Gluteal Region, Femur, and Hip Joint Anatomy PDF

XY2141. ANATOMY. GLUTEAL REGION. HIP JOINT Dr Viktoriia Yerokhina, Lecturer in Medical Sciences [email protected]  LEARNING OUTCOMES ANAT.33 - Glut. Region ANAT.33.01 - Identify and describe the key bones (and bony features) of the lower extremi...

XY2141. ANATOMY. GLUTEAL REGION. HIP JOINT Dr Viktoriia Yerokhina, Lecturer in Medical Sciences [email protected]  LEARNING OUTCOMES ANAT.33 - Glut. Region ANAT.33.01 - Identify and describe the key bones (and bony features) of the lower extremity. ANAT.33.02 - Identify and describe the major joints of the lower extremity (hip, knee, ankle, foot). Name their functions. ANAT.33.03 - Demonstrate movement of the lower limb. ANAT.33.04 - Summarize the main muscle groups (compartments & muscles within) of the lower extremity and describe the functions of key muscles. ANAT.33.05 - Review and describe the course and distribution of the venous drainage, arterial supply and innervation of the lower extremity. ANAT.33.06 - Describe the lymphatic drainage of the lower limb. ANAT.33.07 - Discuss the muscles, nerves and blood vessels of the gluteal region. ANAT.33.08 - Review the actions of the muscles of the gluteal region. ANAT.33.09 - Apply your anatomical knowledge to clinical problems associated with the gluteal region (e.g. Trendelenburg sign, intra-muscular injection site, Piriformis syndrome, bursitis), as discussed PARTS / REGIONS OF THE LOWER LIMB For descriptive purposes, the lower limb is divided into six parts or regions: Gluteal region Thigh or femoral region Knee or knee region Leg or leg region Ankle or talocrural region Foot or foot region  FEMUR Longest bone and strongest bone of the human body. It is covered by a thick layer of muscles and therefore only a small proportion is palpable from the skin. Latin femur = thigh Femur consists of three parts: Upper end, Shaft/body, Lower end.  FEMUR 1. Head (caput femoris) – forms the articular head of the hip joint 1.1 Fovea of head of femur (fovea capitis femoris) – site of attachment of the ligament of the head of the femur 2. Neck (collum femoris) – articular capsule of the hip joint attaches to the dorsal 2/3 of the neck.  FEMUR 3. Shaft of the femur (corpus femoris) – body of the femur 3.1 Greater trochanter (trochanter major) – insertion of the gluteus medius, gluteus minimus, piriformis, obturator internus, gemellus superior and gemellus inferior 3.2 Trochanteric fossa (fossa trochanterica) – insertion of the obturator externus 3.3 Lesser trochanter (trochanter minor) – dorsomedial prominence – insertion of the iliopsoas FEMUR FEMUR  FEMUR 3.4 Intertrochanteric line (linea intertrochanterica) – ventral line connecting both trochanters – attachment of the articular capsule of the hip joint 3.5 Intertrochanteric crest (crista intertrochanterica) – dorsal crest connecting both trochanters 3.6 Pectineal line (linea pectinea) – insertion of the pectineus; located below the lesser trochanter 3.7 Gluteal tuberosity (tuberositas glutea) – insertion of the gluteus maximus; located below the greater trochanter 3.8 Linea aspera – attachment site for many muscles of the thigh  FEMUR 3.9 Lateral supracondylar line (linea supracondylaris lateralis) – origin of the plantaris 3.10 Medial supracondylar line (linea supracondylaris medialis) 3.11 Popliteal surface (facies poplitea) – floor of the popliteal fossa  FEMUR 4. Condyles of femur (condyli femoris) – distal end of the femur – articular surfaces that articulate with the tibia 4.1 Medial condyle (condylus medialis femoris) 4.1.1 Medial epicondyle (epicondylus medialis) – attachment of the tibial collateral ligament – origin of the medial head of the gastrocnemius 4.1.2 Adductor tubercle (tuberculum adductorium) – insertion of the extensor part of the adductor magnus. FEMUR  FEMUR 4.2 Lateral condyle (condylus lateralis femoris) 4.2.1 Lateral epicondyle (epicondylus lateralis) – attachment of the fibular collateral ligament – origin of the lateral head of the gastrocnemius  FEMUR 4.3 Intercondylar line (linea intercondylaris) – attachment of the oblique popliteal ligament 4.4 Intercondylar fossa (fossa intercondylaris) – attachment of the cruciate ligaments of the knee joint 4.5 Patellar surface (facies patellaris) – ventral surface for articulation with the patella FEMUR  REVISION SLIDE - HIP BONE Hip bone (innominate bone) is comprised: ilium, pubis and ischium. Prior to puberty triradiate cartilage separates these parts – and fusion only begins at the age of 15-17. Together ilium, pubis and ischium form a cup-shaped socket known as acetabulum (Latin = ‘vinegar cup‘). Head of the femur articulates with the acetabulum to form the hip joint.  FEMORAL NECK ABNORMALITIES: COXA VARA/ COXA VALGA Caput-collum-diaphyseal angle (CCD angle) Angle formed by the main axis of the femoral neck and the longitudinal axis of the femoral shaft (coxa norma) Normal angle: ∼ 125° in adults ∼ 150° in newborns Coxa vara – deformity of the proximal femur due to a decreased femoral neck-shaft angle (< 120°), with shortening and thickening of the femoral neck. Coxa valga – deformity of the femur due to an increased femoral neck-shaft angle (> 140°).  FEMORAL NECK ABNORMALITIES Coxa magna is the asymmetrical, circumferential enlargement and deformation of the femoral head and neck. Definitions in the literature vary but enlargement with asymmetry >10% in size is a reasonable cut-off for diagnosis. A 75-year-old woman has been suffering from osteoporosis for the past year. During her annual check-up, radiologic examination reveals an angle of 150 degrees made by the axis of the femoral neck to the axis of the femoral shaft. Which of the following conditions is associated with these examination findings? A. Coxa vara B. Coxa valga C. Coxa magna  Legg-Calvé-Perthes disease (Idiopathic avascular necrosis of the femoral head) Perthes’ disease (pseudocoxalgia): clinical condition characterised by destruction and flattening of the head of femur with an increased joint space in the radiograph.  HIP JOINT 1. Type: simple (articulation of two bones in the abscence of articular discs and menisci) 2. Shape: limited ball-and-socket (cotyloid) 3. Articular head: head of the femur 4. Articular fossa: acetabulum 4.1 Lunate surface (facies lunata) – articular facet in the acetabulum 5. Capsule: attaches to the margins of the acetabulum and across the posterior aspect of the neck (1 cm above the intertrochanteric crest). HIP JOINT LIGAMENTS OF HIP JOINT 6.1 Iliofemoral ligament (ligamentum iliofemorale) – prevents hyperextension of the hip joint 6.2 Pubofemoral ligament (l. pubofemorale) – limits abduction and external rotation 6.3 Ischiofemoral ligament (l. ischiofemorale) – limits adduction and internal rotation. LIGAMENTS OF HIP JOINT  LIGAMENTS OF HIP JOINT 6.4 Transverse acetabular ligament (l. transversum acetabuli) – bridges the acetabular notch 6.5 Ligament of head of femur (l. capitis femoris) – small ligament connecting the transverse acetabular ligament and fovea for the ligament of the head of the femur – contains artery of the head of the femur 7. Accessory features: 7.1 Acetabular labrum – fibrocartilaginous rim that enlarges the cavity of the acetabulum 7.2 Acetabular fat pad – fat pad in the acetabular fossa. LIGAMENTS OF HIP JOINT  MOVEMENTS OF THE HIP JOINT Flexion: 0–130° Extension: 0–30° – limited by tension of the iliofemoral ligament Abduction: 0–45° Adduction (hyperadduction): 0–30° External rotation: to 45° Internal rotation: to 35° Neutral position: mild flexion, mild external rotation and mild abduction.  ARTERIAL SUPPLY OF THE HIP JOINT Superior and inferior gluteal arteries Deep femoral artery: main branch of the femoral artery Medial femoral circumflex artery Supplies the head and neck of the femur Lateral femoral circumflex artery Supplies the head and neck of the femur Foveolar artery Most commonly arises from the obturator artery and less commonly from the medial circumflex femoral artery Passes through the ligament of the femur head Supplies the head of the femur.  CLINICAL CORRELATION Dislocation of the hip joint may be caused by a high energy trauma. This typically occurs in car accidents when the knees are impacted on the car dashboard (dashboard injury). 90% of the cases are posterior dislocations, which occur through a weak spot between the ligaments strengthening the articular capsule.  CLINICAL CORRELATION Developmental dysplasia of the hip (DDH) - congenital deformity of the hip joint which, if not treated, causes orthopedic problems throughout life. Incidence: most common congenital abnormality of skeletal development Hip instability: 1 in 100 births Dislocation: 1 in 1000 births Sex: > (4–5:1) Charactered by a misshapen acetabulum and/or head and neck of the femur. This causes a misalignment of the “bone-to-bone” contact between the articular head and fossa.  CLINICAL CORRELATION Total hip replacement (endoprosthesis) is an orthopeadic procedure that replaces the articular head and fossa of the hip joint with an artificial prosthesis. Severely damaged hips are indicated for this operation, such as occur in osteoarthrosis or after injuries. Hemiarthropathy of the hip is a replacement of the articular head only. This is usually indicated in femoral neck fractures occuring in elderly people.  MUSCLES OF THE HIP JOINT 1. Anterior group 1.1 Iliopsoas (m. iliopsoas) 2. Posterior group Superficial layer 2.1 Gluteus maximus (m. gluteus maximus) 2.2 Gluteus medius (m. gluteus medius) 2.3 Gluteus minimus (m. gluteus minimus) 2.4 Tensor fasciae latae / tensor of fascia lata (m. tensor fasciae latae) Deep layer – pelvitrochanteric muscles 2.5 Piriformis (m. piriformis) 2.6 Gemellus superior / superior gemellus (m. gemellus superior) 2.7 Obturator internus (m. obturatorius internus) 2.8 Gemellus inferior / inferior gemellus (m. gemellus inferior) 2.9 Quadratus femoris (m. quadratus femoris). *All superficial gluteal muscles abduct and medially rotate the thigh. All deep gluteal muscles and the gluteus maximus laterally rotate the thigh.  MUSCLES OF THE HIP JOINT – ANTERIOR GROUP Consists of one muscle: iliopsoas. Iliopsoas consists of two parts: iliacus, psoas major. Both parts fuse when passing through the muscular space under the inguinal ligament and they insert on the femur. Occasionally, a third part, psoas minor, is present. It originates with the psoas major on the lumbar vertebral column.  MUSCLES OF THE HIP JOINT – ANTERIOR GROUP liopsoas (m. iliopsoas) Origin: 1. Iliacus (m. iliacus): ilium – iliac fossa 2. Psoas major (m. psoas major): bodies of T12–L5, intervertebral discs (as 5 digitations), vertebrae L1–L5 – costal processes 3. Psoas minor (m. psoas minor) – bodies of T12 and L1 and the intervertebral discs between them. Insertion: 1,2 Iliacus and psoas major: femur – lesser trochanter 3 Psoas minor: iliopubic ramus MUSCLES OF THE HIP JOINT  MUSCLES OF THE HIP JOINT – ANTERIOR GROUP Function: 1,2 Iliacus and psoas major: flexion and external rotation of the thigh 2,3 Psoas major and psoas minor: ventral flexion of the lumbar vertebral column 2. Psoas major: lateroflexion of the trunk to the side of the contracted muscle and rotation to the opposite side (unilateral contraction) Innervation (T12–L4): femoral nerve (iliacus), lumbar plexus – branches of the spinal nerves L1–L3 (psoas major and psoas minor).  MUSCLES OF THE HIP JOINT – POSTERIOR GROUP (SUPERFICIAL LAYER) Consists of the gluteal muscles and the tensor fasciae latae. These muscles facilitate standing up from a sitting position and climbing stairs, keep the pelvis in retroversion and prevent the hip from deviating to one side. Group is innervated by superior and inferior gluteal nerves. MUSCLES OF THE HIP JOINT – POSTERIOR GROUP (SUPERFICIAL LAYER) Gluteus maximus (m. gluteus maximus) O: gluteal surface of the ilium – dorsal to the posterior gluteal line, iliac crest, thoracolumbar fascia – posterior layer, sacrum, coccyx, sacrotuberous ligament, gluteal aponeurosis I: femur – gluteal tuberosity, tibia – lateral condyle (via the iliotibial tract).  FUNCTIONS OF GLUTEUS MAXIMUS Abduction of the thigh (cranial fibers), Extension, External rotation and adduction of the thigh (caudal fibers), Maintains extension of the knee joint (by stretching the iliotibial tract), Keeps the pelvis in retroversion, Maintains the erect standing position, Provides lateral stability to the trunk (most important function). MUSCLES OF THE HIP JOINT – POSTERIOR GROUP (SUPERFICIAL LAYER) Gluteus medius (m. gluteus medius) O: gluteal surface of the ilium – between the posterior and anterior gluteal lines, iliac crest I: femur – greater trochanter F: abduction of the thigh and tilting of the pelvis (middle fibers), flexion and internal rotation of the thigh (anterior fibers), extension and external rotation of the thigh (posterior fibers). MUSCLES OF THE HIP JOINT – POSTERIOR GROUP (SUPERFICIAL LAYER) Gluteus minimus (m. gluteus minimus) O: gluteal surface of the ilium – between the anterior and inferior gluteal lines, iliac crest I: femur – greater trochanter F: abduction of the thigh and tilting of the pelvis (middle fibers), flexion and internal rotation of the thigh (anterior fibers), extension and external rotation of the thigh (posterior fibers). INTRA-MUSCULAR INJECTION SITE Muscles commonly used for intramuscular injection in the lower limb: a) Gluteus medius of gluteal region in adults (most common site) b) Vastus lateralis muscle of the thigh region in children. Gluteus medius is a fan-shaped muscle. Its posterior 1/3 is deep and covered by the gluteus maximus while its anterior 2/3 is superficial and not covered by the gluteus maximus → intramuscular injection should be ideally given in this part. MUSCLES OF THE HIP JOINT – POSTERIOR GROUP (SUPERFICIAL LAYER) Tensor fasciae latae / tensor of fascia lata (m. tensor fasciae latae) O: ilium – anterior superior iliac spine I: tibia – tuberosity for the iliotibial (on the lateral condyle) tract of Gerdy (via the iliotibial tract) F: extension of the knee joint (“locking of the knee joint”), abduction, flexion and internal rotation of the thigh, stabilisation of both knee joints and the hip joint during walking.  MUSCLES OF THE HIP JOINT – POSTERIOR GROUP (DEEP LAYER) Muscles of the deep layer are called the pelvitrochanteric muscles. They are short muscles with insertions around the greater trochanter. Functions: maintain stability of the hip joint and have important postural functions. Piriformis (m. piriformis) Gemellus superior (m. gemellus superior) Obturator internus (m. obturatorius internus) Gemellus inferior (m. gemellus inferior) Quadratus femoris (m. quadratus femoris) MUSCLES OF THE HIP JOINT – POSTERIOR GROUP (DEEP LAYER)  CLINICAL CORRELATION Piriformis muscle arises from the pelvic surface of the sacrum, passes through the greater sciatic notch, and inserts at the greater trochanter. It is considered the “anatomical key” to gluteal anatomy; the greater sciatic foramen is the “door.” Gluteus medius lies posterior to the piriformis. Sciatic nerve emerges from the greater sciatic foramen, normally through the infrapiriformic space. Spine of the ischium separates the greater and lesser sciatic foramina.  PIRIFORMIS SYNDROME A condition caused by entrapment of the sciatic nerve by the piriformis muscle. Manifestations include pain, tingling, and numbness in the buttock and distribution of the sciatic nerve. SUPERFICIAL AND DEEP MUSCLES OF THE GLUTEAL REGION  ANTIGRAVITY MUSCLES OF THE LOWER LIMB They are far better developed than those of the upper limb because they lift up the whole body to attain the erect posture and in walking up the staircase. These muscles are: gluteus maximus (extensor of the hip), quadriceps femoris (extensor of the knee), gastrocnemius, soleus (plantarflexors of the ankle). They have extensive origin and bulky muscle belly. Thank you for attention! Have a nice day! REFERENCES