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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
Name the ligaments connecting the pubic sympysis
Superior pubic ligament (stronger) Inferior (arcuate) public ligament
26
What type of joint is the pubic symphysis?
Synovial amphiarthroidal joint
27
What do the medial sacral crest and alae of the sacrum represent embryologically?
Medial sacral crest: fused spinous processes Alae and SI articular processes: fused TP and costal processes
28
What strucures are near the posterior sacral foramina?
Dorsal primary rami
29
What structures are near the anterior sacral foramina?
Ventral primary rami
30
In which direction are the coccyx of men and women directed?
Men: anteriorly towards pubis (like a penis) Women: vertically
31
List the signs of sacral dysmorphism
5 signs: Sacralization of L5 Lumbarization of S1 Mammillary processes Oval or oblong foramen Tongue in Groove sign of SI joint
32
What are the superficial surface markings of the SI joint?
Dimples of Venus
33
Name the ligaments of the SI joint
Posterior Anterior Interosseous
34
WHere does the sacrotuberous ligament, sacrosinous ligament and iliolumbar ligaments run?
Sacrotuberous: sacrum to ischial tuberosity Sacrospinous: sacrum to ischial spine Iliolumbar: iliac crest fo 5th lumbar TP
35
What are the boundaries of the greater sciatic notch?
PSIS Ischial spine Note: the sacrospinous ligament changes the "notch" into a "foramen"
36
What are the borders of the lesser sciatic foramen?
Ischial spine and tuberosity sacrospinous ligament (superior border) sacrotuberous ligament (inferior border)
37
What the obturator foramen, membrane and canal?
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
What attaches to the obturator membrane?
Obturator internus and externus
39
What is the anteversion of the femoral neck?
15 degrees
40
What is the average neck shaft angle of the femur?
~127 degrees
41
What is the version of the acetabulum?
15 degrees anteverted (to match the femur)
42
What are the ligaments that make up the hip capusle?
**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
What is the zona orbicularis?
Circular fibers that form a collar around the femoral neck Form the annular ligament of the femoral neck
44
The labrum is continuous with what structure?
Transverse acetabular ligament
45
Describe the criteria for an adequate AP pelvis x-ray
Coccyx in line with symphysis Symmetric teardrops symmetric Obturator foramina Symhysis:sacrococcygeal distance of: 32mm in men 47mm in women
46
What angle is classically measured off a Dunn view?
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
What angle is measured from a false profile view?
Anterior CEA
48
List the 6 fundamental lines of Letournel
Anterior wall Posterior wall roof (or dome/tectum) iliopectineal line (anterior column) ilioischial line (posterior column) teardrop
49
List the levels of: Aortic bifurcation Common iliac bifurcation
Aortic bifurcation: L4 Common iliac bifurcation: S1
50
Name the branches of the internal iliac artery (6)
Obturator Superior and inferior gluteal Internal pudendal Vesicular Lateral sacral
51
What is the corona mortis? Where is it located?
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
What are the branhces of the profunda femoral artery?
Medial and lateral femoral circumflex arteries Perforators
53
Descibe the course of the femoral artery in the thigh
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
What is the primary blood supply to femoral head?
Medial femoral circumflex artery
55
Describe the proximal femur blood supply
MFCA: femoral head via retinacular vessels LFCA: GT Obturator: vessels within ligamentum teres
56
What are the borders of the femoral triangle? What makes up the floor, in what order?
Sartorius: laterally Adductor longus: medially inguinal ligament: superiorly Floor (lat to med): iliacus, psoas, pectineus, adductor longus
57
What are the contents of the femoral triangle?
NAVEL (spell NAVEL towards the navel, aka lateral to medial)
58
Describe the safe zone for acetabular screws: Which zone is safe? Dnagerous? What is at risk in each zone?
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
Name the short external rotators, from most proximal to most distal:
Piriformis Gemellus superior Obturator internus Gemellus inferior Obturator externus Quadratus femoris
60
Name the OINA of all the muscles of the hip - see list in answers
Good luck
61
Name the hip flexors and extensors:
Flexors: Iliopsoas Rectus femoris Sartorius Extensors: Gluteus maximus Hamstrings: (ST, SM, BF)
62
Name the hip aB and aDDuctors
ABductors: gluteus medius gluteus minimus TFL (in a flexed hip) Adductors: Adductor brevis, longus, magnus Pectineus Gracilis
63
What is the innervation of adductor magnus?
Dual: Obturator (adductor) posterior division Tibial of sciatic (hamstrings)
64
Name the internal rotators of the hip
Gluteus medius (anterior fibers) Gluteus minimus (anterior fibers) TFL semimembranosus semitendinosus pectineus adductor magnus (posterior fibers)
65
Describe the lubosacral plexus +/- draw it.....
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
Name the origin and course of femoral nerve
Origin: L2-4 Emerges between psoas and ilicus Runs superficial and medial to psoas tendon Into femoral triangle divides and innervates quads
67
What is the origin of LFCN and where does it exit pelvis?
L2-3 Exits pelvis under inguinal ligament, 2cm distal to ASIS
68
Where is the sciatic nerve most likely to be found in relation to piriformis and SERs?
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
What is the internervous plane of the anterior approach to the hip?
Femoral and superior gluteal nerve Superficial: sartorius & TFL Deep: Rectus femoris and gluteus medius
70
In the lateral approach to the hip, where does the superior gluteal nerve run?
3-5cm above GT
71
What is the interval for the medial (Ludloff) approach to the hip?
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
Name the dangers of the ilioinguinal approach
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
Where do the cluneal nerves run in a posterior bone graft approach?
8cm lateral to midline, so stay medial
74
Where do the superior gluteal vessels run in a posterior approach to bone graft?
Near the sciatic notch Stay proximal to sciatic notch
75
What is the most common nerve injured during THA?
Sciatic, peroneal division b/c it is more lateral
76
What is the only muscle innervated by peroneal nerve proximal to the fibular neck?
Short head of biceps femoris
77
What is the most common complication in posterior iliac crest bone graft harvesting?
Injury to the superior gluteal artery
78
Which vessel provides the dominant supply to the femoral head?
Lateral epiphyseal vessels of the MCFA
79
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
4: Loss of great toe extension due to damage to L5
80
What is the only hip approah with a true internervous plane? What is the plane?
Anterior (Smith Peterson) approach Femoral & superior gluteal nerves Superficial: Sartorius & TFL Deep: G. med & rectus femoris
81
What are the dangers of the anterior approach to the hip?
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
What are the planes and dangers of the lateral approach to the hip?
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
What is the plane and dangers of the anterolateral approach to the hip?
Plane: No true internervous plane: SGN TFL/G. medius Dangers: femoral n/a/v overlying psoas: protect with careful anterior retraction
84
What is the plane/dangers of the posterior approch to the hip?
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
What is the most common position of the sciatic nerve in relation to the piriformis? What are the other variants?
See picture
86
Describe the position, incision, plane and dangers of the surgical dislocation of the hip:
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
Describe the medial approach to the hip: Position Incision Plane Dangers
**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
What are the dangers in a posterior approach to PSIS for bone grafting? what is more commonly injured?
Superior gluteal a/v (more commonly injured) Cluneal nerves: 8cm lateral to midline at PSIS
89
What does the external iliac artery become?
Common femoral artery, after the inguinal ligament
90
At what age are the SI joints fused by?
Age 50

Anatomy (13 decks)

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