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