Hip/Glutes

Question 1

The os coxae or innominate bone is _______ in newborns and children, then becomes _____ in adulthood

Answer 1

• separated (by epithelia)
• fused

Question 2

These two ligaments form these two important foramina within the pelvic region for passage of structures into and out of the gluteal region:

Answer 2

• ligaments: sacrospinous L. and sacrotuberous L.
• foramina: greater sciatic foramen and lesser sciatic foramen

Question 3

What contents pass through the greater sciatic foramen?

Answer 3

(all exit)

• piriformis M.
• sciatic N.
• guteal neurovascular bundles
• posterior femoral cutaneous N.
• pudendal N. and internal pudendal A.
• obturator internus/superior gemellus N.

Question 4

What contents pass through the lesser sciatic foramen?

Answer 4

• pudendal N. and internal pudendal A. (enter)
• obturator internus/superior gemellus N. (enter)
• obturator internus (exit)

Question 5

What nerves supply the cutaneous and deep region of the hips/glutes?

Answer 5

• cutaneous: cluneal (clunial) nerves
• deep: deep nerves (sacral plexus branches, leave pelvis via greater sciatic foramen)

Question 6

What nerves supply the superior/middle and inferior areas of the cutaneous glute/hips?

Answer 6

• superior/middle: lateral branches of L1-3 and S1-3 dorsal (posterior) rami, supply superior 2/3, sacrum, and adjacent area
• inferior: gluteal branches of posterior femoral cutaneous N. (S1-3 ventral (anterior) rami branches), supply inferior 1/3

Question 7

What are the courses and innervations of the 2 deep nerves of gluteal region? (superior gluteal N. and inferior gluteal N.)

Answer 7

• superior gluteal N. course: leaves pelvis superior to piriformis w/ superior gluteal A., runs between gluteus medius and gluteus minimus
• superior gluteal N. innervation: gluteus medius, gluteus minimus, and tensor fasciae latae
• inferior gluteal N. course: leaves pelvis inferior to piriformis w/ inferior gluteal A.
• inferior gluteal N. innervation: gluteus maximus

Question 8

• nerve derived from L4-S3 ventral (anterior) rami
• largest nerve in the body
• course: leaves pelvis inferior to piriformis, runs inferiorly deep to gluteus maximus, usually divides about half way down thigh into tibial and common fibular Ns.
• does not supply any gluteal structures

Answer 8

sciatic nerve

Question 9

Innervates the cutaneous portion of the posterior thigh and supplies more skin than any other cutaneous nerve:

Answer 9

posterior femoral cutaneous N.

Question 10

• nerve that arises from anterior divisions of S2-S4 ventral rami
• most medial structure exiting greater sciatic foramen
• reenters pelvis via lesser sciatic foramen to supply perineal structures

Answer 10

pudendal N.

Question 11

What are the 3 main branches arising from the internal iliac A.?

Answer 11

• superior gluteal A.
• inferior gluteal A.
• internal pudendal A.

Question 12

• largest internal iliac A. branch
• deep branch supplies: gluteus medius, gluteus minimus, tensor fascia lata

Answer 12

superior gluteal A.

Question 13

• artery that branches off the internal iliac A.
• supplies: gluteus maximus, small lateral rotators, superior hamstrings
• aids in cruciate anastomosis of thigh: transverse branch of the medial circumflex femoral A., terminal part of the transverse branch of the lateral circumflex femoral A., first perforating A., and this artery

Answer 13

inferior gluteal A.

Question 14

What are the arteries that participate in cruciate anastamosis of the leg?

Why is this important?

Answer 14

• inferior gluteal A., medial circumflex femoral A., lateral circumflex femoral A., perforating As.
• important because they can supply blood to the leg if the femoral A. is occluded/severed

Question 15

• artery that branches off the internal iliac A.
• reenters pelvis via lesser sciatic foramen w/ pudendal N.
• supplies perineal Ms. and ext. genitalia
• does not supply any gluteal structures

Answer 15

internal pudendal A.

Question 16

Where should intragluteal injections be made?

Answer 16

In the supero-lateral part of the gluteal region in order to avoid the sciatic N. and other gluteal nerves and vessels

Question 17

What are the superficial gluteal muscles?

Answer 17

• gluteus medius
• tensor fasciae latae
• gluteus maximus

Question 18

Gluteus Maximus

• Origin:
• Insertion:
• Action:
• Innervation:

Answer 18

Gluteus Maximus

(largest gluteus muscle)

• Origin: lateroposterior surface of sacrum and coccyx, gluteal surface of ilium (behind posterior gluteal line), thoracolumbar fascia, sacrotuberous ligament
• Insertion: iliotibial tract, gluteal tuberosity of femur
• Action: chief extensor of the thigh, lateral rotation, slight extension of leg when working w/ tensor fascia lata
• Innervation: inferior gluteal N.

Question 19

Gluteus Medius and Gluteus Minimus

• Origin:
• Insertion:
• Action:
• Innervation:

Answer 19

Gluteus Medius and Gluteus Minimus

(both partially covered by gluteus maximus)

• Origin of medius: gluteal surface of ilium (between anterior and posterior gluteal lines)
• Insertion of medius: lateral aspect of greater trochanter of femur
• Origin of minimus: gluteal surface of ilium, (between anterior and inferior gluteal lines)
• Insertion of minimus: anterolateral aspect of greater trochanter of femur
• Action: thigh abduction and medial rotation (particularly minimus)
• Innervation: superior gluteal N.

Question 20

Summarize the gait cycle:

(just memorize this shit, I literally have no idea what the %’s mean and I don’t really care)

Answer 20

• gait sequence composed of 60% stance phase (20% double support [10% right foot forward, 10% left foot forward] and 40% single support) and 40% swing phase
• swing phase occurs during single support stance phase (both = 40%)
• two double support phases for a single gait cycle

Question 21

Gluteus Medius and Minimus dysfunction:

• condition names:
• causes:
• effect:

Answer 21

Gluteus Medius and Minimus dysfunction:

• condition names: gluteal gait or Duchenne’s limp (positive Trendelenburg’s sign)
• causes: superior gluteal N. injury (or stroke that causes other underlying nerve injury)
• effect: patient loses steadying action of gluteus medius and minimus, they lean toward effected side during stance phase of gait

Question 22

What causes the leaning gait on the stance side within gluteus dysfunction?

Answer 22

• contraction on stance side keeps greater trochanter in proximity to the iliac blade
• thereby keeping the pelvic level and maintaining a smooth gait
• if dysfunctional, the pelvis tilts toward the swing side

Question 23

Tensor Fascia Lata

• Origin:
• Insertion:
• Action:
• Innervation:

Answer 23

Tensor Fascia Lata

(enclosed by fascia lata, has the IT band)

• Origin: outer lip of anterior iliac crest, anterior superior iliac spine (ASIS)
• Insertion: iliotibial tract
• Action: abducts, medially rotates, and flexes thigh; slight extension of knee along w/ the gluteus maximus
• Innervation: superior gluteal N.

Question 24

• a tendon in the lateral leg that runs from iliac tubercle to tubercle (Gerdy’s) on lateral tibial condyle
• reinforced by tendinous fibers from tensor fascia lata and gluteus maximus
• function: assists in decelerating adduction of thigh; laterally stabilizes knee; extends leg, compensate for quadriceps paralysis via gluteus maximus flexion; pulls patella laterally, antagonist of vastus medialis, and synergist w/ flexing vastus lateralis for this action; stretch to treat chondromalacia patella

Answer 24

iliotibial band (IT band)

Question 25

Piriformis M. - Origin: - Insertion: - Action: - Innervation:

Answer 25

Piriformis M. (lies deep to gluteus maximus and medial to gluteus medius, demarcates gluteal blood vessels and nerves) - Origin: anterior surface of the sacrum (between the S2 and S4), gluteal surface of ilium (near posterior inferior iliac spine), (sacrotuberous ligament) - Insertion: apex of greater trochanter of femur - Action: external rotation and abduction of thigh, stabilizes head of femur acetabulum - Innervation: nerve to piriformis (S1-2)

Question 26

Obturator Internus - Origin: - Insertion: - Action: - Innervation:

Answer 26

Obturator Internus (leaves pelvis through lesser sciatic foramen) - Origin: posterior surface of the obturator membrane; bony boundaries of the obturator foramen - Insertion: medial surface of greater trochanter of femur - Action: external rotation of extended thigh; abduction of flexed thigh; stabilization of hip joint - Innervation: nerve to obturator internus (L5 and S1)

Question 27

Superior and Inferior Gemelli - Origin: - Insertion: - Action: - Innervation:

Answer 27

Superior and Inferior Gemelli - Origin: ischial tuberosity - Insertion: medial surface of greater trochanter of femur (via tendon of obturator internus) - Action: thigh external rotation, thigh abduction (from flexed hip), stabilizes head of femur in acetabulum - Innervation of superior: nerve to obturator internus and superior gemellus - Innervation of inferior: nerve to quadratus femoris and inferior gemellus

Question 28

Obturator Externus M. - Origin: - Insertion: - Action: - Innervation:

Answer 28

Obturator Externus M. (deep to pectineus) - Origin: external margins of obturator foramen - Insertion: trochanteric fossa - Action: thigh external rotation, thigh abduction (from flexed hip); stabilizes head of femur in acetabulum - Innervation: obturator N.

Question 29

Quadratus Femoris M. - Origin: - Insertion: - Action: - Innervation:

Answer 29

Quadratus Femoris M. - Origin: ischial tuberosity - Insertion: intertrochanteric crest of femur - Action: thigh external rotation; stabilizes head of femur in acetabulum - Innervation: nerve to quadratus femoris (L4-S1)

Question 30

What are the vertically oriented and horizontally oriented gluteal muscles?

Answer 30

Question 31

What are the dynamics of the glutei muscles?

Answer 31

Question 32

What are the bursae of the gluteal region?

Answer 32

- ischial bursa - trochanteric bursa - gluteofemoral bursa

Question 33

Hip joint - articular surfaces: - joint type: - movements:

Answer 33

Hip joint - articular surfaces: head of femur articulates w/ acetabulum of hip - joint type: diarthrotic ball and socket type of synovial joint - movements: flexion-extension, abduction-adduction, circumduction, medial-lateral rotation

Question 34

Hip joint: articular surfaces - rim of acetabulum is incomplete inferiorly (acetabular notch): - acetabulum has a centrally located nonarticular area (acetabular fossa): - acetabulum depth increased by fibrocartilaginous acetabular labrum:

Answer 34

Hip joint: articular surfaces - rim of acetabulum is incomplete inferiorly (acetabular notch): bridged by transverse acetabular ligament - acetabulum has a centrally located nonarticular area (acetabular fossa): fatpad covered by a synovial membrane occupies acetabular fossa, malleable nature permits positional changes of femoral head during hip joint movements - acetabulum depth increased by fibrocartilaginous acetabular labrum: deepens socket for femoral head

Question 35

- injury that can be induced by twisting on a weight bearing hip, majority (80%) have no known direct cause - pain may become diffuse and difficult to pinpoint - not possible to see swelling, although the inflamed joint may become larger in volume because of an "effusion" due to trauma - if the front of the hip joint is affected there may be a pinching sensation when the person flexes the hip by bringing the knee up to the chest - pain may be reproduced in sport during activities that require weight bearing and twisting (i.e. kicking a football) - can be repaired arthroscopically

Answer 35

acetabular labrum tears

Question 36

Hip joint: articular capsule - proximally attached to the edge of acetabulum - distally attached to the neck of femur - some deep fibers pass circularly around neck (orbicular zone): - some deep longitudinal fibers form a retinaculum (L., band or halter):

Answer 36

- some deep fibers pass circularly around neck (orbicular zone): forms a collar around neck (helps hold femoral head in acetabulum) - some deep longitudinal fibers form a retinaculum (L., band or halter): retinacular fibers are reflected superiorly along neck

Question 37

Hip joint: articular capsule - thickened parts of fibrous (articular) capsule are called: - three hip joint intrinsic ligaments:

Answer 37

- thickened parts of fibrous (articular) capsule are called: instrinsic ligaments - three hip joint intrinsic ligaments: iliofemoral L., pubofemoral L., ischiofemoral L.

Question 38

- intrinsic hip ligament - strong y-shaped band that covers anterior aspect of hip - anterior inferior iliac spine and acetabular rim to intertrochanteric line - helps prevent overextension

Answer 38

iliofemoral L.

Question 39

- intrinsic hip ligament - strengthens anterior and inferior parts of fibrous capsule - arises from obturator crest of pubic bone and passes laterally to blend with joint capsule and iliofemoral ligament - helps prevent overabduction and overextension

Answer 39

pubofemoral L.

Question 40

- intrinsic hip ligament - strengthens joint capsule posteriorly - arises from ischial part of acetabular rim - fibers spiral anterolaterally to attach to femoral neck - helps prevent overextension

Answer 40

ischiofemoral L.

Question 41

- comprises 10-15% of traumatic hip dislocations - occur when knee strikes dashboard w/ thigh abducted, falls from height, or from a blow to the back in a squatted position - neck of femur or greater trochanter impionges on rim of acetabulum and thereby levers head of femur out of acetabulum through tear in anterior hip capsule

Answer 41

anterior hip dislocation

Question 42

- type of hip dislocation - occurs when thigh is adducted, medially rotated, and flexed - can cause damage to the sciatic nerve - may result in paralysis of hamstrings and muscles distal to the knee - sensory change may occur in skin over the posterolateral aspects of leg and most of foot

Answer 42

posterior hip dislocation

Question 43

What is the degenerative process that may cause someone to require a hip replacement? How is a hip replacement done generally? Lol

Answer 43

- osteoarthritis - metal prosthesis anchored to femur by bone cement to replace femoral head and neck, plastic socket cemented to hip bone to replace acetabulum

Question 44

What are the differences in clinical presentation of a hip fracture vs. a hip dislocation?

Answer 44

- fracture: injured leg is shortened and laterally rotated - dislocation: leg is normal length and medially rotated