greater part of the prominent mass on the lateral side of
the thigh. Its surface is covered by a glistening aponeurosis.
The descending branch of the lateral circumflex artery con-
stitutes the best guide to its anterior border, and when that
margin is raised it will be seen that the muscle lies upon, and
is partially blended with, the vastus intermedius.

The vastus lateralis arises ( i ) from the upper part of the
intertrochanteric line; (2) from the front of the trochanter
major, distal to the insertion of the glutaeus minimus; (3)
from the inferior part of the trochanter major distal to the
insertion of the glutaeus medius ; (4) from the lateral part
of the gluteal tuberosity, anterior to the insertion of the
glutaeus maximus ; (5) from the proximal part of the linea
aspera ; and (6) from the lateral intermuscular septum (Figs.
117, 1 1 8, 121). The fleshy fibres are for the most part
directed distally and forwards. By means of the common
tendon of insertion the muscle gains attachment to the patella
and, at the same time, gives an expansion to the capsule of the
knee joint. It is supplied by the femoral nerve.

Dissection. Divide the rectus femoris about its middle, and
pull the distal part forcibly towards the foot. The narrow
interval between the tendons of the vastus intermedius and
vastus medialis will then become apparent, and will serve as a
guide to the line along which the muscles must be separated.
Another guide to the line of separation is the long, slender
nerve of supply to the articular muscle of the knee ; it runs
along the medial edge of the vastus intermedius. When the
anterior border of the vastus medialis is raised from the vastus
intermedius the medial surface of the body of the femur will be
seen to be almost bare. Few muscular fibres arise from that
bony surface. The fleshy mass of the vastus medialis may now,
with advantage, be divided transversely about two inches proximal
to the patella. The muscle can then be thrown medially, and
its origin studied.

M. Vastus Medialis. The vastus medialis is intimately
connected with the vastus intermedius, but not to such an
extent as might be inferred from a superficial inspection. In



264



THE INFERIOR EXTREMITY



its proximal part the anterior border, which is fleshy, is either
contiguous to or blended with the intermedius; distally, the



Head of femur



Neck of femur'

Intertrochanteric line

Lesser trochante

Attachment of lower band o
ilio-femoral ligament



Attachment of upper band of ilio-femoral ligament
Obturator internus and gemelli
Piriformis



"Glutaeus minir



Vastus lateralis
Vastus medialis



Adductor tubercle ^.

Medial epicondyle and
tibial collateral ligament



Patellar surface-




Anterior surface of femur



Medial border of femu



-Vastus intermedius
Vastus intermedius



M. articularis genu



. Lateral head of gastrocnemius
Lateral epicondyle and fibular

collateral ligament
Popliteus



FIG. n 8. Diagram of the Femur seen from in front.

anterior border is tendinous and overlaps the intermedius,
but it is not, as a rule, fused with it.

The vastus medialis arises (i) from the lower part of the



THE THIGH 265

intertrochanteric line; (2) from the line extending from the
intertrochanteric line to the linea aspera ; (3) from the medial
lip of the linea aspera ; (4) from the proximal part of the
medial supracondylar line as far distally as the opening in the
adductor magnus (Figs. 118, 121); (5) from the rounded
tendon of the adductor magnus. The fleshy fibres are
directed distally and anteriorly, and end in the common
tendon of the quadriceps muscle, which is inserted into the
patella and becomes connected with the capsule of the knee
joint. The muscle is supplied by the femoral nerve.

M. Vastus Intermedius (O.T. Crureus). The vastus inter-
medius covers the anterior, and lateral aspects of the body
of the femur, from both of which, as well as from the distal
part of the lateral intermuscular septum, it takes origin. It
is inserted into the patella through the medium of the
common tendon. It is supplied by the femoral nerve.

Common Tendon of the Quadriceps. It should now be
noticed that the common tendon of the quadriceps muscle
closes the knee joint proximal to the patella. It is inserted into
the proximal border of that bone, and is intimately connected
with the capsule of the knee joint. Some fibres are carried
distally, across the surface of the patella, into the ligamentum
patellae. A pouch of the synovial stratum is prolonged
proximally beyond the level of the patella, between the
quadriceps and the bone. Into the wall of that pouch the
articular muscle of the knee is inserted.

Dissection. The vastus intermedius should be divided in a
vertical direction, so as to bring the little articular muscle into
view, and at the same time the long, slender nerve-filament
which runs along the medial border of the vastus intermedius
may be traced to the muscle and the synovial stratum of the
knee joint. The articular muscle consists of a few slips of
muscle fibres which spring from the lower part of the front of
the femur. They are inserted into the upper part of the synovial
stratum of the capsule of the knee joint.

The ligamentum patella, which connects the patella with
the tuberosity of the tibia, and through which the quadri-
ceps is attached to that bone, will be studied in connection
with the knee joint. It may be noted now that it is a
broad, thick tendon, which extends from the patella to the
tuberosity of the tibia.

The quadriceps femoris, acting as a whole, is an extensor
of the knee, but the rectus femoris can also flex the hip joint.



2 66 THE INFERIOR EXTREMITY

The articularis genu merely lifts the upper part of the synovial
stratum of the capsule of the knee to prevent its being caught
between the bones as the knee joint is extended.



MEDIAL SIDE OF THE THIGH.

The group of adductor muscles on the medial aspect of the
thigh, together with the blood-vessels and nerves associated
with them, must next be dissected. As the dissection
proceeds the following structures will be displayed :

fPectineus.
Adductor longus.

,, , I Adductor brevis.
Muscles, 4 Adductor magnus-

Gracilis.
l.Obturator externus.

. , . f Profunda femoris (and its branches).
Arteries, ( Obturator>

^ / The two divisions of the obturator nerve.

' \The accessory obturator nerve, when present.

The adductor muscles are disposed in three strata. The
anterior strattim is formed by the pectineus and the adductor
longus, which lie in the same plane. Their adjacent borders
touch one another proximally, but distally they are separated
by a small interval. The second stratum is formed by the
adductor brevis ; and the third, or posterior layer^ by the
adductor magnus. The gracilis muscle, also an adductor,
extends along the medial aspect of the thigh. It is a long,
strap-like muscle, applied against the adductor brevis and
adductor magnus. Interposed between the three muscular
layers are the two divisions of the obturator nerve. The
anterior division is placed between the anterior and middle
layers ; the posterior division lies between the middle and
posterior layers. In other words, the adductor brevis inter-
venes between them. At the distal border of the adductor
longus, a fine branch from the anterior division of the
nerve makes its appearance ; it takes part in the formation
of the sub -sartorial nerve plexus already dissected. The
profunda artery and its branches also are to be followed.
For a part of its course this vessel is placed between the
anterior and middle muscular strata.

M. Adductor Longus. The adductor longus muscle is



MEDIAL SIDE OF THE THIGH 267

placed on the medial side of the pectineus. It is somewhat
triangular in shape, being narrow at its origin and expanded
at its insertion. It arises by a short, but strong, tendon from
the anterior surface of the body of the pubis, immediately
below the pubic crest (Fig. 116), and it is inserted into
the medial lip of the linea aspera of the femur by a thin,
tendinous expansion. It is supplied by the anterior division of
the obturator nerve. It acts like the adductor brevis (p. 272).

Dissection. Divide the adductor longus 25 mm. below its
origin. Turn the proximal part upwards and notice how the
flat tendon is so curved upon itself that it simulates the appear-
ance of a round tendon. Turn the distal portion towards the
femur, and secure its nerve of supply from the anterior division
of the obturator nerve, which lies posterior to the muscle. As
the femur is approached the muscle fibres will be found to
terminate in a thin aponeurosis, by which the muscle is attached
to the linea aspera. This aponeurosis of insertion is intimately
connected anteriorly with the vastus medialis and posteriorly
with the adductor magnus. Separate it from both as far as
possible ; especially from the adductor magnus, in order to
display the profunda vessels, which lie, in part of their course,
between the adductors longus and magnus.

Art. Profunda Femoris. This large vessel is the chief
artery of supply to the muscles of the thigh. It arises, in the
femoral triangle, from the lateral and posterior aspect of the
femoral artery, about an inch and a half distal to the inguinal
ligament. At first it is placed on the iliacus, but, as it pro-
ceeds distally, it inclines medially, and thus it crosses posterior
to the femoral artery, and conies to lie on the pectineus.
Reaching the upper border of the adductor longus, it passes
posterior to that muscle, and is continued distally, close to the
body of the femur, in front of the adductor brevis and adductor
magnus. Numerous large branches spring from the profunda
femoris, so that it rapidly diminishes in size. Ultimately it
is reduced to a fine terminal twig, which turns backwards
through the adductor magnus, and receives the name of the
fourth perforating artery. The following are the relations of
the profunda femoris: (i) It lies anterior to the iliacus,
on the lateral side of the femoral artery. (2) It is anterior
to the pectineus and posterior to the femoral artery, but
separated from it by the femoral vein and the profunda femoris
vein. (3) It is anterior to the adductor brevis, and, more
distally, to the adductor magnus, and it is posterior to the
adductor longus, which separates it from the femoral vessels.



268



THE INFERIOR EXTREMITY



(4) The terminal twig, called the fourth perforating artery,
pierces the adductor magnus in the middle third of the thigh.

The branches which spring from the profunda femoris
are : the two femoral circumflex arteries, the four perforating
arteries, and some muscular branches.

The lateral femoral circumflex artery arises from the lateral
aspect of the profunda, close to its origin. It has already
been followed to its distribution (p. 260). The medial



. rectus femoris (straight head of origin)

M. rectus femoris (reflected head of origin)
Attachment of the lig.

ilio-femorale M. adductor longus (origin)

M. pyramidalis abdominis (orij
M. rectus abdominis (ori|




M. semimem

branosus (origin)

M. quadratus

femoris (origin)

Mm. biceps and

semitendinosus

(origin)



M. gracilis (origin)



M. adductor brevis (origin)



FlG. 119. External Surface of the Os Pubis and Ischium,
with Attachments of Muscles mapped out.

femoral circumflex artery which takes origin at the same
level, but from the medial and posterior aspect of the pro-
funda, will be studied when the pectineus muscle is reflected.
The medial femoral circumflex artery frequently arises from
the femoral trunk. The muscular branches are irregular both
in origin and size. They supply the adductor muscles, and give
twigs which pierce the adductor magnus to reach the ham-
string muscles.

Arterise Perforantes. The perforating arteries arise in



MEDIAL SIDE OF THE THIGH



269



M. obturator externus



Lateral

circumflex

artery



series from the profunda femoris, and pass backwards through
the adductor muscles to the posterior region of the thigh.
They may be recognised from the close relation which they
bear to the linea aspera of the femur. The first perforating
artery comes off at the level of the distal or medial border of
the pectineus. It proceeds backwards through the adductor
brevis and adductor
magnus. The second
perforating artery
takes origin a short
distance distal to
the first perforating,
or perhaps by a
common trunk with
it. It pierces the
same muscles, viz.,
the adductor brevis is t, 2 nd, and
and adductor
magnus. The third
perforating artery
springs from the
profunda, distal to
the adductor brevis,
and passes back-
wards through the
adductor magnus.
The fourth perforat-
ing artery, as before
noted, is the
terminal branch of
the profunda
femoris ; it pierces
the adductor
magnus alone.



hes



Femoral artery




r magnus

Art. genu
suprema (O.T.
anastomotic)



Femoral artery



FIG. 1 20. The Profunda Femoris Artery and its
The Superior Branches.

nutrient artery of the femur may spring from either the second
or the third perforating branch. An inferior nutrient artery
is frequently present; it is often derived from the fourth
perforating artery.

When the adductor magnus is more fully exposed it
will be seen that the perforating arteries, as they pierce its
tendon, are protected by a series of fibrous arches. The



THE INFERIOR EXTREMITY



further course of the perforating arteries is dealt with on
P- 323-



Obturator externus
Glutaeus medius

Intertrochanteric crest
Quadratus femoris

Vastus lateralis
Glutaeus maximus

Vastus intermedius -
Lateral lip of linea aspe



Head of femur



Ligamentum teres



* Neck of femur

'Line of attachment of articular capsule
Lesser trochanter and ilio-psoas



Adductor longus
-Vastus medialis



Short head of biceps femoris

Vastus lateral!
Vastus intermedia



Popliteal surface

Plantaris

Lateral head of gastrocnemiu?

Lateral epicondyk

Fibular collateral ligament




Adductor magnus
Medial lip of linea aspera



Adductor tubercle'



Medial head of gastro-

cnemius

Fibial collateral ligament



Medial condyle
Lateral condyle " * Posterior cruciate ligament

Anterior cruciate ligament
FIG. 121. Diagram of the Femur seen from behind.

M. Pectineus. The pectineus muscle is placed between
the adductor longus and the ilio-psoas. It is flat and some-
what broader at its origin from the brim of the pelvis than



MEDIAL SIDE OF THE THIGH



271



obturator interims



Quadratu
femoris



at its insertion into the femur. It has a fleshy origin, from
the pectineal line of the pubis, and from the surface of the
hip bone anterior to it (Fig. 116). Some fibres are derived
also from the lacunar ligament. It descends obliquely,
laterally and backwards, and gains insertion into the back
of the femur, lateral to
the lesser trochanter,
and to a certain extent
also into the line which
leads from that promin-
ence towards the linea
aspera (Figs. 121, 122).
It is supplied by the
femoral nerve. The
pectineus adducts the
femur and rotates the
thigh laterally. It also
assists in flexion of the
hip joint.

Dissection. De-
tach the pectineus from
its origin, and throw
it towards its insertion.
Whilst separating the
muscle from the pubis
the dissector must bear
in mind that in some
cases an accessory ob-
turator nerve descends
into the thigh, under
cover of its lateral
margin, and over the
pubis. Care must also
be taken not to injure

(1) the anterior division

of the obturator nerve which lies posterior to the muscle, or

(2) the medial femoral circumflex artery which passes posteriorly
in contact with the lateral border of the muscle (Fig. 113).

Nervus Obturatorius Accessorius. The accessory obturator nerve,
when present, arises within the abdomen either from the lumbar plexus or
from the obturator trunk near its origin (Fig. 124). In the thigh it gives
a branch to the hip joint and joins the anterior division of the obturator
nerve. It is very rare to find a twig given to the pectineus either by it or
by the trunk of the obturator nerve itself.

Art. Circumflexa Femoris Medialis. The medial femoral
circumflex artery springs from the medial and posterior aspect




FIG. 122. Posterior Aspect of Proximal
Portion of Femur, with the Attachments
of Muscles mapped out.



272 THE INFERIOR EXTREMITY

of the profunda femoris artery, at the same level as the lateral
femoral circumflex branch. It passes posteriorly between the
adjacent margins of the psoas and the pectineus, and then
between the adductor brevis and the obturator externus, to
the posterior region of the thigh, where, close to the lesser
trochanter, it divides into an ascending and a transverse
terminal branch. Before the main trunk divides it gives off
(i) a superficial branch which passes, medially, across the
front of the pectineus and then between the adductors longus
and brevis, and (2) an articular branch which enters the
hip joint through the acetabular notch. The terminal
branches will be examined in the dissection of the gluteal
region.

Branches of the Femoral Artery. In every region of the thigh the
dissector has met with branches of the femoral artery. It is well now
that he should revert to this vessel and study its branches in the order in
which they arise. The following Table may aid him in doing this :
Aa. pudenda; exterme. } Superficial

A. epgastrica super ficiahs inguinal.

A. circumflexa ilium superficialis. J

A. circumflexa femoris lateralis.
A. circumflexa femoris medialis-.



A. femoralis. -



A. perforans prima.



A. profunda. < A ; perforans secun d a . { Aa. Nutritise.

A. perforans tertia.
j^A. perforans quarta (terminal).
Rami Musculares.
A. genu suprema.

M. Adductor Brevis. The short adductor muscle lies
posterior to the adductor longus and the pectineus. It
arises, below the origin of the adductor longus, from the
anterior aspect of the body and the inferior ramus of the
os pubis (Fig. 1 1 6). As it descends it inclines posteriorly
and laterally; and it is inserted, posterior to the pectineus,
into the greater part of the line which extends from the
lesser trochanter to the linea aspera (Fig. 121), and into
the proximal part of the linea aspera, lateral to the adductor
longus. It is supplied by the obturator nerve. It is an
adductor and a lateral rotator of the thigh and a flexor of
the hip joint.

Dissection. Divide the adductor brevis, parallel with and
close to its origin, and turn it towards its insertion, but do not
injure the anterior division of the obturator nerve which lies
in front of it. When the muscle is reflected the posterior
division of the obturator nerve will be exposed. Trace the
nerve, proximally, to the point where it pierces the obturator



MEDIAL SIDE OF THE THIGH



273



externus at the obturator foramen, and, distally, to its disappear-
ance in the adductor magnus.

Nervus Obturatorius. The obturator nerve is a branch
of the lumbar plexus. It escapes from the pelvis by passing,



Anterior superior \

spine of ilium

M. tensor fasciae

lata:

M. sartorius

Anterior inferior
spine of ilium

M. rectus femori



M. glutaeus
minimus



M. glutaeus
medius



M. iliacus

M. psoas

External iliac vessels

Femoral nerve (O.T. anterior crura)

Capsule of hip joint, grooved
M. pectineus

Obturator
nerve



M. ilio-psoa




M. pectineus : > vl A > }



Profunda femoris.
vessels



M. vastus lateralis



M. vastus inter-
medius



M. rectus femoris 1



Femoral vessels and
saphenous nerve



M. sartorius



FIG. 123. Dissection of the Front of the Thigh. The hip joint has been
exposed by removing portions of the muscles which lie anterior to it.

with its companion vessels, through the upper part of the



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