Scenario 18: Harold's Painful Hip Flashcards
What are the attachments of the capsule of the hip joint?
Acetabular labrum and adjacent structures proximally and distally, to the neck of the femur posteriorly and to the intertrochanteric line anteriorly
What limits the extension of the hip?
Iliofemoral and pubofemoral ligaments
What are the boundaries of the gluteal region?
The skin dimples of the PSIS mark the boundary above, the lower boundary is formed of deep fascia. The midline groove is the natal cleft. The superior boundary is the liac crest.
Where does psoas major arise from and insert onto?
Arises from lumbar vertebrae, intervertebral discs and transverse processes of L1-L5 and inserts onto lesser trochanter
What is the subsartorial canal and what are it’s borders?
A canal which transmits the femoral vessels and saphenous nerve. Bordered by sartorius anteriorly, adductor longus posteriorly, vastus medialis antero-laterally, adductor longus and mangus lie posteromedially
What are the medial rotators of the hip joint?
Gluteus medius and minimus (anterior parts) tensor of fascia lata
Where do the small lateral rotators of the hip arise from and insert onto?
All arise via greater and lesser sciatic forament and insert onto the trochanteric fossa
What limits the adduction of the hip?
Other limb
Where does sartorius arise from and insert onto?
Arises from ASIS and inserts onto the medial aspect of the shaft of the tibia after winding round the posterio-medial aspect of the thigh
What are the symptoms of vitamin D intoxication?
Nausea, vomitting, hypercalcaemia, ectopic calcification
What are the attachments of the pubofemoral ligament?
Arises from pubic margin of acetabulum and superior ramus of the pubis and inserts onto the lesser trochanter
What limits the medial rotation of the hip?
Ischiofemoral ligaments
What is the course of the short saphenous vein?
Commences on the lateral aspect of the dorsal venous arch and ascends behind the lateral malleolus. It courses up the back of the leg to end in the popliteal fossa
Which muscles are in the anterior compartment of the thigh?
Sartorius, pectineus, psoas major, iliacus, quadriceps femoris
What are the attachments of gracilis?
Arises body of pubis and inferior pubic ramus, inserts medial shaft of the tibia
Which bodily processes utilise calcium?
Bone mineralisation, blood clotting, muscle contraction, inhibition of enzymes, excitability at neuromuscular junction
Where does semimembranosus arise from and insert onto?
Arises from the ischial tuberosity, inserts onto medial tibial epicondyle giving recurrent slip of tendon across the back of the knee joint
What forms the sciatic nerve?
The combination of tibial and common fibular nerves in the sciatic sheath form the sciatic nerve
What is the function of biceps femoris?
Extensors of thigh at hip joint and flexors of knee. Small degree of lateral or medial rotation
What are the normal free ionic concentrations of calcium?
1.2 mM
What is the RNI for calcium for men and women?
Men: 1g/day Women: 0.8g/day (in lactation it is 1.25g/day)
What is the function and nerve supply of gluteus maximus?
Inferior gluteal nerve (L5-S2), extensor of the hip, aids extension of knee
What physiological mechanism of fear makes us shake?
Hyperventilation increases blood pH making blood negatively charged so calcium ions bind to negatively charged proteins. This decreases calcium concentration causing tremor.
What are the attachments of adductor brevis, longus and mangus?
Arise from pubis or ischiopubic ramus. Adductor portion of adductus mangus arises from ischial tuberosity. Adductor mangus inserts along the length of the linea aspera in its adductor part but has a slip (hamstring part) which attaches to the adductor tubercle on the medial epicondyle of the femur.
What is the action of vitamin D in the intestine?
Acts as a steroid hormone. Binds to intracellular receptor, is transported to DNA and promotes synthesis of calbindins.
Which bones form the hip joint?
The head of the femur and the acetabulum (which is formed by the fusion of ilium, ischium and pubis)
What happens in hypocalcaemia and what levels of calcium would be lethal?
Hyperexcitable nervous system, tetany. Less than 1.5 mM would be lethal
What substances increase the absorption of calcium?
Lactose, basic amino acids and vitamin D
How is vitamin D metabolised?
Activated by 2 hydroxylation in liver or kidney
What is the nerve and blood supply of semitendinosus?
Blood is from the perforating arteries arising from profunsa femoris. The nerve supply is the tibial nerve (L5-S1)
What is coxa vagla?
When the angle of inclination is obtuse (180 degrees) so that the femur is too close to the hip joint
What is coxa vara?
When the angle of inclination is too acute (90 degrees) so the femur is far away from the hip joint
What is the nerve supply of adductor brevis, longus and mangus?
The adductor part of adductor mangus is supplied by the obturator nerve, the hamstring part by the tibial nerve. The others by the obturator nerve.
Which two anastomoses supply the hip joint?
Cruciate and trochanteric anastomoses with supply from lateral and medial circumflex arteries
What is intermittent claudication?
A dull cramp like pain on walking caused by obstructive occlusion of the femoral artery
Where is the safe injection zone of the gluteal region?
The upper lateral quadrant of the gluteal region is safe for injection. The quadrants are formed by a horizontal line which passes through the two PIIS (skin dimples) and a vertical line drawn down from the highest point of the iliac crest
Where does the cruciate anastomoses lie and what is it formed of?
At the level of the lesser trochanter, 2 circumflex arteries joint an ascending branch from the thigh and a descending branch from the inferior gluteal artery
What are the attachments of the iliofemoral ligament?
Iliac margins of the acetabular labrum and extends proximally towards AIIS attaching distally to greater and lesser trochanters
What is the course of the superior gluteal artery?
Enters through a gap above piriformis, part of the greater sciatic foramen. It divides into a deep branch which course between gluteus minimus and medius and a superficial branch which lies external to gluteus medius to supply gluteus maximus as well
What are the boundaries of the popliteal fossa?
Medially: hamstring muscles (semitendinous and semimembraneous) above and medial head of gastrocnemius below
Laterally: biceps femoris above and lateral head of gastrocnemius below
Roof: skin and popliteal fascia
Floor: femur, oblique popliteal ligament and capsule of knee joint and popliteus muscle
Which nerve supplies the anterior and lateral leg and dorsum of the foot?
Common peroneal nerve
What are the normal plasma concentrations of calcium?
2.5 mM
What are the causes of primary and secondary vitamin D deficiency?
Primary: rickets in children, osteomalacia in adults. Caused by lack of sunlight and low in diet
Secondary: bile duct obstruction, coeliac disease, liver and renal disease
What is the difference between the anatomical and mechanical axis of the femur?
The anatomical axis is the true angle of the femur as the distal end lies more medially than the proximal end. The mechanial axis is the imaginary line drawn between the hip and knee joint around which the femur will pivot
What are the four parts of quadriceps femoris?
Rectus femoris, vastus medialis, vastus intermedius, vastus lateralis
What substances decrease the absorption of calcium?
Phytic acid (inositol hexaphosphate) decreases calcium absorption
Which ligaments anchor the hip bone to the sacrum?
Sacroiliac ligaments
What are the attachments of quadriceps femoris?
Arises: rectus femoris from AIIS, vastus lateralis from the lateral side of the linea aspera, vastus medialis from the medial side of the linea aspera, vastus intermedius from the femoral shaft.
Inserts: onto tibial tuberosity
What is the nerve and blood supply of sartorius?
Branches of femoral artery and femoral nerve
Where can the posterior tibial pulse be felt?
Behind and below the medial side of the ankle
Where does the trochanteric anastomoses lie and what is it formed of?
At the level of the greater trochanter with branches from the circumflex arteries which form retinacular arteries that supply the femoral head
What is the nerve and blood supply of pectineus?
Femoral artery and nerve and often the obturator nerve
What are the branches of the profunda femoris artery?
Medial and lateral circumflex arteries and 4 perforating arteries which perforate the intermuscular septum to supply medial and posterior compartments of the thigh
Which ligament bridges the ends of the lunate surface of the acetabulum and what gap is left behind?
The transverse acetabular ligament leaving the acetabular foramen for the access of the obturator nerve and artery to the joint
What happens in hypoparathyroidism?
Surgical removal of parathyroid glands in thyroidectomy leads to hypocalcaemia
At what point does the femoral artery become the popliteal artery?
As it passes through the adductor hiatus
Where does popliteus arise from and insert onto?
Arises from the posterior aspect of the tibia and inserts onto the lateral femoral epicondyle
What injury can occur to gluteus minimus and medius?
When these muscles are paralysed by lesion of the L4-S1 spinal cord, the pelvis is tilted giving a positive Trendelenburg’s sign as well as wasting of the buttocks and a waddling gait on walking
What does vitamin D do to blood calcium and phosphate levels?
Increases both
Where can the dorsalis pedis pulse be felt?
On the dorsum of the foot
Which muscles are in the posterior compartment of the thigh? (hamstrings)
Biceps femoris, semitendinosus, semimembranosus
What are the attachments of the ischiofemoral ligament?
Arises from ischial margin of the acetabulum and inserts largely into the iliofemoral ligament and greater trochanter
What are Shenton’s lines?
The arches of the hip joint visible on x-ray which will be disrupted if there is a dislocated or displaced fracture of the hip
What happens in avascular necrosis of the femoral head?
A fracture through head or neck of the femur may impeded the retinacular arteries which cuts off blood supply to the femoral head. This will cause the head to die leading to severe joint problems
What does calcitonin do and where is it formed?
Formed in C or parafollicular cells of thyroid. Secreted when blood calcium is high and acts via cAMP on osteoclasts to suppress their activity
Where does pectineus arise from and insert onto?
Arises proximally from the pecten of the pubis and inserts distally to the spiral line of the femur
What is the angle of anteversion and how much is it usually?
Angles the neck 12 degrees forwards and pushes the centre of gravity forwards
Where does gluteus maximus arise from and insert to?
Arises behind the posterior line of the ilium, the sacrum and sacrotuberous ligament and inserts onto the gluteal tuberosity on the shaft of the femur (deep part) and the iliotibial tract (superficial tract)
What is the zona orbicularis?
Circular ligament which pinches the capsule around the neck of the femur to hold the head in it’s socket
At what point does the external iliac artery become the femoral artery?
As it crosses over the inguinal ligament
What is the function of sartorius?
Puts the leg in a crossed legged position
What is the supply and function of piriformis?
Supplied by S1-2 directly in pelvis region. Has neurovascular bundles arranged around it and the sciatic nerve running through it sometimes.
At what joint do the hip bones articulate with the sacrum?
Sacro-iliac joint
What are the boundaries of the femoral triangle?
Superior wall: inguinal ligament
Lateral wall: medial border of sartorius
Medial wall: medial border of adductor longus
Roof: fascia lata and skin of anterior thigh which is perforated by saphenous opening through which the superficial vessels pass with cribiform fascia
Floor: iliopsoas, pectineus and adductor longus
Where does gluteus medius and minimus arise from and insert to?
Gluteus medius arises from the lateral surface of the ilim between the anterior and posterior gluteal lines. Gluteus minimus arises between the anterior and inferior gluteal lines. Both insert onto the greater trochanter
What is the nerve supply and function of gracilis?
Obturator nerve (L2-4), weak flexor of the knee and adduction of the hip
What happens in hypercalcaemia and what levels of calcium would be lethal?
Sluggish nervous responses, ectopic calcification of soft tissue/synovial fluid. More than 3.75 mM would be lethal
What happens in hyperparathyroidism?
Gland hyperfunctions or hyperplasia leading to hypercalcaemia through excessive bone reabsorption
How can the safe injection of the gluteal region zone be located?
Placing index finger on ASIS and middle finger onto the iliac tuberosity and injecting between the two fingers
What are the adductors of the hip joint?
Adductor longus and brevis and mangus, gracialis, pectineus, obturator externus
What is the function of pectineus?
Adductor of the hip and aids flexion and medial rotation of hip
Where can the popliteal pulse be felt?
In a flexed knee at the back when pushed deeply
How does calcium absorption vary with physiological state?
High in childhood, pregnancy, lactation.
Low when intake is high and with increased age
Where does the femur articulate with the hip joint?
At the pelvic girdle
What is the course of the inferior gluteal artery?
Emerges through the greater sciatic foramen passing inferior to piriformis.
What is the function of the quadriceps femoris?
Extensor of the knee, vastus lateralis and intermedius are powerful pullers of the tendon along the shaft of the femur as if to dislocate the patella laterally. Vastus medius counters this pull medially
What limits the lateral rotation of the hip?
Pubofemoral ligaments
What are the muscles of the medial compartment of the thigh?
Gracilis, obturator externus, adductus longus, mangus and brevis
Which nerve supplies the anterior thigh?
Femoral nerve (L2-4)
What is the function of semitendinosus?
Extensors of thigh at hip joint and flexors of knee joint. Small degree of lateral or medial rotation
At which joint do the hip bones articulate with each other?
Pubic symphyses
What is the fascia of the thigh called and where is it attached?
Fascia lata attached above the iliac crest posteriorly and just below the inguinal ligament in front
Which ligaments form the greater and lesser sciatic foramen?
Sacrospinous and sacrotuberous ligaments
What limits the abduction of the hip?
Pubofemoral ligament and greater trochanter
How is PTH released in low calcium levels?
Low calcium concentration inhibits PLC so IP3 decretion decreases and the inhibition of PTH secretion is inhibited. As well as this, adenylate cyclase is activated which activates cAMP to increases PTH secretion. PTH is released from vesicles in the parathyroid gland
What is the function and nerve supply of gluteus medius and minimus?
Superior gluteal nerve (L4-S1) Work during walking to prevent falling over when the opposite limb is lifted off the ground
What are the extensors of the hip joint?
Hamstrings: semitendinosus, semimembranosus, long head of biceps femoris, adductor mangus (posterior part) gluteus maximus
What are the small lateral rotators of the hip?
Piriformis, obturator internus, superior and inferior gemelli and quadratus femoris
Why is PTH not released in calcium overload?
High calcium concentration activates PLC, decreasing IP3 secretion and preventing the inhibition of PTH secretion. As well, AC is inhibited so cAMP is inhibited as is PTH secretion
Where does biceps femoris arise from and insert onto?
The long head arises from the ischial tuberosity, the short head from the lateral surface of the shaft of the femur. Both heads combine to inserts onto the head of the femur
What is the course of the great saphenous vein?
Arises from medial end of the venous arch, ascends on the medial side of the leg in front of the medial malleolus and ends in the saphenous opening at the top of the thigh where it joins the femoral vein
What is the difference between osteoporosis and osteomalacia?
Osteomalacia is a ratio of minerals lost due to vitamin D deficiency. Osteoporosis is bone thinning usually due to lack of oestrogen in post-menopausal woman
What are the flexors of the hip joint?
Iliopsoas, satorious, tensor of fascia lata, rectus femoris, pectineus, adductor longus, adductor brevis, adductor mangus (anterior part) gracilias
What are the two main points of perforation of the deep fascia of the thigh?
Saphenous opening at the top of the thigh and the popliteal opening at the back of the knee
Which muscles flex the knee joint?
Semimembranosus, semitendinosus, biceps femoris, gracilis, sartorius, popliteus, gastrocnemius
What is the nerve supply and function of obturator externus?
The nerve supply is the obturator nerve and the function is external rotation of the hip
What is the angle of inclination and how much is it usually?
Usually about 125 degrees, this angle displaces the femur from the hip bone laterally so it is not too close to the joint
What limits the flexion of the hip?
The meeting of the abdomen and the flesh of thigh/ tension of hamstrings when knee is straight
What is Cloquet’s node?
A lymph node found at the femoral canal
What are the normal plasma concentrations of calcium in complexes?
0.3 mM
What is the contents of the femoral triangle?
Femoral artery, femoral vein, deep lymphatics and deep inguinal nodes all in femoral sheath. Lateral to this is the femoral nerve.
What are the attachments of obturator externus?
Arises from the obturator membrane and surrounding bones and inserts into the trochanteric fossa
What are the normal plasma protein bound concentrations of calcium?
1 mM
What are the lateral rotators of the hip joint?
Obturator externus, obturator internus, gemelli, piriformis, quadratus femoris, gluteus maximus
Where does iliacus arise from and insert onto?
Arises from the iliac fossa and inserts onto the lesser trochanter of the femur
What is the acetabular labrum?
The lip of the acetabulum surrounding the lunate surface, a ring of fibrocartilage which deepens the joint socket
Where can the femoral pulse be felt?
The mid-inguinal point- midway between ASIS and the pubic symphysis
Which muscles extend the knee joint?
Rectus femoris and vasti muscles
What does calcitonin do to blood calcium and phosphate levels?
Decreases both
What is the function and innervation of popliteus?
Tibial nerve and laterally rotating the femur when the knee joint is locked in full extension so that the knee can be unlocked and flexed
What is the nerve supply of biceps femoris?
Long head is supplied by the tibial nerve (L5-S1) short head by the common peroneal nerve
What is the nerve supply of iliacus?
Nerve supply is femoral nerve (L2-3)
What does PTH do to blood calcium and phosphate levels?
Increases calcium and decreases phosphate
What can cause spasm of psoas major?
If pus from infection of lumbar vertebrae tracks down through the psoas sheath and irritates the muscle
What movements are permitted at the hip joint?
Flexion, extension, abduction, adduction, medial and lateral rotation
What is the effect of PTH on kidney?
Increases calcium reabsorption in the distal tubule and decreases phosphate reabsorption (increase excretion)
Where does semitendinosus arise from and insert onto?
Arises from ischial tuberoisty and inserts onto the medial surface of the proximal shaft of the tibia
Where does the profunda femoris artery supply?
The medial and posterior compartments of the thigh
Which tendon does the patella lie in?
The patella lies in the tendon of rectus femrois or common tendon. Distally this is the ligamentum patellae
How is the centre of gravity of the leg maintained?
It lies posterior to the hip, pulled back by tonal control, compensating by pull of ankle and knee which bring it anteriorly.
Which 3 ligaments prevent over tilting of the pelvic girdle?
Sacroiliac, sacrotuberous and sacrospinous ligaments
What is the contents of the popliteal fossa?
Popliteal artery (deep) and vein (superficial). Tibial and common fibular nerves and the posterior cutaneous nerve of the thigh and genicular branch of the obturator nerve. Lymphatics may be found in the fat-filled space.
What is the function and supply of tensor fascia lata?
Superior gluteal nerve and it tightens the iliotibial tract and extends the knee. it also flexes the hip.
Where does tensor fascia lata arise from and insert to?
Arises from ASIS and anterior part of iliac crest and attaches to the anterior aspect of the iliotibial tract
What are some bony features of the proximal end of the femur?
Head, neck, a non articular notch- the fovea, greater and lesser trochanters joined by intertrochanteric line and intertrochanteric crest, quadrate tubercle, linea aspera which terminates as spiral line medially and gluteal tuberosity laterally, shaft
What is the function and nerve supply of psoas major?
L1-3 directly from lumbar plexus. It is the main flexor of the hip joint and stabiliser and flexor of the trunk
How can knee extension be tested?
By the patellar tap which transiently stretches the patellar ligament causing reflex contraction of quadriceps. This tests L3 and L4 segments of spinal cord
From where does the inguinal ligament run to and from?
From ASIS to the pubic tubercle
What is the function of semimembranosus?
Extensors of thigh at hip joint and flexors of knee joint. Small degree of lateral or medial rotation
Where does piriformis arise from and insert onto?
Arises from the anterior surface of the sacrum and inserts onto the trochanteric fossa
What are the risks of injecting outside the safe injection zone of the gluteal region?
The sciatic nerve lies in the lower medial quadrant and if it is injected then the patient will feel pain that burns and radiates down the leg or even paralysis of the leg and foot drop
Which nerve supplies the posterior thigh?
Tibial nerve
Where does the posterior cutaneous nerve of the thigh supply?
Skin of thigh and half way down the back of the leg. Comes from anterior rami of S2-3 spinal nerves
What is the name given to the articular surface of the acetabulum?
The lunate surface
Which nerve supplies the medial thigh?
Obturator nerve (L2-4)
What is the nerve and blood supply of semimembranosus?
Blood is from the perforating arteries arising from profunsa femoris. The nerve supply is the tibial nerve (L5-S1)
What kind of bone is the patella?
Sesamoid
What is the effect of PTH on bone?
PTH binds and activates AC producing cAMP which inhibits osteoblast collagen synthesis. Osteoblasts release cytokines to activate osteoclasts. Osteoclasts release their calcium and phosphate as well as H+ and collagenase in lacuna. This causes reabsorption of calcium and phosphate from bone to increase blood concentrations of these
What is the treatment for osteoporosis?
Calcium treatment, oestrogen replacement therapy/receptor modulators, strontium, biphosphates, low dose synthetic PTH
What is the iliotibial tract?
Thickening of fascia lata along the lateral border of the thigh
