Hip joint pdf - Lower limb

Basic Anatomy

467

peroneal nerves (Figs. 10.29 and 10.31). Occasionally, the

The synovial membrane lines the capsule and is

membrane (Fig. 10.18).

notch. It lies within the joint and is ensheathed by synovial

the transverse ligament and the margins of the acetabular

on the head of the femur (fovea capitis) and by its base to

angular (Fig. 10.18). It is attached by its apex to the pit

is flat and tri

ligament of the head of the femur

The

through which the blood vessels and nerves enter the joint.

10.18). The ligament converts the notch into a tunnel

acetabular labrum as it bridges the acetabular notch (Fig.

is formed by the

transverse acetabular ligament

The

limits extension.

and are attached to the greater trochanter. This ligament

margin (Fig. 10.32). The fibers pass upward and laterally

attached to the body of the ischium near the acetabular

is spiral shaped and is

ischiofemoral ligament

The

extension and abduction.

part of the intertrochanteric line. This ligament limits

of the pubis, and the apex is attached below to the lower

The base of the ligament is attached to the superior ramus

is triangular (Fig. 10.32).

pubofemoral ligament

The

extension during standing.

teric line of the femur. This strong ligament prevents over

attached to the upper and lower parts of the intertrochan

inferior iliac spine above; below, the two limbs of the Y are

ligament (Fig. 10.32). Its base is attached to the anterior

is a strong, inverted Y-shaped

iliofemoral ligament

The

These blood vessels supply the head and neck of the femur.

retinacula.

reflected upward along the neck as bands called

front, some of its fibers, accompanied by blood vessels, are

behind. At its attachment to the intertrochanteric line in

halfway along the posterior aspect of the neck of the bone

to the intertrochanteric line of the femur in front and

ular labrum medially (Fig. 10.18). Laterally, it is attached

The capsule encloses the joint and is attached to the acetab

The hip joint is a synovial ball-and-socket joint.

Type

The articular surfaces are covered with hyaline cartilage.

(Fig. 10.18).

transverse acetabular ligament

notch and is here called the

The labrum bridges across the acetabular

tabular labrum.

ace

by the presence of a fibrocartilaginous rim called the

The cavity of the acetabulum is deepened

acetabular notch.

lum is horseshoe shaped and is deficient inferiorly at the

hip bone (Fig. 10.18). The articular surface of the acetabu

head of the femur and the cup-shaped acetabulum of the

The hip joint is the articulation between the hemispherical

run medially to supply the muscles (Figs. 10.29 and 10.31).

arise from the tibial component of the sciatic nerve and

hamstring part of the adductor magnus. These branches

ris, the semitendinosus, the semimembranosus, and the

to the long head of the biceps femo

Muscular branches

course is described on page 479.

fossa on the lateral side of the tibial nerve. Its further

sciatic nerve (Figs. 10.29 and 10.31), enters the popliteal

a terminal branch of the

common peroneal nerve,

The

Its further course is described on page 479.

(Figs. 10.17, 10.29, and 10.31), enters the popliteal fossa.

a terminal branch of the sciatic nerve

tibial nerve,

The

Branches

even inside the pelvis.

level—in the upper part of the thigh, the gluteal region, or

sciatic nerve divides into its two terminal parts at a higher

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Hip Joint

Articulation

Capsule

Ligaments

-
-

Synovial Membrane

attached to

the articular surfaces (Fig. 10.18).

the margins of

the joint capsule. It ensheathes the ligament of the head of

It covers the portion of the neck of the femur that lies within

anterior inferior
iliac spine

opening for bursa

superior ramus of pubis

pubofemoral
ligament

intertrochanteric
line

iliofemoral ligament

capsule

ischium

iliofemoral ligament

ischiofemoral
ligament

intertrochanteric
crest

area of loose attachment
of capsule

FIGURE 10.32

Anterior aspect (A) and posterior aspect (B) of the right hip joint.

468

CHAPTER 10

ing movements take place:

tion is limited by the ischiofemoral ligament. The follow

iliofemoral and pubofemoral ligaments, and medial rota

the femur. Lateral rotation is limited by the tension in the

site limb and by the tension in the ligament of the head of

ament, and adduction is limited by contact with the oppo

Abduction is limited by the tension of the pubofemoral lig

the iliofemoral, pubofemoral, and ischiofemoral ligaments.

ward to the anatomic position, is limited by the tension of

Extension, which is the movement of the flexed thigh back

limited by the tension of the hamstring group of muscles.

rior abdominal wall. When the knee is extended, flexion is

surface of the thigh coming into contact with the ante

When the knee is flexed, flexion is limited by the anterior

ing part in the articulation and on the strong ligaments.

of the joint depends largely on the shape of the bones tak

The hip joint has a wide range of movements. The strength

quadratus femoris supply the area.

Femoral, obturator, and sciatic nerves and the nerve to the

beneath the psoas tendon (Figs. 10.32

psoas bursa

forms the

between the pubofemoral and iliofemoral ligaments, and

protrudes through a gap in the anterior wall of the capsule,

tabular fossa. A pouch of synovial membrane frequently

the femur and covers the pad of fat contained in the ace

The Lower Limb

and 10.33).

Nerve Supply

Movements

-
-

ligament of femoral head

synovial pad of fat

gluteus medius

gluteus
minimus

gluteus
maximus

piriformis

gemellus superior

obturator internus

gemellus inferior

sciatic nerve

quadratus femoris

hamstrings

ischium

obturator externus

adductor magnus

root of scrotum

gracilis

adductor brevis

adductor longus

posterior division

anterior division

obturator nerve

medial circumflex

femoral artery

pectineus

femoral vein

femoral artery

femoral nerve

iliopsoas

bursa

sartorius

rectus femoris

lateral cutaneous
nerve of thigh

tensor fasciae
latae

anterior superior iliac spine

capsule

synovial membrane

anterior

posterior

FIGURE 10.33

Structures surrounding the right hip joint.

Basic Anatomy

Adduction

and piriformis.

minimus, assisted by the sartorius, tensor fasciae latae,

is performed by the gluteus medius and

Abduction

muscles.

is performed by the gluteus maximus and the hamstring

(a backward movement of the flexed thigh)

Extension

and sartorius and also by the adductor muscles.

is performed by the iliopsoas, rectus femoris,

Flexion

469

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is performed by the adductor longus and

brev

and the adductor fibers of the adductor magnus. These
muscles are assisted by the pectineus and the gracilis.

fasciae latae.

the gluteus medius and gluteus minimus and the tensor

is performed by the anterior fibers of

Medial rotation

and quadratus femoris, assisted by the gluteus maximus.

tor internus and externus, superior and inferior gemelli,

is performed by the piriformis, obtura

Lateral rotation

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Referred Pain from the Hip Joint

(posterior dislocation). The close relation of the sciatic nerve to

tabulum, and it comes to rest on the gluteal surface of the ilium

The head of the femur is displaced posteriorly out of the ace

it can lodge, rides up out of the acetabulum onto the gluteal

the head of the femur, having no stable platform under which

upper lip of the acetabulum fails to develop adequately, and

ments. In congenital dislocation of the hip (see page 512), the

The stability of the hip joint depends on the ball-and-socket

The femoral nerve not only supplies the hip joint but, via the

intermediate and medial cutaneous nerves of the thigh, also sup-

plies the skin of the front and medial sides of the thigh. It is not

surprising, therefore, for pain originating in the hip joint to be

referred to the front and medial side of the thigh. The posterior

division of the obturator nerve supplies both the hip and knee

joints. This would explain why hip joint disease sometimes gives

rise to pain in the knee joint.

Congenital Dislocation of the Hip

arrangement of the articular surfaces and the strong liga-

surface of the ilium.

Traumatic Dislocation of the Hip

Traumatic dislocation of the hip is rare because of its strength; it

is usually caused by motor vehicle accidents. However, should it

occur, it usually does so when the joint is flexed and adducted.

the posterior surface of the joint makes it prone to injury in pos-

terior dislocations.

Hip Joint Stability and Trendelenburg’s Sign

The stability of the hip joint when a person stands on one leg with

the foot of the opposite leg raised above the ground depends on

three factors:

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The gluteus medius and minimus must be functioning

ion, adduction, and external rotation and is produced initially by

reflex spasm of the surrounding muscles. The deformity is flex

supplies both joints). The stiffness is caused by the pain and

the adult, causes pain, stiffness, and deformity. The pain may be

the most common disease of the hip joint in

increased amount of synovial fluid secreted. The hip joint is par

or she will show the characteristic “dipping” gait. In patients

will sink below the horizontal. If the patient is asked to walk, he

Trendelenburg’s sign, and the unsupported side of the pelvis

the opposite leg clear off the ground, will exhibit a positive

tion of the hip, when asked to stand on the right leg and raise

clear of the ground before it is thrust forward in taking the

at the hip joint and moved forward—that is, the leg is raised

on one side and then on the other, allowing the leg to be flexed

other. By this means, he or she is able to raise the pelvis first

gluteus medius and minimus, first on one side and then on the

Normally, when walking, a person alternately contracts the

downward on the opposite, unsupported side. The patient is then

The neck of the femur must be intact and must have a normal

normally.

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The head of the femur must be located normally within the

acetabulum.

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angle with the shaft of the femur.

If any one of these factors is defective, then the pelvis will sink

said to exhibit a positive Trendelenburg’s sign (Fig. 10.34).

forward step. A patient with a right-sided congenital disloca-

with bilateral congenital dislocation of the hip, the gait is typi-

cally “waddling” in nature.

Arthritis of the Hip Joint

A patient with an inflamed hip joint will place the femur in the

position that gives minimum discomfort—that is, the position in

which the joint cavity has the greatest capacity to contain the

tially flexed, abducted, and externally rotated.

Osteoarthritis,

in the hip joint itself or referred to the knee (the obturator nerve

muscle spasm and later by muscle contracture.

C L I N I C A L N O T E S

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Superiorly:

the sciatic nerve (Fig. 10.32).

the quadratus femoris muscles separate the joint from

The obturator internus, the gemelli, and

Posteriorly:

ral vessels and nerve from the joint (Fig. 10.33).

muscles. The iliopsoas and pectineus separate the femo

Iliopsoas, pectineus, and rectus femoris

Anteriorly:

Important Relations

than the medial rotators.

flexor group, and the lateral rotators are more powerful

The extensor group of muscles is more powerful than the

movements.

is a combination of the previous

Circumduction

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Piriformis and gluteus minimus (Fig. 10.33).

Obturator externus tendon (Fig. 10.33).

Inferiorly:

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