Applied Anatomy Of Hip

PMR PG Teaching- August 2016

-Dr. Kamal Kant Sain Resident, Deptt. Of PMR

SMS Medical College, Jaipur

The Hip Joint

• Type- Ball and socket variety of synovial joint• Articular surfaces- The head of femur

articulates with acetabulam of hip bone.• Largest joint of the body• Unique in having high degree of stability as

well as mobility.

The Acetabulam• Horseshoe shaped structure• Formed by the pubis ilium and ischium bones• Allows the proximal transmission of weight from the

axial skeleton to the lower extremity• Its development starts by the age of 8yrs and depth

incresase in puberty due to development of three secondary centres of ossification

• It forms lunate articular surface,an acetabular notch and acetabular fossa.

• A fibrocartilaginous ring called acetabular labrum deepens the acetaulam

The Femur

• Longest bone of the body consists of head,neck and greater and lesser trochenter

• Head of femur is covered with hyaline cartilage except for fovea capitis which serves as attachment for ligamentum teres.

• The femoral neck is externally rotated with respect to the shaft and also forms an angle of anteversion/declination.

• In normal adults neck forms an angle of 135 degree with respect to the shaft.

• Femoral neck and head is formed by trabecular bone core with thin cortical bone shell.

The angle of inclination

• In normal adults it is 120-135 degree.• In coxa valga - >135 degree• In coxa vara - <120 degree

Joint capsule

• A cylindrical Sleeve• Proximally : Pelvis• Laterally : Acetabular labrum and extends laterally to the femoral head• Anteriorly : Intertrochanteric line• Posterorly : neck of the femur 1cm medial to the intertrochentric crest• Both the capsule and the articular cartilage are thicker anterosuperiorly

consequently thinner posteroinferiorly• Anteerosupeirorly part has maximum tension in the standing posture• Supported by muscles and by intra/extra articular ligaments• Capsule has circular and longitudional fibres.• Circular fibres forms collar around the neck called zona orbicularis• Longitudional fibres travels along the neck and carries blood vessels

Ligaments of Hip joint

• It includes-• Intraarticular- 1.the ligamentum teres 2.the transverse acetabular liga. 3. the acetabular labrum

Extraarticular- 1.the iliofemoral ligament 2.the pubofemoral ligament 3.the ischiofemoral ligament

The ligamentum teres

• Also called round ligament• Flat triangular ligament• Apex is attach to the fovea capatis and base to the

transverse ligament and margins of acetabular notch.• It transmits arteries to the head of femur(acetabular

branches of obturator and medial circumflex femoral arteries)

• It tightens during adduction,flexion and external rotation.• It prevents subluxation of femoral head superiorly and

laterally in adduction and external rotation movements of hip.

The transverse acetabular ligament

• Fibrous link from the inferior acetabular notch that connects the anteroinferior and posteroinferior horns of the semilunar surface of the acetabulum

• Posterior aspect: bone beneath the lunate surface• Anterior aspect: labrum• Due to this acetabular notch converted into a

foramen which transmits vessel and nerves to the joints.

The acetabular labrum• It is a fibrocartilaginous rim attached to the margins

of acetabulam.• It narrows the mouth of acetabulam.• Mostly made up of type 1 collagen fibres• It helps in holding head of femur in position.• It provide stability by creating negative

intraarticular pressure in the hip joint.• It improve mobility of hip by providing elastic

alternative to bony rim.

The iliofemoral ligament

• Also called ligament of bigelow• It is inverted Y shaped• Strongest ligament of the body• Triangular in shape.• It consists of 2 parts- inferior(medial) and superior(lateral)• Apex is attached to the lower half of the anterior inferior iliac

spine and base to the intertrochantric line.• It blends with the iliopsoas muscle• It limits hyperextension of hip and prevents the trunk from

falling backwards in the standing posture.

The pubofemoral ligament

• It supports the joint inferiomedially.• It is also triangular in shape• Superiorly- attached to iliopubic eminence, the

obturator crest and obturator membrane.• Inferiorly –merge with the anteroinferior part of

the capsule and with the lower band of the iliofemoral ligament.

• It tightens during extension and abduction.

The ischiofemoral ligament

• It is a weak ligament• It covers the joint posteriorly• It arises from the posteroinferior margin of the

acetabulam rim and passes laterally to the capsule and blends with the zona orbicularis.

• It tighten with internal rotation of hip• It is more commonly injured ligament than other

hip ligaments.

Muscles producing movements at the hip joint

movements chief muscles accessory muscles

1.Flexion Psoas major and iliacus Pectineus,rectus femoris,sartorius and adductor longus

2.Extension Gluteus maximus,biceps femoris,semimembrenosis and semitendinosis

Gluteus medius

3.Adduction Adductor longus,brevis magnus Pectineus and gracilis

4.Abduction Glutei medius,minimus,tensor fasciae latae

Sartorius, piriformis

5.Medial rotation Tensor fasciae latae and anterior fibres of glutei medius and minimus

Adductor longus,brevis,pectineus

6.Lateral rotation Obturator internus,externus,gemellus superior,gemellus inferior,quadratus femoris,gluteus maximus sartorius

Piriformis ,biceps femoris

Movements

• Flexion- the head of femur rotates along a transverse axis that passes through the acetabula.

• It limited by thigh touching the abdomen, the range is 120 degree.

• Mainly due to contraction of iliopsoas muscles with the help of sartorius,rectus femoris and pectineus muscles.

• Extension- rotates around the transverse axis• It is limited by tension in iliofemoral ligament• Range is 20 degree.• Mainly due to gluteus maximus muscles with

the help of hamstring muscles.

• Flexion and extension occurs around a transverse axis.range of flexion is 120 degree limited by thigh touching the abdomen and extension is 20 degree,limited by tension in iliofemoral ligament.

• Abduction and adduction occur around an anteroposterior axis.Adduction is limited by ontact with other leg, range is 30 degree . Abduction is limited by tension in adductors and pubofemoral ligament,range is 60 degree.

• Medial and lateral rotation occur around vertical axis.range is around 40 degree.

Bursae around the hip

• Iliopsoas bursa• Largest and most constant bursa about the hip present in

98% of adult individuals• Situated deep to the iliopsoas tendon and serves to

cushion the tendon from the structures on the anterior aspect of the hip joint• Can become inflamed and distendend MC: RA; can also

be associated with athletic activity; overuse and impingement syndromes; OA; pigmented villonodular synovitis; villonodular synovitis, synovial chndromatosis, infection, pseudogout, metastatic bone disease and in rare cases after total hip athroplasty

• Trochanteric bursa• 2 clinical significant trochanteric bursae: one between the

gluteus medius and minimus and a superficial one located between the greater trochanter and the TFL; compression and friction of the bursa from an adaptively shortened TFL can result in trochanteric bursitis

• Ischiogluteal bursa• Located between the ischium and the gluteus maximus; can

be painfully squeezed between the ischial tuberosity and the hard surface of a chair during sitting, producing an ischial bursitis (weaver’s bottom)

Vascular supply

• Medial and lateral femoral circumflex supplies proximal femur

• Femoral head is supplied by a small branch off obturator artery

• Acetabulum is supplied by branches from superior and inferior gluteal arteries

Nerve supply• Posterior Gluteal Region (Cutaneous)

• Subcostal nerve• Iliohypogastric nerve• Posterior Rami of L1-L3• Posterior Primary Rami of S1-S3

• Anterior Region (Cutaneous) • Iliohypogastric nerve (superior to the inguinal ligament)• Subcostal nerve (inferior to the inguinal ligament)• Fermal branch of the genitofemoral nerve• Ilioinguinal nerve

Pain referred from the hip joint may be felt anywhere in the thigh leg or foot

Femoral triangle

• Superior border : Inguinal Ligament• Lateral border: Sartorius Muscle• Medial border: Adductor longus Muscle

Congenital dislocation of hip

• Head of femur slips upwards on to the gluteal surface of the ilium because of developmentaly deficient upper margin of acetabulam.

• Lurching gai• Trendelenburg test is positive

Fracture of neck of femur

References

• Surgical Anatomy Mc Gregar• Gray’s Anatomy• B. D. Chaurasia Human Anatomy

Thanks