Anatomy of Hip joint

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

3. 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
MOB TCD

4. •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

5. 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
MOB TCD

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

7. •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

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

9. 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
MOB TCD

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

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

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

13. Ligaments of Hip
•Acetabular labrum
•Transverse ligament
•Ligament of head
•Iliofemoral ligament
•Pubofemoral ligaments
•Ischiofemoral ligaments
•Zona orbicularis
MOB TCD

14. •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

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

16. •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 Ligament
MOB TCD

17. 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

18. 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

19. 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
MOB TCD

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

21. 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

22. 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

23. •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

24. •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

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

26. 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

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

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

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

30. 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°
MOB TCD

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

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

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

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

35. Trendelenburg Tests
MOB TCD

36. Fractured Neck of Femur
MOB TCD

37. 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

38. Hip Problems
MOB TCD

39. 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

40. 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

41. 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
MOB TCD

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

43. Hip Joint Labral Tear
•Chronic
•Secondary to acetabular
dysplasia
•Part of “rim lesion” complex
Renström, 2008
MOB TCD

44. Labrum Tears and Cartilage LossLabrum 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
MOB TCD

45. 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
MOB TCD

46. 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
MOB TCD

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

48. P Renstrom 08
Cam Impingement
MOB TCD

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