Hip Joint.pptx

The hip joint is the hip bone (fusion of ilium, ischium, and pubis) fused with head of femur
The hip bone forms the bony connection between the sacrum and femur
Hip bone has 3 primary ossification centers which appear at 8wks, 4 mths, 5 mths for the ilium, ischium and pubis respectively.
At birth, these three are separated by a Y shaped cartilage and fusion occurs at age of 18

1. THE HIP JOINT dr ndayisaba corneille

2. Introduction The hip joint is the hip bone (fusion of ilium, ischium, and pubis) fused with head of femur The hip bone forms the bony connection between the sacrum and femur Hip bone has 3 primary ossification centers which appear at 8wks, 4 mths, 5 mths for the ilium, ischium and pubis respectively. At birth, these three are separated by a Y shaped cartilage and fusion occurs at age of 18

3. The hip joint Consists of acetabulum (formed by the ilium, ischium and pubis) and head of femur The acetabulum is partly articular and partly non articular Articular area is shoe shaped occupying anterior, superior and posterior walls Most body weight is transmitted superiorly Inferior has the trans ligament for support Head of femur is more than ½ sphere facing upwards, medially and slightly forwards The proximal and distal surfaces are joined together by a capsular ligament and directly by ligamentum teres

4. The Ilium Comprises the largest part of the hip bone and contributes the superior part of the acetabulum Anteriorly , the ilium has an anterior superior iliac spine and inferior to it an anterior inferior iliac spine. It also has the Iliac crest, Gluteal Line, Posterior superior iliac spine

5. The Ischium Composes the posteroinferior part of the hip bone The superior part of the body of the ischium fuses with the pubis and ilium, forming the posteroinferior aspect of the acetabulum Ramus of the ischium Ischial spine Ischial tuberosity; the body weight rest on this in the sitting position

6. The Pubis Composes the anteromedial part of the hip bone Contributes the anterior part of acetabulum Is divided into a flattened body and two rami, superior and inferior Body of pubis Pubic crest

7. The Acetabulum Is the large cup-shaped cavity or socket on the lateral aspect of the hip bone Articulates with the head of the femur to form the hip joint The Ilium, Ishium, and Pubis join to form the acetabulum

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9. Description of the Hip Joint Multiaxial ball & socket synovial joint Articulation is between head of femur and acetabulum of hip bone The head forms about two thirds of a sphere and articulates with the acetabulum of the hip bone to form the hip joint. In the center of the head is a small depression, called the fovea capitis, for the attachment of the ligament of the head . Part of the blood supply to the head of the femur from the obturator artery is conveyed along this ligament and enters the bone at the fovea.

10. Articular surfaces: Cup-like Acetabulum The weight – bearing area is the wide superior part of the articular surface of the acetabulum. Thus, the ilium bears the weight. Rim of acetabulum defective inferiorly at acetabular notch. Notch is bridged by transverse acetabular ligament (TAL) , creating foramen for passage of nn & vv. Acetabular labrum is a fibrocartilagenous structure that increases the depth of the acetabulum. Labrum attaches to bony rim of acetabulum & TAL above, and inferiorly it clasps the neck of the femur so firmly that it prevents dislocation of head. The real articular surface of the acetabulum is horseshoe-shaped; surronds acetabular fossa (non articular) occupied by fat pad & lined by synovial membrane, hence bone there is thin.

11. Articular Surfaces: Globular Head of Femur Head of femur (HOF) is approximatley 2/3 of a sphere. Covered by hyaline cartilage except over fovea, to which the ligament of head of femur (LOHOF), aka Ligamentum capitis femoris attaches. LOHOF connects HOF to margins of acetabular notch & TAL. LOHOF is weak; its only role is that it contains Artery of head of femur , a branch of Obturator A. It can be torn in posterior dislocation → avascular necrosis.

12. The Articular Capsule of the Hip Joint The fibrous capsule is strong and dense. Proximally: attached to edge of acetabulum, just distal to the acetabular labrum, and to the TAL Distally, attached to neck of femur as follows: - anteriorly to the intertrochanteric line and the root of the greater trochanter -posteriorly to the neck -proximal to the intertrochanteric crest. The fibrous capsule forms a cylindrical sleeve that encloses the hip joint and most of the neck of the femur.

13. Fibrous capsule cont.d Most of its fibers are longitudinal but some deep fibers form a circular collar around the neck of the femur; This constricts the capsule and helps to hold the femoral head in the acetabulum. Some deep longitudinal fibers of the fibrous capsule form retinacula, which are reflected superiorly along the neck of the femur as longitudinal bands that blend with the periosteum. The retinacula contain blood vessels that supply the head and neck of the femur.

14. Fibrous intrinsic ligaments Iliofemoral Ligament: It is on anterior aspect of hip joint. It is inverted Y-shaped and strong; It is attached proximally to the anterior inferior iliac spine (AIIS) and the acetabular rim and distally to the intertrochanteric line of the femur; It has important role in preventing overextension of hip joint during standing (i.e., helps maintain the erect posture; It screws head of femur into acetabulum and thereby maintains the integrity of the joint. ii) Pubofemoral Ligament: It extends from the pubic part of the acetabular rim and the iliopubic eminence to blend with medial part of iliofemoral ligament; It strengthens inferior and anterior parts of the fibrous capsule; It becomes tense during abduction and tends to prevent over-abduction of the thigh at the hip joint.

15. Ligaments cont.d iii Ishiofemoral Ligament It reinforces the fibrous capsule posteriorly; -arises from ischial portion of acetabular rim to the neck of the femur; -tends to screw femoral head medially into acetabulum during extension of the thigh, thereby preventing hyperextension. iv) Ligament of the Head of the Femur Its intracapsular, weak and appears to be of little importance in strengthening the hip joint. It’s attached to the margins of the acetabular notch and to the TAL, and to the fovea or pit in the femur; -contains artery to the head of the femur, a branch of the obturator artery.

16. The Synovial membrane Lines internal surface of fibrous capsule Also- forms sleeve for LOHOF - lines acetabular fossa, covering the fat that fills it. It attaches to the edges of the acetabular fossa and TAL.

17. Anterior ligaments Posterior Hip ligaments

18. Stability of the Hip Joint Strong and stable articulation. Its surrounded by powerful muscles It has dense fibrous capsule, which is strengthened by strong intrinsic ligaments, particularly the iliofemoral ligament which unites the articulating bones. Its stability is largely the result of the adaptation of the articulating surfaces of the acetabulum and the femoral head to each other. Anterior aspect has fewer muscles and strong ligaments. Posterior aspect has stronger muscles and fewer ligaments. Position of weakness is when the hip joint is flexed, adducted and medially rotated

19. Anterior Hip muscles POSTERIOR Hip muscles

20. Muscles and movements The hip muscles act on three mutually perpendicular main axes, all of which pass through the center of the femoral head, resulting in three degrees of freedom and three pairs of principal directions: i ) Flexion and extension around a transverse axis (left-right); ii) Lateral rotation and medial rotation around a longitudinal axis (along the thigh); iii) Abduction and adduction around a sagittal axis (forward-backward) A combination of these movements (i.e. circumduction)

21. Lateral or external rotation This is 30° with the hip extended, 50° with the hip flexed. Muscles involved are: gluteus maximus; quadratus femoris ; obturator internus; dorsal fibers of gluteus medius and minimus ; iliopsoas (including psoas major from the vertebral column);obturator externus; adductor magnus, longus, brevis, and minimus ; piriformis; and sartorius.

22. Medial or internal rotation (40°): anterior fibers of gluteus medius and minimus; tensor fascia latae; the part of adductor magnus inserted into the adductor tubercle; with the leg abducted also the pectineus

23. Extension or retroversion (20°): gluteus maximus (if put out of action, active standing from a sitting position is not possible, but standing and walking on a flat surface is); dorsal fibers of gluteus medius and minimus; adductor magnus; and piriformis. Additionally, the following thigh muscles extend the hip: semimembranosus, semitendinosus, and long head of biceps femoris.

24. Flexion or anteversion (140°): iliopsoas (with psoas major from vertebral column); tensor fascia latae, pectineus, adductor longus, adductor brevis, and gracilis. Thigh muscles acting as hip flexors: rectus femoris and sartorius.

25. Abduction (50° with hip extended, 80° with hip flexed): gluteus medius; tensor fascia latae; gluteus maximus with its attachment at the fascia lata; gluteus minimus; piriformis; and obturator internus.

26. Adduction (30° with hip extended, 20° with hip flexed): adductor magnus, adductor minimus ; adductor longus , adductor brevis , gluteus maximus gracilis pectineus, quadratus femoris ; obturator externus . semitendinosus 29

27. Blood supply to Hip joint Main supply to neck and head of femur is from trochanteric anastomosis; Formed between retinacular artery (branches of medial & lateral circumflex femoral artery branches of femoral artery) & Superior and Inferior gluteal aa. Artery of head of femur, branch of obturator artery.

28. Cruciate anastomosis Formed at the level of the lesser trochanter By anastomosis between internal iliac artery and femoral artery, 1 st perforating artery, Lateral and medial femoral circumflex arteries and Inferior gluteal artery

29. Nerve supply Femoral nerve via nerve to rectus femoris muscle Obturator nerve via its anterior division Sciatic nerve via nerve to quadratus femoris Superior gluteal nerve. A twig from sciatic nerve (occasional). N.B. Four consecutive spinal segments (L2, L3, L4, L5)control the movements of the hip joints as under: L2 and L3 regulate flexion, adduction, and medial rotation. L4 and L5 regulate extension, abduction, and lateral rotation.

30. Clinical Correlates The Neck of the Femur and Coxa Valga and Coxa Vara coxa valga : occurs in cases of congenital dislocation of the hip. In this condition, adduction of the hip joint is limited. coxa vara : occurs in fractures of the neck of the femur and in slipping of the femoral epiphysis. In this condition, abduction of the hip joint is limited. Shenton's line is a useful means of assessing the angle of the femoral neck on a radiograph of the hip region

31. Coxa valga An angle between femoral neck and shaft that is less than 115°; this increases stress on femoral neck. Effects: 1. shortens the limb; 2. decreases the effectiveness of the abductors; 3. increases the load on the femoral neck; 4. reduces the load on the femoral head.

32. Coxa vara An angle between femoral neck and shaft greater than 140°; This increases pressure into the joint This: 1. lengthens the limb; mimics contracture of the hip abductors; reduces the load on the femoral neck; increases the load on the femoral head.

33. Subcapital Common in elderly – osteoporotic bones. Characteristic features – lateral rotation & shortening of limb due to superior pull of muscles due to spasms. Disruption of blood flow → risk of avascular necrosis

34. Trochanteric fractures Commonly occurs in the young and middle-aged as a result of direct trauma. The fracture line is extracapsular, and both fragments have a profuse blood supply. If the bone fragments are not impacted, the pull of the strong muscles will produce shortening and lateral rotation of the leg.

35. Referred pain from hip disease to knee. Knee also supplied by femoral, sciatic, and obturator nerves. Congenital hip dislocation. Hypoplasia of acetabulum and head of femur. Affected limb is shorter and unable to abduct. Acquired dislocation rare because joint is strong & stable. May occur in RTA when hip is flexed, adducted, & medially rotated, & knee strikes dashboard. Head of femur pops out through posterior tear in capsule. Often, acetabular

36. Arthritis of the Hip Joint The head of the femur that is, that part that is not intra-acetabular can be palpated on the anterior aspect of the thigh just inferior to the inguinal ligament and just lateral to the pulsating femoral artery. Tenderness over the head of the femur usually indicates the presence of arthritis of the hip joint. Dislocation may occur. 40

37. Sciatic nerve (L4-S3) closely related to posterior aspect of hip joint, lying just below piriformis muscle, and exiting pelvis with it through greater sciatic foramen. May be injured in subcapital dislocations. Signs : paralysis of hamstrings & leg & foot, sensory changes in skin over posterior & lateral aspects of leg. Piriformis syndrome – sciatica due to inflammed piriformis.

38. Angle of torsion cAnteversion >15 b a Normal 12 o -14 o Normal 12 -14

39. SURGICAL RELEVANCE HIP REPLACEMENT BIOPSY GIRDLESTONE

40. REDUCTION OF POST DISLOCATION 44

41. Other causes of Hip Pain Trochanteric Bursitis Tendonitis Osteonecrosis Lumbar pain- referred symptoms Snapping hip syndrome Muscles strains Childhood hip problems Developmental dysplasia Legg-calve-perthes disease

42. Treatments Rest Ice and heat application Stretching Physical Therapy Anti-inflammatory Medications Hip Replacement

43. Hip Replacement First performed in 1960 More than 193,000 total hip replacements each year Beneficial if: Hip pain limits activities of daily living like walking or bending Hip pain continues while resting, either day or night Stiffness in hip limits mobility Little relief from medications No relief after physical therapy or use of gait aid such as a cane

44. Hip Replacement Surgery Admission into hospital General anesthesia or spinal anesthesia Usually takes a few hours Process- removal of damaged cartilage and bone, then position new metal, plastic, or ceramic joint surfaces to restore alignment and function. A ball and socket component is used. Surgical cement may be used to fill the gap between prosthesis and remaining bone to secure the new joint In younger- more active patients, non-cemented prosthesis so the bone can grow into the prosthesis.

45. END BY DR NDAYISABA CORNEILLE MBChB,DCM,BCSIT,CCNA,Cyber Security contact: [email protected] , [email protected] tel :[phone] THANKS FOR LISTENING