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MOB TCD

Groin
Professor Emeritus Moira O’Brien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
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
MOB TCD

Hip and Groin Pain
• Spinal problems such as disc
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lesions
Intra-abdominal problems
Gynecological disorders
Urological problems
Urinary tract infection
Pelvic inflammatory conditions
Genital swelling or inflammation
Epididymis, hydrocele, variocele
MOB TCD

Groin
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Os coxae (hip bone) femur
Pubic symphysis
Hip joint
Femoral artery
Femoral vein
Long saphenous vein
Inguinal lymph glands
Nerves
Muscles
Bursae
Hernia
MOB TCD

Cutaneous Nerves
MOB TCD

Inguinal Glands
• Proximal group parallel to
inguinal ligament
• Enlarged tender inguinal
glands
• Part of a generalised
lymphadenopathy
• Secondaries
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
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
MOB TCD

Cutaneous Nerves of Thigh
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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
MOB TCD

Anterior Abdominal Wall
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Superficial fatty layer
Membranous layer of superficial fascia
Below umbilicus
Continuous with Colles’ fascia in the
perineum
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
MOB TCD

Abdominal Muscles
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External oblique
Internal oblique
Transversus
Rectus abdominus
Pyramidalis
Nerves and vessels
Lie between internal oblique and
transversus
MOB TCD

External Oblique
• Origin
• Outer surfaces lower borders lower
eight ribs
• Interdigitating serratus anterior
• Latissimus dorsi
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
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
MOB TCD

Insertion – External Oblique
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Pubic crest
Gap for superficial ring
Pubic bone
Linea alba
Anterior wall of the
rectus sheath
• Zyphoid process
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
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
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
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
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
MOB TCD

Rectus Abdominus
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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
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
MOB TCD

Inguinal Canal
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Intramuscular canal
Deep inguinal ring
Superficial ring
Transmits spermatic cord in male
Round ligament in female
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
MOB TCD

Deep Inguinal Ring
• Oval opening 2.5 cm
• Above the middle of inguinal ligament
• Inferior epigastric artery medial to
ring
MOB TCD

Inguinal Canal
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Anterior wall
External oblique
Whole anterior wall
Lateral half
Internal oblique
MOB TCD

Inguinal Canal
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Posterior wall
Transversalis fascia
Whole of wall
Medial half conjoint tendon
Medial quarter, reflected portion
of inguinal ligament
MOB TCD

Roof of Inguinal Canal
• Roof
• Arching fibres of internal oblique
• Transversus as they arise from the
inguinal ligament
MOB TCD

Floor of Inguinal Canal
• Floor
• Inguinal ligament
medial half
• Lacunar ligament
Passing through Deep Ring
Male
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Vas deferens
Testicular artery
Pampiniform plexus of veins
Remains of processus vaginalis
Genital branch of genitofemoral nerve
Lymphatics from testes
Cremaster artery

MOB TCD
Passing through Superficial Ring
Male
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Everything that went through deep ring
Plus:
Ilioinguinal nerve
Internal spermatic fascia
Cremaster muscle and fascia

MOB TCD
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
Passing through Superficial Ring
Female
• Everything that went through
deep ring:
• Plus ilioinguinal nerve

MOB TCD
MOB TCD

Inguinal Canal
• Contraction of the abdominal
muscles increases the
obliquity of the inguinal canal
• Protecting the two rings
Lytle, 1945
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
MOB TCD

Hernia
• Chronic pain in the groin in an
athlete
• May be due to a hernia or a
potential hernia
MOB TCD

Inguinal Hernia
• Sudden severe pain in lower
abdomen
• Associated with lifting a heavy
object
• Common history of a direct
inguinal hernia
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
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
MOB TCD

Inguinal Versus Femoral Hernia
• Inguinal above and medial to pubic
tubercle
• Femoral below and lateral
MOB TCD

Femoral Ring
MOB TCD

Femoral Hernia
• Enters through femoral ring
• Enters femoral canal
• Medial compartment of femoral
sheath
• More common in women
MOB TCD

Femoral Hernia
MOB TCD

Saphenous Varix
• Swelling is soft
and diffuse
• Empties on
minimal pressure
• Refills on release
• Cough impulse is
present
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
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
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
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
MOB TCD

Gilmore’s Groin Surgery
• Treatment is surgical
• 90% return to sport
• Strengthen lower abdominal
muscles
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
MOB TCD

Anatomy of Nerve Injuries
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Dermatomes
Entrapment of nerves
Pierce muscle
Pierce fascia
Repetitive movements
MOB TCD

Anatomy of Nerve Injuries
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Must know the course of nerve
Dermatomes
Entrapment of nerves
Pierce muscle
Pierce fascia
Repetitive movements
MOB TCD

Dermatomes and Myotomes
• Nerves supply
• Skin
• Muscles (group)
• Tendons
• Bones
• Joints
• Blood vessels
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
MOB TCD

Extrinsic Factors
• Fibrous bands
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Accessory muscles
Spurs
Narrow notches
Anatomical variations of the nerve itself
MOB TCD

Lumbo-Sacral Plexus
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
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
MOB TCD

Cutaneous Nerves of Thigh
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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
MOB TCD

Cutaneous Nerves
MOB TCD

Ilio-Hypogastric Nerve L1
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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
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
MOB TCD

Ilio-Inguinal Nerve
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Ilio-inguinal nerve
L1 branch of lumber plexus
Lateral border of psoas
Anterior to quadratus lumborum
Neurovascular plane between
internal oblique and transversus
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
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
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
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
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
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
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
MOB TCD

Genitofemoral Nerve
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
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
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
MOB TCD

Femoral Nerve L2,3,4
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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
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
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
MOB TCD

Femoral Nerve

Femoral nerve

Saphenous
MOB TCD

Obturator Nerve
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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
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
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
MOB TCD

Anterior Divison Obturator
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Adductor longus
Adductor brevis
Gracilis
It gives an articular twig to the
hip joint
• Skin on the medial side of the
thigh
MOB TCD

Obturator Nerve
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
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
MOB TCD

Obturator Nerve

obturator nerve fascial planes
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
MOB TCD

Obturator Nerve
MOB TCD

Psoas Muscle
MOB TCD

Sacral Plexus
MOB TCD

Pudendal Nerve
MOB TCD

Pudendal Nerve
• Compression of pudendal nerve
in cyclists due to saddle
• History of change of saddle
• Compressing dorsal nerve of
penis
MOB TCD

Psoas Muscle
MOB TCD

Iliacus
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Iliac fossa and iliac crest
Inserts into psoas
Major
Nerve L23
Psoas bursa
MOB TCD

Rectus Femoris Muscle
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Upper half of anterior inferior iliac spine
Area above actetabulum
Inserted into quadriceps tendon
Flexes hip
Extends knee
Femoral nerve
MOB TCD

Hip Joint
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Synovial ball and socket joint
Multiaxial
Three degrees of freedom
Movement in three planes
Close pack extension and
medial rotation
• Least pack semiflexion
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
MOB TCD

Acetabulum
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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
MOB TCD

Articular Surface of Hip Joint
• Semilunar articular surface
covered with hyaline cartilage
• Deepened by labrum
acetabulare
• Wedge shaped fibrocartilage
MOB TCD

Articular Surface
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Head of femur 2/3rd of sphere
Pit for ligamentum teres
Covered with articular cartilage
Cartilage thicker posterior superior
Epiphyseal line for head
intracapsular
MOB TCD

Femur
• Trabeculae develop along lines of
stress
• Calcar femorale is the cortical
bone on inferior aspect of neck
• Neck is cancellous bone
MOB TCD

Capsule of Hip
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Proximally attached
Margins of the acetabular fossa
Base of labrum
Distally, anterior to the
intertrochanteric line
• Inferiorly, femoral neck close to
lesser trochanter
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
MOB TCD

Capsule of Hip
• Strongest superiorly
• Anteromedially, deep fibres
reflected head of rectus femoris
• Iliopsoas is anterior
• Lateral deep fibres of gluteus
minimus
MOB TCD

Retinacular Fibres
• Fibres of capsule reflected
along neck to articular margin
called retinacular fibres
• Blood supply to head run under
retinacular fibres
MOB TCD

Ligaments of Hip
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Labrum acetabulare
Transverse ligament
Ligament of head
Iliofemoral ligament
Pubofemoral ligament
Ischiofemoral ligament
Zona orbicularis
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
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
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
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
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
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
MOB TCD

Bursa Under Glueus Maximus
• Trochanteric bursa
• Posterolateral aspect of
greater trochanter
gluteofemoral
• Vastus lateralis ischial bursa
• Ischial tuberosity
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
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
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
MOB TCD

Nerve Supply
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Femoral nerve
Obturator nerve
Superior gluteal nerve
Nerve to quadratus femoris
Posterior dislocation may
damage sciatic
• Pain in hip referred to knee
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
MOB TCD

Anterior Relations
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Rectus femoris
Adductor longus
Pectineus
Psoas, iliacus
Femoral sheath
Femoral nerve
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
MOB TCD

Lateral Relations
• Gluteus minimus
• Gluteus medius
• Superior gluteal vessels and nerves
between
• Iliotibial tract
• Superficial three quarters of gluteus
maximus
MOB TCD

Posterior Relations
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•

Piriformis
Superior gemellus
Obturator internus
Inferior gemellus
Quadratus femoris
Adductor magnus
Obturator externus
Gluteus maximus
MOB TCD

Movements: Flexion
•
•
•
•
•
•

Limited by anterior abdominal wall
Psoas
Iliacus
Pectineus
Adductor longus and brevis
Rectus femoris
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 °
MOB TCD

Movements: Adduction
•
•
•
•
•

Obturator nerve
Adductor longus
Adductor brevis
Adductor magnus
Can flex or extend depending on
position of hip
MOB TCD

Movements: Abduction
• Gluteus medius
• Gluteus minimus
• Standing on leg, gluteus medius
and minimus abduction
• By preventing adduction
MOB TCD

Movements: Medial Rotation
• Iliopsoas
• Adductors
• Anterior fibres of gluteus medius
MOB TCD

Movements: Lateral Rotation
•
•
•
•
•
•

Obturator internus
Piriformis
Superior gemmelus
Obturator internus
Inferior gemmelus
Quadratus femoris
MOB TCD

Trendelenburg Tests
MOB TCD

Fractured Neck of Femur
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
MOB TCD

Hip Problems
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
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
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
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
MOB TCD

Hip Joint Labral Tear
• Chronic
• Secondary to acetabular dysplasia
• Part of ‘rim lesion’ complex
Renstrom, 2008

•
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
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
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
MOB TCD

Cam Impingement
•
•

Loss of roundness contributes to
abnormal contact between the head and
socket
Male, 20-30 years

Renström, 2008
MOB TCD

Cam Impingement

Renström, 2008
“BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”

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Anatomy of Groin

  • 1.
  • 2. MOB TCD Groin Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin
  • 3. 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
  • 4. 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
  • 5. 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
  • 7. MOB TCD Inguinal Glands • Proximal group parallel to inguinal ligament • Enlarged tender inguinal glands • Part of a generalised lymphadenopathy • Secondaries
  • 8. 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
  • 9. 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
  • 10. 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
  • 11. MOB TCD Anterior Abdominal Wall • • • • Superficial fatty layer Membranous layer of superficial fascia Below umbilicus Continuous with Colles’ fascia in the perineum
  • 12. 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
  • 13. MOB TCD Abdominal Muscles • • • • • • • External oblique Internal oblique Transversus Rectus abdominus Pyramidalis Nerves and vessels Lie between internal oblique and transversus
  • 14. MOB TCD External Oblique • Origin • Outer surfaces lower borders lower eight ribs • Interdigitating serratus anterior • Latissimus dorsi
  • 15. 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
  • 16. 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
  • 17. MOB TCD Insertion – External Oblique • • • • • Pubic crest Gap for superficial ring Pubic bone Linea alba Anterior wall of the rectus sheath • Zyphoid process
  • 18. 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
  • 19. 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
  • 20. 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
  • 21. 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
  • 22. 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
  • 23. 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
  • 24. 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
  • 25. MOB TCD Inguinal Canal • • • • • Intramuscular canal Deep inguinal ring Superficial ring Transmits spermatic cord in male Round ligament in female
  • 26. 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
  • 27. MOB TCD Deep Inguinal Ring • Oval opening 2.5 cm • Above the middle of inguinal ligament • Inferior epigastric artery medial to ring
  • 28. MOB TCD Inguinal Canal • • • • • Anterior wall External oblique Whole anterior wall Lateral half Internal oblique
  • 29. MOB TCD Inguinal Canal • • • • • Posterior wall Transversalis fascia Whole of wall Medial half conjoint tendon Medial quarter, reflected portion of inguinal ligament
  • 30. MOB TCD Roof of Inguinal Canal • Roof • Arching fibres of internal oblique • Transversus as they arise from the inguinal ligament
  • 31. MOB TCD Floor of Inguinal Canal • Floor • Inguinal ligament medial half • Lacunar ligament
  • 32. 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
  • 33. Passing through Superficial Ring Male • • • • • Everything that went through deep ring Plus: Ilioinguinal nerve Internal spermatic fascia Cremaster muscle and fascia MOB TCD
  • 34. 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
  • 35. Passing through Superficial Ring Female • Everything that went through deep ring: • Plus ilioinguinal nerve MOB TCD
  • 36. MOB TCD Inguinal Canal • Contraction of the abdominal muscles increases the obliquity of the inguinal canal • Protecting the two rings Lytle, 1945
  • 37. 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
  • 38. MOB TCD Hernia • Chronic pain in the groin in an athlete • May be due to a hernia or a potential hernia
  • 39. MOB TCD Inguinal Hernia • Sudden severe pain in lower abdomen • Associated with lifting a heavy object • Common history of a direct inguinal hernia
  • 40. 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
  • 41. 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
  • 42. MOB TCD Inguinal Versus Femoral Hernia • Inguinal above and medial to pubic tubercle • Femoral below and lateral
  • 44. MOB TCD Femoral Hernia • Enters through femoral ring • Enters femoral canal • Medial compartment of femoral sheath • More common in women
  • 46. MOB TCD Saphenous Varix • Swelling is soft and diffuse • Empties on minimal pressure • Refills on release • Cough impulse is present
  • 47. 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
  • 48. 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
  • 49. 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
  • 50. 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
  • 51. MOB TCD Gilmore’s Groin Surgery • Treatment is surgical • 90% return to sport • Strengthen lower abdominal muscles
  • 52. 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
  • 53. MOB TCD Anatomy of Nerve Injuries • • • • • Dermatomes Entrapment of nerves Pierce muscle Pierce fascia Repetitive movements
  • 54. MOB TCD Anatomy of Nerve Injuries • • • • • • Must know the course of nerve Dermatomes Entrapment of nerves Pierce muscle Pierce fascia Repetitive movements
  • 55. MOB TCD Dermatomes and Myotomes • Nerves supply • Skin • Muscles (group) • Tendons • Bones • Joints • Blood vessels
  • 56. 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
  • 57. MOB TCD Extrinsic Factors • Fibrous bands • • • • Accessory muscles Spurs Narrow notches Anatomical variations of the nerve itself
  • 59. 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
  • 60. 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
  • 61. 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
  • 63. 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
  • 64. 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
  • 65. 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
  • 66. 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
  • 67. 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
  • 68. 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
  • 69. 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
  • 70. 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
  • 71. 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
  • 72. 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
  • 74. 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
  • 75. 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
  • 76. 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
  • 77. 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
  • 78. 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
  • 79. 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
  • 80. MOB TCD Femoral Nerve Femoral nerve Saphenous
  • 81. 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
  • 82. 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
  • 83. 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
  • 84. 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
  • 86. 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
  • 87. 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
  • 88. MOB TCD Obturator Nerve obturator nerve fascial planes
  • 89. 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
  • 94. MOB TCD Pudendal Nerve • Compression of pudendal nerve in cyclists due to saddle • History of change of saddle • Compressing dorsal nerve of penis
  • 96. MOB TCD Iliacus • • • • • Iliac fossa and iliac crest Inserts into psoas Major Nerve L23 Psoas bursa
  • 97. 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
  • 98. 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
  • 99. 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
  • 100. 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
  • 101. MOB TCD Articular Surface of Hip Joint • Semilunar articular surface covered with hyaline cartilage • Deepened by labrum acetabulare • Wedge shaped fibrocartilage
  • 102. 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
  • 103. MOB TCD Femur • Trabeculae develop along lines of stress • Calcar femorale is the cortical bone on inferior aspect of neck • Neck is cancellous bone
  • 104. 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
  • 105. 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
  • 106. MOB TCD Capsule of Hip • Strongest superiorly • Anteromedially, deep fibres reflected head of rectus femoris • Iliopsoas is anterior • Lateral deep fibres of gluteus minimus
  • 107. MOB TCD Retinacular Fibres • Fibres of capsule reflected along neck to articular margin called retinacular fibres • Blood supply to head run under retinacular fibres
  • 108. MOB TCD Ligaments of Hip • • • • • • • Labrum acetabulare Transverse ligament Ligament of head Iliofemoral ligament Pubofemoral ligament Ischiofemoral ligament Zona orbicularis
  • 109. 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
  • 110. 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
  • 111. 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
  • 112. 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
  • 113. 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
  • 114. 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
  • 115. MOB TCD Bursa Under Glueus Maximus • Trochanteric bursa • Posterolateral aspect of greater trochanter gluteofemoral • Vastus lateralis ischial bursa • Ischial tuberosity
  • 116. 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
  • 117. 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
  • 118. 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
  • 119. 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
  • 120. 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
  • 121. MOB TCD Anterior Relations • • • • • • Rectus femoris Adductor longus Pectineus Psoas, iliacus Femoral sheath Femoral nerve
  • 122. 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
  • 123. MOB TCD Lateral Relations • Gluteus minimus • Gluteus medius • Superior gluteal vessels and nerves between • Iliotibial tract • Superficial three quarters of gluteus maximus
  • 124. MOB TCD Posterior Relations • • • • • • • • Piriformis Superior gemellus Obturator internus Inferior gemellus Quadratus femoris Adductor magnus Obturator externus Gluteus maximus
  • 125. MOB TCD Movements: Flexion • • • • • • Limited by anterior abdominal wall Psoas Iliacus Pectineus Adductor longus and brevis Rectus femoris
  • 126. 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 °
  • 127. MOB TCD Movements: Adduction • • • • • Obturator nerve Adductor longus Adductor brevis Adductor magnus Can flex or extend depending on position of hip
  • 128. MOB TCD Movements: Abduction • Gluteus medius • Gluteus minimus • Standing on leg, gluteus medius and minimus abduction • By preventing adduction
  • 129. MOB TCD Movements: Medial Rotation • Iliopsoas • Adductors • Anterior fibres of gluteus medius
  • 130. MOB TCD Movements: Lateral Rotation • • • • • • Obturator internus Piriformis Superior gemmelus Obturator internus Inferior gemmelus Quadratus femoris
  • 133. 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
  • 135. 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
  • 136. 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
  • 137. 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
  • 138. 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
  • 139. MOB TCD Hip Joint Labral Tear • Chronic • Secondary to acetabular dysplasia • Part of ‘rim lesion’ complex Renstrom, 2008 •
  • 140. 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
  • 141. 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
  • 142. 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
  • 143. MOB TCD Cam Impingement • • Loss of roundness contributes to abnormal contact between the head and socket Male, 20-30 years Renström, 2008
  • 145. “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”

Editor's Notes

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