hip joint bmj
TRANSCRIPT
-
7/28/2019 Hip Joint BMJ
1/49
-
7/28/2019 Hip Joint BMJ
2/49
MOB TCD
Hip Joint
Professor Emeritus Moira OBrien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
-
7/28/2019 Hip Joint BMJ
3/49
Hip Joint
Synovial ball and socketjoint
Multiaxial
Three degrees of freedom
Movement in three planes Close pack extension and
medial rotation
Least pack semiflexion
MOB TCD
-
7/28/2019 Hip Joint BMJ
4/49
One of most stable joints inthe body
Articular surface of hip joint
are reciprocally curved
Superior surface of femur andacetabulum sustain greatest
pressure
Hip JointMOB TCD
-
7/28/2019 Hip Joint BMJ
5/49
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
-
7/28/2019 Hip Joint BMJ
6/49
Articular Surface of Hip Joint
Semilunar articular surfacecovered with hyaline
cartilage
Deepened by acetabular
labrum Wedge shaped fibrocartilage
MOB TCD
-
7/28/2019 Hip Joint BMJ
7/49
Head of femur 2/3rd
of sphere Pit for ligamentum teres
Covered with articular cartilage
Cartilage thicker posterior superior
Epiphyseal line for headintracapsular
Articular SurfaceMOB TCD
-
7/28/2019 Hip Joint BMJ
8/49
Femur
Trabeculae develop along linesof stress
Calcar femorale is the cortical
bone on inferior aspect of neck
Neck is cancellous bone
MOB TCD
-
7/28/2019 Hip Joint BMJ
9/49
Capsule of Hip
Proximally attached Margins of the acetabular
fossa
Base of labrum
Distally, anterior to theintertrochanteric line
Inferiorly, femoral neck close
to lesser trochanter
MOB TCD
-
7/28/2019 Hip Joint BMJ
10/49
Posterior Free border, fingers breath
from trochanteric crest due
to insertion of obturator
externus Into trochanteric fossa and
Root greater trochanter
Capsule of Hip
MOB TCD
-
7/28/2019 Hip Joint BMJ
11/49
Strongest superiorly Anteromedially, deep fibres
reflected head of rectus
femoris
Iliopsoas is anterior Lateral deep fibres of gluteus
minimus
Capsule of Hip
MOB TCD
-
7/28/2019 Hip Joint BMJ
12/49
Retinacular Fibres
Fibres of capsule reflected alongneck to articular margin called
retinacular fibres
Blood supply to head run under
retinacular fibres
MOB TCD
-
7/28/2019 Hip Joint BMJ
13/49
Ligaments of Hip
Acetabular labrum Transverse ligament
Ligament of head
Iliofemoral ligament
Pubofemoral ligaments
Ischiofemoral ligaments
Zona orbicularis
MOB TCD
-
7/28/2019 Hip Joint BMJ
14/49
Transverse ligament is part ofthe labrum
Ligamentum teres is
triangular, its base is attached
to transverse ligament, andthe 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 HipMOB TCD
-
7/28/2019 Hip Joint BMJ
15/49
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
-
7/28/2019 Hip Joint BMJ
16/49
One of strongestligaments in body
Tightens in extension
Helps maintain erect
posture Facet on anterior aspect
of neck
Prevents hyperextension
Fulcrum reducing hip
Iliofemoral LigamentMOB TCD
-
7/28/2019 Hip Joint BMJ
17/49
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
-
7/28/2019 Hip Joint BMJ
18/49
Ischiofemoral Ligament
Ischium to posterior part ofjoint (weak)
Circular fibres called zona
orbicularis
Centre of gravity in front ofhead
Synovial under obturator
externus
MOB TCD
-
7/28/2019 Hip Joint BMJ
19/49
Synovial Membrane
Lines inner portion of capsuleand non articular structures
Ligament of head
Fat in acetabular fossa
May communicate with psoasbursa
Bursa under obturator
externus
MOB TCD
-
7/28/2019 Hip Joint BMJ
20/49
Bursa Under Gluteus Maximus
Trochanteric bursa Posterolateral aspect of
greater trochanter
gluteofemoral
Vastus lateralis ischial bursa Ischial tuberosity
MOB TCD
-
7/28/2019 Hip Joint BMJ
21/49
Blood Supply to Head of Femur
Child, obturator artery vialigamentum teres supplies
epiphysis
Elderly, main supply via
retinacular vessels from
trochanteric and cruciate
anastamoses
Medial and lateral circumflex
femoral vessels
MOB TCD
-
7/28/2019 Hip Joint BMJ
22/49
Blood Supply
Superior gluteal supplies the upperpart of the acetabulum
Inferior gluteal supplies the inferior
and posterior and the capsule
Transverse and ascendingbranches of lateral circumflex
femoral artery
Transverse and ascending branch
of medial circumflex femoral Cruciate and trochanteric
anastomosis
MOB TCD
-
7/28/2019 Hip Joint BMJ
23/49
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 SupplyMOB TCD
-
7/28/2019 Hip Joint BMJ
24/49
Femoral nerve
Obturator nerve
Superior gluteal nerve
Nerve to quadratus femoris
Posterior dislocation maydamage sciatic
Pain in hip referred to knee
Nerve SupplyMOB TCD
MOB TCD
-
7/28/2019 Hip Joint BMJ
25/49
Anterior Relations
Rectus femoris Adductor longus
Pectineus
Psoas and iliacus
Femoral sheath
Femoral nerve
MOB TCD
MOB TCD
-
7/28/2019 Hip Joint BMJ
26/49
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
MOB TCD
-
7/28/2019 Hip Joint BMJ
27/49
Lateral Relations
Gluteus minimus Gluteus medius
Superior gluteal vessels and
nerves between
Iliotibial tract Superficial three quarters of
gluteus maximus
MOB TCD
MOB TCD
-
7/28/2019 Hip Joint BMJ
28/49
Posterior Relations
Piriformis Superior gemellus
Obturator internus
Inferior gemellus
Quadratus femoris Adductor magnus
Obturator externus
Gluteus maximus
MOB TCD
MOB TCD
-
7/28/2019 Hip Joint BMJ
29/49
Movements: Flexion
Limited by anterior abdominalwall
Psoas
Iliacus
Pectineus Adductor longus and brevis
Rectus femoris
MOB TCD
MOB TCD
-
7/28/2019 Hip Joint BMJ
30/49
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
MOB TCD
-
7/28/2019 Hip Joint BMJ
31/49
Obturator nerve Adductor longus
Adductor brevis
Adductor magnus
Can flex or extend dependingon position of hip
Movements: AdductionMOB TCD
MOB TCD
-
7/28/2019 Hip Joint BMJ
32/49
Gluteus medius Gluteus minimus
Standing on leg, gluteus medius and
minimus abduction
By preventing adduction
Movements: AbductionMOB TCD
MOB TCD
-
7/28/2019 Hip Joint BMJ
33/49
Iliopsoas Adductors
Anterior fibres of gluteus medius
Movements: Medial RotationMOB TCD
MOB TCD
-
7/28/2019 Hip Joint BMJ
34/49
Obturator internus Piriformis
Superior gemmelus
Obturator Internus
Inferior gemmelus
Quadratus femoris
Movements: Lateral Rotation
MOB TCD
-
7/28/2019 Hip Joint BMJ
35/49
Trendelenburg Tests
MOB TCD
-
7/28/2019 Hip Joint BMJ
36/49
Fractured Neck of Femur
MOB TCD
-
7/28/2019 Hip Joint BMJ
37/49
Hip Problems in Children
Apophysitis
Avulsion fractures
After 13 years
11-40% of all hip and pelvic fracturesBoyd et al., 1997
Anterior superior iliac spine
Anterior inferior iliac spine
Ischial tuberosity commonest
MOB TCD
-
7/28/2019 Hip Joint BMJ
38/49
Hip Problems
MOB TCD
-
7/28/2019 Hip Joint BMJ
39/49
Pain in a Child
5-10 year old child
Aching pain in hip
Limp
Limitation of movement
Perthes Osteochondritis of head of femur
MOB TCD
-
7/28/2019 Hip Joint BMJ
40/49
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
-
7/28/2019 Hip Joint BMJ
41/49
Femoral Anteversion
Femoral version is the angular difference between axis
of femoral neck and transcondylar axis of the knee
Femoral anteversion ranges from 30 - 40 at birth
Decreases progressively 15 at skeletal maturation
Adults
Anteversion
Average of 8 in men and 14 in women
Most common cause of in-toeing
If associated with internal tibial torsion, may lead topatellofemoral subluxation due to an increase in the
Q-angle
MOB TCD
-
7/28/2019 Hip Joint BMJ
42/49
Tumors and Neoplasms
Young, healthy athletes do get cancer!
Fortunately most tumors are benign!
Bone pain at night
Tumor till proved otherwiseRenstrm, 2008
MOB TCD
-
7/28/2019 Hip Joint BMJ
43/49
Hip Joint Labral Tear
Chronic
Secondary to acetabulardysplasia
Part of rim lesion complexRenstrm, 2008
MOB TCD
-
7/28/2019 Hip Joint BMJ
44/49
Labrum Tears and Cartilage LossLabrum Tears and Cartilage Loss
Labrum tears and cartilage loss arecommon 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
diagnosisBurnett et al., J Bone Joint Surg (Am), 2006
MOB TCD
-
7/28/2019 Hip Joint BMJ
45/49
MR-Arthrography (MRA)
MR arthrogram has an
accuracy of 91% for labral
tearsChan et al, Arthroscopy 2005
Sensitivity labral tear
MR 25%, MRA 92%
Toomayan et al., Am J Roentgenol 2006
MOB TCD
-
7/28/2019 Hip Joint BMJ
46/49
Pincer Impingement
The acetabulum covers too much of thefemoral head
Secondary to retroversion, of thesocket
Or a profunda socket that is too deep
Most of the time the cam and pincerforms exist together
Female, 30-40 yearsRenstrm, 2008
MOB TCD
-
7/28/2019 Hip Joint BMJ
47/49
Loss of roundness contributes toabnormal contact between the head andsocket
Male, 20-30 yearsRenstrm, 2008
Cam Impingement
MOB TCD
-
7/28/2019 Hip Joint BMJ
48/49
P Renstrom 08
Cam Impingement
-
7/28/2019 Hip Joint BMJ
49/49
BMJ Publishing Group Limited (BMJ Group) 2012. All rights reserved.