Hip joint Flashcards
What muscles are responsible for lateral / external rotation of the Hip ?
Where are they located ?
0 Piriformis - origin - anterior sacrum —-> travels through greater sciatic forearm —-> inserts onto greater trocanter.
( closely related to sciatic . )
0 Gemelli - 2 - superior & inferior (narrow & triangular ) - sepearted by obturator internus
1. Superior - orginates form ischial spine
2. Inferior - orginates from ischial tuberosity
( both insert onto gretaer trocanter )
0 Obturator internus
- originates from pubis & ischium at obturator forearm (posterior surface of the obturator membrane - internal (internus ) )——> leaves pelvis via lesser sciatic forearm ——> greater trocnater.
0 Quadratas femoris - flat , square shaped.
( most inferior of the deep muscles )- loacted beneath all of them.
Originates from lateral side of ischial tuberosity - inserts onto quadate tuberosity on intertrochnateric crest.
0 Obturator externus - origin from external part of obturator membrane
ACTION - Thigh abdcutuon , lateral rotation ,stabilises hip joint.
Gluteal region - deep muscles .
*All carry out abduction & insert onto greater trocanter apart from fermoris - intertrochaneric crest & only lateral rotation.
Gemelli - superior & inferior , piriformis , obturator internus ( join to form a commoon tendon - Triceps coxae - before inserting onto the medial aspect of the greater trochanter.
Muscles of the gluteal region ?
Superior muscles
Gluteus minimus
Gluteus Medius
Gluteus maximus
All cary out abduction & medial rotation & innervated by superior gluteal n. - apart from maximus ( inferior gluteal n. & lateral rotation & extension of lower limb)
- there is also the tensor fascia Lata
tightens fascia Lata —-> medially rotates lower limb & abducts. - superior gluteal N.
Deep muscles
0 Piriformis
0 Gemelli
0 Obturator internus
( located within both pelvic and gluteal regions - originates from posterior surface of obturator forearm )
(lateral rotation & abduction )
0 Quadratas femoris
(lateral rotation )
What is the Hip joint ?
PARTS
0 Acetabulum
0 Joint capsule
0 Ligaments
MOVEMENTS
0 Ball and socket synovial joint - very stable - not very mobile.
0 Articulation btw head of femur and acetabulum of pelvis.
MOVEMENTS
- Abduction
- adduction
- flexion
- extension
- lateral rotation
- medial rotation.
PARTS
- ACETABULUM
0 Acetabulum - Lunate (articular) surface
0 Acetabulum labrum - fibrocartilaginous collar around the lunate surface - deepens the acetabulum - stabilises hip joint
0 Tranverse Acetabulum Ligament - As Acetabulum labrum cross Acetabulum notch - forms Transverse Acetabulum ligament.
0 Acetabulum notch - space btw two ends of lunate surface
0 Acetabulum Fossa - Point of attachment for ( ligamentum teres ) ligament of head of femur - FOVEA
- LIGAMENTS
Intracapsular
0 Ligamentum teres -carries Acetabular branch of obturator a.
0 Transverse Acetabulum Ligament
Extracaspcular
0 Iliofemoral -strongest
0 Pubofemoral
0 Ischiofemoral - weakest.
JOINT CAPSULE
joint capsule - made up of circular ( Zona orbicularis ) & longitudinal fibres.
from acetabulum & transverse acetabulum L to neck of femur ( intertrochanteric crest)
Capsule thicker anterosuperiorly (maximal stress occurs here - especially when standing ) than posteroinferiorly
Zona Orbicularis - on neck of femur - encircles femoral neck - attaches to intertrochanteric line - BV travel underneath joint capsule , up neck to head of femur - intra - capsular fracture to neck -damage BV - lack of blood supply ——> avascular necrosis (death to tissue due to no blood ) & malunion ( fracture not healing properly )
Extracapsular fracture unlikely to damage BV
Joint capsule supported by 3 ligaments - supported and reinforced by :
0 extracapsular ligaments.
What is a synovial joint ?
Found between bones that move against each other.
0 Contains a synovial membrane - layer of cells that line joint capsule and produces synovial fluid.
Ligaments of the hip joint ?
Intracapsular -
0 Ligamentum teres - round ligament of femoral head.
* DOES NOT SUPPORT JOINT - reminant of fetal development.
Vessel & nerves travel within to supply femoral head.
e.g acetabular branch of obturator a.
0 Transverse Acetabular Ligament - located btw the 2 ends of the acetabulum labrum.
Extracaspcular
0 Iliofemoral -strongest - Y shaped - origin - anterior inferior iliac spine —-> bifurcates - inserts into intertrochanteric line of femur.
ACTION - prevents hyperextension.
0 Pubofemoral - - arises - superior pubic rami and inserts into the intertrochanteric line of femur.
ACTION - prevents excessive abduction and extension.
Reinforces joint anteriorly & extension.
0 Ischiofemoral - weakest - btw
body of the ischium and the greater trochanter of the femur
reinforce joint capscule posteriorly , prevents hyperextension , holds femoral head in acetabulum.
What muscles abduct the Hip ?
POSTERIOR
0 Gluteus Medius
0 Gluteus Maximus
ANTERIOR
0 Fasciae Latae.
0 Saritorius ( not sure )
What muscles abduct the Hip ?
G - Gracilis -
M - Magnus (adductor)
L - Longus (adductor )
B - Brevis (adductor)
P - Pectineus
Great major league Baseball Players
Map the branches of common iliac artery to popliteal a. ?
Abdominal Aorta ——–> bifurcates ——–> common iliac ———> external & internal iliac.
- Internal iliac —-> bifurcates ——-> anterior & posterior division
0 Anterior division - o Obturator a. o Inferior gluteal a. o Inferior Pudendal a. o Inferior vesical a. o Middle rectal a. o Umbilical a o Uterine a. o Vaginal a.
POSTERIOR DIVISION
o Iliolumbar a.
o Superior gluteal a.
o Lateral sacral a. (superior & inferior )
EXTERNAL ILIAC
external iliac —–> common femoral a. ——————————————> ( enters femoral triangle and gives off 4 branches.
- Superfical circumflex
- Superfical Epigastric
- Superfical external Pudendal
- Deep external Pudenal
Further down -
common femoral —— bifurcates ——-> Superficial femoral &Profunda femoris
profunda femoris ( deep femoral a. ) - branches off. -
MAIN SUPPLY TO ADDUCTOR , EXTENSOR , FLEXOR MUSCLES OF THIGH.
Profunda femoris ——————–> gives of 3 branches
- Lateral circumflex femoral - ascending & descending & transverse branch.
- Medial circumflex femoral - ascending branch (anastomes with ascending branch of lateral circumflex) & transverse branch.
MORE DISTAL
3. perforating a.
3 branches - perforate the adductor Magnus muscle .
Superficial Femoral ——- > gives off Descending genicular a. -2 branches ( saphenous & articular —————–>
REST OF FEMORAL A. ———————-> Popliteal a. ( when femoral passes through adductor hiatus ) - enters posterior compartment.
What is the blood supply of the hip ?
2/3 branches of profuna femoris (deep femoral a. )
Medial circumflex femoral
Lateral circumfex femoral
(anastomose - trochanteric anastomosis - )
Foveal a. - branch of obturator a / acetabular branch of the obturator a. . ( branch of internal iliac a. )
if damage to lateral & medial circumflex - fovea a. can prevent avascular necrosis.
Nerve supply of the Hip joint ?
Femoral n. - Hip flexors ( anterior thigh muscles )
Obturator n . - external / lateral rotators of hip (e.g Gemelli , obturator internus & externus etc . )
Superior Gluteal n. — adductors of the hip
( GMLBP)
nerve to quadratus femoris ( actually called that ) - supplies (external rotators )quadratas femoris , inferior gemelli
What imaging is used for Diagnosis of Hip fractures ?
Plain radiographs ( X -ray )
usually AP or Lateral.
Types of Hip Fracture ?
Intracapsular -
1. Subtrochanteric - lesser trochanter to 5cm distal.
- Intertrochanteric - between lesser & greater trochanter.
Intracapsular
- Subcapital - most common form - fracture line extends through junction of head and neck of femur.
- Transcervical - mid - portion of neck .
- Basicervical. - base of femoral neck
- powerpont mentioned
CAPITAL - fracture of femoral head.
Hip joint dislocations ?
Posterior more common
- lower limb will be internally rotated , adducted and flexed.
POSSIBLE CAUSES
- Dashboard injury - impact drives femoral head out of acetabulum
- associated with fracture to posterior lip of acetabulum or labrum.
0 Anterior -
Superior / pubic hip location
(femur moves up but anteriorly )
Inferior/ iliac hip dislocation
( femur moves inferiorly but anteriorly )
on radiograph shenton’ s line may be broken.
Always check sciatic nerve function - common fibular ( peroneal) and deep fibular may be damage - foot drop - weak dorsiflexion at ankle so in permanent plantarflexion - unopposed action of posterior muscles.
Urgent reduction (surgery ) needed to avoid avascular necrosis (disruption to blood supply of femoral head ) —> lead to femoral head collapse .
Imaging - radiograph of anterior hip dislocation ?
What is likely to be seen.
- lesser trochanter more visible in anterior dislocation due to external rotation
- In an anterior dislocation the femoral head will appear larger than the contralateral hip on account of geometric magnification
What are bursae ?
small fluid like sacs- reduce friction between moving parts of the body joints .
help tendons move over bony landmarks.
Bursitis - inflammation / irritation of the bursae.
When is the hip joint more prone to damage during flexion flexion of hip ?
because Ligaments of hip joint are usually taut - twisted
In flexion - muscles loosen so weaker - more prone to damage.
Intracapscular - if damage BV
if bone is going to die - total hip replacement
hemiplasty
Treatment of femur fractures
open reduction
internal fixation
Intracapsular fractures of the neck of the femur do not heal well as the blood supply runs in the capsule and is thus interrupted. In young patients they are reduced and fixed, but still often fail to unite or develop avascular necrosis, necessitating hip replacement.
Older patients are treated intially with hip replacement as the risks of non-union and avascular necrosis are unacceptably high with attempted fixation. Elderly patients who are active and independently mobile should be treated with total hip replacement, but those with pre-existing mobility restrictions can be treated with hemiarthroplasty. Hemiathroplasty is a quicker operation, with a lower risk of post-operative dislocation, but is associated with more long-term pain and worse mobility.
Intra-capsular fractures in elderly people are treated best by removing the broken femoral head and replacing with a replacement, either a hemiarthroplasty or total hip replacement. If fixation is attempted, there is a high risk of non-union and avascular necrosis. Reduction and internal fixation can be attempted in younger patients, but even then the failure rates are high, necessitating total hip replacement.
Fractures of the femoral neck in elderly patients are associated with very high mortality rates. Early surgery followed by aggressive early mobilisation has been shown to reduce mortality rates. Total hip replacements are given to more active patients and hemiarthroplasties to less active patients.
What is skin traction ?
splints , bandages , adhesive tapes applied to skin - directl below fracture.
weights are then applied.
limits movement & fracture - reduces pain., spasm & swelling.
extracapscular fractures - treatment ?
operative fixation - fixed with pin & plate - heal within 3 months
