U18 Flashcards
Anterior and posterior Relations of hip joint
Hip joint is a synovial ball and socket joint between the acetabulum of the pelvis and the head of the femur. The acetabular labrum (made of fibrocartilage) is attached to the peripheral edge of the acetabulum. There is a deep depression on the head of the femur for the attachment of the ligament of the head of the femur (ligamentum teres)
What is the function of the labrum
Joint capsule is attached around labrum and passes literally like a sleeve, to attach to the neck of the femur and then the capsule fibres turn back to attach to around the head of the femur. They hold down the arteries that run up from distal to proximal to supply most of the head of the femur.
Ligaments that reinforce joint capsule
Strongest ligament that reinforces hip capsule
iliofemoral (prevents hyperextension)
Is joint capsule tight in extension or flexion
In general, the hip joint capsule is tight in extension and more relaxed in flexion.
What are the hip flexors and their nerve and blood supply
- Muscles = Iliopsoas
- Femoral nerve
- Ilioplumbar branch of internal iliac artery
Hip Extensors
- Gluteus maximus, Hamstrings
- Inferior gluteal nerve
- Deep femoral artery (hamstrings)
- Inferior gluteal and superior gluteal artery (gluteus maximus)
Hip adductors
- Medial thigh muscle = adductor magnus/longus/brevis
- Obturator nerve
- Longus – profunda femoris artery/deep femoral artery + obturator artery
- Magnus – deep femoral artery branches
- brevis – deep femoral artery
Hip Abductors
- Gluteus medius/minimus, TFL, Obturator internus, gemelli, piriformis
- Superior gluteal nerve
- Gluts – superior gluteal artery
- TFL – latera; circumflex femoral artery
- Gemelli – inferior gluteal
- Piriformis – superior gluteal, inferior gluteal, gemellar branches of internal pudendal artery
Hip internal rotators
- Gluteus Minimus, medius, TFL
- Superior gluteal nerve
- Glut s- superior gluteal artery
- TFL – Lateral cirmflex femorla artery
Hip External rotators
- Gluteus maximus, Piriformis, obturator internis, gemelli
- Superior gluteal nerve
- Gluteus max – superior gluteal artery
- Piriformis – superior/inferior gluteal, gemellar branches internal pudendal
- Gemelli. Ifneiro gluteal artery
Which direction of hip dislocation is the most common and why?
Posterior because anterior ligaments are stronger
Which structure at risk following hip dislocation
Nerve injury – sciatic nerve is most commonly affected
In what position is affected limb likely to be in posteiror hip dislocation
Flexion, adduction and internal rotation with shortening of the leg.
WHat is this?
Fracture of the neck of the femur
What does this show
OA of the hip
What main factors stabilise the hip joint
- Acetabulum – deep to prevent slipping
- Acetabular labrum - increase depth. Long articular surface for stability
- Iliofemoral, pubofemoral, ischiofemoral ligament very strong and thickened joint capsule and spiral orientation so tighter when joint extended
- Anteiror ligsments stronger so medial flexors fewer and weaker and vise versa
What is Trendelenburg’s test
= Place their hands on your outstretched hands (for stability) and ask them to stand on the leg your examining, lifting the contralateral leg off the ground for 30 seconds. Feel for drop in pelvis on contralateral side.
Trendelenburg’s sign
Contralateral side (normal side) will sag down/ indicates weakness sin hip abductor muscles (gluteus Medius and gluteus minimums)
What is a common complication of fracture of the neck.. How do you treat fractured femoral head? How do you treat the complication
Post op complications are pain, bleeding, length llength discrepancies and potential NV damage. Long term complications – joint dislocation, aseptic loosening, peri-prosthetic fracture and deep infection/prosthethic joint infection.
What can be done for an arthritic hip
= Initial management – Adequate pain control to ensure ongoing mobility and QoL. Lifestyle mods including weight loss, regular exercise and smoking cessation. Physiotherapy to slow disease progression.
= Long term management – if conservative don’t work them surgical intervention. Hip replacement (total or hemiarthroplasty). Common post-op complications including TE disease, bleeding, dislocation, infection, loosening of prosthesis and leg length discrepancy.
= Surgical approaches : Posterior approach, anterolateral approach, anterior approach.
Shenton’s line:
Imaginary curved line along inferior border of superior pubic ramus. Should eb continuous and smooth
NV supply of the hip
- Medial + lateral circumflex femoral arteries (branches of profunda femoris artery-deep femoral artery). Anastomose at base femoral neck to form ring where smaller branches arise.
- Medial circumflex femoral artery – majority and damage to this can result in avascular necrosis of femoral head.
- Artery to head of femur + superior/inferior gluteal arteries = provide additional supply.
- Sciatic, femoral and obturator nerves (also innervate knee hence referred pain either way)
2 Types dislocaiton of the hips
- COngenital - DDH when acetabulum shallow because of failure to develop properly in utero
- Acquired dislocation - relatively uncommon and usually from trauma or complication of total hip replacement or hemiarthroplasty. Posterior (msot common) vs anterior.
Damage to superior gluteal nerve
Innervates gluteus medius and minimius. They will become paralysed so pelvis unsteady and get Trendelenburg sign ((pelvic drop on unsupported leg)
Tensor Fascia Lata
gluteal muscles acting as flexor, abductor and internal rotator of hip, Innervated by superior gluteal nerve. When stimulated, tensor fasciae lata tautens iliotibial band and braces the knee.
Fascia
= sheet/band of fibrous tissue lying deep to skin. It lines, invests, and separates structures within the body. 3 main types
Iliotibial Tract: (iliotibial band or IT band)
- Longitudinal thickening of fascia lata, strengthened by fibres form gluteus maximus.
- Located laterally in thigh, extending from iliac tubercle to lateral tibial condyle.
-
3 main functions:
- Movement. Extensor, abductor, lateral rotator of hip with additional role in providing lateral stabilisation to knee joint
- Compartmentalisation – deepest aspect of ITT extends centrally to form lateral IM septum of thigh and attaches to femur.
- Muscular sheath – forms sheath around tensor fascia lata muscle.
- Fascia lata graft – popular choice for tissue graft as iliotibial tract procides particularly high concentration of CT fibres and can be surgically harvested whilst leaving most fibres intact.
Neck of femur fracture - when is it common, classification, blood uspply
- Typically, from low energy injuries like frail in frail older people or high energy injuries like road traffic collision or fall from height and often associated with other significant injuries.
- Anywhere from subcapital region of femoral head to 5cm distal to less trochanter.
Intracapsular: from subcapital region to basocervical region of femoral neck, immediately proximal to trochanters
Extra-capsular: outside capsule. Inter-trochanteric (between GTrochanter + LTrochanter) or Sub-trochanteric (LTrochanter to 5cm distal to point)
- Blood supply – retrograde predominately thorugh medial circumflex femoral artery (directly on intra-capsular femoral neck)
- Displaced intra-capsular fractures – disrupt blood supply so avascular necrosis even if hip is flexed so need joint replacement.
Clinical signs of neck of femur fracture
- Trauma, often low energy then pain and inability to weight bear.
- Pain predominately in groin, thigh or commonly in elderly, referred to knee
- Leg shortened + externally rotated due to pull of short external rotators, with pain on pin rolling the leg and axial loading
- Distal NV deficits rare in isolated neck of femur fractures but full NV exam needed.
Invetsiagtions of neck of femur fracture
- Plain film radiograph imaging – AP and lateral views and AP pelvis. If suspicious patho fracture then full length femoral radiographs.
- Routine bloods, FBC, U&Es, coag screen, G&S, possible creatinine kinase
- Urine dip, CXR, EXG for older people especially for pre and peri operative management.
Management of neck of femur frcture
- A->E approach, analgesia
- No operative – rare
- Post op complications are pain, bleeding, length llength discrepancies and potential NV damage.
- Long term complications – joint dislocation, aseptic loosening, peri-prosthetic fracture and deep infection/prosthethic joint infection.
OA fo the hip summary
- Degenerative joint disease – loss of articular cartilage, associated with periarticular bone response.
- RF = systemic (age, obesity, female, etc) or local (hsitory trauma, muscle weakness etc)
- CLinical = pain (weight bearing aggrevates it) improves with rest, stiff, antalgic gait, passive mvoement painful in severe, possible trendelenburgs
- Ix - narrowing joint space, osteophyte formation, sclerosis of subchondral bon, subchondral bone cysts
- Classify progression -WOMAC (combien stiffness, pain, function)
- lifetsyle mods, physio, smoking cessation. and if dont work conservative then surgical.
What type fracture
Left sub capital
Types Femoral fractures
What are the borders of pelvic inlet and outlet?
The obturator foramen is almost completely closed by the obturator membranes. Why is it not completely closed?
Leaves small canal for obturator artery, vein, nerve
What structures are transmitted through the greater sciatic foramen?
Piriformis muscles divides it:
- Suprapiriform foramen – superior gluteal nerve/ artery/ vein
- Intrapiriform foramen – sciatic nerve, pudendal nerve, inferior gluteal Nerve/ artery/ vein, posterior femoral cutaneous nerve, nerve to obturator internus, nerve to quadratus femoris.
What type of joint is the sacroiliac joint?
Diarthrodial synovial joint. Surrounded by fibrous capsule containing joint space filled with synovial fluid between articular surfaces.
What are the marked differences between the female and typical male pelvis? What are the reasons for this?
in a male pelvis, the coccyx is projected inwards and immovable compared to a female pelvis that is flexible and straighter which helps women in the delivery process. The female sacrum is wider, shorter, and has less curves. Thus, it provides more space in the pelvic cavity compared to a male’s who has a longer and narrower sacrum. The pelvis is connected to the bones in the lower extremities particularly the femur. The femur is attached to the acetabulum which is located at the pelvis. The acetabulum has a very significant difference between a male and female pelvis. A male acetabulum is much larger than a female acetabulum. The sciatic notch in the female pelvis is wider than that of a male pelvis. The pelvic inlet in a female pelvis is slightly oval in shape while a male pelvis has a heart-shaped pelvic inlet.
Pelvic diaphragm muscles + levator ani labelled
What is the nerve supply of the levator ani?
Pudendal nerve, perineal nerve acting together
Perineal spaces, perineal membrane and perineal body labelled with glands:
Ischioanal fossae (used to be ischiorectal) – these lie deep to skin of anal triangle. What is the anococcygeal body?
Ischioanal fossae is space filled with fat lateral to anal canal and just below pelvic diaphragm. Anococcygeal body is a fibrous median raphe in the floor of pelvis, which extends between coccyx and margin of anus.
Identify the external urethral opening, vagina, uterine cervix, fornices:
Whta is the anaotmcial course of th epudendal nerve
- formed from sacral plexus (ventral rami of psinal nerves S2,3,4)
- Descends + passes between piriformis and ischiococcyeys msucles
- Leaves pelvis through greater sciatic formaen and crsses sacrospinous ligament and re-enters pelvis in lesser sciatic formen.
fetal skull and the way it rotates in birth
Name the layers of tissue surrounding the testis from superficial to deep.
Tunica vaginalis (outermost tissue) which has visceral, cavum vaginale and parietal layer. Then tunica albuginea (thick and protective), then first thin layer is tunica vasculosa ->
