Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Pelvis, Hip, and Thigh Conditions Chapter 17

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Pelvis, Hip, and Thigh ConditionsChapter 17Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 1Skeletal Features of Pelvis, Hip, and Thigh

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 2PelvisFunctionProtects organsTransmits loads between trunk and lower extremity Provides site for muscle attachments4 fused bonesSacrumCoccyx Innominate bonesIlium, ischium, and pubisCopyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 3Pelvis (cont.)SI jointCritical link between the two pelvic bones Strong ligamentous supportSacrococcygeal jointFused line symphysis united by a fibrocartilaginous disc Pubic symphysisInterpubic disc located between the two joint surfacesCopyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 4Bony Structure of ThighFemurWeakest at femoral neck Angle of inclination Angle of depression formed by a line drawn through the shaft of femur and a line passing through the long axis of femoral neckApproximately 125 in the frontal plane 125 coxa valga125 coxa varaCopyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 5

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 6Bony Structure of Thigh (cont.)FemurAngle of torsionRelationship between femoral head and femoral shaft in transverse planeApproximately 1212 anteversion12 retroversionCopyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 7

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 8Hip JointHead of femur and acetabulum of pelvisBall and socket jointVery stable Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 9Hip Joint CapsuleCompletely surrounds joint, attaching to the labrum of the acetabular socketPasses over a fat pad internally to join to the distal aspect of femoral neck Zona orbicularis

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 10Ligaments of Hip JointIliofemoral ligamentLimits hyperextension

Pubofemoral ligamentLimits abduction and hyperextension

Ischiofemoral ligament Limits extension

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 11Femoral TriangleBordersInguinal ligamentsuperiorSartoriuslateralAdductor longusmedialContentsFemoral nervesFemoral arteryFemoral vein

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 12BursaeIliopsoas Reduces friction between iliopsoas and articular capsuleDeep trochanteric bursa Provides cushion between greater trochanter and gluteus maximus at its attachment to iliotibial tractGluteofemoral bursa Separates gluteus maximus from origin of vastus lateralisIschial bursa Weight-bearing structure during sittingCushions ischial tuberosity where it passes over gluteus maximusCopyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 13Q-AngleAngle between line of resultant force produced by quadriceps and line of patellar tendon Males 13; females 18

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 14Muscles

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 15Muscles (cont.)

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 16Muscles (cont.)

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 17NervesLumbar plexusFemoral nerveObturator nerveSacral plexusSciatic nerve

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 18Blood VesselsExternal iliacFemoralDeep femoralFemoral circumflexF16.10

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 19KinematicsPelvis positioningPelvis tilts to facilitate movement in hipPosterior tiltassists hip flexionAnterior tiltassists hip extensionLateral tiltassists hip abductionCopyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 20Kinematics (cont.)Hip flexorsIliopsoas, pectineus, rectus femoris, sartorius, and tensor fascia lataeTwo-joint musclesRectus femorisactive during hip flexion and knee extensionSartoriusactive during hip flexion and knee extensionHip extensorsGluteus maximus and hamstrings (biceps femoris, semitendinosus, and semimembranosus)Hamstringstwo-joint; hip extension and knee flexion Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 21Kinematics (cont.)Hip abductorsGluteus medius, gluteus minimus Active in stabilizing pelvis during single-leg support and during support phase of walking and runningHip adductors Adductor longus, adductor brevis, and adductor magnus Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 22Kinematics (cont.)Lateral rotatorsPiriformis, gemellus superior, gemellus inferior, obturator internus, obturator externus, and quadratus femoris Lateral rotation of femur of swinging leg accommodates lateral rotation of pelvis during stride Medial rotators Gluteus minimusTensor fascia latae, semitendinosus, semimembranosus, gluteus medius, and adductorsCopyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 23KineticsBody weight places compression on hip, as does tension in hip muscles

Forces are less during standing than with running and walkingForces translated through the lower extremity; result compression on hipCopyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 24PreventionProtective equipmentHip joint well protected but iliac and pelvis need protectionThighPhysical conditioningShoesCushion forcesCopyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 25ContusionsHip pointerMechanism: direct blow to iliac crestCommonanterior or lateral portion of crestOften from improperly fitting (or absent) hip pads

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 26Contusions (cont.)S&SPoint tenderness; swelling; ecchymosisIndividual prefers slightly forward flexed position to relieve tension of abdominals and iliopsoasAntalgic gait with shortened swing phase pain with active trunk flexion and active hip flexionPain with coughing, laughing, breathingAbdominal muscle spasmManagement: standard acute; rest; protect with hard-shell pad for return to activityCopyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 27Contusions (cont.)Quadriceps contusionMechanism: direct blowCommon anterolateral thighS&S Transitory loss of functionWith continued play, progressively stiffer and unresponsive pain with active knee extension and hip flexionLimited AROM due to pain; knee flexion limited actively and passivelyCopyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 28Contusions (cont.)Management: Standard acute; with knee in maximum flexionHard-shell pad for return to activityPhysician referral if myositis ossificans orcompartment syndrome is suspected

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 29

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 30Contusions (cont.)Myositis ossificans Develops secondary to single significant blow or repetitive blows to same area Evident on radiograph 34 weeks after injury

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 31Contusions (cont.)S&SWarm, firm, swollen thigh; 24 cm larger Palpable, painful mass may limit passive knee flexion to 2030Active quadriceps contractions and straight leg raisesdifficult Management: standard acute; physician referralSelf-limiting injuryMaturation612 months

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 32Contusions (cont.)Compartment syndrome Neurovascular compressionDue to uncontrolled internal bleeding and swelling S&SProgressive, severe pain with passive motion and isometric contraction of quadriceps pressure femoral sensation and motor weakness; distal pulse and capillary refill may be normalManagement: ice (no compression); immediate physician referralCopyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 33BursitisMechanism Excessive friction or shear forces due to overusePosttraumatic bursitis from direct blows that cause bleeding in the bursaGreater trochanteric bursitisInfluence of Q-angle

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 34Bursitis (cont.)S&SBurning or aching over or posterior to greater trochanter Aggravated with: Hip abduction against resistanceHip flexion and extension on weight bearingReferred painlateral aspect of the thigh

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 35Bursitis (cont.)Iliopsoas bursitisPain medial and anterior to joint; cannot be easily palpated pain with passive hip rotation; resisted hip flexion, abduction, and external rotationIschial bursitisPain aggravated by prolonged sitting and uphill running,Point tenderness directly over ischial tuberosity pain with passive and resisted hip extensionCopyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 36Bursitis (cont.)Bursitis managementStandard acute; deep friction massage; NSAIDs; stretching program for involved muscle On-going prevention: biomechanical analysis; technique analysis

Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 37Bursitis (cont.)Snapping hip syndromeCauses: intra- and extra-articular (refer to Box 15.2)TypesExternalIT band or gluteus maximus snapping over greater trochanter during hip flexion trochanteric bursitisInternaliliopsoas snaps over structures deep to musculotendinous unit (e.g., iliopsoas bursa) Intra-articularlesions of the joint (e.g., labral tear)Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 38Bursit