Dr. kamal kant applied anatomy of hip

PMR PG Teaching

1. Applied Anatomy Of Hip PMR PG Teaching- August 2016 - Dr. Kamal Kant Sain Resident, Deptt. Of PMR SMS Medical College, Jaipur

2. The Hip Joint Type- Ball and socket variety of synovial joint Articular surfaces- The head of femur articulates with acetabulam of hip bone. Largest joint of the body Unique in having high degree of stability as well as mobility.

3. The Acetabulam Horseshoe shaped structure Formed by the pubis ilium and ischium bones Allows the proximal transmission of weight from the axial skeleton to the lower extremity Its development starts by the age of 8yrs and depth incresase in puberty due to development of three secondary centres of ossification It forms lunate articular surface,an acetabular notch and acetabular fossa. A fibrocartilaginous ring called acetabular labrum deepens the acetaulam

4. The Femur Longest bone of the body consists of head,neck and greater and lesser trochenter Head of femur is covered with hyaline cartilage except for fovea capitis which serves as attachment for ligamentum teres. The femoral neck is externally rotated with respect to the shaft and also forms an angle of anteversion/declination. In normal adults neck forms an angle of 135 degree with respect to the shaft. Femoral neck and head is formed by trabecular bone core with thin cortical bone shell.

5. The angle of inclination In normal adults it is 120-135 degree. In coxa valga - >135 degree In coxa vara - <120 degree

6. Joint capsule A cylindrical Sleeve Proximally : Pelvis Laterally : Acetabular labrum and extends laterally to the femoral head Anteriorly : Intertrochanteric line Posterorly : neck of the femur 1cm medial to the intertrochentric crest Both the capsule and the articular cartilage are thicker anterosuperiorly consequently thinner posteroinferiorly Anteerosupeirorly part has maximum tension in the standing posture Supported by muscles and by intra/extra articular ligaments Capsule has circular and longitudional fibres. Circular fibres forms collar around the neck called zona orbicularis Longitudional fibres travels along the neck and carries blood vessels

7. Ligaments of Hip joint It includes- Intraarticular- 1.the ligamentum teres 2.the transverse acetabular liga. 3. the acetabular labrum Extraarticular- 1.the iliofemoral ligament 2.the pubofemoral ligament 3.the ischiofemoral ligament

8. The ligamentum teres Also called round ligament Flat triangular ligament Apex is attach to the fovea capatis and base to the transverse ligament and margins of acetabular notch. It transmits arteries to the head of femur(acetabular branches of obturator and medial circumflex femoral arteries) It tightens during adduction,flexion and external rotation. It prevents subluxation of femoral head superiorly and laterally in adduction and external rotation movements of hip.

9. The transverse acetabular ligament Fibrous link from the inferior acetabular notch that connects the anteroinferior and posteroinferior horns of the semilunar surface of the acetabulum Posterior aspect: bone beneath the lunate surface Anterior aspect: labrum Due to this acetabular notch converted into a foramen which transmits vessel and nerves to the joints.

10. The acetabular labrum It is a fibrocartilaginous rim attached to the margins of acetabulam. It narrows the mouth of acetabulam. Mostly made up of type 1 collagen fibres It helps in holding head of femur in position. It provide stability by creating negative intraarticular pressure in the hip joint. It improve mobility of hip by providing elastic alternative to bony rim.

11. The iliofemoral ligament Also called ligament of bigelow It is inverted Y shaped Strongest ligament of the body Triangular in shape. It consists of 2 parts- inferior(medial) and superior(lateral) Apex is attached to the lower half of the anterior inferior iliac spine and base to the intertrochantric line. It blends with the iliopsoas muscle It limits hyperextension of hip and prevents the trunk from falling backwards in the standing posture.

12. The pubofemoral ligament It supports the joint inferiomedially. It is also triangular in shape Superiorly- attached to iliopubic eminence, the obturator crest and obturator membrane. Inferiorly –merge with the anteroinferior part of the capsule and with the lower band of the iliofemoral ligament. It tightens during extension and abduction.

13. The ischiofemoral ligament It is a weak ligament It covers the joint posteriorly It arises from the posteroinferior margin of the acetabulam rim and passes laterally to the capsule and blends with the zona orbicularis. It tighten with internal rotation of hip It is more commonly injured ligament than other hip ligaments.

14. Muscles producing movements at the hip joint movements chief muscles accessory muscles 1.Flexion Psoas major and iliacus Pectineus,rectus femoris,sartorius and adductor longus 2.Extension Gluteus maximus,biceps femoris,semimembrenosis and semitendinosis Gluteus medius 3.Adduction Adductor longus,brevis magnus Pectineus and gracilis 4.Abduction Glutei medius,minimus,tensor fasciae latae Sartorius, piriformis 5.Medial rotation Tensor fasciae latae and anterior fibres of glutei medius and minimus Adductor longus,brevis,pectineus 6.Lateral rotation Obturator internus,externus,gemellus superior,gemellus inferior,quadratus femoris,gluteus maximus sartorius Piriformis ,biceps femoris

15. Movements Flexion- the head of femur rotates along a transverse axis that passes through the acetabula. It limited by thigh touching the abdomen, the range is 120 degree. Mainly due to contraction of iliopsoas muscles with the help of sartorius,rectus femoris and pectineus muscles.

16. Extension- rotates around the transverse axis It is limited by tension in iliofemoral ligament Range is 20 degree. Mainly due to gluteus maximus muscles with the help of hamstring muscles.

17. Flexion and extension occurs around a transverse axis.range of flexion is 120 degree limited by thigh touching the abdomen and extension is 20 degree,limited by tension in iliofemoral ligament. Abduction and adduction occur around an anteroposterior axis.Adduction is limited by ontact with other leg, range is 30 degree . Abduction is limited by tension in adductors and pubofemoral ligament,range is 60 degree. Medial and lateral rotation occur around vertical axis.range is around 40 degree.

18. Bursae around the hip Iliopsoas bursa Largest and most constant bursa about the hip present in 98% of adult individuals Situated deep to the iliopsoas tendon and serves to cushion the tendon from the structures on the anterior aspect of the hip joint Can become inflamed and distendend MC: RA; can also be associated with athletic activity; overuse and impingement syndromes; OA; pigmented villonodular synovitis; villonodular synovitis, synovial chndromatosis, infection, pseudogout, metastatic bone disease and in rare cases after total hip athroplasty

19. Trochanteric bursa 2 clinical significant trochanteric bursae: one between the gluteus medius and minimus and a superficial one located between the greater trochanter and the TFL; compression and friction of the bursa from an adaptively shortened TFL can result in trochanteric bursitis Ischiogluteal bursa Located between the ischium and the gluteus maximus; can be painfully squeezed between the ischial tuberosity and the hard surface of a chair during sitting, producing an ischial bursitis (weaver’s bottom)

20. Vascular supply Medial and lateral femoral circumflex supplies proximal femur Femoral head is supplied by a small branch off obturator artery Acetabulum is supplied by branches from superior and inferior gluteal arteries

21. Nerve supply Posterior Gluteal Region (Cutaneous) Subcostal nerve Iliohypogastric nerve Posterior Rami of L1-L3 Posterior Primary Rami of S1-S3 Anterior Region (Cutaneous) Iliohypogastric nerve (superior to the inguinal ligament) Subcostal nerve (inferior to the inguinal ligament) Fermal branch of the genitofemoral nerve Ilioinguinal nerve Pain referred from the hip joint may be felt anywhere in the thigh leg or foot

22. Femoral triangle Superior border : Inguinal Ligament Lateral border: Sartorius Muscle Medial border: Adductor longus Muscle

23. Congenital dislocation of hip Head of femur slips upwards on to the gluteal surface of the ilium because of developmentaly deficient upper margin of acetabulam. Lurching gai Trendelenburg test is positive

24. Fracture of neck of femur

25. References Surgical Anatomy Mc Gregar Gray’s Anatomy B. D. Chaurasia Human Anatomy

26. Thanks