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Anatomy > Hip And Pelvis > Flashcards

Hip And Pelvis Flashcards

1
Q

List four dangers of the Stoppa approach

A

Corona Mortis (lateral 1/3 sup. pubic ramus)

Bladder (insert foley)

Obturator nerve and vessels (when exposing quad plate)

External iliac vessels (mobilize early)

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2
Q

What is the potential space of retzius ?

A

Anterior to bladder post to pubic symphisis

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3
Q

What muscle do you have to take down to see quadrilateral plate?

A

Rectus abdominus

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4
Q

What fascia separates the middle and lateral window of the ilioinguinal approach?

A

Iliopectineal fascia

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5
Q

List five contents of the Greater sciatic notch

A

piriformis

superior and inferior gluteal vessels and nerves

sciatic and posterior femoral cutaneous nerves

internal pudendal vessels

nerves to the obturator internus and quadratus femoris

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6
Q

List the structures that separate the windows in the ilioinguinal approach

A

Lateral: Iliac wing to Iliopsoas and femoral nerve

Middle: psoas to External iliac vessels

Medial: External iliac vesselst to rectus abdominus

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7
Q

What are the Denis zones of the sacrum?

A

1: lateral to foramen
2: middle
3: medial to foramina into spinal canal

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8
Q

What nerve root runs along the sacral ala?

A

L5

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9
Q

What is the sacral ala?

A

Top of sacrum forming iliosacral triangle

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10
Q

What is the importance of iliac cortical density?

A

On the lateral this parallels the alar slope, you want to be below this when inserting an SI screw

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11
Q

On an AP pelvis is the posterior wall lateral or anterior?

A

Lateral!

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12
Q

Judet views describe

A

Obturator oblique - AC (iliopectineal line), PW

Iliac oblique - AW, PC (ilioischial line)

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13
Q

What is a morale lavale lesion?

A

Internal degloving of subcutaneous tissue off of the lumbosacral fascia

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14
Q

What are key SI ligaments? What are the other three important ones?

A

Anterior, Posterior, Interosseous Sacrotuberous, Sacrospinous, Iliolumbar ligament

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15
Q

Name the Contents of the Sciatic Notch Relative to Piriformis

A

Contents of GSN

Above piriformis:

Superior Gluteal Nerve & Artery

Below Piriformis:

Pudendal nerve and internal pudendal artery

Nerve to obturator internus

Posterior femoral cutaneous nerve

Sciatic nerve

Inferior gluteal artery and nerve

Nerve to quadratus femoris

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16
Q

What travels through LSN?

A

Obturator internus muscle

Nerve to obturator internus

Pudendal nerve

Internal pudendal vein

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17
Q

What is the cruciate anastomosis made of?

A

First perforator of profunda

Inferior gluteal artery

MCFA

LCFA

Clinical Relevance:
The cruciate anastomosis is clinically relevant because if there is a blockage between the femoral artery and external iliac artery, blood can reach the popliteal artery by means of the anastomosis. The route of blood is:

Internal iliac –> inferior gluteal artery –> a perforating branch of the deep femoral artery –> lateral circumflex femoral artery –> its descending branch –> superior lateral genicular artery –> popliteal artery.

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18
Q

Nerves relative to psoas Lateral (3) Medial (2) Between iliac and psoas 1 Piercing than anterior

A

Lateral - iliohypogastric, lioinguinal, LFCN

Medial - obturator, lumbosacral trunk

Between - femoral

Piercing - genitofemoral

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19
Q

What nerve is at risk with a retractor under transverse acetabular ligament?

A

Obturator

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20
Q

How can we adduct after an obturator neurectomy

A

Pectineus, femoral

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21
Q

What nerve is above piriformis?

A

Superior gluteal nerve

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22
Q

What structure is most at risk of posterior ICBG harvest?

A

Superior gluteal artery, to a lesser extent cluneal nerves

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23
Q

Between What muscles does the posterior obturator nerve run between?

A

Adductor brevis and magnus

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24
Q

In the anterior Smith-Peterson approach the deep interval is between?

A

Rectus femoris and Gluteus medius

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25
Q

Name the ligaments connecting the pubic sympysis

A

Superior pubic ligament (stronger)

Inferior (arcuate) public ligament

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26
Q

What type of joint is the pubic symphysis?

A

Synovial amphiarthroidal joint

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27
Q

What do the medial sacral crest and alae of the sacrum represent embryologically?

A

Medial sacral crest: fused spinous processes

Alae and SI articular processes: fused TP and costal processes

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28
Q

What strucures are near the posterior sacral foramina?

A

Dorsal primary rami

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29
Q

What structures are near the anterior sacral foramina?

A

Ventral primary rami

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30
Q

In which direction are the coccyx of men and women directed?

A

Men: anteriorly towards pubis (like a penis)

Women: vertically

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31
Q

List the signs of sacral dysmorphism

A

5 signs:

Sacralization of L5

Lumbarization of S1

Mammillary processes

Oval or oblong foramen

Tongue in Groove sign of SI joint

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32
Q

What are the superficial surface markings of the SI joint?

A

Dimples of Venus

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33
Q

Name the ligaments of the SI joint

A

Posterior

Anterior

Interosseous

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34
Q

WHere does the sacrotuberous ligament, sacrosinous ligament and iliolumbar ligaments run?

A

Sacrotuberous: sacrum to ischial tuberosity

Sacrospinous: sacrum to ischial spine

Iliolumbar: iliac crest fo 5th lumbar TP

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35
Q

What are the boundaries of the greater sciatic notch?

A

PSIS

Ischial spine

Note: the sacrospinous ligament changes the “notch” into a “foramen”

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36
Q

What are the borders of the lesser sciatic foramen?

A

Ischial spine and tuberosity

sacrospinous ligament (superior border)

sacrotuberous ligament (inferior border)

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37
Q

What the obturator foramen, membrane and canal?

A

Foramen: big hole between pubic rami

Membrane: Membrane that covers the foramen (obturator int/ext attach)

Canal: superior opening in membrane, allowing passage of obturator n/a/v

38
Q

What attaches to the obturator membrane?

A

Obturator internus
and externus

39
Q

What is the anteversion of the femoral neck?

A

15 degrees

40
Q

What is the average neck shaft angle of the femur?

A

~127 degrees

41
Q

What is the version of the acetabulum?

A

15 degrees anteverted (to match the femur)

42
Q

What are the ligaments that make up the hip capusle?

A

Anterior:

Iliofemoral ligament (Y ligament of Bigelow): Strongest ligament that runs from AIIS to intertrochanteric line

Pubofemoral ligament

Posterior:

Ischiofemoral ligament: attaches to femoral neck

43
Q

What is the zona orbicularis?

A

Circular fibers that form a collar around the femoral neck

Form the annular ligament of the femoral neck

44
Q

The labrum is continuous with what structure?

A

Transverse acetabular ligament

45
Q

Describe the criteria for an adequate AP pelvis x-ray

A

Coccyx in line with symphysis

Symmetric teardrops

symmetric Obturator foramina

Symhysis:sacrococcygeal distance of:

32mm in men

47mm in women

46
Q

What angle is classically measured off a Dunn view?

A

Alpha angle

The alpha angle is formed by a line drawn from the center of the femoral head through the center of the femoral neck, and a line from the center of the femoral head to the femoral head/neck junction, found by the point by which the femoral neck diverges from a circle drawn around the femoral head. At present, the upper end of normal is an alpha angle of 50 - 55 degrees.

47
Q

What angle is measured from a false profile view?

A

Anterior CEA

48
Q

List the 6 fundamental lines of Letournel

A

Anterior wall

Posterior wall

roof (or dome/tectum)

iliopectineal line (anterior column)

ilioischial line (posterior column)

teardrop

49
Q

List the levels of:

Aortic bifurcation

Common iliac bifurcation

A

Aortic bifurcation: L4

Common iliac bifurcation: S1

50
Q

Name the branches of the internal iliac artery (6)

A

Obturator

Superior and inferior gluteal

Internal pudendal

Vesicular

Lateral sacral

51
Q

What is the corona mortis? Where is it located?

A

Common Anatomic variant (+ in 83%)

Anatomosis between:

Obturator + external iliac OR inferior epigastric arteries or

Located 40-96mm from the pubic symphysis (median 6cm)

52
Q

What are the branhces of the profunda femoral artery?

A

Medial and lateral femoral circumflex arteries

Perforators

53
Q

Descibe the course of the femoral artery in the thigh

A

Enters thigh from under inguinal ligament as the common femoral artery, a continuation of the external iliac artery

Here, it lies midway between the ASIS and the symphysis pubis

The common femoral artery gives off the profunda femoris artery and becomes the superficial femoral artery

Superficial descends along the anteromedial part of the thigh in the femoral triangle

Then it enters and passes through the adductor (subsartorial) canal

Becomes the popliteal artery as it passes through an opening in adductor magnus near the junction of the middle and distal thirds of the thigh

54
Q

What is the primary blood supply to femoral head?

A

Medial femoral circumflex artery

55
Q

Describe the proximal femur blood supply

A

MFCA: femoral head via retinacular vessels

LFCA: GT

Obturator: vessels within ligamentum teres

56
Q

What are the borders of the femoral triangle?

What makes up the floor, in what order?

A

Sartorius: laterally

Adductor longus: medially

inguinal ligament: superiorly

Floor (lat to med): iliacus, psoas, pectineus, adductor longus

57
Q

What are the contents of the femoral triangle?

A

NAVEL (spell NAVEL towards the navel, aka lateral to medial)

58
Q

Describe the safe zone for acetabular screws:

Which zone is safe? Dnagerous? What is at risk in each zone?

A

Divided into quadrants with one line running from ASIS to center of acetabulum and another line perpendicular to that

Posterior superior (Safest): sciatic nerve, superior gluteal n/a/v

Posterior inferior: safe if screws

Anterior superior: UNSAFE: external iliac artery/veins

Anterior inferior: UNSAFE: obturator n/a/v (b/c aiming for obturator foramen)

59
Q

Name the short external rotators, from most proximal to most distal:

A

Piriformis

Gemellus superior

Obturator internus

Gemellus inferior

Obturator externus

Quadratus femoris

60
Q

Name the OINA of all the muscles of the hip - see list in answers

A

Good luck

61
Q

Name the hip flexors and extensors:

A

Flexors:

Iliopsoas

Rectus femoris

Sartorius

Extensors:

Gluteus maximus

Hamstrings: (ST, SM, BF)

62
Q

Name the hip aB and aDDuctors

A

ABductors:

gluteus medius

gluteus minimus

TFL (in a flexed hip)

Adductors:

Adductor brevis, longus, magnus

Pectineus

Gracilis

63
Q

What is the innervation of adductor magnus?

A

Dual:

Obturator (adductor) posterior division

Tibial of sciatic (hamstrings)

64
Q

Name the internal rotators of the hip

A

Gluteus medius (anterior fibers)

Gluteus minimus (anterior fibers)

TFL

semimembranosus

semitendinosus

pectineus

adductor magnus (posterior fibers)

65
Q

Describe the lubosacral plexus +/- draw it…..

A

Made up of lumbar and sacral plexi from T12 - S3

Lumbar plexus: ventral rami of L1-L4 on anterior surface of quadratus lumborum within/deep to psoas major

Sacral plexus: ventral rami from L4-S4

66
Q

Name the origin and course of femoral nerve

A

Origin: L2-4

Emerges between psoas and ilicus

Runs superficial and medial to psoas tendon

Into femoral triangle

divides and innervates quads

67
Q

What is the origin of LFCN and where does it exit pelvis?

A

L2-3

Exits pelvis under inguinal ligament, 2cm distal to ASIS

68
Q

Where is the sciatic nerve most likely to be found in relation to piriformis and SERs?

A

Deep to piriformis, superficial to SER

  • Usually sits on top of SER, that’s why during a posterior approach you can use them to protect it
69
Q

What is the internervous plane of the anterior approach to the hip?

A

Femoral and superior gluteal nerve

Superficial: sartorius & TFL

Deep: Rectus femoris and gluteus medius

70
Q

In the lateral approach to the hip, where does the superior gluteal nerve run?

A

3-5cm above GT

71
Q

What is the interval for the medial (Ludloff) approach to the hip?

A

Incision: 3cm below pubic tubercle

No real internervous plane

Superficial: adductor longus/gracilis: both anterior division of obturator nerve

Deep: adductor brevis and adductor magnus: posteriorly by sciatic nerve, anterior adductor division by the posterior division of the obturator nerve

Dangers:

Anterior division of obturator nerve between longus/brevis

Posterior division of obturator nerve on magnus & under brevis

Medial femoral circumflex artery on distal psoas

72
Q

Name the dangers of the ilioinguinal approach

A

Nerves:

Femoral nerve: running beneath inguinal canal on iliopsoas

LFCN: medial to ASIS beneath external oblique

Vessels:

Femoral vessels: in femoral sheath

Inferior epigastric artery: medial to inginal ring. Ligate

Corona mortis

Other:

Bladder

Spermatic cord/round ligament

73
Q

Where do the cluneal nerves run in a posterior bone graft approach?

A

8cm lateral to midline, so stay medial

74
Q

Where do the superior gluteal vessels run in a posterior approach to bone graft?

A

Near the sciatic notch

Stay proximal to sciatic notch

75
Q

What is the most common nerve injured during THA?

A

Sciatic, peroneal division b/c it is more lateral

76
Q

What is the only muscle innervated by peroneal nerve proximal to the fibular neck?

A

Short head of biceps femoris

77
Q

What is the most common complication in posterior iliac crest bone graft harvesting?

A

Injury to the superior gluteal artery

78
Q

Which vessel provides the dominant supply to the femoral head?

A

Lateral epiphyseal vessels of the MCFA

79
Q

A patient is undergoing percutaneous S1 SI screw fixation for a sacroiliac joint diastasis. What is the most common strength deficit sequela of this proposed screw trajectory?

  1. Loss of hip flexion
  2. Loss of knee extension
  3. Loss of ankle dorsiflexion
  4. Loss of great toe extension
  5. Loss of ankle plantar flexion
A

4: Loss of great toe extension due to damage to L5

80
Q

What is the only hip approah with a true internervous plane? What is the plane?

A

Anterior (Smith Peterson) approach

Femoral & superior gluteal nerves

Superficial: Sartorius & TFL

Deep: G. med & rectus femoris

81
Q

What are the dangers of the anterior approach to the hip?

A

LFCN: 2.5cm below ASIS, passing over sartorius

  • Go through fascia of TFL (Hueter approach) to avoid damaging it

Femoral artery and nerve

Ascending branch of LFCA

82
Q

What are the planes and dangers of the lateral approach to the hip?

A

Plane: No true internervous plane:

Muscle splitting: Gluteus medius (SGN) proximally and v.laterais (femoral) distally

Dangers:

SGN: 3-5cm proximal to GT

Femoral bundle: gentle anterior retractor placement

Transverse branch of the lateral femoral circumflex artery

83
Q

What is the plane and dangers of the anterolateral approach to the hip?

A

Plane: No true internervous plane: SGN

TFL/G. medius

Dangers:

femoral n/a/v overlying psoas: protect with careful anterior retraction

84
Q

What is the plane/dangers of the posterior approch to the hip?

A

Plane: No true plane: ITB/glut maximus split

Dangers:

Sciatic nerve: reflect SER to protect it. Beware early division variant

Inferior gluteal artery: when splitting g.max, ligate/coagulate if seen. May retract into pelvis causing uncontrollable bleeding

Ascending branches of medial femoral circumflex artery. Protect by preserving quadratus femoris. Safe to release the proximal 1cm of quadratus femoris

85
Q

What is the most common position of the sciatic nerve in relation to the piriformis? What are the other variants?

A

See picture

86
Q

Describe the position, incision, plane and dangers of the surgical dislocation of the hip:

A

Position: Lateral

Incision: Lateral skin incision or one that is just anterior to the usual posterior approach incision

Plane: None: SGN only

Incise TFL & ID g. medius

GT osteotomy

Elevate g. minimus and capsule

Capsulotomy

Dislocate anteriorly

87
Q

Describe the medial approach to the hip:

Position

Incision

Plane

Dangers

A

Position: Supine with hip flexed, abducted and ER (figure 4)

Incision: 3cm below pubic tubercle. Can be either mini transverse (for adductor release) or longitudinal down adductor longus

Plane:

Superficial: adductor longus/gracilis. Both anterior division of the obturator nerve

Deep: Adductor brevis/Adductor magnus. Posteriorly by sciatic nerve. Anteriorly by posterior division of the obturator nerve

Dangers:

Anterior division of obturator nerve: between longus and brevis

Posterior division of obturator nerve: runs on adductor magnus and under brevis

Medial femoral circumflex artery: runs medally on distal part of psoas tendon

88
Q

What are the dangers in a posterior approach to PSIS for bone grafting? what is more commonly injured?

A

Superior gluteal a/v (more commonly injured)

Cluneal nerves: 8cm lateral to midline at PSIS

89
Q

What does the external iliac artery become?

A

Common femoral artery, after the inguinal ligament

90
Q

At what age are the SI joints fused by?

A

Age 50

Anatomy (13 decks)

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