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 socket joint Multiaxial Three degrees of freedom Movement in three planes Close pack extension and medial rotation Least pack semiflexion

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Hip Joint
One of most stable joints in the body Articular surface of hip joint are reciprocally curved Superior surface of femur and acetabulum sustain greatest pressure

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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 surface covered with hyaline cartilage Deepened by acetabular labrum Wedge shaped fibrocartilage

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Articular Surface
Head of femur 2/3rd of sphere Pit for ligamentum teres Covered with articular cartilage Cartilage thicker posterior superior Epiphyseal line for head intracapsular

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Femur
Trabeculae develop along lines of 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 the intertrochanteric line Inferiorly, femoral neck close to lesser trochanter

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Capsule of Hip
Posterior Free border, fingers breath from trochanteric crest due to insertion of obturator externus Into trochanteric fossa and Root greater trochanter

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Capsule of Hip
Strongest superiorly Anteromedially, deep fibres reflected head of rectus femoris Iliopsoas is anterior Lateral deep fibres of gluteus minimus

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Retinacular Fibres
Fibres of capsule reflected along neck 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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Ligaments of Hip
Transverse ligament is part of the labrum Ligamentum teres is triangular, its base is attached to transverse ligament, and the apex to the pit on the head of femur Blood supply to epiphysis from obturator artery Only supplies a flake of bone in elderly

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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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Iliofemoral Ligament
One of strongest ligaments in body Tightens in extension Helps maintain erect posture Facet on anterior aspect of neck Prevents hyperextension Fulcrum reducing hip

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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 of joint (weak) Circular fibres called zona orbicularis Centre of gravity in front of head Synovial under obturator externus

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Synovial Membrane
Lines inner portion of capsule and non articular structures Ligament of head Fat in acetabular fossa May communicate with psoas bursa 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 via ligamentum 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 upper part of the acetabulum Inferior gluteal supplies the inferior and posterior and the capsule Transverse and ascending branches of lateral circumflex femoral artery Transverse and ascending branch of medial circumflex femoral Cruciate and trochanteric anastomosis

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Blood Supply
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

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Nerve Supply
Femoral nerve Obturator nerve Superior gluteal nerve Nerve to quadratus femoris Posterior dislocation may damage sciatic Pain in hip referred to knee

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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 abdominal wall 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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Movements: Adduction
Obturator nerve Adductor longus Adductor brevis Adductor magnus Can flex or extend depending on position of hip

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Movements: Abduction
Gluteus medius Gluteus minimus Standing on leg, gluteus medius and minimus abduction By preventing adduction

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Movements: Medial Rotation

Iliopsoas Adductors Anterior fibres of gluteus medius

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Movements: Lateral Rotation

Obturator internus Piriformis Superior gemmelus Obturator Internus Inferior gemmelus Quadratus femoris

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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 fractures

Boyd 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 to patellofemoral 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 otherwise

Renstrm, 2008

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Hip Joint Labral Tear

Chronic Secondary to acetabular
dysplasia Part of rim lesion complex
Renstrm, 2008

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Labrum Tears and Cartilage Loss

Labrum tears and cartilage loss are common 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 diagnosis
Burnett et al., J Bone Joint Surg (Am), 2006

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MR-Arthrography (MRA)
MR arthrogram has an
accuracy of 91% for labral tears
Chan 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 the
femoral head Secondary to retroversion, of the socket Or a profunda socket that is too deep Most of the time the cam and pincer forms exist together Female, 30-40 years

Renstrm, 2008

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Cam Impingement

Loss of roundness contributes to abnormal contact between the head and socket Male, 20-30 years

Renstrm, 2008

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Cam Impingement

P Renstrom 08

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