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Dr. S. Nishan Silva (MBBS)

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1 Dr. S. Nishan Silva (MBBS)
Hip Region Dr. S. Nishan Silva (MBBS)

2 Regional anatomy of the lower limb

3 Parts and regions of the lower limb
Gluteal region－between iliac crest superiorly and gluteal fold inferiorly Thigh－between hip and knee knee－joint between leg and thigh Leg－between knee and foot Ankle Foot

4 Joints of Lower Limb Hip (femur + acetabulum) Knee (femur + patella)
Ball + socket Multiaxial Synovial Knee (femur + patella) Plane Gliding of patella Knee (femur + tibia) Hinge Biaxial Frolich, Human Anatomy, Lower LImb

5 Joints of Lower Limb Proximal Tibia + Fibula Distal Tibia + Fibula
Plane Gliding Synovial Distal Tibia + Fibula Slight “give” Fibrous Ankle (Tibia/Fibula + Talus) Hinge Uniaxial pg 218 Frolich, Human Anatomy, Lower LImb

6 Lower Limb Movements Hip Knee
Flexion/extension Abduction/adduction Lateral/medial rotation Knee Ankle Dorsiflexion/plantarflexion Inversion/eversion Toes Bending on posterior side is flexion (except hip) Bending on anterior sided is extension (except hip) Frolich, Human Anatomy, Lower LImb

7 Surface anatomy of lower limb
Gluteal region and thigh anterior superior and inferior iliac spines tubercle of iliac crest ischial tuberosity greater trochanter pubic tubercle pubic crest superior border of pubic symphysis

8 Surface Anatomy: Posterior Pelvis
Iliac crest Gluteus maximus = cheeks Natal/gluteal cleft = crack Gluteal folds = bottom of cheek pg 789 Frolich, Human Anatomy, Lower LImb

9 Surface Anatomy of the Lower Limb
Gluteus maximus muscle Gluteus medius muscle Gluteal cleft Gluteal fold Ischeal tuberosity Greater trochanter

10 Nelaton’s line a line drawn from the anterior superior lilac spine to the ischial tuberosity, passing over or near the top of the greater trochanter. The trochanter can be felt superior to this line in a person which a dislocated hip or a fractured femoral neck.

11 Hip - Anatomy Multiaxial ball & socket joint Acetabulum 1/2 sphere
Hip Exam 2 Feb 98 Hip - Anatomy Multiaxial ball & socket joint Acetabulum 1/2 sphere Femoral head 2/3 sphere Strong ligaments & capsule Maximally stable Michael Johnson, MD

12 Anatomy Forces Standing - 0.3 times body weight
Standing on 1 leg times body weight Walking to 5.8 times body weight Walking up stairs - 3 times body weight Running times body weight

13 Movements of the Hip Joint
Flexion and Extension Abduction and Adduction External Rotation and Internal Rotation. Range of Motion ROM: Flexion - 0 to 140 degrees Extension - 0 to 15 degrees Abduction - 0 to 30 degrees Adduction - 0 to 25 degrees External Rot. - 0 to 90 degrees Internal Rot. - 0 to 70 degrees (when flexed) less when extended The ROM values reported are very dependent on the position in which the hip, knee, and pelvic girdle is during measurement. Knee joint position is important during flexion because of the large number of muscles that cross the hip and the knee joint. Flexion of the hip is limited primarily by the passive insufficiency of the hamstrings, although active insufficiency is present in the rectus femoris. The influence of pelvic girdle position will be discussed later. Hyperextension is limited primarily by the iliofemoral ligament, the anterior joint capsule, and the strong hip flexors.

14 Bony Anatomy Femur Femoral Head Femoral Neck Greater Trochanter
Lesser Trochanter Intertrochanteric Crest Intertrochanteric Line Gluteal Tuberosity

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16 BONY ANATOMY OF THE HIP

17 BONY ANATOMY OF THE HIP

18 Bony Anatomy Pelvic Girdle Acetabulum 3 bones fused together Ilium
Iliac fossa Iliac Crest ASIS AIIS PSIS PIIS Gluteal Lines Greater Sciatic Notch Lateral View

19 Bony Anatomy Ilium Iliac fossa Iliac Crest Iliac Tuberosity ASIS AIIS
PSIS PIIS Gluteal Lines Medial View

20 Bony Anatomy Ilium Ishium Ramus of ishium Ishial tuberosity
Ishial spine Lessor Sciatic Notch

21 Bony Anatomy Ilium Ishium Pubis Superior Ramus of Pubis
Inferior Ramus of Pubis Pubic Crest Pubic Tubercle Pectin Symphyseal Surface

22 22

23 Anatomy Ligaments Iliofemoral ligament (Y ligament of Bigelow)
Reinforces anterior joint capsule (limits hyperextension) Keeps us upright Pubofemoral ligament Limits abduction & hyperextension Inguinal ligament Runs from ASIS to pubic symphysis Superior border of femoral triangle

24 Anatomical Components:
Added Anatomical Components: Articular Capsule Acetabular labrum Ligaments: Iliofemoral Pubofemoral Ischiofemoral Ligament of the head of the femur Transverse ligament of the acetabulum

25 Anterior view

26 Posterior view

27 Medial view with acetabular floor removed

28 Anterior view with capsule removed

29 Ligamentous and Cartilogenous Structures for the Hip and Pelvic Girdle
Sacroiliac Joint Sacrotuberous Sacrospinous Function of these two ligaments Iliolumbar Interosseous Sacroiliac

30 Ligamentous and Cartilogenous Structures for the Hip and Pelvic Girdle
Sacroiliac Joint Sacrotuberous Sacrospinous Function of these two ligaments Iliolumbar Interosseous Sacroiliac

31 Ligamentous and Cartilogenous Structures for the Hip and Pelvic Girdle
Sacroiliac Joint Sacrotuberous Sacrospinous Function of these two ligaments Iliolumbar Interosseous Sacroiliac Dorsal Sacroiliac

32 Ligamentous and Cartilogenous Structures for the Hip and Pelvic Girdle
Sacroiliac Joint Hip Joint Capsule Three thickenings of the capsule Iliofemoral Pubofemoral Ishiofemoral Ligamentum Teres Inguinal

33 Ligamentous and Cartilogenous Structures for the Hip and Pelvic Girdle
Sacroiliac Joint Hip Joint Capsule Three thickenings of the capsule Iliofemoral Pubofemoral Ishiofemoral Ligamentum Teres Inguinal

34 Ligamentous and Cartilogenous Structures for the Hip and Pelvic Girdle
Sacroiliac Joint Hip Joint Capsule Three thickenings of the capsule Iliofemoral Pubofemoral Ishiofemoral Ligamentum Teres Inguinal

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40 AP HIP ACETABLUM FEMORAL HEAD FEMORAL NECK GREATER TROCHANTER
FOVEA CAPITIS Vastus lateralis attaches to greater trochanter; the obturator internus, superior and inferior gamelli attach to the medial surface of the greater trochanter, Guteus medius to the lateral surface of the greater trochanter, and gluteus minimus to anterior surface of greater trochanter. Iliopsoas attaches to lesser trochanter Pectineus attaches just distal to the lesser trochanter LESSER TROCHANTER CORTICAL BONE MEDULLARY BONE

41 CORONAL MRI Note epiphyseal growth plate at femoral head and greater trochanter on MRI RT. HIP

42 Normal angle of inclination Coxa valga (abnormally increased angle of inclination, in cases of congenital dislocation of the hip) Coxa vara (abnormally decreased angle of inclination, it occurs in fractures of the neck of the femur and slipping of the femoral epiphysis )

43 ANGLE OF INCLINATION Coxa Vara Coxa Valga
The angle of inclination is between the long axis of the femoral neck and the femoral shaft and it varies with age, sex, and development of the femor. The angle of inclination in a three year old child is 45 in an adult it is 126 and in an elderly individual the angle of inclination is 120. The angle is less in females because of the increased width between the acetabula and the greater obliquity of the shaft. The angle of inclination allows greater mobility of the femur at the hip joint because it places the head and neck more perpendicular to the acetabulum in the neutral postion. When the angle is decreased the condition is known as coxa vara (angle is less than 120) and when it is increased it is known as coxa valga (usually greater than 135). Coxa vara causes a mild shortening of the lower limb and limits passive abduction of the hip. Coxa Vara Coxa Valga

44 Articulations of the Hip and Pelvis
Pubic Symphysis Interpubic disk Some movement

45 Articulations of the Hip and Pelvis
Pubic Symphysis Sacroiliac Joints

46 Articulations of the Hip and Pelvis
Pubic Symphysis Sacroiliac Joints Hip Joints

47 Ligamentous and Cartilogenous Structures for the Hip and Pelvic Girdle
Sacroiliac Joint Hip Joint Capsule Three thickenings of the capsule Iliofemoral Pubofemoral Ishiofemoral Ligamentum Teres Inguinal

48 Buttock Supericial Gluteus Maximus Gluteus Medius – reverse action
Gluteus Minimus Tensor Fascia Latae – iliotibial band, functional considerations “Gower’s” Sign Positive Trendelenburg

49 Gluteus Maximus

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51 Gluteus Medius and Minimus

52 G Med., G Min, TFL

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56 Trendelenburg

57 Deep Buttocks “External Rotators of the Hip” Small Muscles
Mostly attach near or on greater trochanter Excellent mechanical advantage for 1) producing external rotation and 2) to help maintain stability of the hip All but one innervated by named nerves specific to one or two of them The exception is the obturator externus – innervated by posterior brach of obturator n.

58 Deep Buttock Muscles: Piriformis Superior Gemellus Obturator Internus
Inferior Gemellus Quadratus Femoris Obturator Externus

59 Deep Muscles of Buttocks

60 Hip Muscles Anterior Rectus Femoris Sartorius Iliopsoas Muscle Group
Iliacus Psoas Major

61 Hip Muscles Anterior Rectus Femoris Sartorius Iliopsoas Muscle Group
Iliacus Psoas Major

62 Hip Muscles Posterior Semimembranosus Semitendinosus Biceps Femoris
Gluteus Maximus

63 Hip Muscles Medial Adductor Brevis Adductor Longus Adductor Magnus
Pectineus Gracilus

64 Hip Muscles Lateral Gluteus Medius Gluteus Minimus Tensor Fascia Lata
Six Intrinsic External Rotators Periformis Quadratus Femoris Obturator Internus Obturator Externus Gemellua Superior Gemellus Inferior

65 Hip Muscles Lateral Gluteus Medius Gluteus Minimus Tensor Fascia Lata
Six Intrinsic External Rotators Periformis Quadratus Femoris Obturator Internus Obturator Externus Gemellua Superior Gemellus Inferior

66 Femoral Triangle Borders Structures Superior Lateral Medial Posterior
Anterior Structures

67 Movements of the Pelvis
Forward and Backward Tilt Left and right Lateral Tilt Left and Right Rotation

68 Kinematics of the Hip Joint Pelvic-on-Femoral Osteokinematics:
Lumbopelvic Rhythm Two contrasting types of lumbopelvic rhythms. Describe direction of rotation at lumbar spine and pelvis.

69 Kinematics of the Hip Joint Pelvic-on-Femoral Osteokinematics:
Abduction and Adduction in the Frontal Plane Right lateral tilt and left lateral tilt

70 The Hip and Pelvic Girdle
General Structure & Function Structure & Function of Specific Joints Muscular Considerations Specific Functional Considerations Common Injuries Make the point that there are no pelvic girdle muscles.

71 Muscular Considerations: Sagittal Plane Pelvic Motion
Pelvic-on-Femoral Flexion: Anterior Pelvic Tilt Force couple Hip flexors Lower trunk extensors Anterior pelvic tilt is performed by a force-couple bet/ hip flexors and low-back extensor muscles. When the femurs are fixed, contraction of the hip flexors rotates pelvis about the med-lat axis. Femoral-on-Pelvic Hip flexion involves synergy bet/ hip flexors and abdominal muscles

72 Muscular Considerations: Sagittal Plane Pelvic Motion
Pelvic-on-Femoral Flexion: Posterior Pelvic Tilt Force couple Hip extensors Lower trunk flexors Anterior pelvic tilt is performed by a force-couple bet/ hip flexors and low-back extensor muscles. When the femurs are fixed, contraction of the hip flexors rotates pelvis about the med-lat axis. Femoral-on-Pelvic Hip flexion involves synergy bet/ hip flexors and abdominal muscles

73 Muscular Considerations: Overall Function of the Hip Flexors
2. Femoral-on-Pelvic Hip Flexion synergy between hip flexors and abdominal muscles Femoral-on-Pelvic Hip flexion involves synergy bet/ hip flexors and abdominal muscles. (e.g. consider stabilizing role of abd during leg raise). Requires abdominal muscles to create posterior pelvic tilt to neutralize anterior pelvic tilt created by hip flexors.

74 Muscular Considerations: Extensors
Pelvic-on-Femoral Hip Extension Overall function of hip extensors -Pelvic-on-femoral extension: Posterior pelvic tilt using force coupling with abdominal muscles = hip extension and reduces lumbar lordosis (similar to hip flexor force coupling).

75 Muscular Considerations: Hip Adductors
Hip Adduction Pelvic Action? Muscles being utilized? Frontal plane adductor torque may control both femoral-on-pelvic and pelvic-on-femoral motion within same movement.

76 Primary Movements of the Pelvis as Performed in a Standing Position
Spinal Joints Hip Joints Forward Tilt Hyperextension Slight Flexion Backward Tilt Complete Ext. Lateral Tilt Left Slight Lateral Flexion RT R = ADD L= ABD Rotation Left Rotation RT R = Slight ER L= Slight IR

77 Movements of the Pelvis Secondary to those of the Spine
Flexion Posterior Tilt Hyperextension Anterior Tilt Lateral Flex Left Lateral Tilt Left Rotation Left

78 Sacral plexus (sciatic nerve)
With leg out to side like quadruped, lumbar-anterior, sacral-posterior makes sense Lumbar plexus (femoral nerve) Frolich, Human Anatomy, Lower LImb

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82 AP PELVIC ARTERIOGRAM ABDOMINAL AORTA COMMON ILLIAC ARTERY
INTERNAL ILLIAC ARTERY EXTERNAL ILLIAC ARTERY COMMON FEMORAL ARTERY LUMBAR ARTERY 1 6 2 3 4 Abdominal aorta branches into the two common iliac arteries. The iliac artery gives an external and internal illiac arteries. The femoral artery is a continuation of the external illiac artery distal to the inguinal ligament. 5

83 Profunda femoris artery Superficial femoral artery
Anterior Thigh External iliac artery Inguinal ligament Common femoral artery Profunda femoris artery Superficial femoral artery 477

84 Common femoral art Profunda femoris art Superficial femoral art

85 Blood supply to lower limb
Internal Iliac Cranial + Caudal Gluteals= gluteals Internal Pudendal = perineum, external genitalia Obturator = adductor muscles External Iliac Femoral = lower limb Deep femoral = adductors, hamstrings, quadriceps Popliteal (continuation of femoral) Geniculars = knee Anterior Tibial = ant. leg muscles, further branches to feet Posterior Tibial = flexor muscles, plantar arch, branches to toes Frolich, Human Anatomy, Lower LImb

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87 Blood Supply to Femoral Head
Artery of Ligamentum Teres Most important in children. Its contribution decreases with age, and is probably insignificant in elderly patients.

88 Blood Supply to Femoral Head
2. Ascending Cervical Branches Arise from ring at base of neck. Ring is formed by branches of medial and lateral circumflex femoral arteries. Penetrate capsule near its femoral attachment and ascend along neck. Perforate bone just distal to articular cartilage. Highly susceptible to injury with hip dislocation.

89 Some pathologies…

90 Common Injuries Dislocation -femoral head moves out of the acetabulum
-usually it goes posterior into notch -position typically flexion, adduction, and internal rotation -common mechanism: knee to dashboard during traffic collision -signs and symptoms: extreme pain, obvious deformity, unwilling to move the extremity

91 Hip Dislocation: Mechanism of Injury
Almost always due to high-energy trauma. Most commonly involve unrestrained occupants in MVAs. Can also occur in pedestrian-MVAs, falls from heights, industrial accidents and sporting injuries.

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93 COMMON INJURIES Hip Fracture
-most frequently occurs through the femoral neck -a direct blow to the lateral hip -signs and symptoms: pain, swelling, and loss of function -the involved leg will appear shortened and will be externally rotated

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95 INTERTROCHANTERIC FRACTURE

96 COMMON INJURIES Avascular Necrosis of the Femoral Head
-blood supply to the femur head is severed or is occluded for a prolonged period of time. -this is a common complication following hip dislocations, fractures, and chronic synovitis and often necessitates a hip replacement

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98 This is showing the repair done here
This is showing the repair done here. This is an IM rod that they drill and hammer into your bone to fix the fracture. POST OPERATIVE REPAIR

99 COMMON INJURIES Piriformis Syndrome -sciatic nerve through piriformis
-pressure on the sciatic nerve due to muscle spasm, trigger points, or tightness causing posterior thigh pain -other signs and symptoms: pain, limited ROM, pt tenderness deep to the gluteals

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102 COMMON INJURIES Trochanteric Bursitis
-cause is abnormal friction or irritation of the bursa between the IT band and greater trochanter, direct blow, or improper biomechanics -usually a sport such as running -signs and symptoms: local pain, swelling, pt tenderness, and crepitus over the greater trochanter -patient may complain of hip snapping

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105 COMMON INJURIES Ischial Bursitis -lies over the ischial tuberosity
-may become painful and inflamed with excessive friction -signs and symptoms: pain with sitting, pt tenderness over ischial tuberosity, pain w/ passive hip flexion and active/resistive hip extension -often difficult to differentiate from proximal hamstring tendinitis

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109 COMMON INJURIES Hip Joint Sprain -less common
-excessive forcible exertion of the extremity that stretch or tear the surrounding ligaments -signs and symptoms: pain and decrease ROM

110 COMMON INJURIES Hip Joint Strains
-resulting from overstretching or from a rapid, forceful contraction of the muscle -explosive starts and slipping of the foot during cutting are common mechanisms for hip flexor and adductor strains -these injuries frequently occur during the beginning of practice and preseason training -signs and symptoms: pain, pt tenderness, muscle spasm, swelling, ecchymosis , and decreased ROM

111 COMMON INJURIES Legg-Calve-Perthes Disease
-characterized by avascular necrosis of the proximal femoral epiphysis -a chronic condition that develops slowly in children -more often in males than in females -signs and symptoms: pain in the hip or groin that radiates to the knee, limping, decreased ROM, and hip flexor tightness may be noted -physician should be consulted to rule out serious pathologies such as this

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114 COMMON INJURIES Chronic Synovitis
-inflammatory process at the hip that is characterized by chronic irritation and excess secretion of synovial fluid within the capsule -this condition is very difficult to detect -may lead to avascular necrosis of the femoral head

115 Hemi ORIF THR

116 Hips The End

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