Hip Region

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Hip Region

• Dr. S. Nishan Silva
• (MBBS)

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Regional anatomy of the lower limb
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Parts and regions of the lower limb

• Gluteal region-between iliac crest superiorly and
  gluteal fold inferiorly
• Thigh-between hip and knee
• knee-joint between leg and thigh
• Leg-between knee and foot
• Ankle
• Foot

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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

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Joints of Lower Limb

• Proximal Tibia Fibula
• Plane
• Gliding
• Synovial
• Distal Tibia Fibula
• Slight give
• Fibrous
• Ankle (Tibia/Fibula Talus)
• Hinge
• Uniaxial
• Synovial

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Lower Limb Movements

• Hip
• Flexion/extension
• Abduction/adduction
• Lateral/medial rotation
• Knee
• Flexion/extension
• Ankle
• Dorsiflexion/plantarflexion
• Inversion/eversion
• Toes
• Flexion/extension

• Bending on posterior side is flexion (except hip)
• Bending on anterior sided is extension (except
  hip)

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Surface anatomy of lower limb

• Gluteal region and thigh
• anterior superior and inferior iliac spines
• tubercle of iliac crest
• ischial tuberosity
• greater trochanter
• pubic tubercle
• pubic crest
• superior border of pubic symphysis

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Surface Anatomy Posterior Pelvis

• Iliac crest
• Gluteus maximus cheeks
• Natal/gluteal cleft crack
• Gluteal folds bottom of cheek

pg 789
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Surface Anatomy of the Lower Limb

• Gluteus maximus muscle
• Gluteus medius muscle
• Gluteal cleft
• Gluteal fold
• Ischeal tuberosity
• Greater trochanter

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Nelatons 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.

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Hip - Anatomy

• Multiaxial ball socket joint
• Acetabulum1/2 sphere
• Femoral head2/3 sphere
• Strong ligaments capsule
• Maximally stable

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Anatomy

• Forces
• Standing - 0.3 times body weight
• Standing on 1 leg - 2.5 times body weight
• Walking - 1.3 to 5.8 times body weight
• Walking up stairs - 3 times body weight
• Running - 4.5 times body weight

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Movements of the Hip Joint

• Flexion and Extension
• Abduction and Adduction
• External Rotation and Internal Rotation.

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Bony Anatomy

• Femur
• Femoral Head
• Femoral Neck
• Greater Trochanter
• Lesser Trochanter
• Intertrochanteric Crest
• Intertrochanteric Line
• Gluteal Tuberosity

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BONY ANATOMY OF THE HIP
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BONY ANATOMY OF THE HIP
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Bony Anatomy

• Pelvic Girdle
• Acetabulum
• 3 bones fused together
• Ilium
• Iliac fossa
• Iliac Crest
• ASIS
• AIIS
• PSIS
• PIIS
• Gluteal Lines
• Greater Sciatic Notch

Lateral View
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Bony Anatomy

• Ilium
• Iliac fossa
• Iliac Crest
• Iliac Tuberosity
• ASIS
• AIIS
• PSIS
• PIIS
• Gluteal Lines

Medial View
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Bony Anatomy

• Ilium
• Ishium
• Ramus of ishium
• Ishial tuberosity
• Ishial spine
• Lessor Sciatic Notch

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Bony Anatomy

• Ilium
• Ishium
• Pubis
• Superior Ramus of Pubis
• Inferior Ramus of Pubis
• Pubic Crest
• Pubic Tubercle
• Pectin
• Symphyseal Surface

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Anatomy

• Ligaments
• Iliofemoral ligament (Y ligament of Bigelow)
• Reinforces anterior joint capsule (limits
  hyperextension)
• Keeps us upright
• Pubofemoral ligament
• Limits abduction hyperextension
• Inguinal ligament
• Runs from ASIS to pubic symphysis
• Superior border of femoral triangle

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Anatomical Components
Added

• Articular Capsule
• Acetabular labrum
• Ligaments
• Iliofemoral
• Pubofemoral
• Ischiofemoral
• Ligament of the head of the femur
• Transverse ligament of the acetabulum

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Anterior view
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Posterior view
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Medial view with acetabular floor removed
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Anterior view with capsule removed
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Ligamentous and Cartilogenous Structures for the
Hip and Pelvic Girdle

• Sacroiliac Joint
• Sacrotuberous
• Sacrospinous
• Function of these two ligaments
• Iliolumbar
• Interosseous Sacroiliac

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Ligamentous and Cartilogenous Structures for the
Hip and Pelvic Girdle

• Sacroiliac Joint
• Sacrotuberous
• Sacrospinous
• Function of these two ligaments
• Iliolumbar
• Interosseous Sacroiliac

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Ligamentous and Cartilogenous Structures for the
Hip and Pelvic Girdle

• Sacroiliac Joint
• Sacrotuberous
• Sacrospinous
• Function of these two ligaments
• Iliolumbar
• Interosseous Sacroiliac
• Dorsal Sacroiliac

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Ligamentous and Cartilogenous Structures for the
Hip and Pelvic Girdle

• Sacroiliac Joint
• Hip Joint
• Capsule
• Three thickenings of the capsule
• Iliofemoral
• Pubofemoral
• Ishiofemoral
• Ligamentum Teres
• Inguinal

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Ligamentous and Cartilogenous Structures for the
Hip and Pelvic Girdle

• Sacroiliac Joint
• Hip Joint
• Capsule
• Three thickenings of the capsule
• Iliofemoral
• Pubofemoral
• Ishiofemoral
• Ligamentum Teres
• Inguinal

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Ligamentous and Cartilogenous Structures for the
Hip and Pelvic Girdle

• Sacroiliac Joint
• Hip Joint
• Capsule
• Three thickenings of the capsule
• Iliofemoral
• Pubofemoral
• Ishiofemoral
• Ligamentum Teres
• Inguinal

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AP HIP
ACETABLUM
FEMORAL HEAD
FEMORAL NECK
GREATER TROCHANTER
FOVEA CAPITIS
LESSER TROCHANTER
CORTICAL BONE
MEDULLARY BONE
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CORONAL MRI
RT. HIP
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Normal angle of inclination 1250-1300
Coxa valga (abnormally increased angle of
inclination, in cases of congenital dislocation
of the hip)
Coxa vara (abnormally decreased angle of
inclination, it occurs in fractures of the neck
of the femur and slipping of the femoral
epiphysis )
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ANGLE OF INCLINATION
Coxa Vara
Coxa Valga
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Articulations of the Hip and Pelvis

• Pubic Symphysis
• Interpubic disk
• Some movement

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Articulations of the Hip and Pelvis

• Pubic Symphysis
• Sacroiliac Joints

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Articulations of the Hip and Pelvis

• Pubic Symphysis
• Sacroiliac Joints
• Hip Joints

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Ligamentous and Cartilogenous Structures for the
Hip and Pelvic Girdle

• Sacroiliac Joint
• Hip Joint
• Capsule
• Three thickenings of the capsule
• Iliofemoral
• Pubofemoral
• Ishiofemoral
• Ligamentum Teres
• Inguinal

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Buttock

• Supericial
• Gluteus Maximus
• Gluteus Medius reverse action
• Gluteus Minimus
• Tensor Fascia Latae iliotibial band, functional
  considerations
• Gowers Sign
• Positive Trendelenburg

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Gluteus Maximus
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Gluteus Medius and Minimus
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G Med., G Min, TFL
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Trendelenburg
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Deep Buttocks

• External Rotators of the Hip
• Small Muscles
• Mostly attach near or on greater trochanter
• Excellent 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.

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Deep Buttock

• Muscles
• Piriformis
• Superior Gemellus
• Obturator Internus
• Inferior Gemellus
• Quadratus Femoris
• Obturator Externus

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Deep Muscles of Buttocks
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Hip Muscles

• Anterior
• Rectus Femoris
• Sartorius
• Iliopsoas Muscle Group
• Iliacus
• Psoas Major

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Hip Muscles

• Anterior
• Rectus Femoris
• Sartorius
• Iliopsoas Muscle Group
• Iliacus
• Psoas Major

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Hip Muscles

• Posterior
• Semimembranosus
• Semitendinosus
• Biceps Femoris
• Gluteus Maximus

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Hip Muscles

• Medial
• Adductor Brevis
• Adductor Longus
• Adductor Magnus
• Pectineus
• Gracilus

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Hip Muscles

• Lateral
• Gluteus Medius
• Gluteus Minimus
• Tensor Fascia Lata
• Six Intrinsic External Rotators
• Periformis
• Quadratus Femoris
• Obturator Internus
• Obturator Externus
• Gemellua Superior
• Gemellus Inferior

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Hip Muscles

• Lateral
• Gluteus Medius
• Gluteus Minimus
• Tensor Fascia Lata
• Six Intrinsic External Rotators
• Periformis
• Quadratus Femoris
• Obturator Internus
• Obturator Externus
• Gemellua Superior
• Gemellus Inferior

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Femoral Triangle

• Borders
• Superior
• Lateral
• Medial
• Posterior
• Anterior
• Structures

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Movements of the Pelvis

• Forward and Backward Tilt
• Left and right Lateral Tilt
• Left and Right Rotation

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Kinematics of the Hip JointPelvic-on-Femoral
Osteokinematics

• Lumbopelvic Rhythm

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Kinematics of the Hip JointPelvic-on-Femoral
Osteokinematics

• Abduction and Adduction in the Frontal Plane
• Right lateral tilt and left lateral tilt

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The Hip and Pelvic Girdle

1. General Structure Function
2. Structure Function of Specific Joints
3. Muscular Considerations
4. Specific Functional Considerations
5. Common Injuries

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Muscular Considerations Sagittal Plane Pelvic
Motion

• Pelvic-on-Femoral Flexion Anterior Pelvic Tilt

• Force couple
• Hip flexors
• Lower trunk extensors

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Muscular Considerations Sagittal Plane Pelvic
Motion

• Pelvic-on-Femoral Flexion Posterior Pelvic Tilt

• Force couple
• Hip extensors
• Lower trunk flexors

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Muscular Considerations Overall Function of the
Hip Flexors

• 2. Femoral-on-Pelvic Hip Flexion

• synergy between hip flexors and abdominal muscles

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Muscular Considerations Extensors
Pelvic-on-Femoral Hip Extension
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Muscular Considerations Hip Adductors

• Hip Adduction
• Pelvic Action?
• Muscles being utilized?

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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
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Movements of the Pelvis Secondary to those of the
Spine
Spine Pelvis
Flexion Posterior Tilt
Hyperextension Anterior Tilt
Lateral Flex Left Lateral Tilt Left
Rotation Left Rotation Left
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• Sacral plexus (sciatic nerve)

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

• Lumbar plexus (femoral nerve)

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AP PELVIC ARTERIOGRAM

1. ABDOMINAL AORTA
2. COMMON ILLIAC ARTERY
3. INTERNAL ILLIAC ARTERY
4. EXTERNAL ILLIAC ARTERY
5. COMMON FEMORAL ARTERY
6. LUMBAR ARTERY

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Anterior Thigh

• External iliac artery
• Inguinal ligament
• Common femoral artery
• Profunda femoris artery
• Superficial femoral artery
  

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• Common femoral art
• Profunda femoris art
• Superficial femoral art

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Blood supply to 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

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Blood Supply to Femoral Head

• Artery of Ligamentum Teres
• Most important in children.
• Its contribution decreases with age, and is
  probably insignificant in elderly patients.

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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.

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Some pathologies
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Common Injuries

• Dislocation
• -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

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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.

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COMMON INJURIES

• Hip 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

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INTERTROCHANTERIC FRACTURE
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COMMON INJURIES

• Avascular 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

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POST OPERATIVE REPAIR
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COMMON INJURIES

• Piriformis 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

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COMMON INJURIES

• Trochanteric 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

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COMMON INJURIES

• Ischial 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

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COMMON INJURIES

• Hip Joint Sprain
• -less common
• -excessive forcible exertion of the extremity
  that stretch or tear the surrounding ligaments
• -signs and symptoms pain and decrease ROM

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COMMON INJURIES

• Hip 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

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COMMON INJURIES

• Legg-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

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COMMON INJURIES

• Chronic 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

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Hemi
ORIF
THR
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HipsThe End
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