3. synovialis ahip jointThe
Ball & socket,polyaxial,
formed by thejoint
articulation of the
rounded head of the
like-and the cupfemur
of the pelvis.acetabulum
It forms the primary
connection between the
bones of the lower limb
ofaxial skeletonand the
the trunk and pelvis
4. Both joint surfaces are
covered with a strong
but lubricated layer
called articular hyaline
except acartilage
central rough
depression on the
head of femur called
the fovea
5. -The cuplike acetabulum forms at the union
of three pelvic bones and the joint may
under the age ofossifiednot be fully
years
6. The shape of the socket
(acetabulum) is a deep cup
shaped cavity with a defect below
called the acetabular notch which
is completed by the acetabular
ligament .
A lip of fibrocartilage called labrum
acetabulare is also found.
The articular cartilages are slippery
and rubbery to allow shock
absorption and provide a smooth
surface to make motion easier.
7. The joint has a strong but loose
fibrous capsule ----- largest
ROM ( second only to the
shoulder) and supports the
weight of the body as well
10. -At the front of the
joint, the strong
iliofemoral ligament
attaches from the
. It isfemurpelvis to
often considered to
be the strongest
ligament in the
human body
11. iliofemoral ligamentFunction of the
Strengthens the anterior aspect of the
capsule
Prevent hyperextension & excessive lateral
rotation of the hip joint.
12. pubofemoral ligamentThe
attaches across the front
of the joint from the
pubis bone of the pelvis
to the femur. This
ligament is orientated
more inferiorly than the
iliofemoral ligament and
reinforces the inferior
part of the hip joint
capsule
13. pubofemoral ligamentFunction of the
It supports the inferomedial aspect of the
capsule.
It limits excessive abduction of the hip.
14. The posterior of the hip
joint capsule is
reinforced by the
ischiofemoral
thatligament
attaches from the
ischial part of the
acetabular rim to the
femur
15. Synovial membrane
It lines the inner surface of the fibrous
capsule.
It invests the ligamentum teres.
It covers the intracapsular non articular
parts of the bones but does not extend on
the articular bony surfaces which are
covered by hyaline cartilage.
16. Nerve supply
-Nerve to rectus femoris (femoral nerve).
-Br. From the anterior division of obturator
nerve.
-Nerve to quadratus femoris.
17. Arterial supply
Arterial supply of the head of
femur:
1- ascending br. Of nutrient
artery of the femur reaches
the head through the neck.
2-capsular ( retinacular)
Bl.v. from trochanteric
anastomosis.
3-arterty of round ligament of
femur from the obturator
artery.
18. Muscles acting on the hip joint
Hip flexors:
-Iliopsoas
-rectus femoris
-Pectineus.
-Sartorius
24. Bursae
-a bursa over the
greater trochanter.
-iliopsoas bursa(located
on the inside).
25. Causes of hip pain are classified into:
1.Causes related to hip joint disorders.
2.Causes related to the periarticular soft
tissues ( in the hip region).
3. Extrinsic sources of hip symptoms
( referred pain).
4. Generalized causes: hip pain may be
just a manifestation of a widespread
disease.
26. Analysis of hip pain:
History:
onset, duration, course, trauma.
associated symptoms as fever, malaise,
loss of weight, night sweating, other
joint problems.
Associated known disease as TB, other
rheumatic disease as RA, AS etc.
27. Site of pain:
True hip pain: is felt mainly in the groin
and in front or inner aspect of the thigh.
Pain is often referred to the knee ( pain in
the knee may be the predominant feature
of a hip disorder).
Referred pain to the hip: Pain referred
from the spine is felt mainly in the gluteal
region down the back or the outer aspect
of the thigh.
Relieving and aggravating factors:
It ↑ by walking and activities necessitate
hip flexion or rotation and ↓ by rest
28. 1. Causes related to hip joint disorders:
Acetabulum and proximal femur: fracture , primary or metastatic
tumors, osteonecrosis of the femoral head ,Perthes’ disease, slipped
upper femoral epiphysis and osteoporosis.
Articular surfaces: transient synovitis of the hip, pyogenic arthritis, TB
,rheumatological diseases as RA , AS and osteoarthritis.
2. Causes related to periarticular soft tissue disorders:
a) Bursae: greater trochanteric bursitis and iliopsoas bursitis.
b) Tendons and fascia: hamstring, adductor and rotator tendinitis and
tightness of fascia lata.
c) Hernias: inguinal and femoral hernias.
3. Extrinsic causes ( referred pain):
a) spine and sacroiliac joint.
b) abdominal and pelvic structures.
c) major vessel occlusion.
29. 1) Fractures:
* Site: femoral neck, acetabulum and pubic ramus.
* Causes: direct trauma, stress # in distance
runners and pathological # e.g. OP.
* Manifestations: Pain in the hip region, external
rotation deformity, shortening of the affected limb,
adduction attitude due to pain .
* Treatment : it differs according to the site and
type of # and the age.
2) Primary and metastatic tumors:
* 1ry: the most common is multiple myeloma.
* 2ry: from tumors of the breast, lung, prostate,
kidney and thyroid gland.
* Manifestations: joint pain, pathological #,
malaise, weight loss and inguinal lymphadenopathy.
30. Transient synovitis
It’s a short term affection of the hip, of
uncertain cause, characterized clinically by
unilateral hip pain, limp & limitation of hip
movement.
Cause: unknown
c/p:<10 y, boys. presenting with pain in groin
& thigh, limping, limitation of movement.
X-ray: normal. Ultrasonography of the hip may
reveal joint effusion.
ESR may be slightly elevated.
Full recovery within 3-6 wks
Treatment: bed rest, analgesics.
DD with other hip problems.
31. Pyogenic arthritis
Uncommon in hip.
Mostly in children, usually secondary to osteomyelitis.
Organism: staph/strep (blood born infection) or spread
from adjacent OM.
Acute inflammation in joint tissues with effusion of pus.
Healing with restoration to normal may occur but
permanent destruction & damage may occur in older
children & adult bony ankylosis may result.
c/p:
-infants: in 1st year, present with anxiety, unwellness &
pyrexia
on examination; restricted hip movement, abscess
pointing at skin surface in buttocks or thigh with
constitutional manifestations .
x-ray; soft tissue shadow, destruction of capital
epiphysis of femur, leading to gradual hip dislocation.
32. #in older children & adults: onset is acute
or subacute with hip pain, severe limping,
joint swelling & restricted painful
movement
x-ray: widening space between
acetabulum & femoral head due to pus,
later: narrowing & destruction of articular
finally bony ankylosis ofcartilage and
joint.
#-treatment:
bed rest and joint rest.
antibiotics therapy
joint aspiration
intra-articular injection
of antibiotics
33. Rheumatoid arthritis
Hip affection is uncommon in RA ,but occur in
severe cases.
It may be bilaterally.
The main symptoms are pain and limitation of
movement aggravated by activity.
Swelling can not be detected clinically because it is
a deeply seated joint.
Fixed flexion or adduction deformity may develop.
Gluteal &thigh muscles are wasted.
By imaging: narrowing of joint space by destruction
of articular cartilage with inward protrusion of
softened medial wall of acetabulum
Degenerative changes may superimpose on top of
inflammation leading to 2ry OA.
35. Tuberculous arthritis
Hip is most frequently affected by TB.
Usually a child 2-5 yrs or a young adult.
Main symptoms pain & limp, impaired general condition.
Examination: synovial thickening is palpable ,limitation of all
hip movement, gluteal &thigh ms are wasted & sometimes cold
abscess is palpable in upper thigh or buttock.
Imaging: early; bone rarefaction with preserved joint space.
later; articular cartilage erosion leading to permanent
joint destruction.
Diagnosis :
history of contact with TB.
presence of tuberculous lesion elsewhere.
cold abscess.
characteristic radiographic changes.
+ve synovial membrane biopsy.
37. Ankylosing spondylitis
It is an inflammatory disease and one of the sero –ve
spondyloarthropathies.
It is primarily a disease of the spine and sacroiliac joint.
It affects the proximal joints especially the hips.
One or both hips may be affected with pain and stiffness which
improve by exercises.
Hip involvement may be so severe--------- hip replacement is
indicated.
Treatment:
Medical: NSAIDS, DMARDs and biological therapy.
Physical therapy:
A corner stone in the management of AS: hydrotherapy, ROM,
breathing exercises etc.
Surgical treatment: hip replacement.
38. Osteoarthritis
OA of hip is one of the causes of severe disablement in elderly.
Causes:
-disease or damage of joint surface accelerates degeneration
(acetabular fracture, Perthes’ disease, SUFE, osteonecrosis).
-2ry to developmental dysplasia or congenital sublaxation.
-idiopathic.
Pathology:
-articular cartilage is worn away at sites where wt. is transmitted
-the underlying bone is hard & eburnated. Also osteophytes
formation may occur.
-diminution of joint space.
C/P: The patient is usually elderly
pain in groin & front of the thigh and commonly in the knee. Pain
is worsened by walking &relieved by rest
joint stiffness & limited ROM.
fixed deformity (flexion, adduction, lat. Rotation).
shortening due to loss of joint space.
39. Imaging:
diminution of joint space, subchondral
bone sclerosis, osteophyte formation at
joint margin.
Treatment:
#Conservative treatment:
-relative rest in early stages.
-analgesic, NSAIDS, ABCS.
-physiotherapy: local heat, cold
therapy, exercise to strengthen ms &
preserve ROM.
-IA injection: as hyaluronic.
#Operative treatment: arthroplasty,
osteotomy, arthrodesis
40. Perthes’ disease
IT IS OSTEOCHONDRITIS OF THE EPIPHYSIS OF THE FEMORAL HEAD
It is a condition in children characterized by a temporary
loss of blood supply to femoral head. Without an adequate
blood supply, the rounded head of femur dies.
It is temporary softened and may become deformed.
-Perthes’ disease usually is seen in children between 5 -10
yrs of age. It is five times more common in boys than in
girls.
-Etiology:
unknown.
most popular theory is temporary interruption of blood
supply to femoral head leading to multiple episodes of
infarction.
41. stages (2-3 years):
1) Ingrowth of new blood vessels and removal of dead
bone by steoclasts.
2) New bone is laid down on the dead trabeculae with
gradual constitution of the bone nucleus.
3) Remodeling --- but bone necrosis and replacement
is not uniform ---- so the nucleus appears
fragmented on X-ray.
4) Net result is deformation of the epiphysis and
flattening of the femoral head.
42. Four Stages of Perthes’ disease:
Femoral head becomes more dense
with possible fracture of supporting
bone.
Fragmentation and reabsorption of
bone.
Reossification when new bone has
regrown.
Healing, when new bone reshapes.
Phase I takes about 2-6 months,
Phase 2 takes one year or more, and
Phase 3 and 4 may go on for many
years.
43. C/P:
limping with antalgic gait.
mild pain at hip area in the
groin (usually unilateral) or
thigh with insidious onset.
Moderate limitation of all
hip movement with pain and
spasm if movement is forced.
N.B: no impact on general
health but secondary OA of
the hip develops later on.
Diagnosis:
by x-rays and MRI ( early
diagnosis)
44.
45. Treatment:
Nonsurgical treatment:
- anti-inflamatory medication.
-Crutches are used for non-weight bearing
treatment for pain.
-Range of motion exercises may be given
at home.
- abduction splint (leg in abduction,
int. rotation or abd., flexion by plaster
cast or braces to keep femoral head in
acetabulum).
Surgical treatment:
-varus femoral osteotomy to redirect
femoral head in acetabulum
-pelvic osteomy to redirect
acetabulum over femoral head.
46. Osteonecrosis( avascular necrosis)
Necrosis of bone of femoral head may be a complication of trauma,
fracture of femoral neck , but may be a non-traumatic or idiopathic
osteonecrosis is thought to be result of an ischemic episode
affecting the bone and marrow tissue and may cause progressive
collapse of femoral head in young adults.
Cause:
unknown .
Fat embolism, intravascular coagulation.
history of steroid therapy or alcohol addiction.
patients receiving immuno-suppressive therapy following organ
transplantation.
Pathology:
the bone necrosis does not involve the entire femoral head, but
commonly occupies a wedge shaped segment beneath the superior
weight baring surface. This may result in subchondral fracture with
subsequent collapse of articular surface and a progression to
secondary OA.
47. C/P:
The patient is usually young or middle aged, will
present with increasing pain in the hip or thigh during
standing or walking (limping). When bony collapse has
occurred, there may be marked restriction of hip
movement with secondary contractures and limb
shortening.
Diagnosis:
MRI in early stage show low intensity focus in the
affected femoral head.
x-ray: narrowing of joint space with flattening of
weight bearing surface of head and underlying area of
sclerosis in the bone.
Treatment: surgical.
48. Slipped upper femoral epiphysis
This is affection of late childhood in which the upper femoral
epiphysis is displaced from its normal position upon the femoral
neck. The displacement occurs at the growth plate( epiphysial line)
and in both sides.
Cause:
Unknown. The condition is often associated with overweight from
endocrine dysfunction, but in other cases the pt is of normal build.
Pathology:
The junction between the capital epiphysis and the neck of femur
loosens. With the downward pressure of wt bearing and the upward
pull of muscles on the femur the epiphysis displaced from its normal
position. Displaced is always backward & downward , so that the
epiphysis comes to lie at the back of femoral neck.
C/P:
The patient is between 10 and 20 years of age.
gradual onset of pain in the hip with limp. Pain is felt mainly in the
knee
on examination: limitation of certain hip movement (flexion,
abduction &medial rotation).
49. Diagnosis:
x-ray shows slight displacement of the
epiphysis in lateral radiograph.
Complication:
-osteonecrosis.
-OA in severe displacement.
Treatment: surgical.
50.
51.
52. Periarticular structures:
a) Trochanteric bursitis: inflammation of the bursa between the greater
trochanter and the tendon of gluteus maximus and medius.
It is common in elderly. Or in young individuals who perform activities
as walking, running and biking. Manifestations: pain over the greater
trochanter which may radiate down the outer aspect of the thigh. In
severe cases there is limping and stiffness of the hip. Diagnosis:
imaging to exclude other causes. Treatment: NSAIDS, physical
therapy, local steroid injection and rarely surgical removal of the
inflamed bursa.
b) Iliopsoas tendinitis:
Inflammation and irritation of the iliopsoas tendon due to overuse of
repititive microtruamata in sport activities.
c) Iliopsoas bursitis:
Inflammation of the bursa underneath the tendon.
53. Extrinsic causes of hip pain:
Features of referred pain: pain is felt at the hip region but local hip
examination is completely free i.e. no local tenderness, no
limited ROM, imaging study is free as well. Abnormalities can be
detected in the original site of pain e.g. spine, SIJ etc.
a) Disorders of the spine:
Discogenic pain may refer to the gluteal region and the lateral
aspect of the thigh.
b) Disorders of sacroiliac joint:
They include: TB, pyogenic arthritis and AS.
Pain is diffuse and felt over the gluteal area and may extend to
the posterior aspect of the thigh ( sciatica-like pain).
54. c) Disorders of the abdomen and pelvis:
Examples: deep peri appendicular abscess------ irritation of the
obturator nerve and irritative spasm of the hip muscles which
originate from the abdomen and pelvis as psoas major, iliacus,
pyriformis and obturator internus.
Pain may be associated with limited ROM due to muscle
spasm.
Careful history taking, examination and investigation reveal the
proper diagnosis.
d) Occlusive vascular disease:
Examples: thrombosis of the abdominal aorta or main
branches.
Pain is elicited by activity and relieved by rest.
The femoral pulse is weak or absent. Other lower limb
arteries may be strong.
