dr. s. nishan silva (mbbs). parts and regions of the lower limb gluteal region － between iliac...

Dr. S. Nishan Silva(MBBS)

Parts and regions of the lower limb

Gluteal region － between iliac crest superiorly and gluteal fold inferiorly

Thigh － between hip and kneeknee － joint between leg and

thighLeg － between knee and footAnkleFoot

Frolich, Human Anatomy, Lower LImb

Joints of Lower Limb

Hip (femur + acetabulum) Ball + socket Multiaxial Synovial

Knee (femur + patella) Plane Gliding of patella Synovial

Knee (femur + tibia) Hinge Biaxial Synovial

Frolich, Human Anatomy, Lower LImb

Joints of Lower Limb

Proximal Tibia + Fibula Plane Gliding Synovial

Distal Tibia + Fibula Slight “give” Fibrous

Ankle (Tibia/Fibula + Talus) Hinge Uniaxial Synovial

pg 218

Frolich, Human Anatomy, Lower LImb

Lower Limb MovementsHip

Flexion/extensionAbduction/adductionLateral/medial rotation

KneeFlexion/extension

AnkleDorsiflexion/

plantarflexionInversion/eversion

ToesFlexion/extension

Bending on posterior side is flexion (except hip)

Bending on anterior sided is extension (except hip)

Surface anatomy of lower limb

Gluteal region and thighanterior superior and inferior iliac spines

tubercle of iliac crestischial tuberositygreater trochanterpubic tuberclepubic crestsuperior border of pubic symphysis

Frolich, Human Anatomy, Lower LImb

Surface Anatomy: Posterior Pelvis

Iliac crestGluteus maximus = cheeksNatal/gluteal cleft = crackGluteal folds = bottom of

cheek

pg 789

12-9

Surface Anatomy of the Lower Limb Gluteus maximus muscle Gluteus medius muscle Gluteal cleft Gluteal fold Ischeal tuberosity Greater trochanter

Nelaton’s line

a line drawn from the anterior superior lilac spine to the ischial tuberosity, passing over or near the top of the greater trochanter. The trochanter can be felt superior to this line in a person which a dislocated hip or a fractured femoral neck.

Hip - AnatomyMultiaxial ball & socket jointAcetabulum

1/2 sphereFemoral head

2/3 sphereStrong ligaments & capsuleMaximally stable

AnatomyForcesStanding - 0.3 times body weightStanding on 1 leg - 2.5 times body weightWalking - 1.3 to 5.8 times body weightWalking up stairs - 3 times body weightRunning - 4.5+ times body weight

•Flexion and Extension

•Abduction and Adduction

•External Rotation and Internal Rotation.

Bony AnatomyFemur

Femoral HeadFemoral NeckGreater TrochanterLesser TrochanterIntertrochanteric

CrestIntertrochanteric

LineGluteal Tuberosity

Bony AnatomyPelvic Girdle

Acetabulum3 bones fused

together Ilium

Iliac fossa Iliac Crest ASIS AIIS PSIS PIIS Gluteal Lines Greater Sciatic Notch

Lateral View

Bony AnatomyIlium

Iliac fossaIliac CrestIliac TuberosityASISAIISPSISPIISGluteal Lines

Medial View

Bony AnatomyIliumIshium

Ramus of ishiumIshial tuberosityIshial spineLessor Sciatic Notch

Bony AnatomyIliumIshiumPubis

Superior Ramus of Pubis

Inferior Ramus of Pubis

Pubic CrestPubic TuberclePectinSymphyseal Surface

AnatomyLigaments

Iliofemoral ligament (Y ligament of Bigelow) Reinforces anterior joint

capsule (limits hyperextension)

Keeps us uprightPubofemoral ligament

Limits abduction & hyperextension

Inguinal ligament Runs from ASIS to pubic

symphysis Superior border of

femoral triangle

Anatomical Components:1. Articular Capsule2. Acetabular labrum3. Ligaments:

IliofemoralIliofemoral PubofemoralPubofemoral IschiofemoralIschiofemoral Ligament of the head of the femurLigament of the head of the femur Transverse ligament of the acetabulum Transverse ligament of the acetabulum

Added

Anterior view

Posterior view

Medial view with acetabular floor

removed

Anterior view with capsule removed

Ligamentous and Cartilogenous Structures for the Hip and Pelvic Girdle

Sacroiliac JointSacrotuberousSacrospinousFunction of these

two ligamentsIliolumbar Interosseous

Sacroiliac

Ligamentous and Cartilogenous Structures for the Hip and Pelvic Girdle

Sacroiliac JointSacrotuberousSacrospinousFunction of these

two ligamentsIliolumbar Interosseous

Sacroiliac

Ligamentous and Cartilogenous Structures for the Hip and Pelvic Girdle

Sacroiliac JointSacrotuberousSacrospinousFunction of these

two ligamentsIliolumbar Interosseous

SacroiliacDorsal Sacroiliac

Ligamentous and Cartilogenous Structures for the Hip and Pelvic Girdle

Sacroiliac JointHip Joint

CapsuleThree thickenings

of the capsule Iliofemoral Pubofemoral Ishiofemoral

Ligamentum TeresInguinal

Ligamentous and Cartilogenous Structures for the Hip and Pelvic Girdle

Sacroiliac JointHip Joint

CapsuleThree thickenings

of the capsule Iliofemoral Pubofemoral Ishiofemoral

Ligamentum TeresInguinal

Ligamentous and Cartilogenous Structures for the Hip and Pelvic Girdle

Sacroiliac JointHip Joint

CapsuleThree thickenings

of the capsule Iliofemoral Pubofemoral Ishiofemoral

Ligamentum TeresInguinal

AP HIP

ACETABLUMFEMORAL HEAD

GREATERTROCHANTER

LESSER TROCHANTER

FEMORAL NECK

CORTICAL BONE

MEDULLARY BONE

FOVEA CAPITIS

CORONAL MRI

RT. HIP

Coxa vara (abnormally decreased angle of inclination, it occurs in fractures of the neck of the femur and slipping of the femoral epiphysis )

Coxa valga (abnormally increased angle of inclination, in cases of congenital dislocation of the hip)

Normal angle of inclination 1250-1300

Coxa VaraCoxa Valga

ANGLE OF INCLINATION

Articulations of the Hip and PelvisPubic Symphysis

Interpubic diskSome movement

Articulations of the Hip and PelvisPubic SymphysisSacroiliac Joints

Articulations of the Hip and PelvisPubic SymphysisSacroiliac JointsHip Joints

Ligamentous and Cartilogenous Structures for the Hip and Pelvic Girdle

Sacroiliac JointHip Joint

CapsuleThree thickenings

of the capsule Iliofemoral Pubofemoral Ishiofemoral

Ligamentum TeresInguinal

ButtockSupericialGluteus MaximusGluteus Medius – reverse actionGluteus MinimusTensor Fascia Latae – iliotibial band,

functional considerations“Gower’s” SignPositive Trendelenburg

Gluteus Maximus

Gluteus Medius and Minimus

G Med., G Min, TFL

Trendelenburg

Deep Buttocks“External Rotators of the Hip”Small Muscles Mostly attach near or on greater trochanterExcellent mechanical advantage for 1)

producing external rotation and 2) to help maintain stability of the hip

All but one innervated by named nerves specific to one or two of them

The exception is the obturator externus – innervated by posterior brach of obturator n.

Deep ButtockMuscles:PiriformisSuperior GemellusObturator InternusInferior GemellusQuadratus FemorisObturator Externus

Deep Muscles of Buttocks

Hip MusclesAnterior

Rectus FemorisSartoriusIliopsoas Muscle

Group Iliacus Psoas Major

Hip MusclesAnterior

Rectus FemorisSartoriusIliopsoas Muscle

Group Iliacus Psoas Major

Hip MusclesPosterior

SemimembranosusSemitendinosusBiceps FemorisGluteus Maximus

Hip MusclesMedial

Adductor BrevisAdductor LongusAdductor MagnusPectineusGracilus

Hip MusclesLateral

Gluteus MediusGluteus MinimusTensor Fascia LataSix Intrinsic External

Rotators Periformis Quadratus Femoris Obturator Internus Obturator Externus Gemellua Superior Gemellus Inferior

Hip MusclesLateral

Gluteus MediusGluteus MinimusTensor Fascia LataSix Intrinsic External

Rotators Periformis Quadratus Femoris Obturator Internus Obturator Externus Gemellua Superior Gemellus Inferior

Femoral Triangle

BordersSuperiorLateralMedialPosteriorAnterior

Structures

Movements of the PelvisForward and Backward TiltLeft and right Lateral TiltLeft and Right Rotation

Kinematics of the Hip JointPelvic-on-Femoral Osteokinematics:

Abduction and Adduction in the Frontal PlaneRight lateral tilt and left lateral tilt

The Hip and Pelvic GirdleA. General Structure & FunctionB. Structure & Function of Specific JointsC. Muscular ConsiderationsD. Specific Functional ConsiderationsE. Common Injuries

Muscular Considerations: Sagittal Plane Pelvic Motion1. Pelvic-on-Femoral Flexion: Anterior Pelvic Tilt

Force coupleHip flexors Lower trunk extensors

Muscular Considerations: Sagittal Plane Pelvic Motion1. Pelvic-on-Femoral Flexion: Posterior Pelvic Tilt

Force coupleHip extensors Lower trunk flexors

Muscular Considerations: Overall Function of the Hip Flexors2. Femoral-on-Pelvic Hip Flexion

synergy between hip flexors and abdominal muscles

Muscular Considerations: Extensors

Pelvic-on-Femoral

Hip Extension

Muscular Considerations: Hip AdductorsHip AdductionPelvic Action?Muscles being

utilized?

Primary Movements of the Pelvis as Performed in a Standing Position

Pelvis Spinal Joints Hip Joints

Forward Tilt Hyperextension Slight Flexion

Backward Tilt Slight Flexion Complete Ext.

Lateral Tilt Left Slight Lateral Flexion RT

R = ADD

L= ABD

Rotation Left Rotation RT R = Slight ER

L= Slight IR

Movements of the Pelvis Secondary to those of the SpineSpine Pelvis

Flexion Posterior Tilt

Hyperextension Anterior Tilt

Lateral Flex Left Lateral Tilt Left

Rotation Left Rotation Left

Frolich, Human Anatomy, Lower LImb

Lumbar plexus (femoral nerve)

Sacral plexus (sciatic nerve)

With leg out to side like quadruped, lumbar-anterior, sacral-posterior makes sense

AP PELVIC ARTERIOGRAM1. ABDOMINAL

AORTA

2. COMMON ILLIAC ARTERY

3. INTERNAL ILLIAC ARTERY

4. EXTERNAL ILLIAC ARTERY

5. COMMON FEMORAL ARTERY

6. LUMBAR ARTERY

1

4

6

2

3

5

External iliac arteryInguinal ligamentCommon femoral arteryProfunda femoris

arterySuperficial femoral

artery

477

Anterior Thigh

Common femoral art

Profunda femoris art

Superficial femoral art

Frolich, Human Anatomy, Lower LImb

Internal Iliac Cranial + Caudal Gluteals= gluteals Internal Pudendal = perineum, external

genitalia Obturator = adductor muscles

External Iliac Femoral = lower limb

• Deep femoral = adductors, hamstrings, quadriceps

Popliteal (continuation of femoral) • Geniculars = knee• Anterior Tibial = ant. leg muscles, further

branches to feet• Posterior Tibial = flexor muscles, plantar

arch, branches to toes

Blood Supply to Femoral Head

1. Artery of Ligamentum Teres• Most important in children.• Its contribution decreases with age,

and is probably insignificant in elderly patients.

Blood Supply to Femoral Head

2. Ascending Cervical Branches Arise from ring at base of neck. Ring is formed by branches of medial and lateral

circumflex femoral arteries. Penetrate capsule near its femoral attachment

and ascend along neck. Perforate bone just distal to articular cartilage. Highly susceptible to injury with hip dislocation.

Common InjuriesDislocation-femoral head moves out of the

acetabulum-usually it goes posterior into

notch-position typically flexion,

adduction, and internal rotation-common mechanism: knee to

dashboard during traffic collision-signs and symptoms: extreme

pain, obvious deformity, unwilling to move the extremity

Hip Dislocation: Mechanism of Injury

Almost always due to high-energy trauma.Most commonly involve unrestrained

occupants in MVAs.Can also occur in pedestrian-MVAs, falls

from heights, industrial accidents and sporting injuries.

COMMON INJURIESHip Fracture-most frequently occurs through the femoral

neck-a direct blow to the lateral hip-signs and symptoms: pain, swelling, and loss

of function-the involved leg will appear shortened and will

be externally rotated

INTERTROCHANTERIC FRACTURE

COMMON INJURIESAvascular Necrosis of the Femoral Head-blood supply to the femur head is severed or is

occluded for a prolonged period of time.-this is a common complication following hip

dislocations, fractures, and chronic synovitis and often necessitates a hip replacement

POST OPERATIVE REPAIR

COMMON INJURIESPiriformis Syndrome-sciatic nerve through piriformis-pressure on the sciatic nerve due to muscle

spasm, trigger points, or tightness causing posterior thigh pain

-other signs and symptoms: pain, limited ROM, pt tenderness deep to the gluteals

COMMON INJURIESTrochanteric Bursitis-cause is abnormal friction or irritation of

the bursa between the IT band and greater trochanter, direct blow, or improper biomechanics

-usually a sport such as running-signs and symptoms: local pain, swelling,

pt tenderness, and crepitus over the greater trochanter

-patient may complain of hip snapping

COMMON INJURIESIschial Bursitis-lies over the ischial tuberosity-may become painful and inflamed with

excessive friction-signs and symptoms: pain with sitting, pt

tenderness over ischial tuberosity, pain w/ passive hip flexion and active/resistive hip extension

-often difficult to differentiate from proximal hamstring tendinitis

COMMON INJURIESHip Joint Sprain-less common-excessive forcible exertion of the extremity

that stretch or tear the surrounding ligaments

-signs and symptoms: pain and decrease ROM

COMMON INJURIESHip Joint Strains-resulting from overstretching or from a rapid,

forceful contraction of the muscle-explosive starts and slipping of the foot during

cutting are common mechanisms for hip flexor and adductor strains

-these injuries frequently occur during the beginning of practice and preseason training

-signs and symptoms: pain, pt tenderness, muscle spasm, swelling, ecchymosis , and decreased ROM

COMMON INJURIESLegg-Calve-Perthes Disease-characterized by avascular necrosis of the

proximal femoral epiphysis-a chronic condition that develops slowly in

children-more often in males than in females-signs and symptoms: pain in the hip or groin

that radiates to the knee, limping, decreased ROM, and hip flexor tightness may be noted

-physician should be consulted to rule out serious pathologies such as this

COMMON INJURIESChronic Synovitis-inflammatory process at the hip that is

characterized by chronic irritation and excess secretion of synovial fluid within the capsule

-this condition is very difficult to detect-may lead to avascular necrosis of the femoral

head

ORIF

Hemi

THR

Hips

The End