Region of the Hip

8/8/2019 Region of the Hip

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Region Of The Hip

The hip is that portion of the body joining the lower extremity to the trunk. It differs in

construction from the shoulder, because it is designed for strength as well as mobility; hence

it is that the bones are heavier, stronger, with their processes more marked, and that the

muscles also are bigger and more powerful. It is often the seat of injury and disease, the

bones being fractured, the joint luxated, and frequently affected with tuberculosis and other

diseases.

Bones Of The Hip

The bones of the hip are the innominate bone and femur. The innominate bone has itsshape

determined by its relation to the trunk, being adapted to support and protect the viscera, while

the femur has its shape determined by its relation to the extremity, being in the nature of a

pole to support it.

The innominate bone (Figs. 500 and 501) is composed of the ilium, ischium, and pubis. These

are united in the acetabulum by the triangular cartilage and become ossified about the

sixteenth year. The ilium has a crest which serves for the attachment of the transverse

abdominal muscles. At its anterior extremity is the anterior superior spine, and at its posterior

extremity the posterior superior spine. Its large flat portion, called the a/a, gives origin from

both its inner and outer sides to muscles running to the thigh below. The glutei muscles are

attached to its outer surface and the iliacus to its inner. Immediately below the anterior

superior spine is the anterior inferior spine; to it is attached the rectus femoris tendon. The

ischium is below and behind the acetabulum; its tuberosity gives attachment to the hamstring

muscles - biceps (outer), semitendinosus, and semimembranosus (inner). Along the inner

surface of the ramus of the ischium, in a fibrous canal (Alcock's), run the internal pudic

vessels and nerve on their way to the perineum. They lie 4 cm. (1 1/2 in.) from the surface.

The pubis lies below and anterior to the acetabulum. Its upper inner edge forms the

iliopectineal line, which is continued back to form the brim of the true pelvis. The superior or

horizontal ramus goes to the ilium, while its inferior or descending ramus goes to the ischium.

The upper surface of the superior ramus gives origin to the pectineus muscle; it is over this

muscle that femoral hernia descends. The symphysis pubis is the junction of the two pubic

bones in the median line. The crest is the upper anterior edge and gives attachment to the

rectus and pyramidal muscles (for muscular attachments see Figs. 438 and 439, page 432).

The outer extremity of the crest is the spine of the pubis. To it is attached the inner extremity

of Poupart's ligament. The obturator foramen, if the body is in an upright position, is just

below and a little anterior to the acetabulum; it is closed by a membrane which is incomplete

above to give passage to the obturator vessels and nerve. The outer surface of themembrane gives origin to the obturator externus muscle and the inner surface to the obturator

internus. This latter passes out of the pelvis through the lesser sacrosciatic notch just below

the spine of the ischium. Through the greater sacro-sciatic notch, above the spine, comes the

pyriformis muscle and great sciatic nerve. The acetabulum is located at the junction of the

ilium, ischium, and pubis, and lies a little to the outer side of the middle of Poupart's ligament,

with the femoral artery passing nearer its inner than its outer edge. The obturator foramen is

below and a little anterior to the acetabulum when the body is upright and more anterior when



it is horizontal. The bottom of the acetabulum has a large fossa, to the upper portion of which

is attached the ligamentum teres, while the lower portion contains a pad of fat. This fossa

opens by a large notch, called the cotyloid notch, on the side toward the obturator foramen;

therefore the bony socket is incomplete at this point.

Fig. 500. - The innominate bone, viewed from the outside.

Fig. 501. - The innominate bone, viewed from the inside.



Fig. 502. - Innominate bone, resting on its inner side, to show the wedge-shaped formation of

its outer sur. face. The apex of the wedge is Nelaton's line, running from the anterior superior

spine to the tuberosity of the ischium; the anterior plane inclines downward and forward

toward the pubis and the posterior plane inclines downward and backward on the ilium.

Fig. 503. - Anterior view of the upper end of the femur with muscular attachments.

O. H. Allis has pointed out that a line passing from the anterior superior spine to the

tuberosity, called the Roser-Nelaton line, forms the apex of a wedge, the ilium sloping down

on one side while the ischium and pubes pass down the other. It divides the innominate boneinto two parts, an anterior plane and a posterior plane (Fig. 502).

The femur has its neck coming off from the shaft at an upward angle of about 127 degrees

(125 degrees to 130 degrees). The head and neck do not lie in the same transverse plane as

the line joining the two condyles, but are inclined slightly forward (about 12 degrees).

Therefore the neck passes upward, inward, and a little forward. As the result of deformities or

disease, the inclination of the neck to the shaft may be reduced, being 90 degrees or less.

This condition is known as coxa vara. It may be increased, constituting coxa valga. The



articular surface of the head forms slightly more than a hemisphere and has a pit below and

posterior to its centre for the attachment of the ligamentum teres. At the outer upper extremity

of the neck where it joins the shaft is the greater trochanter. Its tip or most prominent point is

toward its posterior surface and is just about opposite the centre of the hip-joint. Downward

and inward from the greater trochanter, on the inner and posterior surface of the shaft, is the

lesser trochanter. Between the trochanters anteriorly and posteriorly run the intertrochanteric

lines. The great trochanter and the part immediately below and posterior gives attachment to

the three glutei muscles, the short rotators (Fig. 504), the pyriformis, the obturators, internus

with its two gemelli and externus, and the quadratus femoris. The lesser trochanter gives

attachment anteriorly to the psoas and the iliacus and immediately below to the pectineus.

Fig. 504. - Posterior view of the upper end of the femur with muscular attachments.

The anterior intertrochanteric line marks the lower attachment of the capsule; the posterior

has inserted into it the quadratus femoris muscle.



Fig. 505. - Muscles of the region of the hip.



Muscles Of The Hip

The muscles of the hip are numerous and their action is often intricate: many muscles are

usually used to produce a single movement. Some muscles not only cross the hip-joint but

another joint as well. Thus the psoas crosses the hip-joint and pelvis to reach the spine. The

hamstring muscles, the rectus femoris, gracilis, and sartorius cross both the hip-joint and

knee-joint, as does practically the tensor fasciae femoris through its prolongation, the iliotibial

band. The movements of the hip are flexion, extension, adduction, abduction, and rotation.

Circumduction is a combine ation of the first four movements.

Flexion is mainly the result of the action of the sartorius, iliacus, psoas, rectus femoris, and

pectineus.

Extension is mainly due to the gluteus maximus, medius, and minimus, biceps,

semitendinosus, and semimembranosus.

Adduction is accomplished by the pectineus, adductor longus, brevis, and magnus, and to a

less extent by the gracilis, quadratus femoris, and lower part of the gluteus maximus.

Abduction in the extended position is due to the tensor fasciae femoris, sartorius, gluteus

medius, and gluteus minimus. When flexed the short rotators also aid.

Internal rotation is produced mainly by the tensor fasciae femoris and the anterior portion of the gluteus medius and minimus; three muscles only. The iliopsoas acts as a weak internal

rotator if the femur is in a position of extreme external rotation.

External rotation is mainly due to the short external rotators - pyriformis, gemelli, obturators,

quadratus femoris, the adductors, and the posterior portion of the three gluteals. To a slight

extent the sartorius, iliopsoas, pectineus, and biceps may also aid at times.

Surface Anatomy

The crest of the ilium can be palpated in its entire length. In very thin people it causes an

elevation of the surface, but usually it is marked by a depression. Its anterior third issubcutaneous and is more easily seen and felt than the posterior two thirds. A line joining the

highest point of the crests passes through the fourth lumbar spine. A line joining the anterior

superior spines in front passes below the promontory of the sacrum. The anterior superior

spine can be readily felt. It lies downward and outward from the umbilicus: as has been said,

measurements are best taken by pressing the tape against its lower surface rather than its

subcutaneous one.



The posterior superior spine, marked by a dimple, is best recognized by following the crest of

the ilium to its posterior extremity. It is opposite the middle of the sacroiliac joint and the

second sacral spine.

The posterior inferior spine is 4 to 5 cm. (1 1/2 to 2 in.) directly below the posterior superior

spine. The spine of the ischium, which marks the position of the pudic and sciatic arteries, is 8

to 10 cm. (3 to 4 in.) below the posterior superior spine and the tuberosity of the ischium is 12

to 15 cm. (5 to

6 in.). Running forward from the posterior inferior spine for a distance of 4 to 5 cm. (1 1/2 to 2

in.) is the great sciatic notch; through it pass the pyriformis muscle, gluteal artery and nerves,

and sciatic nerve. A line joining the posterior superior spine and the tip of the greater

trochanter may be named the posterior iliotrochanteric line

Fig. 506. - Surface anatomy of the region of the hip.

(iliotrochanteric line of Farabeuf). It marks roughly the posterior edge of the gluteus medius

muscle and goes through the upper edge of the gluteus maximus. The gluteal artery and

superior gluteal nerves cross this line at the junction of the upper and middle thirds, this being

about opposite the posterior inferior spine. A line joining the tuberosity of the ischium and tip

of the greater trochanter may be called the ischiotrochanteric line: it is crossed at the junction

of its inner and middle thirds by the sciatic nerve.

The greater trochanter is marked by an eminence in thin people and a depression in the

plump and fat. Its anterior upper edge is crossed by the tendon of the gluteus medius and



cannot be readily outlined. Its upper posterior extremity or tip is readily distinguished and is

the spot used for measurements. This point is called the tip of the greater trochanter and must

be searched for posteriorly. It is opposite the centre of the head of the femur and is on a level

with the spine of the pubis.

The Roser-Nelaton line is one drawn from the anterior superior spine to the tuberosity of the

ischium. It passes through the tip of the greater trochanter. It is of importance in fractures and

dislocations (Fig. 507).

Bryant's triangle ("Bryant's Surgery", vol. ii, p. 412) is to be drawn while the patient is lying on

his back. One side is a perpendicular let fall from the anterior superior spine to the table, the

other side is one joining the anterior superior spine and the tip of the greater trochanter, the

base is a line running horizontally from the tip of the greater trochanter to the perpendicular

line (Fig. 507). If the tip of the trochanter becomes elevated, as in fractures of the neck of the

femur , it shortens the base of the triangle on the affected side as compared with the base of

the triangle on the sound side.

The anterior iliotrochanteric line may be designated as a line joining the anterior superior

spine and the tip of the greater trochanter. In normal individuals it slopes downward and

backward, forming an iliotrochanteric angle (b a c, Fig. 507) of about 30 degrees. In cases of

fracture or luxation this angle becomes reduced as the shortening increases until the tip

reaches the level of the anterior superior spine. A rough estimate of this angle by sight and

palpation usually enables one to decide immediately as to the presence of shortening from

fracture or luxation without the trouble of erecting Bryant's triangle. The anterior

iliotrochanteric line forms the anterior side of Bryant's triangle and the anterior half of the

Roser-Nelaton line.

The gluteal cleft separates the buttocks. In its lower portion can be felt the coccyx. The gluteal

(gluteofemoral) fold is formed mainly by the subcutaneous fatty tissues and passes

horizontally outward from the lower part of the gluteal cleft. A shortening of the leg on either

side causes the corresponding fold to incline downward. It is marked in extension and

gradually lessens on flexion and disappears when 90 degrees is reached. It is crossed

obliquely downward and outward at about its middle by the lower edge of the gluteus

maximus. Its disappearance in coxalgia is caused by the flexion incident to that affection.



Ligation Of The Gluteal, Sciatic, And Internal Pudic Arteries

To ligate the gluteal artery incise the skin and part the fibres of the gluteus maximus in the

upper two-thirds of a line joining the posterior superior spine and the top of the great

trochanter (Fig. 508). Pull the lower edge of the gluteus medius up and the artery and

superior gluteal nerve will be seen coming out between it and the pyri-formis. To ligate the

sciatic and internal pudic arteries an incision parallel to the one just described but about 7.5

cm. (3 in.) lower is made through the gluteus maximus, and just below the edge of the

pyriformis from without inward will be found the great sciatic nerve, lesser sciatic nerve,

sciatic artery, and the internal pudic nerve and internal pudic artery crossing the spine of the

ischium.

Fig. 507. - View of the outer surface of the bones of the hip showing Roser-Nelaton line (a-d).

Bryant's triangle (a b c), iliotrochanteric line, (a c) and the iliotrochanteric angle (b a c).

Bursae

Covering the tuberosity of the ischium is a bursa which sometimes suppurates and forms a

sinus. It can readily be excised. These sinuses are often bilateral.



Fig. 508. - Ligation of the gluteal, internal pudic, and sciatic arteries.



The Hip-Joint

The hip-joint, like the shoulder, is a ball-and-socket joint, and, like it, moves in all directions.

The main function of the shoulder is mobility, but the functions of the hip are mobility and

support. To give the necessary support and security, the band-like ligaments uniting the

bones are strong and the extent of the movements is restricted. Macalister ("Text Book of

Human Anatomy," p. 179) points out that while the shoulder has 118 degrees of motion

around a sagittal axis, abduction and adduction, the hip has only 90 degrees; around a

coronal axis, flexion and extension, the shoulder has 170 degrees and the hip only 140

degrees. In the vertical axis the shoulder rotates 90 degrees, while the hip rotates only 45

degrees. In the upright position the centre of gravity falls in front of the axis of rotation of the

hip-joint.

The head of the femur is 5 cm. (2 in.) in diameter and forms 5/7 of a sphere. Below and

behind its centre is the depression for the attachment of the ligamentum teres. The

acetabulum is much deeper than the glenoid cavity of theshoulder-joint and its depth is

increased by the cotyloid ligament around its edge. This makes the joint air-tight and holds

the femur in place by suction, hence it is called by Allis ("An inquiry into the difficulties

encountered in the reduction of dislocations of the hip," Philadelphia, 1896) the sucker

ligament. The acetabulum is incomplete at its lower anterior edge, forming the cotyloid notch.

The cotyloid ligament bridges over this notch, and its deeper part loses its cartilaginous cells,

becomes fibrous, and is called the transverse ligament.

Beneath the transverse ligament pass vessels, nerves, fatty tissue, and the extremity of the

ligamentum teres, which is attached to the ischium just outside.

Running up in the floor of the acetabulum from the cotyloid notch is a depression in which is

lodged the ligamentum teres and a pad of fat called the Haversian gland. The ligamentum

teres is composed of synovial and connective tissue. It is not strong and ruptures at about 14

kilos; the small artery it contains affords nourishment for itself alone, only a very small amount

of blood going to the head of the femur. Bland Sutton regards it as a vestigial structure and a

regression of the pectineus muscle. It is too weak to add much to the strength of the joint, and

the view of Allis that its function is to distribute the synovial fluid and act as a lubrieating agent

is probably correct. The great pressure to which the articulating surfaces of the hip-joint are

subjected requires special lubrication and this is furnished by the ligamentum teres and

Haversian gland.



Fig. 509. - Anterior view of the ligaments of the hip-joint.

Like other joints, the hip has a capsular ligament which is strengthened by bands or

ligaments. These ligaments are the iliofemoral, pubofemoral, and ischiofemoral.



The Hip-Joint. Continued

Iliofemoral Ligament (Bertins' Ligament Or Y Ligament Of Bigelow)

This is the strongest ligament in the body. The single stem of the Y ligament is attached to the

upper edge of the rim of the acetabulum just below the anterior inferior spine. Its two

branches are attached below to the anterior intertrochanteric line. Its upper edge is reinforced

by a band from the ilium to the trochanter, the iliotrochanteric band, and one from the

reflected tendon of the rectus, the tendinotrochanteric band (Henry Morris) (Fig. 509).

The pubofemoral ligament, also called the pectineofemoral ligament, runs outward into the

capsule from the horizontal ramus of the pubes. It is quite weak.

Ischiofemoral Ligament

Allis describes this ligament as follows: "It arises from the ischial portion of the rim of the

socket and sends its fibres to the capsule to be blended with them. As its fibres extend

upward they separate like two fingers or terminal processes, the one extending forward to the

base of the oblique (posterior ) line, the other running backward to the digital fossa (Fig. 510)".

It will be observed that this makes it a posterior Y ligament with a distinct bony attachment for

its two arms (like the external lateral ligament of the elbow - see page 283). The web of the

two arms is half way down the posterior surface of the neck of the femur.

Capsular Ligament

The capsule of the joint is composed of a thin sac strengthened by the band-like ligaments

just described. Wherever there is no reinforcing band the capsule is weak. The posterior and

lower portion is weaker than the anterior and upper portion. There is a weak spot between the

arms of the iliofemoral ligament anteriorly, a branch of the circumflex artery usually entering

here. Between the pubofemoral and inner edge of the iliofemoral ligament is another weak

point. A bursa here separates the iliopsoas from the joint and often communicates with the

joint. A third weak spot is on the lower posterior part of the neck between the two branches of

the ischiofemoral ligament (Fig. 511). Injections into the joint protrude very markedly at this

point. The weakest part of the joint is the lower anterior, below the pubofemoral ligament and

opposite the cotyloid notch; the strongest part is the upper anterior part.



Fig. 510. - The ischiofemoral or posterior y-ligament. The stem of the Y is attached at the

base of the tuberosity of the ischium and one branch is seen going toward the greater

trochanter and the other toward the lesser, leaving a weak spot between them half-way down

the neck of the bone.



Fig. 511. - Hip-joint distended with wax; the capsule ends posteriorly half-way down the neck

and is seen distended by the injection material protruding between the two arms of the

ischiofemoral ligament.



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Region of the Hip