pelvis and hip (brian) Flashcards
when does trirardiate cartilage fuse?
14-16yo
what type of joint is the pubic symphysis?
non-synovial amphiarthroidal joint
has fibrocartilagenous disc
what are the pubic symphysis ligaments? which is strongest?
superior pubic ligament (strongest)
inferior (arcuate) pubic ligament
coccyx points which way?
men: anteriorly
women: vertically
signs of sacral dysmorphism? clinical relevance?
sacralization of L5
lumbarization of S1
mamillary processes
oval/oblong foramina
tongue-in-groove sign
narrowed S1 tunnel (for SI screws)
recessed sacral ala puts L5 nerve root at risk when XRays appear to show intraosseous screws
what type of joint is the SI joint? when does it fuse?
diarthroidal, gliding synovial
fuses by age 50
list the SI joint ligaments
anterior SI ligs
posterior SI ligs
interosseous SI ligs
what ligament runs from:
sacrum to ischial spine
sacrum to ischial tuberosity
iliac crest to L5 transverse process
sacrospinous
sacrotuberous
iliolumbar
boundaries of greater sciatic notch?
ischial spine
ilium
sacrospinous ligament
greater sciatic notch contents SUPERIOR to piriformis muscle
superior gluteal n and a (and v, vena comitantes)
contents of greater sciatic notch INFERIOR to piriformis muscle
POPS IQ
pudendal n and internal pudendal a (and v, vena comitantes)
nerve to Obturator internus
posterior femoral cutaneous n
sciatic n
inferior gluteal n and a (and v, vena comitantes)
nerve to Quadratus femoris
boundaries of the lesser sciatic notch
ischial spine
ischial tuberosity
sacrospinous lig
sacrotuberous lig
contents of lesser sciatic notch
obturator internus
nerve to obturator internus
pudendal n
internal pudendal a (and v)
what is the obturator canal and what does it contain?
opening at superior end of obturator membrane
obturator n,a,v pass thru it
normal femoral anteversion as adult and at birth?
15 deg. 30-40deg at birth
normal neck shaft angle of femur of adult and at birth?
127 deg. 150 at birth.
acetabular anteversion?
15 deg
name the ligaments that make up the hip capsule. What is strongest?
anterior:
iliofeoral lig (Y-lig of bigelow) - strongest lig in body. from AIIS to intertroch line
pubofemoral lig
posterior:
ischiofemoral lig
what is the zona orbicularis?
circular fibres forming a collar at femoral neck - like its own “annular ligament”
acetabular labrum is ____ with the cartilage posteriorly and _____ anteriorly
continuous, marginally attached
acetabular labrum functions: name 2
deepens socket by 30%
seals fluid - protects cartilage
adequate AP pelvis xray: list criteria
coccyx in-line with symphysis
symmetrical teardrops, obturator foramina, iliac wings
symphysis to sacro-coccygeal junction vertical distance (difficult to see): 32mm men, 47mm women
sympysis to tip of cocyx: 1-3cm
what is the utility of frog-leg lateral xray of hip?
profile of head/neck junction
see subtle SCFEs
How is the Dunn view taken?
what is its utility?
hip flexed to 45 or 90
20 deg abduction, neutral rotation
beam shot straight down at hip
utility: profiles head/neck junction to check alpha angle for FAI (<55 deg=CAM)
how do you take a false profile xray?
what is its utility?
standing patient
ER body relative to cassette 65 deg
beam centred on fem head
utility: for anterior CEA: <20=dysplasia, >40=pincer
what spinal level is the aortic bifurcation?
common iliac bifurcation?
L4, S1
name the internal iliac artery branches
obturator
superior gluteal
inferior gluteal
internal pudendal
vesicular
lateral sacral
what is the corona mortis and where is it?
anatomic variant
anastomosis between obturator artery and either external iliac or inf epigastric artery
ocurs variable distance from symphysis, behind sup pub ramus (40-96mm from symphysis)
what two major arteries supply the proximal femur?
they are branches of what?
MFCA and LFCA
branch of profunda femoris
describe the path of the superficial femoral artery
(start from external iliac artery)
external iliac artery crosses under inguinal ligament into femoral triangle
becomes common femoral artery
divides into profunda femoris and superficial femoral artery
SFA runs along anteromedial thigh under sartorius
in hunter’s canal
between vastus med and adductor longus
exits through adductor hiatus
goes through adductor hiatus and becomes popliteal artery
describe the path of the medial fem circumflex artery
between pectineus and psoas anteriorly
then btw obt externus and adductor brevis
then btw adductor magnus and brevis
then along superior edge of quad fem
ascending branch runs over obturator externus, deep to piriformis into piriformis fossa
describe the path of the lateral fem circumflex artery
lies deep to rectus and sartorius
ascending br to GT
descending br under lateral rectus
what is the cruciate anastomosis?
significance?
anastomosis of:
inferior gluteal a
MFCA
LFCA
first perforator of profunda (ascending branch)
allows collateral flow in case blockage between ext iliac and femoral arteries
femoral triangle:borders and floor?
sartorius, adductor longus, inguinal lig
floor: (lat to med)
iliacus, psoas, pectineus add longus
fem triangle contents
lat to med:
fem N, A, V, and Lymphatics
NAVAL
acetabular zones - what defines them?
line from centre of acetab to ASIS
line perpendicular to that one thru centre of acetab
get 4 zones: PS, PI, AS, AI
acetabular zone: posterior superior
safe for screws?
risks?
safe.
risks: i.e. the stuff in GSN above piriformis and originating above this point
superior gluteal n,a,v
sciatic n
acetabular zone: posterior inferior
safe?
risks?
safe
risks: (the stuff in GSN below piriformis)
sciatic n
inf gluteal n,a,v
pudendal n
internal pudendal a,v
(not posterior fem cutaneous n or n to quad fem)
acetabular zone: anterior superior
safe?
risks?
NOT SAFE
risks: external iliac vessels
acetabular zone: anterior inferior
safe?
risks?
NOT SAFE
risks: obturator n,a,v
name the hip flexors
iliopsoas
rectus femoris
sartorius
name the hip extensors
glut max
hamstrings (semi T, semi M, biceps fem)
name the hip abductors
glut med
glut min
TFL (in flexed hip)
name the hip adductors
adductor longus/brevis/magnus
pectineus
gracillis
list the short external rotators of the hip from superior to inferior (in terms of insertion site)
piriformis - ventral sacrum to piriformis fossa
sup gemellus
obt internus
obt externus:
inf gemellus
quad femoris
list the hip internal rotators
glut medius - anterior fibres
glut min - anterior fibres
TFL
semi-M
semi-T
pectineus
adductor magnus - posterior fibres
list the nerves coming off lumbosacral plexus LATERAL to psoas
iliohypogastric n
ilioinguinal n
LFCN
list the nerves coming off lumbosacral plexus MEDIAL to psoas
obturator n
lumbosacral trunk
what nerve emerges between psoas and iliacus?
femoral n
what nerve pierces the psoas and lies anterior to it?
genitofemoral n
where is the LFCN relative to the ASIS?
2cm medially
what is most common nerve injury during THA? Which division and why?
sciatic n.
peroneal division b/c more lateral
what is the only muscle innervated by peroneal n proximal to fibular neck?
short head of biceps femoris
structure most at risk during posterior ICBG harvest is?
what else is at risk?
superior gluteal artery
also: cluneal nerves, sciatic n
describe the path of the obturator nerve in the thigh
passes through obturator foramen to enter thigh
divides into anterior and posterior branches
anterior: travels anterior to obturator externus
then lies between adductor brevis and longus/pectineus
posterior branch:
pierces obturator externus, then between adductor brevis and magnus
after loss of obturator n, how can the hip still adduct?
with pectineus. supplied by femoral n.
vessel at ligamentum teres comes from what major artery?
posterior branch of obturator artery
describe smith peterson approach
incision from ASIS curved downwards
between sartorius (femoral n) and TFL (sup gluteal n)
between rectus medially (femoral n) and glut medius laterally (sup gluteal n)
dangers of smith peterson approach
femoral n/a/v
ascending branch of LFCA
LFCN
dangers of hardinge approach?
sup glut n - runs betrween medius and minimus
branches 3-5cm above GT
femoral bundle - watch retractors
tnrasverse branch of LFCA
describe watson jones approach
incision along anterior GT
curve incision towards ASIS at GT tip
split ITB curving towards ASIS
retract medius+minimums posteriorly, TFL anteriorly
IM plane - abductors and TFL - both sup glut n
PRN GT osteotomy
dangers of moore’s/southern approach?
AKA posterior approach to hip
sciatic n
inf glut a when splitting maximus
MFCA branch along top of quad fem - can release maximum proximal 1cm
describe medial approach to hip
what is the other name for this approach?
Ludloff approach.
supine with hip in figure-4
incision 3cm below pubic tubercle, longitudinal down longus
plane: between adductor longus and gracillis (IM plane, both obturator n anterior division)
then between adductor brevis and magnus
(IN plane?? posterior magnus=sciatic n)
dangers of ludloff approach?
anterior obturator n - between add longus and brevis
posterior obturator n - on magnus under brevis
MFCA - medial/distal part of psoas tendon
boudaries of the I-I approach lateral window?
iliac wing to psoas (and fem n)
boundaries of middle window of I-I approach?
psoas to external iliac vessels
boundaries of medial window of I-I approach?
external iliac vessels to rectus abdominus
describe modified stoppa approach
surgeon stands on contralateral side
pfannenstiel incision 1-2cm above symphysis
split rectus, incise transversalis
enter space of retzius, potect bladder
subperiosteal dissection along sup pubic ramus/brim up to internal iliac fossa
identify corona mortis - ligate
detach iliopectineal fascia
expose quad plate
dangers of modified stoppa approach?
corona mortis
bladder
spermatic cord (careful laterally)
external iliac vessels
obturator n/a/v
describe extended iliofemoral approach
extension to smith peterson
smith pete incision, but extend proximally along crest and distally along femur as needed
expose both tables of pelvis
outer: from reflected head of rectus to sciatic notch, detach medius and minimus from crest
inner: detach direct head of rectus and stay under iliacus back to sciatic notch
to access posterior column, detach medius and minimums from GT
internervous plane of posterior approach for ICBG?
between glut med/TFL(SGN), glut max (IGN)
and
parapsinal muscles (segmetal) and lat dorsi (long thoracic n)
dangers of posterior approach for ICBG harvest
cluneal nerves - cross crest 8cm aterior to PSIS - stay posterior
sciatic n, superior glut n/a/v (via GSN - stay proximal to it)
