Anatomy of Hip joint
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Anatomy of Hip joint
- 2. MOB TCD Hip Joint Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin
- 3. 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
- 4. 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
- 5. 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
- 6. MOB TCD Articular Surface of Hip Joint • Semilunar articular surface covered with hyaline cartilage • Deepened by acetabular labrum • Wedge shaped fibrocartilage
- 7. 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
- 8. MOB TCD Femur • Trabeculae develop along lines of stress • Calcar femorale is the cortical bone on inferior aspect of neck • Neck is cancellous bone
- 9. 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
- 10. 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
- 11. MOB TCD Capsule of Hip • Strongest superiorly • Anteromedially, deep fibres reflected head of rectus femoris • Iliopsoas is anterior • Lateral deep fibres of gluteus minimus
- 12. MOB TCD Retinacular Fibres • Fibres of capsule reflected along neck to articular margin called retinacular fibres • Blood supply to head run under retinacular fibres
- 13. MOB TCD Ligaments of Hip • • • • • • • Acetabular labrum Transverse ligament Ligament of head Iliofemoral ligament Pubofemoral ligaments Ischiofemoral ligaments Zona orbicularis
- 14. 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
- 15. 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
- 16. 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
- 17. 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
- 18. 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
- 19. 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
- 20. MOB TCD Bursa Under Gluteus Maximus • Trochanteric bursa • Posterolateral aspect of greater trochanter gluteofemoral • Vastus lateralis ischial bursa • Ischial tuberosity
- 21. 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
- 22. 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
- 23. 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
- 24. 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
- 25. MOB TCD Anterior Relations • • • • • • Rectus femoris Adductor longus Pectineus Psoas and iliacus Femoral sheath Femoral nerve
- 26. 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
- 27. MOB TCD Lateral Relations • Gluteus minimus • Gluteus medius • Superior gluteal vessels and nerves between • Iliotibial tract • Superficial three quarters of gluteus maximus
- 28. MOB TCD Posterior Relations • • • • • • • • Piriformis Superior gemellus Obturator internus Inferior gemellus Quadratus femoris Adductor magnus Obturator externus Gluteus maximus
- 29. MOB TCD Movements: Flexion • Limited by anterior abdominal wall • Psoas • Iliacus • Pectineus • Adductor longus and brevis • Rectus femoris
- 30. 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°
- 31. MOB TCD Movements: Adduction • • • • • Obturator nerve Adductor longus Adductor brevis Adductor magnus Can flex or extend depending on position of hip
- 32. MOB TCD Movements: Abduction • Gluteus medius • Gluteus minimus • Standing on leg, gluteus medius and minimus abduction • By preventing adduction
- 33. MOB TCD Movements: Medial Rotation • Iliopsoas • Adductors • Anterior fibres of gluteus medius
- 34. MOB TCD Movements: Lateral Rotation • • • • • • Obturator internus Piriformis Superior gemmelus Obturator Internus Inferior gemmelus Quadratus femoris
- 36. MOB TCD Fractured Neck of Femur
- 37. 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
- 39. 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
- 40. 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
- 41. 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
- 42. 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
- 43. MOB TCD Hip Joint Labral Tear • Chronic • Secondary to acetabular dysplasia • Part of “rim lesion” complex Renström, 2008
- 44. 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
- 45. 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
- 46. 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
- 47. MOB TCD Cam Impingement • • Loss of roundness contributes to abnormal contact between the head and socket Male, 20-30 years Renström, 2008
- 48. MOB TCD Cam Impingement P Renstrom 08
- 49. “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”
Notas del editor
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