hip joint bmj

7/28/2019 Hip Joint BMJ

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MOB TCD

Hip Joint

Professor Emeritus Moira OBrien

FRCPI, FFSEM, FFSEM (UK), FTCD

Trinity College

Dublin


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Hip Joint

Synovial ball and socketjoint

Multiaxial

Three degrees of freedom

Movement in three planes Close pack extension and

medial rotation

Least pack semiflexion

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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


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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

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Articular Surface of Hip Joint

Semilunar articular surfacecovered with hyaline

cartilage

Deepened by acetabular

labrum Wedge shaped fibrocartilage

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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


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Femur

Trabeculae develop along linesof stress

Calcar femorale is the cortical

bone on inferior aspect of neck

Neck is cancellous bone

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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

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Posterior Free border, fingers breath

from trochanteric crest due

to insertion of obturator

externus Into trochanteric fossa and

Root greater trochanter

Capsule of Hip

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Strongest superiorly Anteromedially, deep fibres

reflected head of rectus

femoris

Iliopsoas is anterior Lateral deep fibres of gluteus

minimus

Capsule of Hip

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Retinacular Fibres

Fibres of capsule reflected alongneck to articular margin called

retinacular fibres

Blood supply to head run under

retinacular fibres

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Ligaments of Hip

Acetabular labrum Transverse ligament

Ligament of head

Iliofemoral ligament

Pubofemoral ligaments

Ischiofemoral ligaments

Zona orbicularis

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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


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Iliofemoral Ligament

Thickening of capsule Lower half of anterior

inferior iliac spine and

adjoining acetabulum

Distally Upper and lower parts of

inter trochanteric line

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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


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Pubofemoral Ligament

Superior pubic ramus Inferior part of inter

trochanteric line and upturned

part

Relatively weak Prevents abduction

Bursa between it and

iliofemoral

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Ischiofemoral Ligament

Ischium to posterior part ofjoint (weak)

Circular fibres called zona

orbicularis

Centre of gravity in front ofhead

Synovial under obturator

externus

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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

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Bursa Under Gluteus Maximus

Trochanteric bursa Posterolateral aspect of

greater trochanter

gluteofemoral

Vastus lateralis ischial bursa Ischial tuberosity

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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

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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

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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


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Femoral nerve

Obturator nerve

Superior gluteal nerve

Nerve to quadratus femoris

Posterior dislocation maydamage sciatic

Pain in hip referred to knee

Nerve SupplyMOB TCD

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Anterior Relations

Rectus femoris Adductor longus

Pectineus

Psoas and iliacus

Femoral sheath

Femoral nerve

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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

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Lateral Relations

Gluteus minimus Gluteus medius

Superior gluteal vessels and

nerves between

Iliotibial tract Superficial three quarters of

gluteus maximus

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Posterior Relations

Piriformis Superior gemellus

Obturator internus

Inferior gemellus

Quadratus femoris Adductor magnus

Obturator externus

Gluteus maximus

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Movements: Flexion

Limited by anterior abdominalwall

Psoas

Iliacus

Pectineus Adductor longus and brevis

Rectus femoris

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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

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Obturator nerve Adductor longus

Adductor brevis

Adductor magnus

Can flex or extend dependingon position of hip

Movements: AdductionMOB TCD

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Gluteus medius Gluteus minimus

Standing on leg, gluteus medius and

minimus abduction

By preventing adduction

Movements: AbductionMOB TCD

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Iliopsoas Adductors

Anterior fibres of gluteus medius

Movements: Medial RotationMOB TCD

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Obturator internus Piriformis

Superior gemmelus

Obturator Internus

Inferior gemmelus

Quadratus femoris

Movements: Lateral Rotation

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Trendelenburg Tests

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Fractured Neck of Femur

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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

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Hip Problems

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Pain in a Child

5-10 year old child

Aching pain in hip

Limp

Limitation of movement

Perthes Osteochondritis of head of femur

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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

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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

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Tumors and Neoplasms

Young, healthy athletes do get cancer!

Fortunately most tumors are benign!

Bone pain at night

Tumor till proved otherwiseRenstrm, 2008

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Hip Joint Labral Tear

Chronic

Secondary to acetabulardysplasia

Part of rim lesion complexRenstrm, 2008

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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

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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

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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

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Loss of roundness contributes toabnormal contact between the head andsocket

Male, 20-30 yearsRenstrm, 2008

Cam Impingement

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P Renstrom 08

Cam Impingement

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