Anatomy of Groin

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  • Anatomy of Groin

    1. 1. MOB TCD Groin Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin
    2. 2. MOB TCD Groin • Lower half of anterior abdominal wall • Proximal portion of the thigh • Pain in the groin may be due to local structures • Referred from other areas e.g. the spine or ureter • Pain may be acute or chronic • Quality of pain • Rest or movement
    3. 3. MOB TCD Hip and Groin Pain • Spinal problems such as disc • • • • • • • lesions Intra-abdominal problems Gynecological disorders Urological problems Urinary tract infection Pelvic inflammatory conditions Genital swelling or inflammation Epididymis, hydrocele, variocele
    4. 4. MOB TCD Groin • • • • • • • • • • • Os coxae (hip bone) femur Pubic symphysis Hip joint Femoral artery Femoral vein Long saphenous vein Inguinal lymph glands Nerves Muscles Bursae Hernia
    5. 5. MOB TCD Cutaneous Nerves
    6. 6. MOB TCD Inguinal Glands • Proximal group parallel to inguinal ligament • Enlarged tender inguinal glands • Part of a generalised lymphadenopathy • Secondaries
    7. 7. MOB TCD Inguinal Glands • Proximal group • Lesions in local structures • Skin of lower anterior abdominal wall • Gluteal region • Skin of scrotum or labia • Distal superficial glands • Skin of leg area drained by long saphenous vein • All drain to deep inguinal glands along femoral vein
    8. 8. MOB TCD Skin of Anterior Abdominal Wall • Lower five intercostal nerves • Subcostal nerve T12 • 10th intercostal nerve is at the level of the umbilicus • Iliohypogastric nerve L1 • Ilioinguinal nerve L1
    9. 9. MOB TCD Cutaneous Nerves of Thigh • • • • Subcostal nerve T 12 Iliohypogastric nerve L1 Ilioinguinal nerve L1 Femoral branch of the genitofemoral nerve L1,2 • Lateral cutaneous nerve of the thigh L2,3 • Femoral nerve L2,3,4 • Obturator nerve L2,3,4
    10. 10. MOB TCD Anterior Abdominal Wall • • • • Superficial fatty layer Membranous layer of superficial fascia Below umbilicus Continuous with Colles’ fascia in the perineum
    11. 11. MOB TCD Blood Supply and Lymphatics • Intercostal vessels • Skin above umbilicus: superficial veins and lymphatics drain to axilla • Skin below umbilicus: superficial veins and lymphatics drain to long saphenous vein • Superficial inguinal glands
    12. 12. MOB TCD Abdominal Muscles • • • • • • • External oblique Internal oblique Transversus Rectus abdominus Pyramidalis Nerves and vessels Lie between internal oblique and transversus
    13. 13. MOB TCD External Oblique • Origin • Outer surfaces lower borders lower eight ribs • Interdigitating serratus anterior • Latissimus dorsi
    14. 14. MOB TCD Insertion – External Oblique • Inserted into anterior half of anterior two thirds outer lip of iliac crest • Aponeurosis in inguinal region passes anterior to rectus muscle • Forms the inguinal ligament • Lacunar ligament • Reflected portion of inguinal ligament
    15. 15. MOB TCD Inguinal and Lacunar Ligaments • Inguinal ligament: aponeurosis is folded back from anterior superior iliac spine to pubic tubercle to form inguinal ligament • Lacunar ligament: triangular, attached to pectineal line, lateral free border medial margin of femoral ring
    16. 16. MOB TCD Insertion – External Oblique • • • • • Pubic crest Gap for superficial ring Pubic bone Linea alba Anterior wall of the rectus sheath • Zyphoid process
    17. 17. MOB TCD Internal Oblique • Muscular origin • Lateral two thirds of inguinal ligament • Anterior two thirds intermediate lip of iliac crest • Lumbar fascia • Muscular fibres arch over contents of inguinal canal anterior to rectus muscle
    18. 18. MOB TCD Insertion – Internal Oblique • Into the costal margin, upper three as fleshy fibres • Next three as aponeurotic • Inserted into linea alba • Between zyphoid and half way between umbilicus and pubic symphysis, aponeurosis splits • Anterior fuses with external oblique • Posterior with transversus
    19. 19. MOB TCD Internal Oblique – Conjoint Tendon • Half way between umbilicus and pubic symphysis • Aponeurosis of the internal oblique and transversus fuse to form conjoint tendon • Anterior portion of rectus sheath • Inserted into pectineal line behind superficial inguinal ring
    20. 20. MOB TCD Transversus Abdominus • Origin • Lateral one third of inguinal ligament • Anterior two thirds of inner lip of iliac crest • Lumbar fascia • Lower border and inner surfaces lower six ribs interdigitating with diaphragm
    21. 21. MOB TCD Insertion – Transversus Abdominus • Into zyphoid, linea alba • Half way between umbilicus and pubic symphysis • Fuses with posterior lamella of the internal oblique • Below forms conjoint tendon • Inserted into pectineal line behind superficial inguinal ring
    22. 22. MOB TCD Rectus Abdominus • • • • • Segmental muscle Two heads Anterior pubic symphysis Pubic crest Inserted anterior aspect of 5,6,7th costal cartilages • Adhesions anterior • Segmental blood and nerve supply from intercostals
    23. 23. MOB TCD Transversalis Fascia • Lines deep aspect of transversus abdominus • Fuses with inguinal ligament • Continuous with iliac fascia • Except in region femoral vessels • Forms anterior wall of femoral sheath
    24. 24. MOB TCD Inguinal Canal • • • • • Intramuscular canal Deep inguinal ring Superficial ring Transmits spermatic cord in male Round ligament in female
    25. 25. MOB TCD Superficial Inguinal Ring • Triangular opening in aponeurosis of external oblique • Base pubic crest • Superior crus to pubic crest • Inferior attached to pubic tubercle • External spermatic fascia arises from its margins
    26. 26. MOB TCD Deep Inguinal Ring • Oval opening 2.5 cm • Above the middle of inguinal ligament • Inferior epigastric artery medial to ring
    27. 27. MOB TCD Inguinal Canal • • • • • Anterior wall External oblique Whole anterior wall Lateral half Internal oblique
    28. 28. MOB TCD Inguinal Canal • • • • • Posterior wall Transversalis fascia Whole of wall Medial half conjoint tendon Medial quarter, reflected portion of inguinal ligament
    29. 29. MOB TCD Roof of Inguinal Canal • Roof • Arching fibres of internal oblique • Transversus as they arise from the inguinal ligament
    30. 30. MOB TCD Floor of Inguinal Canal • Floor • Inguinal ligament medial half • Lacunar ligament
    31. 31. Passing through Deep Ring Male • • • • • • • Vas deferens Testicular artery Pampiniform plexus of veins Remains of processus vaginalis Genital branch of genitofemoral nerve Lymphatics from testes Cremaster artery MOB TCD
    32. 32. Passing through Superficial Ring Male • • • • • Everything that went through deep ring Plus: Ilioinguinal nerve Internal spermatic fascia Cremaster muscle and fascia MOB TCD
    33. 33. Passing through Deep Ring Female • Round ligament of uterus • Remains of processus vaginalis • Genital branch of genitofemoral nerve • Lymphatics from uterus, region of cornu MOB TCD
    34. 34. Passing through Superficial Ring Female • Everything that went through deep ring: • Plus ilioinguinal nerve MOB TCD
    35. 35. MOB TCD Inguinal Canal • Contraction of the abdominal muscles increases the obliquity of the inguinal canal • Protecting the two rings Lytle, 1945
    36. 36. Increase in Intra Abdominal Pressure • Pain aggravated by an increase in intraabdominal pressure • Hernia • Inguinal or femoral hernia • Entrapment of the ilioinguinal nerve MOB TCD
    37. 37. MOB TCD Hernia • Chronic pain in the groin in an athlete • May be due to a hernia or a potential hernia
    38. 38. MOB TCD Inguinal Hernia • Sudden severe pain in lower abdomen • Associated with lifting a heavy object • Common history of a direct inguinal hernia
    39. 39. MOB TCD Indirect Inguinal Hernia • Passes through • Deep inguinal ring • May extend to pass through the superficial ring into the scrotum • Congenital or acquired • Congenital inside the tunica vaginalis (serous membrane, covers part of testes) • Acquired outside
    40. 40. MOB TCD Direct Inguinal Hernia • Direct inguinal hernia • Enters through posterior wall of the inguinal canal • Leaves through superficial inguinal ring • Above and medial to pubic tubercle
    41. 41. MOB TCD Inguinal Versus Femoral Hernia • Inguinal above and medial to pubic tubercle • Femoral below and lateral
    42. 42. MOB TCD Femoral Ring
    43. 43. MOB TCD Femoral Hernia • Enters through femoral ring • Enters femoral canal • Medial compartment of femoral sheath • More common in women
    44. 44. MOB TCD Femoral Hernia
    45. 45. MOB TCD Saphenous Varix • Swelling is soft and diffuse • Empties on minimal pressure • Refills on release • Cough impulse is present
    46. 46. MOB TCD Gilmore’s Groin • Common cause of chronic groin pain in field sports • Particularly soccer players • Pain on any sudden change of movement, sneezing, coughing
    47. 47. MOB TCD Gilmore’s Groin • Trying to sprint will increase the pain • Pain is worse getting out of bed the day after a match or a training session
    48. 48. MOB TCD Gilmore’s Groin • Pain is increased by external rotation • Or hyperextension of hip • Pain is localised to lower anterior abdominal wall • Adductor or perineal region
    49. 49. MOB TCD Gilmore’s Groin • Torn external oblique aponeurosis • Torn conjoint tendon • A dehiscence between conjoint tendon and the inguinal ligament • The absence of a hernial sac • Superficial inguinal ring on the affected side is dilated and tender • Cough impulse
    50. 50. MOB TCD Gilmore’s Groin Surgery • Treatment is surgical • 90% return to sport • Strengthen lower abdominal muscles
    51. 51. MOB TCD Gilmore’s Groin Surgery 1. Plication of the transversalis fascia in ‘shouldice hernia repair’ 2. Repair of torn conjoint tendon 3. Approximation of conjoint tendon to the inguinal ligament 4. Repair of the external oblique 5. Reconstitution of the superficial inguinal ring
    52. 52. MOB TCD Anatomy of Nerve Injuries • • • • • Dermatomes Entrapment of nerves Pierce muscle Pierce fascia Repetitive movements
    53. 53. MOB TCD Anatomy of Nerve Injuries • • • • • • Must know the course of nerve Dermatomes Entrapment of nerves Pierce muscle Pierce fascia Repetitive movements
    54. 54. MOB TCD Dermatomes and Myotomes • Nerves supply • Skin • Muscles (group) • Tendons • Bones • Joints • Blood vessels
    55. 55. MOB TCD Extrinsic Factors • External forces • Fibro-osseous tunnels, tether the nerve • Oedema • Callus formation as a result of a fracture • External compression due to specific movements • Mechanical compression • Compartment syndromes • The nerve is tender at the site of compression
    56. 56. MOB TCD Extrinsic Factors • Fibrous bands • • • • Accessory muscles Spurs Narrow notches Anatomical variations of the nerve itself
    57. 57. MOB TCD Lumbo-Sacral Plexus
    58. 58. Entrapment Syndromes in Lower Limb • Affects branches of lumbar or sacral plexuses • Pierces muscle • Pierces fascia • Increase in compartment pressure • Compressed by external pressure MOB TCD
    59. 59. MOB TCD Skin of Anterior Abdominal Wall • Lower five intercostal nerves • Subcostal nerve T12 • 10th intercostal nerves at the level of the umbilicus • Iliohypogastric nerve L1 • Ilioinguinal nerve L1
    60. 60. MOB TCD Cutaneous Nerves of Thigh • • • • Subcostal nerve T 12 Iliohypogastric nerve L1 Ilioinguinal nerve L1 Femoral branch of the genitofemoral nerve L1,2 • Lateral cutaneous nerve of the thigh L2,3 • Femoral nerve L2,3,4 • Obturator nerve L2,3,4
    61. 61. MOB TCD Cutaneous Nerves
    62. 62. MOB TCD Ilio-Hypogastric Nerve L1 • • • • Branch of lumbar plexus Lateral border of psoas Anterior to quadratus lumborum Neurovascular plane between internal oblique and transversus • Lateral cutaneous supplies upper part of buttock
    63. 63. MOB TCD Ilio-Hypogastric Nerve • Pierces internal oblique above anterior superior iliac spine • Pierces aponeurosis of external oblique an inch above superficial ring • Supplies skin over lower part of rectus sheath • Can be trapped piercing aponeurosis
    64. 64. MOB TCD Ilio-Inguinal Nerve • • • • • Ilio-inguinal nerve L1 branch of lumber plexus Lateral border of psoas Anterior to quadratus lumborum Neurovascular plane between internal oblique and transversus
    65. 65. MOB TCD Ilio-Inguinal Nerve • Pierces internal oblique 4 cm medial to • Anterior superior iliac spine • Enters inguinal canal • Leaves through superficial ring • Supplies the skin of the medial part of the thigh • Adjoining portion of the scrotum and labia
    66. 66. MOB TCD Ilio-Inguinal Nerve • May be trapped post surgery, due to adhesions • Poor tone in abdominal muscles • Pain increased by increased tension in the anterior abdominal wall • Hyperextension of hip • Tenderness 4 cm from anterior superior iliac spine
    67. 67. MOB TCD Ilio-Inguinal Nerve Entrapment • Pain increased • Increased tension in the anterior abdominal wall • Hyperextension of hip • Tenderness 4 cm medial to anterior superior iliac spine
    68. 68. MOB TCD CutaneousNerves • Iliohypogastric in 5.6% • Ilioinguinal 90.7% • Union of branches of ilioinguinal and genital branch of the genitofemoral nerve 13% • Genitofemoral passing through superficial inguinal ring 35.2% • Piercing inguinal ligament 5.6% • Femoral branch 13% Akita et al., 1999
    69. 69. MOB TCD Genitofemoral Nerve • Lumbar plexus L1,2 • Anterior aspect of the psoas • Genital branch enters the deep inguinal ring • Femoral branch lies on the lateral side of femoral artery in the femoral sheath
    70. 70. MOB TCD Femoral Branch Genitofemoral • Enters thigh on lateral aspect of femoral artery in femoral sheath • Pierces anterior wall of the sheath • Supplies skin a hands breath below the inguinal ligament
    71. 71. MOB TCD Genitofemoral Nerve • Union with ilioinguinal nerve on anterior aspect of spermatic cord • Supplies ventral aspect of scrotum and adductor region • Cutaneous branch on the dorsalcaudal aspect • May also supply dorsal scrotum Akita et al., 1999
    72. 72. MOB TCD Genitofemoral Nerve
    73. 73. MOB TCD Lateral Cutaneous Nerve • The lateral cutaneous nerves of the thigh L2,3 • Lumbar plexus in psoas • Lateral aspect of psoas • Pierces inguinal ligament • Lies in fibrous tunnel • Divides into two • Pierces deep fascia
    74. 74. MOB TCD Lateral Cutaneous Nerve of Thigh • A centimeter medial to anterior superior iliac spine • Crosses the lateral angle of femoral triangle • Divides into two • Pierces deep fascia • Anterolateral aspect of the thigh • Anterior portion of gluteal region
    75. 75. MOB TCD Lateral Cutaneous Nerve of Thigh • Entrapment in the fascial tunnel • Injured in the thigh by asymmetric bars in gymnastics • Causes meralgia paraesthetica • Post laparoscopic surgery
    76. 76. MOB TCD Femoral Nerve L2,3,4 • • • • • • • • • The largest branch of the lumbar plexus Lateral aspect of psoas Passes under the inguinal ligament Outside femoral sheath 2 cm below Divides into terminal branches Muscular Articular Cutaneous
    77. 77. MOB TCD Femoral Nerve Muscular branches • Rectus femoris • Vastus medialis • Vastus lateralis • Vastus intermedius • Sartorius, pectineus Cutaneous • Medial cutaneous nerves of thigh • Intermediate cutaneous nerves of thigh • Saphenous Articular branches to hip and knee joints
    78. 78. MOB TCD Femoral Nerve • Dancers may stretch the nerve by prolonged hyperextension of the hip • Compress the nerve under the inguinal ligament • The nerve may also be compressed due to a haematoma following a partial tear of the iliacus O’Brien, 1997
    79. 79. MOB TCD Femoral Nerve Femoral nerve Saphenous
    80. 80. MOB TCD Obturator Nerve • • • • • • The obturator nerve L2-3-4 Lumbar plexus in psoas Medial aspect of psoas Side wall of pelvis under peritoneum Leaves through obturator foramen Divides into anterior and posterior divisions
    81. 81. MOB TCD Obturator Nerve • Supplies the parietal peritoneum on side wall of the pelvis • It is related to the ovary • Pathology in the ovary or endometriosis may result in referred pain to the hip, knee or medial side of the high
    82. 82. MOB TCD Anterior Divison Obturator • The anterior division of the obturator leaves pelvis • Anterior to obturator externus • Descends in front of adductor brevis • Behind pectineus and adductor longus obturator nerve
    83. 83. MOB TCD Anterior Divison Obturator • • • • Adductor longus Adductor brevis Gracilis It gives an articular twig to the hip joint • Skin on the medial side of the thigh
    84. 84. MOB TCD Obturator Nerve
    85. 85. MOB TCD Posterior Divison Obturator • It may be entrapped as it leaves the pelvis • Pierces and supplies the obturator externus • Causing spasm of the adductor muscles
    86. 86. MOB TCD Posterior Divison Obturator • Supplies adductor portion of adductor magnus, above hiatus • Articular twig to knee joint and cruciate ligaments • Causing spasm of the adductor muscles • It may be entrapped as it leaves the pelvis or between fascial planes
    87. 87. MOB TCD Obturator Nerve obturator nerve fascial planes
    88. 88. MOB TCD Howship Rhomberg Sign • Pressure on obturator nerve • Pain on inner aspect of thigh relieved by flexion of hip • Increased by extension, adduction and medial rotation
    89. 89. MOB TCD Obturator Nerve
    90. 90. MOB TCD Psoas Muscle
    91. 91. MOB TCD Sacral Plexus
    92. 92. MOB TCD Pudendal Nerve
    93. 93. MOB TCD Pudendal Nerve • Compression of pudendal nerve in cyclists due to saddle • History of change of saddle • Compressing dorsal nerve of penis
    94. 94. MOB TCD Psoas Muscle
    95. 95. MOB TCD Iliacus • • • • • Iliac fossa and iliac crest Inserts into psoas Major Nerve L23 Psoas bursa
    96. 96. MOB TCD Rectus Femoris Muscle • • • • • • Upper half of anterior inferior iliac spine Area above actetabulum Inserted into quadriceps tendon Flexes hip Extends knee Femoral nerve
    97. 97. MOB TCD Hip Joint • • • • • Synovial ball and socket joint Multiaxial Three degrees of freedom Movement in three planes Close pack extension and medial rotation • Least pack semiflexion
    98. 98. MOB TCD Hip Joint • One of most stable joints in the body • Articular surface of hip joint are reciprocally curved • Superior surface of femur and acetabulum sustain greatest pressure
    99. 99. MOB TCD Acetabulum • • • • • Y shaped epiphyseal cartilage Start to ossify at 12 Fuse 16-17 Acetabular notch is inferior Nonarticular fossa, thin related medially to obturator internus • Pad of fat, proprioceptive nerves
    100. 100. MOB TCD Articular Surface of Hip Joint • Semilunar articular surface covered with hyaline cartilage • Deepened by labrum acetabulare • Wedge shaped fibrocartilage
    101. 101. MOB TCD Articular Surface • • • • • Head of femur 2/3rd of sphere Pit for ligamentum teres Covered with articular cartilage Cartilage thicker posterior superior Epiphyseal line for head intracapsular
    102. 102. MOB TCD Femur • Trabeculae develop along lines of stress • Calcar femorale is the cortical bone on inferior aspect of neck • Neck is cancellous bone
    103. 103. MOB TCD Capsule of Hip • • • • Proximally attached Margins of the acetabular fossa Base of labrum Distally, anterior to the intertrochanteric line • Inferiorly, femoral neck close to lesser trochanter
    104. 104. MOB TCD Capsule of Hip • Posterior • Free border, finger’s breadth from trochanteric crest due to insertion of obturator externus • Into trochanteric fossa and • Root greater trochanter
    105. 105. MOB TCD Capsule of Hip • Strongest superiorly • Anteromedially, deep fibres reflected head of rectus femoris • Iliopsoas is anterior • Lateral deep fibres of gluteus minimus
    106. 106. MOB TCD Retinacular Fibres • Fibres of capsule reflected along neck to articular margin called retinacular fibres • Blood supply to head run under retinacular fibres
    107. 107. MOB TCD Ligaments of Hip • • • • • • • Labrum acetabulare Transverse ligament Ligament of head Iliofemoral ligament Pubofemoral ligament Ischiofemoral ligament Zona orbicularis
    108. 108. MOB TCD Ligaments of Hip • Transverse ligament is part of the labrum • Ligamentum teres is triangular • Its base is attached to transverse ligament and the apex to the pit on the head of femur • Blood supply to epiphysis from obturator artery • Only supplies a flake of bone in elderly
    109. 109. MOB TCD Iliofemoral Ligaments • Thickening of capsule • Lower half of anterior inferior iliac spine and adjoining acetabulum • Distally • Upper and lower parts of inter trochanteric line
    110. 110. MOB TCD Iliofemoral Ligaments • One of strongest ligaments in body • Tightens in extension • Helps maintain erect posture • Facet on anterior aspect of neck • Prevents hyperextension • Fulcrum reducing hip
    111. 111. MOB TCD Pubofemoral Ligament • Superior pubic ramus • Inferior part of inter trochanteric line and upturned part • Relatively weak • Prevents abduction • Bursa between it and iliofemoral
    112. 112. MOB TCD Ischiofemoral Ligament • Ischium to posterior part of joint (weak) • Circular fibres called zona orbicularis • Centre of gravity in front of head • Synovial under obturator externus
    113. 113. MOB TCD Synovial Membrane • Lines inner portion of capsule and nonarticular structures • Ligament of head • Fat in acetabular fossa • May communicate with psoas bursa • Bursa under obturator externus
    114. 114. MOB TCD Bursa Under Glueus Maximus • Trochanteric bursa • Posterolateral aspect of greater trochanter gluteofemoral • Vastus lateralis ischial bursa • Ischial tuberosity
    115. 115. MOB TCD Blood Supply to Head of Femur • Child: obturator artery via ligamentum teres supplies epiphysis • Elderly: main supply via retinacular vessels from trochanteric and cruciate anastamoses • Medial and lateral circumflex femoral vessels
    116. 116. MOB TCD Blood Supply • Superior gluteal supplies the upper part of the acetabulum • Inferior gluteal supplies the inferior and posterior and the capsule • Transverse and ascending branches of lateral circumflex femoral artery • Transverse and ascending branch of medial circumflex femoral • Cruciate and trochanteric anastomosis
    117. 117. MOB TCD Blood Supply • Fractures of neck may cause avascular necrosis, extra capsular arteries enter the trochanter at the base of neck • Medial and lateral circumflex femoral vessels and superior gluteal
    118. 118. MOB TCD Nerve Supply • • • • • Femoral nerve Obturator nerve Superior gluteal nerve Nerve to quadratus femoris Posterior dislocation may damage sciatic • Pain in hip referred to knee
    119. 119. MOB TCD Stability of Hip • One of the most stable joints • Congenital dislocations is common • 1.5 per 1000 live births • Female : Male = 8:1 • Ultrasound best method of detecting
    120. 120. MOB TCD Anterior Relations • • • • • • Rectus femoris Adductor longus Pectineus Psoas, iliacus Femoral sheath Femoral nerve
    121. 121. MOB TCD Inferior and Posterior Relations • Obturator externus • Passes inferior and then posterior to joint • Superior gluteal nerve • Inferior gluteal nerve • Sciatic nerve • Posterior cutaneous nerve thigh • Nerves to obturator internus and quadratus femoris • Pudendal nerve
    122. 122. MOB TCD Lateral Relations • Gluteus minimus • Gluteus medius • Superior gluteal vessels and nerves between • Iliotibial tract • Superficial three quarters of gluteus maximus
    123. 123. MOB TCD Posterior Relations • • • • • • • • Piriformis Superior gemellus Obturator internus Inferior gemellus Quadratus femoris Adductor magnus Obturator externus Gluteus maximus
    124. 124. MOB TCD Movements: Flexion • • • • • • Limited by anterior abdominal wall Psoas Iliacus Pectineus Adductor longus and brevis Rectus femoris
    125. 125. MOB TCD Movements: Extension • Hamstrings first 10° 1. Long head of biceps 2. Semitendinosus 3. Semimembranosus • • • 123, extended knee ++ Adductor magnus Gluteus maximus most efficient when hip is flexed 45 °
    126. 126. MOB TCD Movements: Adduction • • • • • Obturator nerve Adductor longus Adductor brevis Adductor magnus Can flex or extend depending on position of hip
    127. 127. MOB TCD Movements: Abduction • Gluteus medius • Gluteus minimus • Standing on leg, gluteus medius and minimus abduction • By preventing adduction
    128. 128. MOB TCD Movements: Medial Rotation • Iliopsoas • Adductors • Anterior fibres of gluteus medius
    129. 129. MOB TCD Movements: Lateral Rotation • • • • • • Obturator internus Piriformis Superior gemmelus Obturator internus Inferior gemmelus Quadratus femoris
    130. 130. MOB TCD Trendelenburg Tests
    131. 131. MOB TCD Fractured Neck of Femur
    132. 132. MOB TCD Hip Problems in Children • • • • Apophysitis Avulsion fractures After 13 years 11-40% of all hip and pelvic fractures Boyd et al., 1997 • Anterior superior iliac spine • Anterior inferior iliac spine • Ischial tuberosity commonest
    133. 133. MOB TCD Hip Problems
    134. 134. MOB TCD Pain in a Child • • • • • • 5-10 year old child Aching pain in hip Limp Limitation of movement Perthe’s Osteochondritis of head of femur
    135. 135. MOB TCD Stability of Hip • One of the most stable joints • Congenital dislocations is common • 1.5 per 1000 live births • Female : Male = 8:1 • Ultrasound best method of detecting
    136. 136. MOB TCD Femoral Anteversion • Femoral version is the angular difference between axis of femoral neck and transcondylar axis of the knee • Femoral anteversion ranges from 30º - 40º at birth • Decreases progressively 15º at skeletal maturation • Adults • Anteversion • Average of 8º in men and 14º in women • Most common cause of in-toeing • If associated with internal tibial torsion may lead to patellofemoral subluxation due to an increase in the Q-angle
    137. 137. MOB TCD Tumors and Neoplasms • Young, healthy athletes do get cancer! • Fortunately most tumors are benign! • Bone pain at night • Tumor till proved otherwise Renstrom, 2008
    138. 138. MOB TCD Hip Joint Labral Tear • Chronic • Secondary to acetabular dysplasia • Part of ‘rim lesion’ complex Renstrom, 2008 •
    139. 139. MOB TCD Labrum Tears and Cartilage Loss • Labrum tears and cartilage loss are common in patients with mechanical symptoms in the hip • In young, active patients with a complaint of groin pain • The diagnosis of a labrum tear should be suspected and investigated as radiographs and the history may be nonspecific for this diagnosis Burnett et al., 2006
    140. 140. MOB TCD MR – Arthrography (MRA) • MR arthrogram has an accuracy of 91% for labral tears Chan et al., 2005 • Sensitivity labral tear • MR 25%, • MRA 92% Toomayan et al., 2006
    141. 141. MOB TCD Pincer Impingement • The acetabulum covers too much of the • • • • femoral head Secondary to ‘retroversion’ of the socket Or a ‘profunda’ socket that is too deep Most of the time, the cam and pincer forms exist together Female, 30-40 years Renstrom, 2008
    142. 142. MOB TCD Cam Impingement • • Loss of roundness contributes to abnormal contact between the head and socket Male, 20-30 years Renström, 2008
    143. 143. MOB TCD Cam Impingement Renström, 2008
    144. 144. “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”

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