2023 Lecture 30 Gluteal Region; Hip Joint.pdf

Hip Joint Gluteal Region Moore (9th ed.) 674-682, 731-738, 741-749 John Gassler PT, DPT, DOSYS 701 LSCI 501 Lecture 30, September 20, 2023  Notice and Agreement Medical Gross Anatomy - Lecture # 30 Gluteal Reg...

Hip Joint Gluteal Region Moore (9th ed.) 674-682, 731-738, 741-749 John Gassler PT, DPT, DOSYS 701 LSCI 501 Lecture 30, September 20, 2023  Notice and Agreement Medical Gross Anatomy - Lecture # 30 Gluteal Region; Hip Joint This session is being recorded Class recordings are distributed for the exclusive use of students in the LMU DeBusk College of Osteopathic Medicine. Student access to and use of class recordings are conditioned on agreement with the terms and conditions set below. Any student who does not agree to them is prohibited from accessing or making any use of such recordings. Any student accessing class recordings (1) acknowledges the faculty members’ intellectual property rights in recorded lectures and class materials and that distribution of the recordings violates the DCOM Copyright Policy; (2) recognizes the privacy rights of fellow students who speak in class; (3) accepts that distributing, posting, or uploading class recordings to students or any other third party not authorized to receive them or to those outside DCOM is an Honor Code violation; and (4) agrees that recordings are to be accessed and used only as directed by the faculty member(s) teaching the course.  Learning Objectives At the end of this lecture the student will be able to: Identify important bony landmarks in the gluteal region Name, identify, and describe the attachments, nerve supply, and action of the muscles of the gluteal region Describe the spinal makeup, and the course and relationships of the named nerves and blood vessels in the gluteal region Identify the bony and soft tissue structures of the hip joint Determine the functional deficit in the lower limb due to injury or pathologic conditions of the hip Identify bony anatomical structures in radiographic images of the hip region 3  Lower Limb Function – the Gait Cycle Iliopsoas Gluteus Rectus f. maximus Rectus Quads Quadriceps femoris Intrinsic femoris Hamstrings Tibialis Triceps surae Foot mm Ant. anterior Triceps surae Tib. 4 Moore Fig. 7.23  Lower Limb Regions Lower Limb Lower Extremity Popliteal region Gray’s Anatomy for Students 5  HAT Lower Limb Osteology Sacro-iliac joint Axial - Appendicular Articulations -Sacroiliac Joints Weight of body above the pelvis (HAT – head, arms, trunk) is transmitted to the os coxae through the sacro-iliac joints Body weight above hip joints is transmitted to the lower limbs through the hip joints 6 Gray’s Anatomy for Students  Pelvic bone Pelvic Girdle Os coxae Transfers body weight from spine to lower limbs “Bony pelvis” = both os coxae + sacrum Large area of bone for large muscle attachments Gilroy Fig 24.21A 7  Bony Pelvis Tubercle of the iliac crest Lateral PSIS ASIS Acetabulum forms the AIIS concave surface of the hip joint PIIS Greater sciatic notch Forms at the junction of the three parts of the Lesser sciatic notch pelvic bone Ischiopubic ramus Gilroy Fig 19.3A, p. 229 8  Hip Joint Anterior inferior iliac spine Body of pubis Ischiopubic ramus Anterior Gilroy Fig 31.6A and B, p. 408 Posterior 9  Proximal Femur Head Shaft Anterior Posterior "Trokhos" (Greek) = "wheel", with reference to the spherical femoral head which was first Gilroy Fig 31.4 A and B, p. 406 named "trokhanter". 10 Abnormal angles of inclination  Hip Joint Capsule Gilroy Fig 31.10B, Os coxa - capsule p. 411 Posterior attaches Anterior Gilroy Fig 31.9B, p. 411 Posterior femur – capsule circumferentially Anterior femur – capsule attaches attaches to intertrochanteric crest around the to intertrochanteric line acetabulum 11  Hip Joint Capsule Iliofemoral lig. Pubofemoral lig. Iliofemoral ligament limits hyperextension at hip joint prevents anterior dislocation of femur from acetabulum Pubofemoral ligament limits abduction of thigh at hip joint Gilroy Fig 31.9A, p. 411 12 Hip Joint Capsule Ischiofemoral lig. Ischiofemoral ligament limits hyperextension of femur at hip joint prevents posterior dislocation of femur from acetabulum Gilroy Fig 31.10A, p. 411 ligament 13  Hip Joint Acetabulum Fibrocartilage extension of joint cavity Gilroy Fig 31.8B, p. 410 14 Moore Fig 7.83A, p. 797  Hip Joint Acetabulum Labrum – fibrocartilage ring at edge of bony acetabulum Deepens socket to increase stability of hip joint Ligament of the head of the femur – attaches from labrum to head of femur Contains artery for blood Obturator a. supply to head of femur – branch of obturator a. Gilroy Fig 31.8C, p. 410 15  A-P Pelvis Used as a survey of pelvic region in trauma cases to identify areas of potential injury 16  Articular surface Hip PA/AP of acetabulum Acetabular fossa Head of femur Fovea, head of femur Neck of femur Superior pubic ramus Obturator foramen Greater trochanter Ischiopubic ramus Intertrochanteric region Ischial tuberosity Lesser trochanter 17 Hip Lateral Head of femur Neck of femur Greater trochanter Lesser trochanter Shaft of femur 18  Blood Supply to Head of Femur Moore Fig 7.86, p. 801 Medial circumflex femoral artery is the primary Gilroy Fig 34.4A, p. 467 contributor to blood supply to the head of the femur in adults 19  Blood Supply to Head of Femur Arteries penetrate the joint capsule at the lower neck of the femur and travel up the neck of the femur to the head 20 Gilroy Fig 34.4B, p. 467  Proximal Femur Fractures Displaced femoral neck fracture Intertrochanteric fracture 21 Fixation of Proximal Femur Fractures Old New Fixation of Fixation of Fixation of non-displaced displaced intertrochanteric fractures femoral neck femoral neck fracture fracture 22 Degenerative Arthritis of Hip Joint Hip Resurfacing Total Hip Arthroplasty (THA) 23  Hip Joint Movements Open chain – foot off the ground 24 Gray’s Anatomy for Students  Hip Joint Movements X X Rotation Medial Lateral Circumduction Gray’s Anatomy for Students 25 Palpable Bony Landmarks - Gluteal Gilroy Fig 31.1B, p. 402 26 Cutaneous Nn. of Gluteal Region Collectively named Superior, middle, and inferior clunial nerves Gilroy Fig 34.26B, p. 480 27  Fascia Lata Deep fascia of the gluteal region and thigh Continuous with crural fascia of the leg and deep fascia of foot (Crural fascia) Gray’s Anatomy for Students 28  Iliotibial Tract Tensor Fasciae Latae M. IT Band IT band is a thickening of the fascia lata on Gilroy Fig 31.16, the lateral aspect of p. 419 the thigh IT band attaches to lateral tibia Gray’s Anatomy for Students 29  Gluteal Fascia Portion of fascia lata covering gluteal muscles 30 Gilroy Fig 34.32A, p. 484  Gluteus Maximus m. Inferior Gluteal N. Gluteus maximus L5,S1,2 Medial (superior) attachment – ilium, sacrum, coccyx, sacrotuberous ligament Gilroy Fig 34.32B, p. 484 31  Gluteus Maximus m. Lateral attachment Superior portion attaches to iliotibial tract Inferior portion attaches to gluteal Tensor fasciae latae tuberosity Function Primary – Extension and lateral rotation of the thigh at the hip joint Primary muscle used for standing up from squat or sitting, climbing steps Gray’sAnatomy for Students 32  Trochanteric Bursa/Bursitis Gilroy Fig 34.35B, p. 487 Lies over greater trochanter and deep to IT Band 33  Gluteus Medius m. Superior Gluteal N. L5,S1 Lateral ilium to greater trochanter Gilroy Fig 34.20A, p. 421 34  Gluteus Minimus m. Superior Gluteal N. L5,S1 Lateral ilium to greater trochanter, deep to gluteus medius 35 Gilroy Fig 31.14B, p. 416 Gluteus Medius and Minimus Mm. G. medius G. minimus 36  Gluteus Medius and Minimus Function Gluteus medius Gluteus minimus Piriformis Primary action Open chain (foot off the ground) – hip abduction Closed chain (foot on ground and weight bearing on one foot) – maintain level pelvic girdle or elevate opposite side of pelvis 37 Secondary action – medial rotation of femur at hip joint  Hip Abductor Functional Strength Function of hip abductors when weight bearing on one lower extremity (closed chain) is for the abductors of the stance limb to contract isometrically to maintain a level pelvic girdle If stance limb hip abductors are weak, pelvis will drop to the opposite side Trendelenberg Sign Normal Weak hip abductors When walking - Trendelenberg gait 38 Moore Fig B7.19, p. 750 pattern  Tensor Fasciae Latae Origin: Anterior iliac crest Insertion: Iliotibial tract Tensor fasciae latae Innervation: Superior gluteal n. Action: Abduct and medially rotate thigh 39 Greater and Lesser Sciatic Foramina Gilroy Fig 19.11A, p. 235 40 Gilroy Fig 31.8A, p. 410  Lateral Rotators Piriformis Origin - anterior sacrum exits pelvis through greater sciatic foramen Obturator internus Origin - bone around obturator foramen, obturator membrane exits pelvis through lesser sciatic foramen Gilroy Fig 31.20B, p. 421 Gemelli – superior and inferior O: Ischial spine (superior) O: Ischial tuberosity (inferior) All attach laterally to Quadratus femoris greater trochanter region Ischial tuberosity to intertrochanteric crest 41  Piriformis m. Obturator Internus m. Pelvic Attachments Piriformis – anterior sacrum Obturator internus – Pelvic surface of obturator membrane and surrounding bone 42 Gilroy Fig 31.13, p. 415 Obturator Internus m. 43  Obturator Externus Anterior Posterior Gluteus maximus Gilroy Fig 31.22B, p. 423 Bone surrounding obturator foramen, Obturator membrane → greater trochanter Gilroy Fig 31.15A, p. 418 44  Rotator Muscles of the Hip Joint How They Work Superior and Inferior gemelli Superior view Moore Fig 7.42D, p. 737 Moore Fig 7.83A, p. 797 45  Lumbosacral Plexus L1 L4,5,S1,2,3 L4 Formed by part of L5 L4 Lumbosacral trunk anterior ramus of L4 L5 and all of anterior ramus of L5 The lumbosacral trunk (L4-L5) joins the sacral plexus (S1-S3) to form the lumbosacral plexus (L4 – S3) 46 Gray’s Anatomy for Students  Superior Gluteal n. (L4)-L5,S1 Exits pelvis superior to piriformis Located between gluteus medius and gluteus minimus Innervates: Gluteus medius m. Gluteus minimus m. Tensor fasciae latae m. Gilroy Fig 34.21A, p. 477 47  Inferior Gluteal n. L5,S1-2 Exits pelvis inferior to piriformis Gluteus maximus m. Gilroy Fig 34.21B, p. 477 48  Sciatic n. -Tibial n. L4-5,S1-3 -Common Fibular L4-5,S1-2 Sciatic n. exits pelvis inferior to piriformis 49 Gilroy Fig 34.32C, p. 484  Sciatic Nerve Variations 87% Common fibular portion of sciatic n. may pass through or over piriformis m. 12.5% 0.5% Moore Fig 7.46, p. 744 50 Safe Zone For Intramuscular (IM) Injection in Gluteal Region Clemente Figs. 434-435 51  Other Motor Nerves Gluteal Region Anterior rami of S1,2 piriformis N. To Obturator internus L5,S1 Obturator internus Superior gemellus N. To Quadratus femoris L5,S1 Inferior gemellus Quadratus femoris Netter Plate 490 52 Posterior Femoral Cutaneous n. S1-3 Skin over inferior portion of buttock Skin of posterior thigh Posterior femoral cutaneous n. Gilroy Fig 34.19, p. 476 53  Pudendal N. (S2-4) Exits pelvis through greater sciatic foramen Piriformis Crosses over sacrospinous ligament Enters ischio-anal fossa through lesser sciatic foramen Internal pudendal a. and v. travel with pudendal n. Inferior rectal n. Netter Plate 490 54 Gluteal Region Dermatomes A and B – Map corresponds to clinical findings C and D – More traditional map, corresponds to principles of development of lower limb Moore Fig 7.19, p. 705 55  Lower Limb Blood Supply Abdominal Aorta -Common Iliac a. -External Iliac a. -Femoral a. -Profunda Femoris a. -Internal Iliac a. -Superior Gluteal a. -Inferior Gluteal a. 56 Gilroy Fig 34.2, p. 467  Gluteal Region Gluteus medius Blood Supply Gluteus minimus Superior gluteal a. exits pelvis superior to piriformis m. travels between gluteus medius and minimus with superior gluteal n. TFL Small branch supplies upper portion of gluteus maximus m. Inferior gluteal a. exits pelvis inferior to piriformis m. Supplies gluteus maximus m. Gray’s Anatomy for Students 57  Gluteal Region Lymphatic Drainage Superficial tissues drain to superficial inguinal nodes Deep tissues drain to internal iliac Moore Fig 7.48, p. 746 58 nodes along gluteal vessels