HIP JOINTHIP JOINT

…..the largest joint in the body

Dr. Zeenat Dr. Zeenat ZaidiZaidi

ARTICULATIONARTICULATION Hemispherical Hemispherical

head of Femurhead of Femur Cup-shapedCup-shaped

acetabulumacetabulum of of the hip bonethe hip bone

Articular Articular surfaces covered surfaces covered with with hyalinehyaline cartilage cartilage

Head of FemurHead of Femur Globular, more than a Globular, more than a

hemispherehemisphere Directed upward, medially, Directed upward, medially,

and a little forwardand a little forward Surface is smooth, covered Surface is smooth, covered

with with hyaline cartilagehyaline cartilage, , except over an ovoid except over an ovoid depression, the depression, the fovea capitis fovea capitis femorisfemoris, which is situated a , which is situated a little below and behind the little below and behind the center of the headcenter of the head

The fovea gives attachment The fovea gives attachment to the to the ligament of the ligament of the head of femurhead of femur

ACETABULUMACETABULUM

Horse-shoe shaped articular surface

Deficient inferiorly as the acetabular notch that is filled up by transverse acetabular ligament

Deepened by fibro-cartilaginous rim called acetabular labrum

Nonarticular part, acetabular fossa, lodges pad of fat

TYPETYPE

SynovialSynovial A perfect A perfect

example of a example of a ‘‘Ball and SocketBall and Socket’’ jointjoint

CAPSULECAPSULE Encloses the jointEncloses the joint Attachment:Attachment:• Medially:Medially: Acetabular labrum Acetabular labrum• Laterally:Laterally:

• Anteriorly:Anteriorly: to the to the intertrochanteric lineintertrochanteric line. . Some fibers reflect upward Some fibers reflect upward along the neck, form along the neck, form ‘‘retinacularetinacula’ (carry blood ’ (carry blood vessels for head & neck of vessels for head & neck of femur)femur)

• Posteriorly Posteriorly halfway along halfway along the posterior aspect of the posterior aspect of neckneck

LIGAMENTSLIGAMENTS

IliofemoralIliofemoral PubofemoralPubofemoral IschiofemoralIschiofemoral Transverse acetabular Transverse acetabular Ligament of head of femurLigament of head of femur

Iliofemoral LigamentIliofemoral Ligamento Strong, Y-shapedStrong, Y-shapedo Attachment: Attachment:

BaseBase to anterior to anterior inferior iliac spineinferior iliac spine

Two limbsTwo limbs to upper to upper & lower ends of & lower ends of intertrochanteric intertrochanteric lineline

Prevents over-extension during standing

Pubofemoral LigamentPubofemoral Ligamento Triangular in Triangular in

shapeshapeo Attachment:Attachment:

Base Base to superior to superior ramus of pubisramus of pubis

ApexApex to lower to lower part of inter-part of inter-trochanteric linetrochanteric line

Limits extension & abduction

Ischiofemoral LigamentIschiofemoral Ligamento Spiral in shapeSpiral in shapeo Attachment:Attachment:

MediallyMedially to the to the body of the body of the ischium near ischium near acetabulumacetabulum

LaterallyLaterally to the to the greater greater trochantertrochanter

Limits extension

Transverse Acetabular LigamentTransverse Acetabular Ligament

o Formed by Formed by acetabular labrumacetabular labrum

o Bridges Bridges acetabular notch, acetabular notch, converting it into converting it into tunnel through tunnel through which vessels and which vessels and nerves enter the nerves enter the jointjoint

Ligament of Head of FemurLigament of Head of Femuro Flat & triangularFlat & triangularo Attachment:Attachment:

ApexApex to the pit to the pit (fovea) on the head (fovea) on the head of femurof femur

BaseBase to transverse to transverse ligament & the ligament & the margin of margin of acetabulumacetabulum

o Intracapsular, Intracapsular, ensheathed by ensheathed by synovial membranesynovial membrane

Carries articular branch of obturator artery to the joint

SYNOVIAL MEMBRANESYNOVIAL MEMBRANE Lines the capsuleLines the capsule Attached to Attached to

margins of margins of articular surfacesarticular surfaces

Covers Covers intracapsular part intracapsular part of the neck of of the neck of femurfemur

Ensheaths Ensheaths ligament of head ligament of head of femurof femur

Covers pad of fat Covers pad of fat in acetabular fossain acetabular fossa

Protrudes Protrudes anteriorly anteriorly through gap through gap between between pubofemoralpubofemoral & & iliofemoraliliofemoral ligaments and ligaments and forms forms psoas psoas bursabursa

RELATIONSRELATIONSAnterior

Pectineus

Rectus femoris

Iliopsoas Inferior

Obturator externus

Superior

Gluteus minimus

Piriformis

Posterior

Obturator internus

Sciatic nerve

Quadratus femoris

Superior & inferior Gemelli

BLOOD SUPPLYBLOOD SUPPLY Head & intra-capsular Head & intra-capsular

part of neck receives its part of neck receives its blood supply from blood supply from trochanteric trochanteric anastomosis,anastomosis, mainly mainly from branches of from branches of medial medial circumflex arterycircumflex artery

A branch from A branch from obturator obturator arteryartery in the ligament of in the ligament of head of femur is head of femur is importanat in young importanat in young childchild

NERVE SUPPLYNERVE SUPPLY

The nerve supplying The nerve supplying a joint also supplies a joint also supplies both the:both the:

Muscles Muscles that move that move the jointthe joint & &

Skin Skin covering the covering the articular insertionarticular insertion (area of action) (area of action) of of those musclesthose muscles

These nerves also supply knee joint &

therefore pain arising in the hip joint may be referred to the

knee

• Femoral• Obturator• Sciatic• Nerve to quadratus femoris

Apply Hilton’s law

STRENGTH & STABILITYSTRENGTH & STABILITY

Depends largely on the:Depends largely on the: Shape of the bonesShape of the bones LigamentsLigaments

MOVEMENTSMOVEMENTS Wide range (less than shoulder joint)Wide range (less than shoulder joint) Some movements sacrificed in order Some movements sacrificed in order

to provide strength & stabilityto provide strength & stability Movements are:Movements are:

Flexion/ExtensionFlexion/Extension Abduction/AdductionAbduction/Adduction Lateral/Medial rotation Lateral/Medial rotation CircumductionCircumduction

FLEXIONFLEXION FlexorsFlexors::

IliopsoasIliopsoas Rectus femorisRectus femoris SartoriusSartorius Adductor musclesAdductor muscles

Limitation: with the knee flexed: Anterior surface of thigh coming in contact with the anterior abdominal wallwith the knee extended: Tension of hamstring group of muscles

EXTENSIONEXTENSION

ExtensorsExtensors:: Gluteus Gluteus

maximusmaximus Hamstring Hamstring

musclesmuscles

Limitation: Tension of iliofemoral, pubofemoral & ischiofemoral ligaments

ABDUCTIONABDUCTION AbductorsAbductors::

Gluteus Gluteus medius & medius & minimusminimus

PiriformisPiriformis SartoriusSartorius Tensor fascia Tensor fascia

latalataLimitation: Tension of pubofemoral ligament

ADDUCTIONADDUCTION AdductorsAdductors:: Adductors Adductors

(longus, brevis & (longus, brevis & adductor part of adductor part of magnus)magnus)

PectineusPectineus GracilisGracilis

Limitation: Contact with the opposite limb & by tension in ligament of head of femur

LATERAL ROTATIONLATERAL ROTATION Lateral RotatorsLateral Rotators::

PiriformisPiriformis Obturator internus Obturator internus

& externus& externus GemilliGemilli Quadratus femorisQuadratus femoris Gluteus maximusGluteus maximus

Limitation: tension in iliofemoral & pubofemoral ligaments

MEDIAL ROTATIONMEDIAL ROTATION Medial RotatorsMedial Rotators::

Anterior fibers of Anterior fibers of gluteus medius gluteus medius & minimus& minimus

Tensor fascia Tensor fascia lata.lata.

Limitation: tension of ischiofemoral ligament.

CLINICAL ANATOMYCLINICAL ANATOMY

Referred Pain From the Hip JointReferred Pain From the Hip Joint The pain originating in the hip joint The pain originating in the hip joint

to be referred to the to be referred to the front and front and medial side of the thigh medial side of the thigh (femoral (femoral nerve)nerve)

The hip joint disease may give rise The hip joint disease may give rise to to pain in the knee jointpain in the knee joint (posterior (posterior division of the obturator nerve division of the obturator nerve supplies both the hip and knee supplies both the hip and knee joints)joints)

Congenital DislocationCongenital Dislocation Affects 1-2 babies in every Affects 1-2 babies in every

10001000 Associated with a Associated with a shallow shallow

acetabulumacetabulum and and an an altered angle of the altered angle of the femoral headfemoral head

May be May be bilateralbilateral FemalesFemales affected more affected more

than malesthan males May be caused by May be caused by

mechanical factors i.e. mechanical factors i.e. malformed uterusmalformed uterus

The affected limb is The affected limb is shortershorter than the normal than the normal limblimb

• CapsuleCapsule is looseis loose• Upper lip of Upper lip of

acetabulum acetabulum is not is not developed properly developed properly (hypoplasia). (hypoplasia).

• Head of femur Head of femur moves moves up out of acetabulum up out of acetabulum and lies against the and lies against the gluteal surface of gluteal surface of ilium.ilium.

• Characteristic clinical Characteristic clinical sign is the inability to sign is the inability to abduct the hipabduct the hip

Traumatic DislocationTraumatic Dislocation Rare, because of the Rare, because of the

strength of jointstrength of joint Occurs when joint is Occurs when joint is

flexed & abductedflexed & abducted. .

This can occur in a car crash where the knee is pushed backwards, often breaking off the posterior rim of the acetabulum

• The head of femur is The head of femur is displaced displaced posteriorlyposteriorly and and rests on the gluteal surface rests on the gluteal surface of ilium (posterior of ilium (posterior dislocation).dislocation).

• Sciatic nerveSciatic nerve is prone to get is prone to get injured. injured.

• Lower limb is Lower limb is flexed, flexed, adducted & medially adducted & medially rotatedrotated and is shorter than and is shorter than the normal limb the normal limb

• Positive Trendelenburg’s Positive Trendelenburg’s signsign

• ‘‘DippingDipping’ (unilateral ’ (unilateral dislocation) or ‘dislocation) or ‘waddlingwaddling’ ’ (bilateral dislocation) gait(bilateral dislocation) gait

OsteoarthritisOsteoarthritis Most common disease Most common disease

of hip joint in the of hip joint in the adultsadults Results in: Results in:

PainPainStiffnessStiffness (due to pain (due to pain

and reflex spasm of and reflex spasm of muscles)muscles)

DeformityDeformity i.e. flexion, i.e. flexion, adduction & external adduction & external rotation (due to rotation (due to muscle spasm & later muscle spasm & later on muscle on muscle contractures)contractures)

Arthritis of the Hip JointArthritis of the Hip Joint A patient with an inflamed hip joint A patient with an inflamed hip joint

will place the femur in the position will place the femur in the position that gives minimum discomfort (the that gives minimum discomfort (the position in which the joint cavity position in which the joint cavity has the greatest capacity to contain has the greatest capacity to contain the increased amount of synovial the increased amount of synovial fluid secreted).fluid secreted).

The hip joint is partially The hip joint is partially flexedflexed, , abductedabducted, and , and externally rotatedexternally rotated

Tenderness over the head of the femur (on the anterior aspect of the thigh just inferior to the inguinal ligament and just lateral to the pulsating femoral artery) usually indicates the presence of arthritis of the hip joint.

Thank You & Good LuckThank You & Good Luck