Pelvis, Hip, and Gluteal Anatomy PDF

Pelvis, Hip, and Gluteal 1 PT 500: Human Anatomy Hip, Pelvis and Gluteal Muscles 1. Osteology of the Pelvis a. Bony Skeleton i. Inominate (pelv...

Pelvis, Hip, and Gluteal 1 PT 500: Human Anatomy Hip, Pelvis and Gluteal Muscles 1. Osteology of the Pelvis a. Bony Skeleton i. Inominate (pelvic bone) 1. Ilium 2. Ischium 3. Pubis 4. What is the tri-radiate cartilage? ii. Sacrum iii. Coccyx b. Bony Landmarks and Structures of the Pelvic/Inominate bones i. Acetabulum ix. Greater Sciatic Notch ii. Blade/Wing of the ilium (what passes through?) iii. Arcuate Line x. Lesser Sciatic Notch iv. Anterior Superior Iliac (what passes through?) Spine (ASIS) xi. Ischial Tuberosity v. Anterior Inferior Iliac xii. Ischial Spine Spine (AIIS) xiii. Pubic Tubercle vi. Posterior Superior Iliac xiv. Pectin Pubis Spine (PSIS) xv. Superior Pubic Ramus vii. Posterior Inferior Iliac xvi. Inferior Pubic Ramus Spine (PIIS) xvii. Body of Pubis viii. Iliac Crest xviii. Infrapubic Angle xix. Obturator Foramen Section 1 Pelvis, Hip, and Gluteal 2 c. Bony Landmarks of the Sacrum i. Superior articular v. Ala/Wing of the Sacrum processes vi. Auricular Surface ii. Ventral sacral foramina vii. Median Crest and iii. Dorsal Sacral foramina Spinous Tubercles iv. Sacral Promentory viii. Sacral Hiatus Section 1 Pelvis, Hip, and Gluteal 3 d. Pelvic Cavity Boundaries i. Superior Aperature (pelvis inlet/pelvic bring) 1. Ala and promontory of sacrum, arcuate line, pectin pubis ii. Inferior Aperature (pelvic outlet) 1. Pubic arch, ischial tuberosities, inferior margin of sacrotuberous ligament, tip of the coccyx iii. False versus True Pelvis 1. True Pelvis (inferior to the inlet/brim) a. Anterior Boundary: body, rami, and symphysis of pubis; internal obturator m/fascia, b. Lateral: obturator internus, pelvic fascia c. Posterior: piriformis m, sacrum, ilium, SI joints and ligaments d. Floor: pelvic diaphragm 2. False Pelvis: superior to brim and inlet e. Sex Differences in the Pelvis. Compared to the male, the female pelvis: i. Hip bones farther apart (wider sacrum) ii. Ischial tuberosities and spines farther apart iii. Sacrum is less curved iv. Wider superior aperature (more rounded) v. Wider inferior aperature vi. Shallower false pelvis Section 1 Pelvis, Hip, and Gluteal 4 2. The Hip Joint a. Structure of the Hip Joint i. Synovial ball and socket joint ii. Joint Surfaces 1. Acetabulum a. Concave surface formed by union of ilium, ischium and pubis b. Lunate Surface i. Articular surface of the acetabulum (Horseshoe shaped, covers the anterior and lateral portions) ii. Covered with articular cartilage c. Acetabular Labrum i. Fibrocartilage attached to margins of acetabulum  deepens the acetabular socket (increases contact by 10%) d. Acetabular Notch i. Gap in the lunate surfaace e. Transverse Acetabular Ligament i. Bridges the acetabular notch ii. Ligamentum fovea capitus passes deep to the ligament 2. Head of the Femur a. Spherical, covered in hyaline cartilage b. Fovea Capitus = indentation in center of head of femur (not covered with cartilage) i. Ligament of the head of the femur (Ligamentous Fovea Capitus) b. Ligaments of the Hip Joint Section 2 Pelvis, Hip, and Gluteal 5 i. Capsule of the Hip Joint 1. Attachments a. Attaches to acetabular labrum b. Intertrochnateric line and crest of the femur 2. Retinacula a. Reflections of the joint capsule medially on the neck of the femur towards the head of the femur b. Carry blood vessels to the head of the femur 3. Thickenings of the capsule form the named ligaments ii. Iliofemoral (Y) Ligament 1. Attaches from AIIS to intertrochanteric line of the femur 2. Limits hyperextension of the hip 3. People with paraplegia can weight-bear on the ligament in standing. iii. Pubofemoral Ligament 1. Attaches from pubic margin and blends with medial portion of iliofemoral ligament 2. Limits extension and abduction iv. Ischiofemoral Ligament 1. Attaches from ischium to greater trochanter deep to iliofemoral, some fibers blend with orbicular zone (spirals around) 2. Screws the head of the femur into the acetabulum aiding medial rotation during extension and limits hyperextension. v. Orbicular Zone 1. Circularly oriented fibers of the capsule around its insertion near the neck of the femur 2. Help maintain the head of the femur in the acetabulum. vi. Transverse Acetabular Ligament 1. Converts the acetabular notch to a foramen for the ligamentum teres (round ligament, ligament of the head of the femur), which carries blood supply to the femoral head Section 2 Pelvis, Hip, and Gluteal 6 Modified from Pansky, Review of Gross Anatomy, 1984 Section 2 Pelvis, Hip, and Gluteal 7 c. Movements of the Hip Joint i. The hip joint has three degrees of freedom ii. Flexion/Extension 1. Hip flexion: a. 0-125º with knee flexion: limited by soft tissues b. 0-90º with knee extended: limited by hamstrings 2. Hip extension: a. 125-0º return from flexion with knee flexed, may be limited by tight hip flexors. b. 0-15º hyperextension; limited by iliofemoral ligament iii. Abduction/Adduction 1. Hip abduction: a. 0-45º limited by iliofemoral ligament; pubofemoral ligament, adductor muscles, and the joint surfaces. 2. Hip adduction: a. 45-0º limited by contralateral lower extremity or abductor tightness; adduction with hip flexion adds 20º; limited by iliofemoral ligament, capsule, and abductors. iv. Internal and External Rotation 1. Hip internal rotation: a. 0-45º limited by capsular tightness, ischiofemoral ligament, external rotators. 2. Hip external rotation: a. 0-45º limited by iliofemoral ligament and internal rotators. v. Movement of the Pelvis (when the lower extremity is fixed: ie standing) 1. Anterior tilt 2. Posterior tilt 3. Lateral tilt (hike/drop) 4. Forward rotation 5. Backward rotation Section 3 Pelvis, Hip, and Gluteal 8 d. Blood Supply to the Hip Joint i. Medial and lateral circumflex femoral arteries from the Profunda Femoral (branches off femoral in proximal thigh) retinacular arteries deep to synovium ii. Ligamentum fovea capitis (from the obturator artery off the internal iliac) iii. Inferior gluteal artery and a deep branch of the superior gluteal artery (off the internal iliac) e. Innervation of the Hip Joint (any nerve crossing a joint innervates that joint) i. Femoral Nerve ii. Anterior Division of Obturator Nerve iii. Superior Gluteal Nerve iv. Nerve to Quadratus Femoris/Obturator Internus Section 3 Pelvis, Hip, and Gluteal 9 3. Fascia of the Gluteal Region a. Superficial Fascia i. Fat storage in the hypodermis gives the shape to the gluteal region b. Deep Fascia (Fascia Lata) i. Attached to iliac crest, dorsal sacrum, sacrotuberous ligament, inferior ramus, body, and superior ramus of the pubic bone ii. Thickening of fascia lata along the lateral thigh is the iliotibial (IT) tract iii. Gluteus maximus and Tensor fascia lata insert into the IT tract  provide lateral stability for pelvis iv. Inferiorly the fascia lata blends with the crural fascia of the leg 4. Superficial Gluteal Muscles (gluteus maximus, medius and minimus and TFL) a. Role i. Extend hip (gluteus maximus) ii. Stabilize pelvis during single limb stance (gluteus medius and minimus) iii. Trendelenburg Gait (weakness of gluteus med/min) iv. Consider the impact of weak hip abductors on the frontal plane forces at the knee b. Muscles (see chart with deep muscles) Section 5 Pelvis, Hip, and Gluteal 10 5. Deep Gluteal Muscles a. Role i. Stabilize the hip joint ii. Can perform lateral rotation of the hip b. Relationships of other structures iii. Location of piriformis can be estimated by considering a line from the midpoint of PSIS to Coccyx and extending the line to the greater trochanter iv. Superior gluteal vessels and nerve pass into the gluteal region superior to piriformis v. All other vessels and nerves pass into the gluteal region inferior to piriformis c. Learning the muscles vi. PGOGOQ is the order of the muscles from superior to inferior vii. Tendon of Obturator externus is deep to the other muscles as it inserts in the trochanteric fossa Section 5 Pelvis, Hip, and Gluteal 11 d. Muscles Muscle Origin Insertion Nerve Action Ilium posterior to Most fibers end in Extends thigh and posterior gluteal line, IT tract which assists in its lateral Inferior Gluteus dorsal surface of inserts into lateral rotation, steadies gluteal nerve maximus sacrum and coccyx, condyle of tibia, thigh and assists in L5, S1,S2 sacrotuberous some insert of rising from sitting ligament gluteal tuberosity position External surface of ilium between Lateral surface of Superior Gluteus anterior and greater trochanter gluteal nerve medius Abduct and medially posterior gluteal of femur L5, S1 rotate thigh, keep lines pelvis level when External surface of Anterior surface of Superior Single leg standing Gluteus ilium between greater trochanter gluteal nerve minimus anterior and inferior of femur L5, S1 gluteal lines Abduct and medially IT band, which Superior Tensor ASIS, anterior part of rotate thigh, keep attaches to lateral gluteal nerve fascia lata iliac crest pelvis level when condyle of tibia L5, S1 Single leg standing Anterior surface of Superior border of Nerve to sacrum, Piriformis greater trochanter Piriformis: sacrotuberous of femur S1, S2 ligament Pelvic surface of Nerve to Obturator obturator membrane Trochanteric Fossa obturator Laterally rotate internus and surrounding of femur internus L5, extended thigh and bones S1 abduct flexed thigh, Superior: steady femoral head same as in acetabulum Superior obturator Superior: ischial and Trochanteric Fossa internus spine inferior of femur Inferior; same Inferior: ischial tub gamelli as nerve for quadratus femoris Margins of obturator Obturator Trochanteric Fossa Obturator foramen and Externus of femur Nerve L3, L4 membrane Laterally rotates Quadrate tubercle thigh steadies on Nerve to femoral head in Quadratus Lateral border of intertrochanteric quadratus acetabulum femoris ischail tuberosity crest of femur and femoris L5 S1 area inferior to it Section 5 Pelvis, Hip, and Gluteal 12 6. Bursa of the Gluteal Region a. Trochanteric Bursa i. Separates gluteus maximus from greater trochanter b. Ischial Bursa ii. Separates gluteus maximus from ischial tuberosity c. Gluteofemoral Bursa iii. Separates IT tract from proximal portion of vastus lateralis Section 5 Pelvis, Hip, and Gluteal 13 7. Neurovascular Supply of the Gluteal Region a. Branches of the internal iliac artery i. Superior gluteal vessels  gluteus medius, minimus, and tensor fascia lata ii. Inferior gluteal vessles  gluteus maximus and the deep muscles iii. Internal pudendal artery passes through but does not serve the gluteal region b. Seven nerves enter the gluteal region through the greater sciatic foramen formed by the greater sciatic notch, and sacrotuberous ligament a. Superior gluteal nerve b. Inferior gluteal nerve c. Sciatic nerve d. Posterior femoral cutaneous nerve e. Nerve to obturator internus (also innervates sperior gemellus) f. Nerve to quadratus femoris (also innervates inferior gemellus) g. Pudendal nerve Section 5 Pelvis, Hip, and Gluteal 14 c. All structures Passing through Greater Sciatic Notch: i. 7 Nerves a. Superior gluteal nerve b. Inferior gluteal nerve c. Sciatic nerve d. Posterior femoral cutaneous nerve e. Nerve to obturator internus (also innervates sperior gemellus) f. Nerve to quadratus femoris (also innervates inferior gemellus) g. Pudendal nerve ii. 3 Vessel Sets: a. Superior Gluteal Artery & Vein b. Inferior Gluteal Artery & vein c. Internal Pudendal Artery & vein iii. 1 Muscle: a. Piriformis Section 5 Pelvis, Hip, and Gluteal 15 8. Clinical Considerations for the Hip and Pelvis a. Arthritis of the hip: a very common condition. Osteoarthritis is particularly common. Bony outgrowth of the acetabular bone is seen. The hip has a restricted range of movement and capsular tightness and may be associated with chronic pain. Many individuals undergo partial or total hip replacement due to osteoarthritis. b. Fractures of the hip: very common especially in older adults- if the retinacula are torn, the blood supply to the head of the femur is compromised. The only source of blood to the head is then the obturator artery through the ligamentum capitis. This is normally inadequate and the femoral head undergoes avascular necrosis. c. Congenital dislocation of the hip. Also common- the articular capsule of the joint is loose and the head hypoplastic. It can be recognized by a shorter limb and limited ability to abduct. d. Fracture dislocation of the hip- common in automobile accidents. The head of the femur is dislocated posteriorly fracturing the posterior acetabular rim. This frequently results in damage to the sciatic nerve that lies posteriorly. e. Femoroacetabular impingement: abnormally shaped acetabulum or femoral neck causes pinching within the hip joint, leads to bone spurs in the region of the joint  can lead to osteoarthritis and/or labral tears. Typically presents with pain in the groin, aggravated by squatting or rotation at the hip. f. Bursitis: inflammation of a bursa (most common are trochanteric and gluteal femoral) g. Weakness or Paralysis of gluteus medius/minimus: May be caused by injury to the nerves or disuse  results in “hip drop” during gait (mild weakness), or if more severe weakness, the patient will tilt his or her trunk laterally outward to the affected side when walking or raising the opposite limb (Trendelenburg gait) h. “Sciatica”: pain in the distribution of the sciatic nerve will radiate vertically downward from the inferior gluteal area to the posterior thigh. What factors might contribute to this problem? What muscle might compress the sciatic nerve? i. Positive “adverse mechanical tension” Section 5