L5: Anantomy of the Hip Flashcards
(88 cards)
1
Q
What are the three main articulations at the hip bone?
A
Sacroilliac joint: Posterior between hips and sacrum
Pubic symphysis: anterior, between L and R hips bone
Hip joint: articulation with head of the femur
2
Q
What are the three parts of the hip bone?
A
Ilium
Pubis
Ischium
3
Q
What is the name of the socket in which they all form? What articulates there?
A
Acetabulum
Head of the femur
4
Q
What cartilage separates the bones during childhood?At what age do they being to and complete fusion?
A
Triradiate cartilage
Beings 15-17 years
Completed 20-25 years
5
Q
What is the anatomy of the ilium?
A
Largest
Forms superior part of acetabulum
Two surfaces–>
internal surface: concave shape, iliac fossa
external surface: convex shape, attachment of gluteal muscles
Superior: iliac crest–> thickened wing, extends for ASIS to PSIS (anterior/posterior superior iliac spine)
Notches: AIIS and PIIS (anterior/ posterior inferior iliac spine)
Posterior: greater sciatic notch –> indentation
6
Q
Describe the anatomy of the pubis?
A
Anterior portion of hip
Pubic body: medial portion,
–> articulates with opposite at pubic symphysis(cartilagenous joint)
–> pubic crest- round thickening
–> pubic tubercle- (rounded projection) marks end of pubic crest
Superior pubic ramus–> extends laterally form pubic symphysis to acetabulum
Inferior pubic ramus–> extends laterally, joins with inferior ischial ramus at ischiopubic ramus
7
Q
What is the obturator foramen? What forms it?
A
Hole Formed by: - Superior pubic ramus - Inferior pubic ramus - Superior ischial ramus - Inferior ischial ramus
8
Q
Describe the anatomy of the ischium?
A
Posterioinferior hip
Supeiror ischial ramus, body and inferior ischial ramus
Ischial tuberosity: posterior inferior part, bit you sit on
Ischial spine: projection of bone between superio ischial ramus and body (posteromedial projection of bone)
9
Q
What important ligaments are attached to the ischium?
A
Sacrospinous ligament: anterior side, lateral, between ischial spine to sacrum
–> creates greater sciatic foramen
Sacrotuberous ligament: posterior side, longitudinal between sacrum to ischial tuberosity
–> creates lesser sciatic foramen
Limit rotatior of inferior part of sacrum
10
Q
What forms the hip joint? Type of joint?
A
Acetabulum and head of femur
Ball and socket
11
Q
What is the main function of the hip joint?
A
Enable movement of the lower limbs
Support weight of the body
12
Q
What is the acetabulum? What structure helps stabilise it?
A
Cup like socket
inferiorlateral aspect
Acetabulum labrum–> fibrocartilagenous, encircles and deepens socket, more secure fit
–> ↑contact area by 10% so > 50% femoral head is in contact
13
Q
What cartilage covers the surface of the head of femur and lines the acetabulum?
A
Hyaline cartilage
Acetabulum–> hyaline incomplete inferiorly–> acetabular notch–> contains fibroelastic fat with synovial membrane
14
Q
What is the osteology of the femur? (label diagram)
A
Head–> covered hyaline cartilage, fovea capitis (depression for attachment of ligamentum teres)
Neck –> inferiorly, posteriorly and laterally, 125 degree angle with shaft
Greater and lesser trochanter–> bony prominence attachment site
Anterior–> Intertrochanteric line –> connect GT and LT
Posterior–> Intertrochanteric crest –> conntect GT and LT
Shaft –> linea aspera (posterior surface) –> intermuscular septa and muscles of thigh attach
Gluteal tuberosity –> between superior aspect of linear aspera and intertrochanteric crest
Lateral and medial supraconylar lines–>linear aspera diverges
Medial supraconylar ends on adductor tubercle (superior to medial epicondyle)
end of femur–> Medial and femoral condyles,
posterior –> separated by intercondylar notch
anterior–> trochlear groove
Medial and lateral epicondyle –> protuberance superior to condyle
15
Q
What does the capsule of the hip attach to?
A
Proximally –> edge of acetabulum 5-6mm outside acetabulum labrum
Distally –> anterior - intertrochanteric line
–> posterior - neck of femur
16
Q
What ligaments are associated with the hip joint?
A
Intracapsular –> ligamentum teres (contain artery)
Extracapsular - 3 ligaments- pull head into joint
–> Iliofemoral
–> Pubofemoral
–> Ischiofemoral
17
Q
What are the features of the iliofemoral ligament?
A
- strongest
- superior and anterior joint capsule, blends with it
- anterior inferior iliac spine to intertrochanteric line (Y shaped insertion)
- Prevents hyperextension
- Screw head into acetabulum (standing)
18
Q
What are the features of the pubofemoral ligament?
A
- inferior and anterior
- superior pubic ramus to inferior part of intertrochanteric line
- prevents excessive abduction and extension of hip
19
Q
What are the features of the ischiofemoral ligament?
A
- posterior surface
- spiral shaped
- body of ischium to spirals superiolaterally to superior lateral intertrochanteric line and anteriormedial apsect of greater trochanter
- prevents excessive internal (medial) rotation of hip
20
Q
What are the features of the ischiofemoral ligament?
A
- posterior surface
- spiral shaped
- body of ischium to spirals superiolaterally to superior lateral intertrochanteric line and anteriormedial apsect of greater trochanter
- prevents excessive internal (medial) rotation of hip
21
Q
What ligament bridges the acetabular notch?
A
Transverse acetabular ligament
22
Q
Where is the synovial membrane located?
A
Under the ligaments
attached to the margins of the articular surfaces
Ensheathes the ligamentum teres and covers the pad of fat contained within
23
Q
What helps to stabilise the hip joint?
A
- C-shaped acetabulum
- Acetabulum labrum
- Capsule
- Ligaments intra and extracapsular
- Muscles
24
Q
How do they muscles and ligaments work in the hip joint?
A
Reciprocal fashion
Anteriorly–> ligaments strongest, muscles weakest
Posteriorly –> ligaments weakest, muscles strongest
25
What movements are possible at the hip joint?
Flexion, extension, abduction, adduction, lateral rotation, medial rotation
26
What is the blood supply to the femoral head and neck?
-Extracaspular arterial ring
--> posteriorly- medial femoral circumflex artery
--> anteriorly- lateral femoral circumflex artery
branches of profunda femoris artery (femoral artery- external iliac artery)
-Ascending cervical arteries aka retinacular (branches of lateral circumflex arteries)--> metaphysis of femoral neck
-Artery of ligamentum teres --> femoral head (major in children, minor in adults)
- Ascending cervcial arteries (retinacular) of medial femoral circumflex artery --> head of femur
27
Why are adults more at risk of avascular necrosis to the head of the femur than children?
Fracture cut of blood supply from ascending cerival arteries of MFCA
Children major blood supply by artery of the ligamentum teres
28
What is the lumbosacral plexus?
Nerve supply to the lower limb
29
What nerve roots contribute the the lumbar plexus?
Anterior rami of L1-4
Divide into cords--> combine to form peripheral nerves
Descends on posterior abdominal wall
30
What contributes to the lumbosacral trunk?
L4 anterior ramus combines with the L5 anterior ramus
| Contribute axons to sacral plexus hence lumbosacral plexus
31
What nerve root contribute to the sacral plexus?
S1- S5 and L4 and L5 (lumbosacral trunk)
| Main destination= lower limb and pelvis, muscles, organs and perineum
32
What does 'I get leftovers on Friday' stand for?
```
Branches of the lumbar plexus
I--> Ilioinguinal (L1)
Get--> Genitofemoral (L1 and L2)
Leftovers--> Lateral femoral cutaneous (L2 and L3)
On--> Obturator (L2, L3 and L4)
Friday--> Femoral (L2, L3 and L4)
```
33
Where does the ilioinguinal nerve innervate?
L1
| Skin of genitalia and upper medial thigh (very upper!!)
34
Where does the genitofemoral nerve innervate?
L1 and L2
Genital branch (not this unit)
Femoral branch--> skin on upper anterior thigh
35
Where does the lateral cutaneous nerve innervate?
Posterior divisions of L2 and L3
| Cutaneous sensation to anterolateral thigh inferiorly as knee
36
Where does the obturator nerve innervate?
Anterior L2, L3 and L4
Skin over medial thigh
Medial compartment of thigh (muscles)
37
Where does the femoral nerve innervate?
Posterior L2, L3 and L4
Skin of anterior thigh (anterior femoral cutaneous branch)
Skin of medial leg (saphenous branch)
Anterior muscles
38
What does 'Salmon is so perfectly pink' stand for?
Branches of the sacral plexus
Salmon--> Superior gluteal (L4, L5 and S1)
Is --> Inferior gluteal (L5, S1 and S2)
So --> Sciatic (L4, L5, S1, S2 and S3)
Perfectly --> Posterior femoral cutaneous (S1, S2 and S3)
Pink --> Pudendal (S2, S3 and S4)
39
What does the superior gluteal nerve innervate?
L4, L5 and S1
No sensory branches
Gluteus medius, gluteus minimus, tensor fascia lata muscles
40
What does the inferior gluteal nerve innervate?
L5, S1 and S2
No sensory branches
Gluteus maximus
41
What does the posterior cutaneous nerve of the thigh innervate?
S1, S2 and S3
Posterior branches S1 and S2, anterior branches of S2 and S3
Innervated skin of posterior thigh and leg
42
What forms the borders of the greater and lesser sciatic foramen?
Great sciatic foramen-->
- anterolaterally --> greater sciatic notch of ilium
- posteriormedially--> upper fibres of sacrotuberous ligaments
- inferiorly--> ischial spine and sacrospinous ligament
Lesser sciatic foramen-->
- Superiorly --> ischial spine and sacrospinous ligament
- Inferiorly --> ischial tuberosity
- Posteriorly --> sacrotuberous ligament
- Anteriolaterally--> lesser sciatic notch
43
What nerves exit through the greater sciatic foramen? What is there relationship to the piriform muslce?
Superior to piriform muscle
- Superior gluteal nerve
Posterior to piriform muscle
- Sciatic nerve
- Inferior gluteal nerve (artery and vein also)
- Posterior femoral cutaneous nerve
- Nerve to quadratus femoris
- Nerve to obturator internus
44
What passes through the lesser sciatic foramen?
Nerve to obturator internus
| Tendon of obturator internus
45
What is the course of the sciatic nerve?
- Largest nerve 2cm in diameter
- Emerges horizontally from pelvic cavitiy, through greater sciatic foramen inferior to piriformis muscle
- Midway between PSIS and ischial tuberosity
- lies on bone of ischium
- Then on superior gemellus, obturator internus, inferior gemellus and quadratus femoris muscle
- passes midway between the greater trochanter and ischial tuberosity to enter posterior compartment of thigh
- On posterior surface of adductor magnus muscle and the long head of the biceps femoris muscle crosses
- Divides into tibial nerve and common peroneal nerve at superior end of popliteal fossa
- Tibial nerve --> hamstring muscles
- Common peroneal --> short head of biceps femoris
46
When administrating an intramuscular injection what nerve do you have to avoid? Where should the injection be done?
Sciatic nerve
Dorsogluteal site--> used in children between the ages of 3 and 7yrs
Ventrogluteal site--> >7 years
--> place hand on side of thigh over greater trochanter, point thumb towards inguinal region, index towards ASIC and middle finger upwards
--> inject between the interphalangeal joints of the index and middle finger
--> into the gluteus medius muscles
47
What is the deep fascia of the thigh called? Why is it important? What is its origin and insertion?
Fascia lata
Encloses the muscles
Site of attachment of intermuscular septae--> divides thigh 3 compartments--> anterior, medial and posterior
Superiorly--> continuous with the fascia of abdominal wall
Inferiorly--> continuous with deep fascia of leg--> Crural fascia
48
How does the thickness of the fascia lata vary over the thigh?
Thinnest medially - over adductor muscles
Thickened lateral aspect - iliotibial tract (iliac crest to lateral tibial condyle)
Opening--> below inguinal ligament, saphenous opening for sapheous vein (into femoral vein) and lymphatic vessels--> superficial inguinal lymph nodes
49
What is the tensor facsia lata?
Muscle
Origin: Anterior superior iliac spine
Insertion: between the layers of the iliotibial band of fascia lata at junction between upper and middle two thirds of thigh
Innervation: Superior gluteal nerve (L5 and S1)
50
What is the function of the tensor fascia lata?
- Pulls on iliotibial tract during extension of leg, stabilising the leg
- Standing: stabilises the knee, steading the condyle of femur on tibia
- Abduction on the leg
- Pulls fascia lata upwards --> tightening the compartments in the thigh--> compressing the veins--> improves venous return
51
What are the superficial muscles of the gluteal region?
Gluteus Maximus
Gluteus Medius
Gluteus Minimus
Tensor fascia lata
52
What are the deep muscles of the gluteal region?
```
Piriformis
Gemellus superior
Obturator Internus
Gamellus inferior
Quadratus femoris
Obturator externus (sometimes included)
```
53
What is the origin, insertion, function and innervation of the gluteus maximus?
O: Posterior surface of ilium, sacrum and coccyx
I: Superficial = iliotibial tract
: Deep = Gluteal tuberosity of the femur
Function:
--> Main extensor of thigh (running, climbing), < Lateral (external) rotation
(--> with hamstring extends trunk by tipping hips backwards, superior fibres assist with flexing knee through iliotibial tract)
Innervation: Inferior gluteal nerve (L5, S1 and S2)
54
What is the origin, insertion, function and innervation of the gluteus medius?
```
Between gluteus maximus and minimus
O: Gluteal surface of ilium
I: Lateral surface of greater trochanter
Function:
--> Abduction
--> Medially (internally) rotates
--> secures pelvis in horizontal allignment
Innervation: Superior gluteal nerve (L4, L5 and S1)
```
55
What is the origin, insertion, function and innervation of the gluteus minimus?
```
Deepest and smallest
O: Ilium
I: Anterior aspect of greater trochanter
Function:
--> Abduction
--> Medially (internally) rotates
Innervation: Superior gluteal nerve (L4, L5 and S1)
```
56
What is the consequence of a superior gluteal nerve injury? What may cause it?
Unable to adbuct the lower limb
Causes: Complication in surgery, injections in buttock, fractures of greater trochanter (site of insertion of G. Medius), dislocation of hip
Trendelenburg sign
57
What is a clinical sign of superior gluteal nerve injury?
Trendelenburgs sign
Asked to stand on injured lower limb, pelvis tips, unsupported side descends as gluteus medius and minimus don't contract
58
What is the origin, insertion, function and innervation of the Piriformis?
Key muscle--> sciatic nerve emerges posterior
O: Anterior surface of sacrum, inferolaterally through greater sciatic foramen
I: Superior aspect of greater trochanter
Function
--> Lateral (external) rotation
--> Abduction
Innervation: Nerve to piriformis
59
What is the origin, insertion, function and innervation of the Obturator Internus?
Forms part of lateral wall of pelvic cavity
O: Medial surface of obturator membrane, adjacent pubis and ischium, through lesser sciatic foramen
I: Posterior aspect of greater trochanter
Fucntion:
--> Lateral (external) rotation
--> Abduction
Innervation: Nerve to obturator
60
What is the origin, insertion, function and innervation of the Superior and Inferior Gemellus?
Narrow triangular muscles, separated by obturator internus tendon
O: Superior: ischial spine
Inferior: ischial tuberosity
I: posterior aspect of greater trochanter, above and below insertion of obturator internus respectively
Function:
--> Lateral (external) rotation
--> Abduction
Innervation: Superior: nerve to obturatus
Inferior: nerve to quadratus femoris
61
What is the origin, insertion, function and innervation of the Quadratus Femoris?
Flat, square shaped muscle, most inferior of the deep muscles
O: lateral aspect of ischial tuberosity
I: Quadrate tubercule (on intertrochanteric crest)
Function:
--> Lateral (external) rotation
Innervation: Nerve to quadratus femoris
62
What is the origin, insertion, function and innervation of the Obturator Externus?
Sometimes deep muscles of gluteal region, sometimes medial compartment of thigh
O: External surface of obturator membrane (Membrane over obturator foramen)
I: Passes posteriorly to neck of femur to posterior aspect of greater trochanter
Function:
--> Lateral (external) rotation
--> Adduction
Innervation:
--> Obturator nerve (L2-L4)
63
What are the muscles of the posterior thigh (hamstrings)?
Biceps Femoris
Semitendinosus
Semimembranous
-Form prominant tendons at medial and lateral knee
64
What is the origin, insertion, function and innervation of the Biceps Femoris?
Two heads; long and short
O: Long head: Ischial tubersity
Short head: Linea aspera on posterior surface of femur
I: Common tendon onto head of fibula
Function:
--> Extension at hip
--> Lateral (external) rotation
--> Flexion of leg at knee
Innervation: Long head: tibial part of sciatic nerve
Short head: common peroneal part of scaitic nerve
65
What is the origin, insertion, function and innervation of the semitendinosus?
Largely tendon
Medial to biceps femoris and superficial to semimembranosus
O: Ischial tuberosity
I: Medial aspect of tibia--> Part of pes anserinus
Function:
--> Extension at thigh
--> Medially (internally) rotates thigh at hip
--> Medially (internally) rotates leg at knee
--> Flexion of leg at knee
Innervation: Tibial part of sciatic nerve
66
What is the origin, insertion, function and innervation of the semimembranosus?
```
Flat broad tendon
O: Ischial tuberosity
I: Medial tibial condyle
Function:
--> Extension at thigh
--> Flexes leg at knee
--> Medially (internally) rotates
Innervation: Tibial part of sciatic nerve
```
67
What is a pulled hamstring?
Sudden tension on the hamstring muscles
| Results in muscle strain, partial tear or complete tear of origin of hamstrings from ischial tuberosity
68
What are the common disorders of the hip?
Osteoarthritis
Fractures
Dislocation
69
What is osteoarthritis?
Common
Affects synovial joints
Degenerative--> Articular hyaline cartilage breaks down
Clinical--> joint pain, functional limitation
70
What are the two classifications of osteoarthritis?
Primary --> causes unknown
-risk factors--> age, sex, ethnicity, nutrition, genetics
Secondary--> caused as a result of something else e.g. obesity, trauma, malalignment, infection, inflammatory arthritis, metabolic disorders of the hip, haematological disorders, endocrine abnormalities
71
What is the pathology of osteoarthritis?
1-Precipitating risk factors (obesity...) --> excessive or uneven loading of joint
2-Damage to hylaine cartilage
3-Hyaline cartilage becomes swollen, ↑ proteoglycan synthesis by chondrocytes (chondrocytes from chondorprogenitor cells)
4-Attempt to repair cartilage
5-Flaking and Fibrillation (vertical clefts) of articular cartilage (normally smooth)
6-Cartilage eroded to subchondral bone--> loss of joint space
7-Altered biomechanics --> vascular invasion and increased cellularity--> thickened and denser at areas of compression --> eburnation--> subchondral sclerosis
8-Traumatised subchondral bone--> cystic degeneration--> subchondral bone cysts due to chronic impaction or intrusion of synovial fluid
9-Osseous metaplasia of CT--> irregular bone outgrowth --> osteophytes
72
What are the signs of osteoarthritis on an x-ray?
1- reduced joint space
2- subcondral sclerosis
3- bone cysts
4- osteophytes
73
What are the symptoms of osteoarthritis in the hip?
Joint stiffness --> getting out of bed or up after sitting for long time
Pain in hip, gluteal and groin regions radiating to knee
Mechanical pain
Crepitus (grating sound, crunching or crackling sensation on movement of joint)
Reduced mobility
74
How is osteoarthritis diagnosed?
Symptoms and signs
| X-rays
75
How is osteoarthritis treated?
Non-operative
-Weight reduction
-Activity modification (if overweight)
-Mechanical aids--> walking stick or frame
-Muscle strengthening exercise and orthopedic footwear --> physiotherapy
Medications
-NSAID
-Cox-2 inhibitors
-Nutritional supplements
-Analgesia
Injections
- Steroid injections (corticosteroids)--> reduce swelling
Viscosupplementation--> increase lubrication and promote cartilage repair
Operative--> Total Hip replacement (only done when there is pain)
76
What are the statistics surrounding osteoarthritis?
More common in women 60%
Average age= 67yrs for men, 69yrs for women
Approx 100,000 hip replacements each year
77
What is the definition of fractures of the femoral neck?
Fracture of proximal femur up to 5cm below the lesser trochanter
78
How are fractures of the femoral neck classified?
Intracapsular
| Extracapsular --> intertrochanteric and subtrochanteric
79
Why are intracapsular fractures considered more dangerous than extracapsular fractures?
Intra--> likely to distrupt the ascending cervical branches of medial femoral circumflex artery
Ligamentum teres minor blood supply in adult
Avascaular necrosis of head of femur
Risk increased if fracture is displaced
80
Who is most at risk of an intracapsular fracture?
Middle aged post-menopausal women with osteoporotic bones
| Occurs after minor fall
81
Who is most at risk of an extracapsular fracture?
Young and middle aged
| Road traffic collisions
82
How are intracapsular fractures treated?
Risk of avascular necrosis --> total hip replacement or surgical replacement of femoral head
83
How common is neck of femur fractures?
```
Very common
Incidence= 100,000 per annum
4 billion worldwide
10% one month mortality
↑ to 20% at one year
30% at one year--> permanent disability
40% unable to walk independently
80% unable to carry out at least one independent activity of daily living
```
84
What are the symptoms of neck of femur fractures?
Reduced mobility / sudden inability to weight bear
Pain felt in hip, groin or knee
Examination
--> if displaced--> affected leg shortened, abducted and externally rotated
--> pain upon palpation of greater trochanter and upon rotation
--> Suspect fracture --> avoid vigorous examination--> risk displacing fracture
85
Why is the leg shortened and externally rotated?
Neck now independent of head
shortened--> strong muscles of hip pull the femur upwards--> Rectus femoris, adductor magnus and hamstring muscles
Externally rotated--> Piriformis, obturator internus, superior and inferior gemelli, quadratus femoris- contract
Abducted--> Gluteus medius and minimus attached to greater trochanter contract
86
How is dislocation defined?
Head of femur being fully displaced out of the cup of the acetabulum
Less than complete dislocation --> sublaxation
87
What are the two broad classifications of hip dislocations?
```
Congential --> Developmental dysplasia
--> not always full dislocation
--> sometimes develops after birth
Traumatic--> severe injury
--> massive amount of force required
--> common in 16-40yr olds
```
88
What types of dislocation can occur?
Posterior--> most common 90%
--> Affected limb shortened, held in position of flexion, adduction, and internal (medial) rotation
--> sciatic nerve palsy present in 8-20% cases
Anterior--> External rotation, abduction and slight flexion
Central dislocation--> Head of femur driven into pelvis through acetabulum
--> Always fracture dislocation
--> Femoral head palpable on rectal examination
--> Internal haemorrhage possible
--> Can be life threatening
