Hip/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)
2
Q
What is the potential space of retzius ?
A
Anterior to bladder post to pubic symphysis
3
Q
What muscle do you have to take down to see quadrilateral plate?
A
Obturator internus
4
Q
What fascia separates the middle and lateral window of the ilioinguinal approach?
A
Iliopectineal fascia
5
Q
List five contents of the Greater sciatic notch
A
Exit above piriformis
- Superior gluteal artery and nerve
Exit below piriformis
POPSIQ
- Posterior femoral cutaneous nerve
- Nerve to Obturator internus
- Pudendal nerve and internal pudendal artery
- Sciatic nerve
- Inferior gluteal nerve and artery
- Nerve to quadratus femoris
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
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 vessels to rectus abdominus
7
Q
What are the Denis zones of the sacrum?
A
1: lateral to foramen
2: middle
3: medial to foramina into spinal canal
8
Q
What nerve root runs along the sacral ala?
A
L5
9
Q
What is the sacral ala?
A
The lateral aspect of the sacrum; lateral to the body, forming articulations with the iliac wing
10
Q
What is the importance of iliac cortical density?
A
On the lateral is the overlying projection of the alar slopes, you want to be behind this when inserting an SI screw in order to avoid the L5 nerve root
11
Q
On an AP pelvis is the posterior wall lateral or anterior?
A
Lateral!
12
Q
Describe what you look for on Judet views.
A
Obturator oblique - AC (iliopectineal line), PW
Iliac oblique - AW, PC (ilioischial line)
14
Q
What is a Morel-Lavallée lesion?
A
Internal degloving of subcutaneous tissue off of the underlying fascia.
Traditionally this term is reserved for lesions overlying the GT however this mechanism and injury has been seen all over the body and Morel-Lavallee is the term generally used.
15
Q
What are key SI ligaments?
What are the other three important pelvic ligaments?
A
The posterior SI ligament complex are the strongest ligaments in the body
- Anterior Sacroiliac ligament - resist external rotation after failure of pelvic floor and anterior structures
- Posterior Sacroiliac ligament - resist cephalad-caudad displacement of pelvis
- Interosseous Sacroiliac ligament -
resist rotation and augment posterior SI ligaments
Also:
- Sacrotuberous - Sacrum to Ischial tuberosity. The sacrotuberous ligament passes behind the sacrospinous ligament. Is the inferior boundary of the lesser sciatic notch
- Sacrospinous - Sacrum to Ischial spine - Converts the sciatic notch into the greater and lesser sciatic foramen. The greater sciatic foramen lies above the ligament, and the lesser sciatic foramen lies below it.
- Iliolumbar ligament- •Iliac crest to transverse processes of 5th Lumbar. It forms the thickened lower border of two of the layers of the thoracolumbar fascia. Fracture of the fifth lumbar vertebra is a clue to an unstable pelvic fracture (JBJS 2011, see below)
An associated fracture of the transverse process of L5 was present in 17 patients; 14 (40%) of whom had an unstable fracture pattern. Overall, 14 of the 35 unstable injuries (40%) had a fracture of the transverse process, compared to only three of the 45 stable fractures (7%). The odds ratio for an unstable fracture of the pelvis in the presence of a fracture of the transverse process of L5 was 9.3 and the relative risk was 2.5. A fracture of the transverse process of L5 in the presence of a pelvic fracture is associated with an increased risk of instability of the pelvic fracture.
FURTHERMORE:
It is well documented that there is a strong association between transverse process fractures and abdominal injury. One study reports an association of up to 50%.9 In our study this was 12% (2 of 17).
16
Q
Name the Contents of the Sciatic Notch Relative to Piriformis
A
Contents of GSN:
Above piriformis:
- Superior Gluteal Nerve & Artery
Below Piriformis (POPS IQ):
- 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
17
Q
What travels through Lesser Sciatic Notch?
A
- Obturator internus muscle
- Nerve to obturator internus
- Pudendal nerve
- Internal pudendal artery and vein
18
Q
Name the nerves relative to psoas:
- Lateral (3)
- Medial (2)
- Between iliac and psoas (1)
- Piercing them (1)
A
Lateral - iliohypogastric, lioinguinal, LFCN
Medial - obturator, lumbosacral trunk
Between - femoral
Piercing - genitofemoral
19
Q
What is the cruciate anastomosis made of?
What vessels is the trochanteric anastamosos comprised of?
A
Cruciate anastamosis (looks like a cross)
First perforator of profunda
Inferior gluteal artery
Transverse branches of MCFA
Transverse branches of LCFA
this is an anastomosis between basically the internal iliac (via gluteal aa) and the Profunda femoris via the lateral circumflex artery.
If either femoral aa (SFA or Profunda) becomes occluded, collateral flow to the popliteal artery can be established via the cruciate anastamosis in the following way:
Internal iliac –> to Inferior Gluteal artery –> to perforator of the Profunda femoris –> to the DESCENDING branch of the lateral circumflex artery to the superior lateral geniculate aa to the popliteal artery.
IT IS NOT ENTIRELY CLEAR WHERE THIS IS REFERENCED FROM.
Trochaneteric Anastamosis
The trochanteric anastomosis is formed by the following arteries:
- Ascending branch of the medial circumflex femoralartery.
- Ascending branch of lateral circumflex femoral artery.
- Descending branch of the inferior gluteal artery .
- Descending branch of the superior gluteal artery.
21
Q
What nerve is at risk with a retractor under transverse acetabular ligament?
If you bagged this nerve what muscles would be affected?
A
Obturator Nerve - posterior division
If you bagged this nerve what muscles would be affected?
- Obturator externus
- Adductor magnus
- Adductor brevis
22
Q
How can we adduct after an obturator neurectomy
A
Pectineus, femoral
23
Q
What nerve is above piriformis?
A
Superior gluteal nerve
24
Q
What structure is most at risk of posterior ICBG harvest?
A
Superior gluteal artery and nerve (penetration into the notch)
cluneal nerves (use a vertical incision to avoid this)
25
Q
Between What muscles does the posterior obturator nerve run between?
A
Adductor brevis and magnus
26
Q
In the anterior Smith-Peterson approach the deep interval is between?
A
Rectus femoris (femoral)
and
Gluteus medius (superior gluteal)
27
What type of joint is the pubic symphysis?
Name the ligaments connecting the pubic sympysis.
non-synovial amphiarthroidal joint
Superior pubic ligament (stronger)
Inferior (arcuate) public ligament
28
What type of joint is the pubic symphysis?
non-synovial amphiarthroidal joint
29
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
30
What strucures are near the posterior sacral foramina?
Dorsal primary rami
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 structures are near the anterior sacral foramina?
Ventral primary rami
33
In which direction are the coccyx of men and women directed?
Men: anteriorly towards pubis (like a penis)
Women: vertically
35
Where does the sacrotuberous ligament, sacrospinous ligament and iliolumbar ligaments run?
Sacrotuberous: sacrum to ischial tuberosity
Sacrospinous: sacrum to ischial spine
Iliolumbar: iliac crest fo 5th lumbar TP
36
What are the superficial surface markings of the SI joint?
Dimples of Venus
also said to be a marker of the PSIS
37
What are the borders of the lesser sciatic foramen?
Ischial spine and tuberosity
sacrospinous ligament (superior border)
sacrotuberous ligament (inferior border)
38
What is 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
39
At what age are the SI joints fused by?
Age 50
40
Name the ligaments of the SI joint
Posterior
Anterior
Interosseous
42
What are the boundaries of the greater sciatic notch?
It is bounded as follows:
* **anterolaterally** by the greater sciatic notch of the ilium
* **posteromedially** by the sacrotuberous ligament
* **inferiorly** by the sacrospinous ligament and the ischial spine
* **superiorly** by the anterior sacroilliac ligament
45
What attaches to the obturator membrane?
Obturator internus
and externus
46
Describe the criteria for an adequate AP pelvis x-ray
1. Coccyx in line with symphysis
2. Symmetric teardrops
3. Symmetric Obturator foramina
4. Symmetric iliac wings
5. Superior border of pubic symphsis to coccyx should be **1-3 cm**
6. Superior border of pubic symphsis to sacrococcygeal junction distance of:
1. 32mm in men
2. 47mm in women
(However, visualization of the sacrococcygeal junc- tion can often be difficult, making the tip of the coccyx a more reliable landmark)
Clohisy, Beaule et al - A Systematic Approach to the Plain Radiographic Evaluation of the Young Adult Hip. JBJS 2008
As seen in Figure 8, the coccyx should be directly in line with the pubic symphysis, and the iliac wings, obturator foramina, and radiographic teardrops should be symmetrical in appearance. Additionally, if pelvic inclination is appropriate, the distance between the superior border of the pubic symphysis and the tip of the coccyx should be approximately 1 to 3 cm. Siebenrock et al.28, who published sex-specific values for pelvic tilt (referencing the distance between the superior aspect of the symphysis and the sacrococcygeal junction), noted that an average distance of 32.3 mm was typical in men, as compared with 47.3 mm in women. However, visualization of the sacrococcygeal junc- tion can often be difficult, making the tip of the coccyx a more reliable landmark.
47
What is the anteversion of the femoral neck?
15 degrees
48
What is the average neck shaft angle of the femur?
~127 degrees
49
List the 6 fundamental lines of Letournel
1. Posterior wall
2. Anterior wall
3. Roof (or dome/tectum)
4. Teardrop
5. ilioischial line (posterior column)
6. iliopectineal line (anterior column)
50
What is the version of the acetabulum?
15 degrees anteverted (to match the femur)
51
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
52
What is the zona orbicularis?
Circular fibers that form a collar around the femoral neck
Form the annular ligament of the femoral neck
53
The labrum is continuous with what structure?
Transverse acetabular ligament
55
What angle is classically measured off a Dunn view?
How do you take a Dunn View?
**Alpha angle**
It is calculated by measuring the angle between two lines: (1) a line from the center of the femoral head to the point on the ante- rolateral aspect of the head-neck junction where the radius of the femoral head first becomes greater than the radius of the femoral head found more centrally in the acetabulum (i.e., where a prominence starts),
and
(2) a line drawn through the center of the femoral neck, connecting to the center of the femoral head. Values of \>42° are suggestive of a head-neck off- set deformity.
( The upper end of normal is an alpha angle of 50 - 55 degrees for measurement on an MRI or CT. i.e \>55 is cam, some au)
**Dunn View**
The positioning for a 45° Dunn view with the hips flexed 45° and abducted 20°. The x-ray beam is centered at a point midway between the pubic symphysis and the anterior superior iliac spine
56
Describe the proximal femur blood supply
MFCA: femoral head via retinacular vessels
LFCA: GT
Obturator: vessels within ligamentum teres
57
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
Roof: Fascia lata except at the saphenous opening where it is bounded by the cribriform fascia (aka Hesselbach's fascia) is the portion of fascia covering the saphenous opening in the thigh. It is perforated by the great saphenous vein and by numerous blood and lymphatic vessels
58
What angle is measured from a false profile view?
Anterior CEA
59
Describe the safe zone for acetabular screws:
Which zone is safe? Dangerous? 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
1. **Posterior superior _(Target zone)_**: sciatic nerve, superior gluteal n/a/v
2. **Posterior inferior (_Caution Zone_)**
1. ****safe if screws \<20mm
1. Dangers
1. sciatic nerve
2. inferior gluteal aa and nn
3. Pudendal nerve and internal pudendal artery
3. **Anterior inferior (_Danger zone)_**:
1. obturator n/a/v (b/c aiming for obturator foramen)
1. In particular the posterior branch of obturator nerve is at risk
4. **Anterior superior (_Death zone)_**
1. Dangers
1. external iliac artery/veins
60
Name the short external rotators, from most proximal to most distal (6):
Piriformis
Gemellus superior
Obturator internus
Gemellus inferior
Obturator externus
Quadratus femoris
61
Name the OINA of all the muscles of the hip - see list in answers
Good luck
63
List the levels of:
Aortic bifurcation
Common iliac bifurcation
Aortic bifurcation: L4
Common iliac bifurcation: S1
Full list:
* Mandible C2-3
* Hyoid Cartilage C3
* Thyroid Cartilage C4-5
* Cricoid Cartilage C6
* Vertebral prominence C7
* Spine of scapula T3
* Vena cava pierces diaphragm T8
* Esophageal hiatus T10
* Aortic hiatus T12
* Renal Artery L2
* Aorta Bifurcation L4
* liac Bifurcation S1
64
Name the branches of the internal iliac artery (10)
Mnemonic
**I Love Going Places In My Very Own Underwear!**
* I: iliolumbar artery
* L: lateral sacral artery
* G: gluteal (superior and inferior) arteries
* P: (internal) pudendal artery
* I: inferior vesical in males/Vaginal (in females) artery
* M: middle rectal artery
* V: Superior vesical
* O: obturator artery
* U: Uterine artery (females) / Artery to Vas Deferens in males
There are typically 10 named branches of the internal iliac artery. Authorities quibble on the details, as we’ll see in a moment, but if you know these 10, you’ll be fine for almost any conceivable purpose. A simple scheme of my own devising for remembering them is 2-4-4:
TWO to the back body wall:
1. **iliolumbar** —may arise from external or common iliac AA; sometimes double
2. **lateral sacral** —note branches to anterior sacral foramina and anastomoses with median sacral A
FOUR leaving the pelvis entirely:
1. **obturator** —often arises from the external iliac A instead, exits pelvis through obturator canal
2. **superior gluteal** —exits pelvis through suprapiriform foramen
3. **inferior gluteal** —exits pelvis through infrapiriform foramen, with internal pudendal A
4. **internal pudenda**l —exits pelvis through infrapiriform foramen, with inferior gluteal A
FOUR to pelvic viscera:
**superior vesical** —usually the dominant artery of the anterior trunk, this is the patent part of the obliterated umbilical artery, which survives as the medial umbilical ligament
**inferior vesical (males) / vaginal (females)**—may branch off uterine A (females) or superior vesical A (both)
**Artery to ductus deferens (males)/uterine A (females)**—major artery to uterus, approaches laterally within the broad ligament.
**middle rectal** —usually the most inferior branch of the entire internal iliac tree (at least inside the pelvis)
65
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)
Tornetta et al CORR 1996
Fifty cadaver halves were dissected to determine the occurrence and location of the corona mortis. Anastomoses between the obturator and external iliac systems occurred in 84% of the specimens. Thirty-four percent had an arterial connection, 70% had a venous connection, and 20% had both. The distance from the symphysis to the anastomotic vessels averaged 6.2 cm (range, 3-9 cm).
66
What are the branhces of the profunda femoral artery?
Medial and lateral femoral circumflex arteries
Perforators
67
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
68
What is the primary blood supply to femoral head?
Medial femoral circumflex artery
69
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
72
What are the contents of the femoral triangle?
NAVEL (spell NAVEL towards the navel, aka lateral to medial)
76
Name the hip flexors and extensors:
Flexors:
Iliopsoas
Rectus femoris
Sartorius
Extensors:
Gluteus maximus
Hamstrings: (ST, SM, BF)
77
Name the hip aB and aDDuctors
**ABductors**:
gluteus medius
gluteus minimus
TFL (in a flexed hip)
**Adductors:**
Adductor brevis, longus, magnus
Pectineus
Gracilis
78
What is the innervation of adductor magnus?
Dual:
**Adductor portion:** posterior division Obturator
**Hamstring portion:** Tibial of sciatic
79
Name the internal rotators of the hip
Gluteus medius (anterior fibers)
Gluteus minimus (anterior fibers)
TFL
semimembranosus
semitendinosus
pectineus
adductor magnus (posterior fibers)
80
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
81
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
82
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
83
What is the origin of LFCN and where does it exit pelvis?
L2-3
Exits pelvis under inguinal ligament, 2cm distal to ASIS
85
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
86
What is the most common position of the sciatic nerve in relation to the piriformis? What are the other variants?
See picture
87
In the lateral approach to the hip, where does the superior gluteal nerve run?
3-5cm above GT
88
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
89
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
90
Where do the cluneal nerves run in a posterior bone graft approach?
8cm lateral to midline, so stay medial
91
Where do the superior gluteal vessels run in a posterior approach to bone graft?
Near the sciatic notch
Stay proximal to sciatic notch
92
What is the most common nerve injured during THA?
Sciatic, peroneal division b/c it is more lateral
93
What is the only muscle innervated by peroneal nerve proximal to the fibular neck?
Short head of biceps femoris
94
What is the most common complication in posterior iliac crest bone graft harvesting?
Injury to the superior gluteal artery
(or nerve) if you enter the sciatic notch. A rare but notable complication
The cluneal nerves are also at risk if you use a horizontal/oblique incision following the crest. Try to use a vertical incision.
Debatable.
95
Which vessel provides the dominant supply to the femoral head?
Lateral epiphyseal vessels of the MCFA
97
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
98
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
99
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.lateralis (femoral) distally
Dangers:
Superior gluteal nerve: 3-5cm proximal to GT
Femoral bundle: gentle anterior retractor placement
Transverse branch of the lateral femoral circumflex artery
100
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
101
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
103
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
104
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
105
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
106
What does the external iliac artery become?
Common femoral artery, after the inguinal ligament
107
What is the position of instabilty with the lateral approach?
Posterior approach?
Lateral approach = anterior dislocation so position of instability is;
Extension (superior dislocation) or flexion (inferior dislocation), external rotation, adduction
Posterior position of instabilty:
Flexion, internal rotation, adduction
108
What are the branches of the femoral artery (6)?
The **superficial circumflex iliac artery** is a small branch that runs up to the region of the anterior superior iliac spine.
The **superficial epigastric artery** is a small branch that crosses the inguinal ligament and runs to the region of the umbilicus.
The **superficial external pudendal artery** is a small branch that runs medially to supply the skin of the scrotum (or labium majus).
The **deep external pudendal artery** runs medially and supplies the skin of the scrotum (or labium majus).
The **profunda femoris artery** is a large and important branch that arises from the lateral side of the femoral artery about 1.5 in. (4 cm) below the inguinal ligament. It passes medially behind the femoral vessels and enters the medial fascial compartment of the thigh. It ends by becoming the fourth perforating artery. At its origin, it gives off the medial and lateral femoral circumflex arteries, and during its course it gives off three perforating arteries.
The **descending genicular artery** is a small branch that arises from the femoral artery near its termination within the adductor canal. It assists in supplying the knee joint.
109
What is the interval in the approach to the SI Joint?
Between Gluteus Maximus (inferior gluteal nerve)
and
Multifidus (mulitple posterior spinal nn branches)
110
What are the 3 variations of the LFCN?
Sartorius type (36%)
Posterior Type (32%)
Fan Type (32%)
111
What muscles attach to the sacrum(8 or 9)?
1. latissimus dorsi
2. piriformis
3. iliacus
1. gluteus maximus
2. coccygeus
3. multifidus
4. sacrospinalis
5. erector spinae
occasionally, extensor coccygis.
112
What are 5 signs of sacral dysmorphism?
Lumbarization of S1
Sacralization of L5
Mamillary processes
Tongue in Groove appearance on CT
Oval foramen
**The radiographic signs of upper sacral dysmorphism are identified on the pelvic outlet plain film and include:**
near colinearity of the iliac crest level and the lumbosacral disc space;
obliquely oriented residual transverse processes on the sacral ala;
noncircular, misshapen first sacral anterior neural tunnel exit sites;
a residual disc space between the upper two sacral segments;
acute sacral alar slopes.
Dysmorphic upper sacral segments also may have radiographic signs on the pelvic computed tomography scan. These include undulating ‘‘tongue-in-groove’’ sacroiliac articulations and acutely sloped sacral alae, which preclude the safe use of the iliac cortical densities as a reliable radiographic landmark
Problems with sacral dysmorphism is that it creates smaller corridors with abnormal sacral orientation. Also radiographic parameters change and it makes it more difficult to get reliable intraoperative fluoroscopy.
113
What are two approaches you can use to access the hip anteriorly, what are their intervals?
1. hueter aka Smith Peterson - TFL and sartorius, rectus, glut medius
2. watson jones - TFL and GM. need to osteotomize GT or release the abductors to dislocate hip and access socket
114
What are 5 blocks to reduction in a congential dislocated hip DDH?
1. pulvinar
2. limbus
3. transverse acetabular ligament
4. capsule (constricted, hourglass)
5. ligamentum teres
6. labrum
115
What are the 4 layers of the abdominal wall from superficial to deep for a pfannenstiel incision?
- campers fascia (fatty layer), scarpas fascia (deep membranous layer)
anterior rectus sheath
rectus abdominus
posterior rectus sheath (only above the arcuate line (occurs about a 1/3 of the distance from the umbilicus to the pubis)
transversalis fascia
The Pfannenstiel incision is usually made below the arcuate line, so the layers incised are as follows: skin, superficial fascia (fatty and membranous), deep fascia, anterior rectus sheath, rectus abdominis muscle, transversalis fascia, extraperitoneal connective tissue, and peritoneum.
