HIP GIRDLE: FROM ANATOMY TO ORTHOPEDICS

PRESENTED BY

DR. MARYNA KORNIEIEVA

ASST. OF ANATOMY

BONNY PELVIS

Hip bone

Femur

Sacrum

Lumbar vertebrae

Hip joint

Sacro-iliac joint

Pubic symphysis

Secondary cartilaginous joint

Typical ball-and-socket

“Pubic symphysitis”, “osteitis pubis”

or adductor longus strain all cause

vague pubic pain and tenderness –

but the diagnosis is often not clear

and may not matter as the

treatment is much the same.

The SI joint is

synovial but with

age becomes more

fibrous.

HIP BONE

Ilium

Pubis

Iliac crestIliac fossa

Internal lip of iliac crest

External lip of iliac crest

IschiumAnterior

Superior

iliac spine

Anterior

inferior

iliac spine

Auricular

surface

Ischial

tuberosity

Ischial spine

Greater sciatic notch

Lesser sciatic notch

Pubic

tubercle

Pubic body

Body of

ischium

Superior pubic ramus

Inferior pubic ramus

Pubic crest

Ischial ramus

Obturator foramen

Acetabulum

RADIOGRAPHIC APPEARANCES OF THE BONY PELVIS

Anteroposterior radiograph of the male pelvis.

Representation of the radiograph of the pelvis.

SACROILIAC JOINT (SI)

Articulation: Adjacent

auricular articular surfaces

of the Ilium and sacrum;

Motion is limited with a mean

of 2.5 (0.8-3.6) degree.

Type: bicondylar synovial

joint, undergoes to gradual

sclerosis trough the age;

The interosseous sacro-iliac joint is probably the strongest in the body – if it is

disrupted it is indicative of a very high energy impact.

Capsule: along the

margins of articular

surfaces;

LIGAMENTS OF SI JOINT

During pregnancy, the ovaries and placenta produce the hormone relaxin which

increases flexibility of the ligaments that hold the sacroiliac joint together, resulting in

a looser joint and increased range of motion to accommodate the head of the fetus

passing through the birth canal.

OTHER LIGAMENTS OF HIP GIRDLE

Sacrotuberous lig.

Sacrospinous lig.

Greater sciatic foramen

Lesser sciatic foramen

Boundaries:

Antero-lateral: greater sciatic

notch of the illium;

Postero-medial: sacrotuberous

ligament;

Inferior: sacrospinous lig and

the ischial spine;

Superior: anterior sacroilliac

ligament.

Boundaries:

Anterior: the tuberosity of the ischium.

Superior: the spine of the ischium and

sacrospinous ligament.

Posterior: the sacrotuberous ligament.

TRAUMAS OF SI JOINT

Dysfunction in the sacroiliac joint, or SI joint, is thought to cause low back and/or leg

pain. The leg pain can be particularly difficult, and may feel similar to sciatica or pain

caused by a lumbar disc herniation.

Pain in the SI joint occurs as result of

excessive motion and in case of excessive

immobilization (as in ankylosing spondylitis).

SI PROCEDURES

SI joint injection

X-ray pictures (or ultrasound) are taken

throughout to ensure the needle is in the

correct area.

Once the needle is

correctly

positioned into the

joint a mixture of

local anaesthetic

with or without a

locally acting

steroid is injected.

HIP JOINT

Acetabular fossa

Labrum acetabulare

Acetabular

notch Transverse

acetabular

ligament

Ligament of the head

of the femur

Articular surfaces: the head of the femur

and the acetabulum of the pelvic bone.

Lunate surface

Kind of joint: synovial

ball and socket joint.

HIP JOINT

Synovial membrane: lines

fibrous capsule from inside

and forms a tubular covering

around the ligamentum teres.

Attachment of the fibrous

capsule:

medially – along the margins of

the acetabulum and transverse

acetabular ligament;

laterally – along the

intertrochanteric line and just

proximal to intertrochanteric

crest.

Acetabular margin

Trochanteric line

Acetabular margin

Neck of the femur

FEMUR

Proximal epiphysis of the femur:

1.Head (with the fovea capitis, for the

attachment of the ligament of the head),

2. Neck, 3. Greater trochanter, 4. Lesser

trochanter, 5. Intertrochanteric line, 6.

Intertrochanteric crest, 6. Gluteal

tuberosity, 7. Linea aspera; 8. Orthopedic

tubercle.

The issue to establish in fractured neck

of femur is whether the head is at risk of

avascular necrosis and therefore will need

to be replaced; avascular necrosis will most

likely occur when the fracture is proximal to

the capsular attachment tearing the

retinacular arteries that run up the femoral

neck to the head.

Capsular

attachment

CLINICAL SOLUTIONS

Radiograph (anteroposterior view) of a displaced femoral neck fracture treated by way of femoral head replacement with a bipolar prosthetic device.

The most common internal fixation device used today is the sliding screw-plate device.

(A) Femoral neck fracture treated by way of internal fixation with 3 parallel cannulated lag screws. (B) Schematic representation of screw configuration as viewed from the side.

BLOOD SUPPLY OF THE HIP

PERTHE’S DISEASE

CAUSES: SYMPTOMS:

MOVEMENTS IN THE HIP

LATERAL ROTATORS:

ABDUCTORS:

Gluteus

medius

Gluteus minimus

Piriformis

Obturator

externus

Obturator

internus

Superior

and

Inferior

gemelli

Quadratus

femoris

MOVEMENTS IN THE HIP

FLEXORS: EXTENSORS:

Sartorius

Iliacus

Psoas

major

Rectus

femoris

Pectineus

Gluteus

Maximus

Biceps

femorisSemiten-

dinous

Semimem-

branous

ADDUCTORS:

Adductor

magnus

Adductor

brevis

Gracilis

Adductor

longus

Pectineus

HIP DISLOCATIONS

Dislocated hip usually occurs

posteriorly due to anatomy (the

acetabulum is directed posteriorly).

Central dislocation through the acetabulum

is also possible.

LIGAMENTS OF THE HIP JOINT

BURSAE AROUND HIP

Trochanteric

bursitis

pain pattern

Hip arthroscopy for trochanteric

bursitis – bursectomy.

X-RAY OF NORMAL HIP

AN ADULT A CHILD

DEVELOPMENTAL DYSPLASIA OF HIP

The cause is unknown.

Low levels of amniotic fluid in the womb

during pregnancy and immaturity can increase

baby's risk of DDH.

DDH is a disruption in the normal

relationship between the head of the

femur and the acetabulum.

Symptoms:

DIAGNOSTICS

Pelvis X-Ray (AP view) showing left

sided dysplastic hip with femur head lying

in the upper outer quadrant and disrupted

Shenton's line.

Shenton's line

The goal of treatment is to keep the femoral

head in good contact with the acetabulum.

ANGLE BETWEEN THE NECK AND SHAFT OF THE FEMUR

COXA VALGA COXA VARANormal adult:

The normal NS angle is about 160° in the young child.

› 130 ‹ 120

CROSS-SECTION THROUGH THE HIP

Trochanteric bursa

Obturator externus

Gluteus medius

Iliopsoas

Tensor fasciae lata

Rectus femoris

SartoriusFemoral vessels

Femoral nerve

Ilio-psoas bursa

Obturator internus

Gemellus inferior

Sciatic nerve

T1FS CORONAL IMAGE OF A NORMAL HIP.

T1FS AXIAL IMAGE OF A NORMAL HIP

T1FS SAGITTAL IMAGE OF A NORMAL HIP

APPEARANCE OF THE ACETABULARLABRUM AT MR ARTHROGRAPHY

T1FS axial image demonstrating the

normal anterior and posterior labrum

(arrows).

• Triangular in cross section, but some

individual variation in labral morphology,

especially in older patients

(?degenerative)

• It measures 3-11 mm in width and 2-5

mm in height

• Normal labrum is hypointense on all

sequences

• Increased signal intensity may represent

labral tears or myxoid degeneration

• Intra-articular gadolinium solution is

hyperintense on T1 weighted images

and may extend into sub-labral

sulci/recesses

SUBLABRAL SULCI

• Normal recesses

adjacent to labrum that

fill with contrast

• May be mistaken for

labral tears/detachments

• Anterosuperior

• Posterinferior

• Anteroinferior

• Posterosuperior

• A tear generally has

irregular edges and

extends more than 50%

across the depth of the

labrum

PD sagittal image demonstrating the

anterior labrum (arrowhead),

acetabular notch (arrow) and

posterior sulcus (double arrow).

PD axial image demonstrating a

posterior sublabral recess

(arrow).

LABRAL PATHOLOGY - LABRAL TEARS

Imaging Features:

• Extension of contrast into the labral tissue

• Associated features include labral blunting, deformity and hypertrophy

• Look for bucket handle tears, especially in cases of labro-acetabular

separation

T1FS axial image demonstrating

labro-acetabular separation (arrow)PD image demonstrating a tear at

the chondro-labral junction

Aetiology:

1) Post-traumatic

• hyperextension,

external rotation:

anterosuperior

labrum

• axial loading of

flexed hip:

posterior labrum

2) Degenerative

3) Associated with

acetabular dysplasia

4) Following

posterior hip

dislocation.