Describe the fusion of the three bones that make up the hip
At birth, the three primary bones are joined by hyaline cartilage.
In children they are incompletely ossified.
At puberty, the three bones are still separated by a Y-shaped Triradiate cartilage centred in the acetabulum, although the two parts of the ischiopubic rami fuse by the 9th year.
The bones begin to fuse between 15 and 17 yesrs of age; fusion is complete between 20 and 25 yesrs LV she.
What is the Obturator Foramen?
Large oval opening in the hip bone.
It is bounded by the pubis and ischium and their rami.
Except for a small passageway for the obturator nerve and vessels (the obturator canal), the obturator foramen is closed by the thin, strong obturator membrane.
The presence of the foramen minimises bony mass (weight) while its closure by the obturator membrane still provides extensive surface area on both sides for fleshy muscle attachment.
What is the pubic symphysis?
The pubic symphysis unites the two hip bones (specifically the bodies of the two opposing pubic parts of the hip bones) anteriorly in the midline.
What is Shenten's line?
When studying a Hip X-Ray, Shenten's line is formed by the medial edge of the femoral neck and the inferior edge of the superior pubic ramus.
Loss of contour of Shenten's Line is a sign of a fractured neck of femur.
Important note: fractures of the femoral neck do not always cause loss of Shenten's line.
Describe Fractures of the Hip Bone
Weak areas are the pubic rami, the acetabula (or the area immediately surrounding them), the region of the sacro-iliac joints and the alae of the ilium.
Fractures can result from direct trauma to the pelvic bones such as occurs during a car accident or can be caused by forces transmitted to these bones from the lower limb during falls on the feet.
Pelvic fractures may cause injury to soft pelvic tissues, blood vessels, nerves and organs.
Fractures in the pubo-obturator area are relatively common and are often complicated because of their relationship to the urinary bladder and urethra which may be ruptured or torn.
Describe fracture of the neck of femur
Most frequently fracture because it is the narrowest and weakest part of the bone and it lies at a marked angle to the line of weight-bearing (pull of gravity).
It becomes increasingly vulnerable with age, especially in females, secondary to osteoporosis.
Fractures are often intracapsular and realignment of the neck fragments require internal skeletal fixation.
Shortening and lateral/external rotation of the lower limb occurs and blood supply is often disrupted - the retinacular arteries of the medial circumflex femoral artery may be torn.
Describe fractures of the proximal femur
Can occur at several locations such as the middle of the neck and intertrochanteric.
Because of the angle of inclination, these fractures are inherently unstable and impact (overriding of fragments resulting in foreshortening of the limb) occurs.
Muscle spams also contribute to the shortening of the limb.
What do fractures of the great trochanter and femoral shaft usually result from?
Direct trauma and are most common during the more active years (during motor vehicle accidents and sports such as skiing and climbing).
In some cases, a spiral fracture of the femoral shaft occurs resulting in foreshortening as the fragments override or the fracture may be comminuted with the fragments displaced in various directions as a result of muscle pull and depending on the level of the fracture, union of this type of fracture may take up to a year.
How may fractures of the inferior or distal femur be complicated by?
By separation of the condyles, resulting in misalignment of the articular surfaces of the knee joint or by haemorrhage from the large popliteal artery that runs directly on the posterior surface of the bone. This fracture compromises the blood supply to the leg.
Describe Tibial Fractures
Tibial shaft is narrowest at the junction of its middle and inferior thirds which is the most frequent site of fracture.
This area of the bone also has the poorest blood supply. Because its anterior surface is subcutaneous, the tibial shaft is the most common site for a compound (open) fracture.
Compound fractures may also result from direct trauma e.g. When a car bumper strikes the leg.
Fracture of the tibia through the nutrient canal predisposes the patient to non-union of the bone fragments resulting from damage to the nutrient artery.
Describe Fibular Fractures
Commonly occur 2-6cm proximal to the distal end of the lateral malleolus and are often associated with fracture-dislocation of the ankle joint, which are combined with tibial fractures.
When a person slips and the foot is forced into an excessively inverted position, the ankle ligaments tear, forcibly tilting the talus against the lateral malleolus and may shear it off.
Fractures of the lateral and medial malleolus are relatively common in soccer and basketball players.
Fibular fractures can be less painful owing to disrupted muscle attachments. Walking is compromised because of the bone's role in ankle stability.
Describe Calcaneal Fractures
A hard fall on the heel may fracture the calcaneous into several pieces, producing a comminuted fracture.
A calcaneal fracture is usually disabling because it disrupts the subtalar (talcalcaneal joint where the talus articulates with the calcaneus).
Describe how a Fracture of the Talar neck may occur
During severe dorsiflexion of the ankle e.g. When a person is pressing extremely hard on the brake pedal of a vehicle during a head-on collision.
In some cases the body of the talus dislocates posteriorly.
Describe Fractures of the Metatarsals
They occur when a heavy object falls on the foot of when it is run over by a heavy object such as a metal wheel.
Metatarsal fractures are also common in dancers - esp. Female ballet.
Fatigue fractures may result from prolonged walking -repeated stress on the metatarsals.
Describe an avulsion fracture of the tuberosity of the 5th metatarsal
When the foot is suddenly and violently inverted, the tuberosity of the 5th metatarsal may be torn away by the tendon of the fibularis brevis muscle.
It is common in basketball and tennis players.
The injury produces pain and oedema at the base of the 5th metatarsal and may be associated with a severe ankle sprain.
Describe Fractures of the Sesamoid bones of the great toe
They may result from a crushing injury.
Sesamoids of the great toe in the tendon of the flexor hallucis longus bear the weight of the body, especially during the latter part of the stance phase of walking, may result from a crushing injury.
Sesamoids develop before birth and begin to ossify during late childhood.
What is the Femoral Sheath?
Funnel shaped fascial tube, formed by an inferior prolongation of transversalis and iliopsoas fascia from the abdomen.
The femoral sheath does not enclose the femoral nerve because it passes through the muscular compartment.
The femoral sheath allows the femoral artery and vein to glide deep to the inguinal ligament during movements of the hip joint.
What are the Femoral Triangle contents and borders?
Lateral to medial: NAVEL: femoral nerve, femoral artery, femoral vein, empty space (to allow vein distension during venous return), lymphatics
Borders: SAIL: Sartorius, Adductor Longus, Inguinal Ligament
What is the Adductor Canal?
Long (~15cm), narrow passageway in the middle third of the thigh, extending from the apex of the femoral triangle, where the Sartorius crosses over the adductor longus, to the adductor hiatus in the tendon of the adductor Magnus.
It provides an intermuscular passage for the femoral artery and vein, branches of the femoral nerve - the saphenous nerve and the slightly larger nerve to vastus medialis, delivering the femoral vessels to the popliteal fossa where they become popliteal vessels.
What are the borders of the Adductor Canal?
Anteriorly and laterally by the Vastus Medialis
Posteriorly by the Adductors Longus and Magnus
Medially by the Sartorius which overlies the groove between the above muscles, forming the roof of the canal.
What is the Adductor Hiatus?
Opening/gap between the aponeurosis distal attachment of the adductor part of the adductor Magnus and the tendinous distal attachment of the hamstring part.
The adductor hiatus transmits femoral artery and vein from the adductor canal in the thigh to the popliteal fossa posterior to the knee.
Opening is located just lateral and superior to the adductor tubercle of the femur.
When the femoral artery passes through the adductor hiatus, it becomes the popliteal artery
What is the Obturator Nerve? Consider nerve roots and muscles it innervates
Major peripheral nerve that innervates the medial compartment of the thigh and the cutaneous branch innervates the skin of the medial thigh (sensory supply).
Nerve roots: L2:L4. Innervates Adductors Longus, Brevis and Magnus (adductor part only), Gracilis and Obturator Externus (lateral rotator).
The hamstring part of the Adductor Magnus is innervated by the Tibial part of Sciatic nerve.
What are possible symptoms of Obturator Nerve Damage?
Numbness and paraesthesia on the medial aspect of the thigh and weakness in adduction of the thigh.
Alternatively the patient could present with posture and gait problems due to the loss of Adduction.
What is the Patella Tendon Reflex?
A firm strike on the patellar ligament sigh a reflex hammer usually causes the leg to extend.
If the reflex is normal, a hand on the person's quadriceps should feel the muscle contract.
This tendon reflex tests the integrity of the femoral nerve and the L2-L4 spinal cord segments.
Tapping the ligament activates muscle spindles in the quadriceps. Afferent impulses from the spindles travel in the femoral nerve to the L2-L4 segments of the spinal cord. From here, efferent impulses are transmitted via motor fibres in the femoral nerve to the quadriceps resulting in a jerk like contraction of the muscle and extension of the leg at the knee joint.
Dimunition of absence of the patella tendon reflex may result from any lesion that interrupts the innervations of the quadriceps e.g. Peripheral nerve disease.
Explain about Pulled Groin Muscles
A strain, stretching and probably some tearing of the proximal attachments of the anteromedial thigh muscles have occurred.
The injury usually involves the flexor and adductor thigh muscles. The proximal attachments of these muscles are in the inguinal region (groin), the junction of the thigh and trunk.
Groin pulls usually occur in sports that require quick starts or extreme stretching.
Describe how to palpate the Femoral Artery
Lay patient in supine position.
The femoral pulse may be palpated midway between the ASIS and the public symphysis: by placing the tip of the little finger on the ASIS and the thumb on the public tubercle, the femoral pulse can be palpated with the midpalm just inferior to the midpoint of the inguinal ligament by pressing firmly.
How is the Femoral Artery pulse normally?
Normally strong, however if the common or external iliac arteries are partially occluded, the pulse may be diminished.
Describe Cardiovascular procedures involving the Femoral Artery
May be cannulated just inferior to the midpoint of the inguinal ligament.
Catheter may be inserted into the artery and used in angiography or coronary arteriography.
Blood may also be taken from the femoral artery for blood gas analysis (the determination of oxygen and carbon dioxide concentrations and pressures with the pH of the blood by laboratory tests).
Describe how to locate the femoral vein
The femoral vein is not usually palpable but its position can be located inferior to the inguinal ligament by feeling the pulsations of the femoral artery which is immediately lateral to the vein.
In thin people, the femoral vein may close to the surface and may be mistaken for the great saphenous vein.
Describe cardiovascular procedures involving the femoral vein
A Catheter is inserted into the femoral vein as it passes through the femoral triangle. Under fluoroscopic control, the catheter is passed superiorly through the external and common iliac veins into the IVC and right atrium of the heart.
Might be used to secure blood samples and take pressure recordings from the chambers of the right side of the heart and/of from the pulmonary artery, and to perform right cardiac angiography.
Femoral venous pressure may also be used for the administration of fluids.
Describe Pathologies of the Femoral Triangle
The superficial position of the femoral artery in the femoral triangle makes it vulnerable to traumatic injury especially laceration.
Commonly both the femoral artery and vein are lacerated in anterior thigh sounds because they lie close together. In some cases, an arterio venous shunt occurs as a result of communication between the injured vessels.
A located dilation of the terminal part of the great saphenous vein, called a saphenous varix (dilated vein) may cause oedema in the femoral triangle.
A saphenous vein may be confused with other groin swellings such as a psoas abscess; however a varix should be considered when varicose veins are present in other parts of the lower limb.