Anatomy of Hip joint

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  • Anatomy of Hip joint

    1. 1. MOB TCD Hip Joint Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin
    2. 2. 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
    3. 3. 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
    4. 4. MOB TCD Acetabulum • • • • • Y-shaped epiphyseal cartilage Start to ossify at 12 years Fuse 16-17 years Acetabular notch is inferior Nonarticular fossa, thin related medially to obturator internus • Pad of fat, proprioceptive nerves
    5. 5. MOB TCD Articular Surface of Hip Joint • Semilunar articular surface covered with hyaline cartilage • Deepened by acetabular labrum • Wedge shaped fibrocartilage
    6. 6. 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
    7. 7. MOB TCD Femur • Trabeculae develop along lines of stress • Calcar femorale is the cortical bone on inferior aspect of neck • Neck is cancellous bone
    8. 8. 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
    9. 9. MOB TCD Capsule of Hip • Posterior • Free border, finger’s breath from trochanteric crest due to insertion of obturator externus • Into trochanteric fossa and • Root greater trochanter
    10. 10. MOB TCD Capsule of Hip • Strongest superiorly • Anteromedially, deep fibres reflected head of rectus femoris • Iliopsoas is anterior • Lateral deep fibres of gluteus minimus
    11. 11. MOB TCD Retinacular Fibres • Fibres of capsule reflected along neck to articular margin called retinacular fibres • Blood supply to head run under retinacular fibres
    12. 12. MOB TCD Ligaments of Hip • • • • • • • Acetabular labrum Transverse ligament Ligament of head Iliofemoral ligament Pubofemoral ligaments Ischiofemoral ligaments Zona orbicularis
    13. 13. 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
    14. 14. MOB TCD Iliofemoral Ligament • Thickening of capsule • Lower half of anterior inferior iliac spine and adjoining acetabulum • Distally • Upper and lower parts of inter trochanteric line
    15. 15. MOB TCD Iliofemoral Ligament • One of strongest ligaments in body • Tightens in extension • Helps maintain erect posture • Facet on anterior aspect of neck • Prevents hyperextension • Fulcrum reducing hip
    16. 16. 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
    17. 17. 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
    18. 18. MOB TCD Synovial Membrane • Lines inner portion of capsule and non articular structures • Ligament of head • Fat in acetabular fossa • May communicate with psoas bursa • Bursa under obturator externus
    19. 19. MOB TCD Bursa Under Gluteus Maximus • Trochanteric bursa • Posterolateral aspect of greater trochanter gluteofemoral • Vastus lateralis ischial bursa • Ischial tuberosity
    20. 20. 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
    21. 21. 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
    22. 22. 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
    23. 23. 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
    24. 24. MOB TCD Anterior Relations • • • • • • Rectus femoris Adductor longus Pectineus Psoas and iliacus Femoral sheath Femoral nerve
    25. 25. 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
    26. 26. MOB TCD Lateral Relations • Gluteus minimus • Gluteus medius • Superior gluteal vessels and nerves between • Iliotibial tract • Superficial three quarters of gluteus maximus
    27. 27. MOB TCD Posterior Relations • • • • • • • • Piriformis Superior gemellus Obturator internus Inferior gemellus Quadratus femoris Adductor magnus Obturator externus Gluteus maximus
    28. 28. MOB TCD Movements: Flexion • Limited by anterior abdominal wall • Psoas • Iliacus • Pectineus • Adductor longus and brevis • Rectus femoris
    29. 29. MOB TCD Movements: Extension • Hamstrings first 10° • Long head of biceps • Semitendinosus • Semimembranosus • 123, extended knee ++ • Adductor magnus • Gluteus maximus most efficient when hip is flexed 45°
    30. 30. MOB TCD Movements: Adduction • • • • • Obturator nerve Adductor longus Adductor brevis Adductor magnus Can flex or extend depending on position of hip
    31. 31. MOB TCD Movements: Abduction • Gluteus medius • Gluteus minimus • Standing on leg, gluteus medius and minimus abduction • By preventing adduction
    32. 32. MOB TCD Movements: Medial Rotation • Iliopsoas • Adductors • Anterior fibres of gluteus medius
    33. 33. MOB TCD Movements: Lateral Rotation • • • • • • Obturator internus Piriformis Superior gemmelus Obturator Internus Inferior gemmelus Quadratus femoris
    34. 34. MOB TCD Trendelenburg Tests
    35. 35. MOB TCD Fractured Neck of Femur
    36. 36. 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
    37. 37. MOB TCD Hip Problems
    38. 38. 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
    39. 39. 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
    40. 40. 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 30 º - 40 º at birth • Decreases progressively 15 º at skeletal maturation • Adults • Anteversion • Average of 8 º 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
    41. 41. MOB TCD Tumors and Neoplasms • • • • Young, healthy athletes do get cancer! Fortunately most tumors are benign! Bone pain at night Tumor till proved otherwise Renström, 2008
    42. 42. MOB TCD Hip Joint Labral Tear • Chronic • Secondary to acetabular dysplasia • Part of “rim lesion” complex Renström, 2008
    43. 43. 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., J Bone Joint Surg (Am), 2006
    44. 44. MOB TCD MR-Arthrography (MRA) • MR arthrogram has an accuracy of 91% for labral tears Chan et al, Arthroscopy 2005 • Sensitivity labral tear • MR 25%, • MRA 92% Toomayan et al., Am J Roentgenol 2006
    45. 45. 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 Renström, 2008
    46. 46. MOB TCD Cam Impingement • • Loss of roundness contributes to abnormal contact between the head and socket Male, 20-30 years Renström, 2008
    47. 47. MOB TCD Cam Impingement P Renstrom 08
    48. 48. “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”

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