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Similar to anatomy of the Hip Joint and clinical significance
anatomy of the Hip Joint and clinical significance
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- 2. OBJECTIVES • Anatomical location,Classification & Articular surfaces • Stability factors • Anatomical relations • Mobility and movements • Blood and nerve supply • Clinical significance
- 3. Introduction • Joints/articulations isany point where two bones meet • Functions of joints: supports the body permits effective movement protects the softer organs • Joints can be:- mobile e.g. shoulder, elbow, and knee less movable e.g. vertebral column Immobile e.g. Bones of the cranium • freely movable joints of the limbs are most severely compromised by disabling diseases such as arthritis.
- 4. Classification of Joints a)functional classification:-focuses on amount of movement allowed. i. synarthroses ;-immovable joints ii. amphiarthroses ;-slightly movable joints iii. diarthroses ; freely movable joints predominantly in limbs b) structural classification • based on: material that binds the bones together presence or absence of a joint cavity. • classified as : Bony joints Fibrous joints Cartilaginous joints Synovial joints
- 5. SYNOVIAL JOINT • Manyare freely movable such as elbow, knee, or knuckles • Others have more limited mobility e.g. wrist and ankle . • Synovial joints are: most structurally complex most likely to develop uncomfortable and crippling dysfunctions. ASWANI CLEVIN
- 6. Classes of SynovialJoints • distinguished by patterns of motion determined by shapes of the articular surfaces of the bones: • multiaxial joint move in any of the three planes E.g. Ball-and- socket • biaxial joint move in two planes e.g. condylar, saddle, and plane • monaxial moves in one plane e.g. hinge and pivot ASWANI CLEVIN
- 7. Hip joint • Synovial,Multiaxial, ball & socket joint • Made of head of femur & cup-shaped acetabulum of the hip bone.
- 8. Acetabulum • c- shapedand formed by all 3 hip bones, ( illium, ischium & pubis). Anteverted and inferiorly inclined • Parts: • Lunate surface: lined with articular cartilage (hyaline) & is articulating suface. • Acetabular fossa; filled with fatty tissue • Atcetabular notch; deficient inferiorly bridged by transverse acetabular ligament. • Acetabular labrum: fibrocartilage rim. • Articular surfaces are lined with cartilage
- 9. Head of femur •Suspended by the neck • Lined with Articular cartilage except the fovea capitis passage of ligamentum teres capitis.
- 10. Radiographic features • Ileopectinealline; anterior column of acetabulum • Ilioischial line; posterior column of acetabulum • tear drop sign formed by acetabulum floor and pelvic • Shenton's line: shows continuity of the inferior femoral neck and inferior margin of the superior pubic ramus
- 11. Important measurement angles •Sharps angle; measures acetabulum inclination.>45° is dysplasia • Tonnis angle; normal 0-10° • Femoral neck-shaft angle;normal 125-145° • Femoral –acetabulum width; distance btwn head & acetabulum
- 12. • Femoral anteversion/tortionangle; angle of anterior diviation of the neck and head of femur.normal 10-15°
- 13. Stability factors ofthe hip joint • They prevent dislocation and limit excessive movements. • Divided in to: – static (bony, capsular and ligaments) – Dynamic (muscular and tendinious)
- 14. a. Static stabilityfactors i. Bony factors • Head & acetabulum fusion, acetabulum labrum deepens the acetabulum enhancing the bony factors • Acetabulum labrum also; – facilitates normal maturation of the acetabulum. – Seals synovial fluid within the hip joint – Enhances the vacuum effect within the hip joint – Has proprioceptive functions; contains receptors creating awareness e.g. standing in darkness
- 15. Acetabulum coverage: Coversabout 75%of the head Measurements of acetabulum coverage: – Lateral center edge(wibergs) angle; measures lateral coverage normal 25-40° – Femoral head extrusion index: less then 25%
- 16. ii. Joint capsule •Encloses the joint and reinforced by ligaments. • Attachments of capsule • Medially - attached to acetabular labrum. • Laterally - attached to intertrochanteric line of femur infront & neck behind. • At the intertrochanteric line some fibers, accompanied by blood vessels, are reflected upward along the neck as bands called retinacula. • These nutrient arteries supply the head & neck of femur & in fracture of femoral neck they tear causing avascular necrosis of the head.
- 17. iii. Ligaments 1- Iliofemoralligament Strongest of all. Attachments Superiorly attached to AIIS above Inferior: 2 limbs of Y - attached to the upper & lower parts of the intertrochanteric line of the femur. Function: prevents hyperextension during standing.
- 18. 2-Pubofemoral ligament It’striangular. Attachments Base - attached to superior pubic ramus Apex - attached below to lower part of the intertrochanteric line. Function - limits extension & abduction
- 19. 3 - Ischiofemoralligament Spiral shaped Attachments attached to ischial body near the acetabular margin. Fibers pass upward & laterally to the greater trochanter. Function - Limits extension
- 20. 4 - Transverseacetabular ligament • Formed by the acetabular labrum • Bridges the acetabular notch in the inferior part to complete the cavity. • Converts the notch into a tunnel through which blood vessels & nerves enter joint
- 21. 5 – Ligamentumteres (Ligament of the head of femur) Flat and triangular. Attachments Apex – attached to pit of femoral head (fovea capitis) Base – attached to transverse ligament & the margins of acetabular notch. Lies within the joint ensheathed by synovial membrane .
- 22. Synovial Membrane • Linesthe capsule & is attached to the margins of the articular surfaces. • Covers part of femoral neck in the joint. • Ensheathes the ligament of femoral head & covers the fat pad in the acetabular fossa. • pouch of the membrane may protrude through a gap in the anterior wall of the capsule btwn pubofemoral and iliofemoral ligaments forming psoas bursa beneath psoas tendon.
- 23. B. Dynamic StabilityFactors • Muscle and tendons surrounding the hip joint – Iliopsoas tendon, anterior to joint and has a bursa between – Obturator externus :below the neck of femur – All other muscles surrounding the hip joint
- 24. Important Relations ofthe joint • Anteriorly: -floor and contents of femoral triangle; Iliopsoas, pectineus & rectus femoris muscles. (Iliopsoas & pectineus separate the femoral vessels and nerve from the joint). • Posteriorly: - Obturator internus, gemelli, & quadratus femoris separate the joint from the sciatic nerve. • Superiorly: - reflected head of rectus femoris, Piriformis and gluteus minimus. • Inferiorly: - pectinius and Obturator externus tendon.
- 25. Nerve Supply • Superiorgluteal n. • Femoral n. • Obturator n. • Sciatic nerves • Nerve to the quadratus femoris.
- 26. Blood supply • MainBranch is PFA • PFA gives LCFA & MCFA which gives rise to two anastomosis a. Cruciate anastomosis formed by: – Transverse branch of LCFA & MCFA – Branch of inferior gluteal artery superiorly – Ascending branch from 1st perforating artery inferiorly
- 27. B. Trochanteric anastomosisat the level of tronchanteric fossa formed by – Ascending branch of LCFA – Superior and inferior gluteal arteries
- 28. • Retinacular arteriesarise from anastomosis and contribute to most of the supply to the head in adults. • Ligamentum teres carpitis has acetabular branch from the obturator artery which is the major blood supply to the head of femur in children. • Nutrient artery also may give blood supply to head of femur
- 29. Movements • Has awide range of movement. • Joint strength depends on shape of the bones involved & strength of ligaments. • When the knee is flexed, flexion is limited by the thigh on the anterior abdominal wall. • When the knee is extended, flexion is limited by the the hamstrings
- 30. Control of movements •Extension is limited by the iliofemoral, pubofemoral & ischiofemoral ligaments. • Abduction - limited by pubofemoral ligament. • Adduction is limited by contact with opposite limb & ligament of femoral head. • Lateral rotation is limited by the iliofemoral and pubofemoral ligaments. • Medial rotation is limited by ischiofemoral lig.
- 31. Movements at thejoint • Flexion - iliopsoas, rectus femoris, sartorius & adductor muscles. • Extension - gluteus maximus & the hamstrings. • Abduction - gluteus medius and minimus, assisted by sartorius, tensor fasciae latae & piriformis • Adduction - adductor longus & brevis & adductor fibers of adductor magnus assisted by pectineus and gracilis.
- 32. Movements cont’d • Lateralrotation - by piriformis, obturator internus and externus, superior & inferior gemelli quadratus femoris & gluteus maximus. • Medial rotation - by anterior fibers of gluteus medius & minimus and tensor fasciae latae. • Circumduction - combination of all the movements. • Extensors are more powerful than flexors & lateral rotators more powerful than the medial rotators.
- 33. Clinical significance Referred PainFrom the Hip Joint • Femoral nerve supplies the hip joint & the skin of front & medial side of the thigh. • Thus pain from the hip joint may be referred to the front and medial side of the thigh. • The posterior division of the obturator nerve supplies both the hip and knee joints. • This is why hip joint disease may give rise to pain in the knee joint.
- 34. Congenital Dislocation ofthe Hip • Stability of the hip joint depends on ball-and-socket arrangement of articular surfaces & ligaments. • In congenital hip dislocation the upper lip of the acetabulum isn’t well developed • The head of the femur having no stable socket to lodge rides up out of the acetabulum onto the gluteal surface of the ilium.
- 35. Traumatic Dislocation ofthe Hip • Its rare because of its stability • It’s usually caused by motor vehicle accidents. • It occurs when the joint is flexed and adducted. • The head of the femur is displaced posteriorly out of the acetabulum • It comes to rest on the gluteal surface of the ilium (posterior dislocation). • The sciatic nerve close to the posterior surface of the joint may be injured.
- 36. Hip Joint Stability& Trendelenburg's Sign • Stability of the hip joint on standing on one leg with the opposite foot raised depends on; 1. The gluteus medius & minimus must be normal. 2. The femur head must fit well in the acetabulum. 3. The neck of the femur must be intact with a normal angle with the shaft of the femur. • If any one of these factors is defective, the pelvis will sink downward on the opposite, unsupported side. • The patient is exhibits a positive Trendelenburg's sign.
- 37. Arthritis of theHip Joint • Patients with inflamed hip joints place the femur in a position giving the least pain. • The position allowing increased joint space to contain the increased synovial fluid. • The joint is partially flexed, abducted, and externally rotated.
- 38. Osteoarthritis • Commonest diseaseof the hip joint in adults. • Causes pain, stiffness and deformity. • The pain is the hip joint or referred to the knee (obturator nerve supplies both joints). • Stiffness is due to pain and reflex spasm of the surrounding muscles. • The deformity is flexion, adduction & external rotation produced initially by muscle spasm but later by muscle contracture.
- 39. Surgical approach tothe hip • Indications – Athrotomy – draining of pus from the hip – Removal of femoral head (dead one) – Total hip replacement • Approaches – Anterior – Antero-lateral – Lateral – posterior
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Editor's Notes
- #8 Triradiate cartilage found in children.it separates the hip bones before fusion. Describe the Acetabulum roof,floor,walls and columns.
- #25 Hiltons law: nerve supplying muscles near joints will give innervation to the joint and skin around it.
- #26 MCFA is the major contributor of blood to the hip joint.
- #40 Smith-Peterson – interval bet sartorius/TFL and Rectus/med-min – true internervous approach. For: open red of congenital dislocations, biopsies, arthrodesis, THA, Hemi, tumor (pelvis)
- #41 Watson-Jones. Intermuscular plane bet TFL and Glut medius. (not a true internervous plane) For: THA, Hemi, ORIF fem neck fx. Iscision 15 cm straight centered on greater troch with leg flexed stightly, adducted