Anatomy of Groin

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

3. 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

4. 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
MOB TCD

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

6. Cutaneous Nerves
MOB TCD

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

8. •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
Inguinal Glands
MOB TCD

9. •Lower five intercostal nerves
•Subcostal nerve T12
•10
th
intercostal nerve

is at the level of
the umbilicus
•Iliohypogastric nerve L1
•Ilioinguinal nerve L1
Skin of Anterior Abdominal Wall
MOB TCD

10. •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
Cutaneous Nerves of Thigh
MOB TCD

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

12. •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
Blood Supply and Lymphatics
MOB TCD

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

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

15. •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
Insertion – External Oblique
MOB TCD

16. •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
Inguinal and Lacunar Ligaments
MOB TCD

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

18. •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
Internal Oblique
MOB TCD

19. •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
Insertion – Internal Oblique
MOB TCD

20. •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
Internal Oblique – Conjoint Tendon
MOB TCD

21. •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
Transversus Abdominus
MOB TCD

22. •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
Insertion – Transversus Abdominus
MOB TCD

23. •Segmental muscle
•Two heads
•Anterior pubic symphysis
•Pubic crest
•Inserted anterior aspect
of 5,6,7
th
costal cartilages
•Adhesions anterior
•Segmental blood and
nerve supply from
intercostals
Rectus Abdominus
MOB TCD

24. •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
Transversalis Fascia
MOB TCD

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

26. •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
Superficial Inguinal Ring
MOB TCD

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

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

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

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

31. •Floor
•Inguinal ligament
medial half
•Lacunar ligament
Floor of Inguinal Canal
MOB TCD

32. •Vas deferens
•Testicular artery
•Pampiniform plexus of veins
•Remains of processus vaginalis
•Genital branch of genitofemoral nerve
•Lymphatics from testes
•Cremaster artery
Passing through Deep Ring
Male
MOB TCD

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

34. •Round ligament of uterus
•Remains of processus vaginalis
•Genital branch of genitofemoral
nerve
•Lymphatics from uterus, region of
cornu
Passing through Deep Ring
Female
MOB TCD

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

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

37. •Pain aggravated by an increase in
intraabdominal pressure
•Hernia
•Inguinal or femoral hernia
•Entrapment of the ilioinguinal nerve
Increase in
Intra Abdominal Pressure
MOB TCD

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

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

40. •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
Indirect Inguinal Hernia
MOB TCD

41. •Direct inguinal hernia
•Enters through posterior wall of the
inguinal canal
•Leaves through superficial inguinal ring
•Above and medial to pubic tubercle
Direct Inguinal Hernia
MOB TCD

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

43. Femoral Ring
MOB TCD

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

45. Femoral Hernia
MOB TCD

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

47. •Common cause of chronic groin
pain in field sports
•Particularly soccer players
•Pain on any sudden change of
movement, sneezing, coughing
Gilmore’s Groin
MOB TCD

48. •Trying to sprint will increase the pain
•Pain is worse getting out of bed the
day after a match or a training
session
Gilmore’s Groin
MOB TCD

49. •Pain is increased by external
rotation
•Or hyperextension of hip
•Pain is localised to lower
anterior abdominal wall
•Adductor or perineal region
Gilmore’s Groin
MOB TCD

50. •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
Gilmore’s Groin
MOB TCD

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

52. 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
Gilmore’s Groin Surgery
MOB TCD

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

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

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

56. •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
Extrinsic Factors
MOB TCD

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

58. Lumbo-Sacral Plexus
MOB TCD

59. •Affects branches of lumbar or
sacral plexuses
•Pierces muscle
•Pierces fascia
•Increase in compartment
pressure
•Compressed by external
pressure
Entrapment Syndromes
in Lower Limb
MOB TCD

60. •Lower five intercostal nerves
•Subcostal nerve T12
•10
th
intercostal nerves at the level of
the umbilicus
•Iliohypogastric nerve L1
•Ilioinguinal nerve L1
Skin of Anterior Abdominal Wall
MOB TCD

61. •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
Cutaneous Nerves of Thigh
MOB TCD

62. Cutaneous Nerves
MOB TCD

63. •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
Ilio-Hypogastric Nerve L1
MOB TCD

64. •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
Ilio-Hypogastric Nerve
MOB TCD

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

66. •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
Ilio-Inguinal Nerve
MOB TCD

67. •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
Ilio-Inguinal Nerve
MOB TCD

68. •Pain increased
•Increased tension in the anterior
abdominal wall
•Hyperextension of hip
•Tenderness 4 cm medial to anterior
superior iliac spine
Ilio-Inguinal Nerve Entrapment
MOB TCD

69. •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
CutaneousNerves
MOB TCD

70. •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
Genitofemoral Nerve
MOB TCD

71. •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
Femoral Branch Genitofemoral
MOB TCD

72. •Union with ilioinguinal nerve on
anterior aspect of spermatic cord
•Supplies ventral aspect of scrotum
and adductor region
•Cutaneous branch on the dorsal-
caudal aspect
•May also supply dorsal scrotum
Akita et al., 1999
Genitofemoral Nerve
MOB TCD

73. Genitofemoral Nerve
MOB TCD

74. •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
Lateral Cutaneous Nerve
MOB TCD

75. •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
Lateral Cutaneous Nerve of Thigh
MOB TCD

76. •Entrapment in the fascial tunnel
•Injured in the thigh by asymmetric bars
in gymnastics
•Causes meralgia paraesthetica
•Post laparoscopic surgery
Lateral Cutaneous Nerve of Thigh
MOB TCD

77. •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
Femoral Nerve L2,3,4
MOB TCD

78. 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
Femoral Nerve
MOB TCD

79. •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
Femoral Nerve
MOB TCD

80. Femoral nerve
Saphenous
Femoral Nerve
MOB TCD

81. •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
Obturator Nerve
MOB TCD

82. •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
Obturator Nerve
MOB TCD

83. •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
Anterior Divison Obturator
MOB TCD

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

85. Obturator Nerve
MOB TCD

86. •It may be entrapped as it leaves the pelvis
•Pierces and supplies the obturator externus
•Causing spasm of the adductor muscles
Posterior Divison Obturator
MOB TCD

87. •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
Posterior Divison Obturator
MOB TCD

88. obturator nerve fascial planes
Obturator Nerve
MOB TCD

89. •Pressure on obturator nerve
•Pain on inner aspect of thigh
relieved by flexion of hip
•Increased by extension,
adduction and medial rotation
Howship Rhomberg Sign
MOB TCD

90. Obturator Nerve
MOB TCD

91. Psoas Muscle
MOB TCD

92. Sacral Plexus
MOB TCD

93. Pudendal Nerve
MOB TCD

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

95. Psoas Muscle
MOB TCD

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

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

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

99. •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
Hip Joint
MOB TCD

100. •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
Acetabulum
MOB TCD

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

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

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

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

105. •Posterior
•Free border, finger’s breadth
from trochanteric crest due to
insertion of obturator externus
•Into trochanteric fossa and
•Root greater trochanter
Capsule of Hip
MOB TCD

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

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

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

109. •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
Ligaments of Hip
MOB TCD

110. •Thickening of capsule
•Lower half of anterior inferior
iliac spine and adjoining
acetabulum
•Distally
•Upper and lower parts of
inter trochanteric line
Iliofemoral Ligaments
MOB TCD

111. •One of strongest ligaments in
body
•Tightens in extension
•Helps maintain erect posture
•Facet on anterior aspect of
neck
•Prevents hyperextension
•Fulcrum reducing hip
Iliofemoral Ligaments
MOB TCD

112. •Superior pubic ramus
•Inferior part of inter trochanteric
line and upturned part
•Relatively weak
•Prevents abduction
•Bursa between it and iliofemoral
Pubofemoral Ligament
MOB TCD

113. •Ischium to posterior part of
joint (weak)
•Circular fibres called zona
orbicularis
•Centre of gravity in front of
head
•Synovial under obturator
externus

Ischiofemoral Ligament
MOB TCD

114. •Lines inner portion of capsule
and nonarticular structures
•Ligament of head
•Fat in acetabular fossa
•May communicate with psoas
bursa
•Bursa under obturator externus
Synovial Membrane
MOB TCD

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

116. •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
Blood Supply to Head of Femur
MOB TCD

117. •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
Blood Supply
MOB TCD

118. •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
Blood Supply
MOB TCD

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

120. •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
Stability of Hip
MOB TCD

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

122. •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
Inferior and Posterior Relations
MOB TCD

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

124. •Piriformis
•Superior gemellus
•Obturator internus
•Inferior gemellus
•Quadratus femoris
•Adductor magnus
•Obturator externus
•Gluteus maximus
Posterior Relations
MOB TCD

125. •Limited by anterior abdominal wall
•Psoas
•Iliacus
•Pectineus
•Adductor longus and brevis
•Rectus femoris
Movements: Flexion
MOB TCD

126. •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 °
Movements: Extension
MOB TCD

127. •Obturator nerve
•Adductor longus
•Adductor brevis
•Adductor magnus
•Can flex or extend depending on
position of hip
Movements: Adduction
MOB TCD

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

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

130. •Obturator internus
•Piriformis
•Superior gemmelus
•Obturator internus
•Inferior gemmelus
•Quadratus femoris
Movements: Lateral Rotation
MOB TCD

131. Trendelenburg Tests
MOB TCD

132. Fractured Neck of Femur
MOB TCD

133. •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
Hip Problems in Children
MOB TCD

134. Hip Problems
MOB TCD

135. •5-10 year old child
•Aching pain in hip
•Limp
•Limitation of movement
•Perthe’s
•Osteochondritis of head of femur
Pain in a Child
MOB TCD

136. •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
Stability of Hip
MOB TCD

137. •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
Femoral Anteversion
MOB TCD

138. •Young, healthy athletes
do get cancer!
•Fortunately most tumors
are benign!
•Bone pain at night
•Tumor till proved
otherwise
Renstrom, 2008
Tumors and Neoplasms
MOB TCD

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

140. •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
Labrum Tears and Cartilage Loss
MOB TCD

141. •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
MR – Arthrography (MRA)
MOB TCD

142. •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
Pincer Impingement
MOB TCD

143. •Loss of roundness contributes to
abnormal contact between the head and
socket
•Male, 20-30 years
Renström, 2008
Cam Impingement
MOB TCD

144. Renström, 2008
Cam Impingement
MOB TCD

145. “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”