Region Of The Hip

The hip is that portion of the body joining the lower extremity to the trunk. It differs in
construction from the shoulder, because it is designed for strength as well as mobility; hence
it is that the bones are heavier, stronger, with their processes more marked, and that the
muscles also are bigger and more powerful. It is often the seat of injury and disease, the
bones being fractured, the joint luxated, and frequently affected with tuberculosis and other
diseases.

Bones Of The Hip

The bones of the hip are the innominate bone and femur. The innominate bone has its shape
determined by its relation to the trunk, being adapted to support and protect the viscera, while
the femur has its shape determined by its relation to the extremity, being in the nature of a
pole to support it.

The innominate bone (Figs. 500 and 501) is composed of the ilium, ischium, and pubis. These
are united in the acetabulum by the triangular cartilage and become ossified about the
sixteenth year. The ilium has a crest which serves for the attachment of the transverse
abdominal muscles. At its anterior extremity is the anterior superior spine, and at its posterior
extremity the posterior superior spine. Its large flat portion, called the a/a, gives origin from
both its inner and outer sides to muscles running to the thigh below. The glutei muscles are
attached to its outer surface and the iliacus to its inner. Immediately below the anterior
superior spine is the anterior inferior spine; to it is attached the rectus femoris tendon. The
ischium is below and behind the acetabulum; its tuberosity gives attachment to the hamstring
muscles - biceps (outer), semitendinosus, and semimembranosus (inner). Along the inner
surface of the ramus of the ischium, in a fibrous canal (Alcock's), run the internal pudic
vessels and nerve on their way to the perineum. They lie 4 cm. (1 1/2 in.) from the surface.
The pubis lies below and anterior to the acetabulum. Its upper inner edge forms the
iliopectineal line, which is continued back to form the brim of the true pelvis. The superior or
horizontal ramus goes to the ilium, while its inferior or descending ramus goes to the ischium.
The upper surface of the superior ramus gives origin to the pectineus muscle; it is over this
muscle that femoral hernia descends. The symphysis pubis is the junction of the two pubic
bones in the median line. The crest is the upper anterior edge and gives attachment to the
rectus and pyramidal muscles (for muscular attachments see Figs. 438 and 439, page 432).
The outer extremity of the crest is the spine of the pubis. To it is attached the inner extremity
of Poupart's ligament. The obturator foramen, if the body is in an upright position, is just
below and a little anterior to the acetabulum; it is closed by a membrane which is incomplete
above to give passage to the obturator vessels and nerve. The outer surface of the
membrane gives origin to the obturator externus muscle and the inner surface to the obturator
internus. This latter passes out of the pelvis through the lesser sacrosciatic notch just below
the spine of the ischium. Through the greater sacro-sciatic notch, above the spine, comes the
pyriformis muscle and great sciatic nerve. The acetabulum is located at the junction of the
ilium, ischium, and pubis, and lies a little to the outer side of the middle of Poupart's ligament,
with the femoral artery passing nearer its inner than its outer edge. The obturator foramen is
below and a little anterior to the acetabulum when the body is upright and more anterior when
it is horizontal. The bottom of the acetabulum has a large fossa, to the upper portion of which
is attached the ligamentum teres, while the lower portion contains a pad of fat. This fossa
opens by a large notch, called the cotyloid notch, on the side toward the obturator foramen;
therefore the bony socket is incomplete at this point.

Fig. 500. - The innominate bone, viewed from the outside.

Fig. 501. - The innominate bone, viewed from the inside.

Fig. 502. - Innominate bone, resting on its inner side, to show the wedge-shaped formation of
its outer sur. face. The apex of the wedge is Nelaton's line, running from the anterior superior
spine to the tuberosity of the ischium; the anterior plane inclines downward and forward
toward the pubis and the posterior plane inclines downward and backward on the ilium.

Fig. 503. - Anterior view of the upper end of the femur with muscular attachments.

O. H. Allis has pointed out that a line passing from the anterior superior spine to the
tuberosity, called the Roser-Nelaton line, forms the apex of a wedge, the ilium sloping down
on one side while the ischium and pubes pass down the other. It divides the innominate bone
into two parts, an anterior plane and a posterior plane (Fig. 502).

The femur has its neck coming off from the shaft at an upward angle of about 127 degrees
(125 degrees to 130 degrees). The head and neck do not lie in the same transverse plane as
the line joining the two condyles, but are inclined slightly forward (about 12 degrees).
Therefore the neck passes upward, inward, and a little forward. As the result of deformities or
disease, the inclination of the neck to the shaft may be reduced, being 90 degrees or less.
This condition is known as coxa vara. It may be increased, constituting coxa valga. The
articular surface of the head forms slightly more than a hemisphere and has a pit below and
posterior to its centre for the attachment of the ligamentum teres. At the outer upper extremity
of the neck where it joins the shaft is the greater trochanter. Its tip or most prominent point is
toward its posterior surface and is just about opposite the centre of the hip-joint. Downward
and inward from the greater trochanter, on the inner and posterior surface of the shaft, is the
lesser trochanter. Between the trochanters anteriorly and posteriorly run the intertrochanteric
lines. The great trochanter and the part immediately below and posterior gives attachment to
the three glutei muscles, the short rotators (Fig. 504), the pyriformis, the obturators, internus
with its two gemelli and externus, and the quadratus femoris. The lesser trochanter gives
attachment anteriorly to the psoas and the iliacus and immediately below to the pectineus.

Fig. 504. - Posterior view of the upper end of the femur with muscular attachments.

The anterior intertrochanteric line marks the lower attachment of the capsule; the posterior
has inserted into it the quadratus femoris muscle.
Fig. 505. - Muscles of the region of the hip.
Muscles Of The Hip

The muscles of the hip are numerous and their action is often intricate: many muscles are
usually used to produce a single movement. Some muscles not only cross the hip-joint but
another joint as well. Thus the psoas crosses the hip-joint and pelvis to reach the spine. The
hamstring muscles, the rectus femoris, gracilis, and sartorius cross both the hip-joint and
knee-joint, as does practically the tensor fasciae femoris through its prolongation, the iliotibial
band. The movements of the hip are flexion, extension, adduction, abduction, and rotation.
Circumduction is a combine ation of the first four movements.

Flexion is mainly the result of the action of the sartorius, iliacus, psoas, rectus femoris, and
pectineus.

Extension is mainly due to the gluteus maximus, medius, and minimus, biceps,
semitendinosus, and semimembranosus.

Adduction is accomplished by the pectineus, adductor longus, brevis, and magnus, and to a
less extent by the gracilis, quadratus femoris, and lower part of the gluteus maximus.

Abduction in the extended position is due to the tensor fasciae femoris, sartorius, gluteus
medius, and gluteus minimus. When flexed the short rotators also aid.

Internal rotation is produced mainly by the tensor fasciae femoris and the anterior portion of
the gluteus medius and minimus; three muscles only. The iliopsoas acts as a weak internal
rotator if the femur is in a position of extreme external rotation.

External rotation is mainly due to the short external rotators - pyriformis, gemelli, obturators,
quadratus femoris, the adductors, and the posterior portion of the three gluteals. To a slight
extent the sartorius, iliopsoas, pectineus, and biceps may also aid at times.

Surface Anatomy

The crest of the ilium can be palpated in its entire length. In very thin people it causes an
elevation of the surface, but usually it is marked by a depression. Its anterior third is
subcutaneous and is more easily seen and felt than the posterior two thirds. A line joining the
highest point of the crests passes through the fourth lumbar spine. A line joining the anterior
superior spines in front passes below the promontory of the sacrum. The anterior superior
spine can be readily felt. It lies downward and outward from the umbilicus: as has been said,
measurements are best taken by pressing the tape against its lower surface rather than its
subcutaneous one.
The posterior superior spine, marked by a dimple, is best recognized by following the crest of
the ilium to its posterior extremity. It is opposite the middle of the sacroiliac joint and the
second sacral spine.

The posterior inferior spine is 4 to 5 cm. (1 1/2 to 2 in.) directly below the posterior superior
spine. The spine of the ischium, which marks the position of the pudic and sciatic arteries, is 8
to 10 cm. (3 to 4 in.) below the posterior superior spine and the tuberosity of the ischium is 12
to 15 cm. (5 to

6 in.). Running forward from the posterior inferior spine for a distance of 4 to 5 cm. (1 1/2 to 2
in.) is the great sciatic notch; through it pass the pyriformis muscle, gluteal artery and nerves,
and sciatic nerve. A line joining the posterior superior spine and the tip of the greater
trochanter may be named the posterior iliotrochanteric line

Fig. 506. - Surface anatomy of the region of the hip.

(iliotrochanteric line of Farabeuf). It marks roughly the posterior edge of the gluteus medius
muscle and goes through the upper edge of the gluteus maximus. The gluteal artery and
superior gluteal nerves cross this line at the junction of the upper and middle thirds, this being
about opposite the posterior inferior spine. A line joining the tuberosity of the ischium and tip
of the greater trochanter may be called the ischiotrochanteric line: it is crossed at the junction
of its inner and middle thirds by the sciatic nerve.

The greater trochanter is marked by an eminence in thin people and a depression in the
plump and fat. Its anterior upper edge is crossed by the tendon of the gluteus medius and
cannot be readily outlined. Its upper posterior extremity or tip is readily distinguished and is
the spot used for measurements. This point is called the tip of the greater trochanter and must
be searched for posteriorly. It is opposite the centre of the head of the femur and is on a level
with the spine of the pubis.

The Roser-Nelaton line is one drawn from the anterior superior spine to the tuberosity of the
ischium. It passes through the tip of the greater trochanter. It is of importance in fractures and
dislocations (Fig. 507).

Bryant's triangle ("Bryant's Surgery", vol. ii, p. 412) is to be drawn while the patient is lying on
his back. One side is a perpendicular let fall from the anterior superior spine to the table, the
other side is one joining the anterior superior spine and the tip of the greater trochanter, the
base is a line running horizontally from the tip of the greater trochanter to the perpendicular
line (Fig. 507). If the tip of the trochanter becomes elevated, as in fractures of the neck of the
femur, it shortens the base of the triangle on the affected side as compared with the base of
the triangle on the sound side.

The anterior iliotrochanteric line may be designated as a line joining the anterior superior
spine and the tip of the greater trochanter. In normal individuals it slopes downward and
backward, forming an iliotrochanteric angle (b a c, Fig. 507) of about 30 degrees. In cases of
fracture or luxation this angle becomes reduced as the shortening increases until the tip
reaches the level of the anterior superior spine. A rough estimate of this angle by sight and
palpation usually enables one to decide immediately as to the presence of shortening from
fracture or luxation without the trouble of erecting Bryant's triangle. The anterior
iliotrochanteric line forms the anterior side of Bryant's triangle and the anterior half of the
Roser-Nelaton line.

The gluteal cleft separates the buttocks. In its lower portion can be felt the coccyx. The gluteal
(gluteofemoral) fold is formed mainly by the subcutaneous fatty tissues and passes
horizontally outward from the lower part of the gluteal cleft. A shortening of the leg on either
side causes the corresponding fold to incline downward. It is marked in extension and
gradually lessens on flexion and disappears when 90 degrees is reached. It is crossed
obliquely downward and outward at about its middle by the lower edge of the gluteus
maximus. Its disappearance in coxalgia is caused by the flexion incident to that affection.
Ligation Of The Gluteal, Sciatic, And Internal Pudic Arteries

To ligate the gluteal artery incise the skin and part the fibres of the gluteus maximus in the
upper two-thirds of a line joining the posterior superior spine and the top of the great
trochanter (Fig. 508). Pull the lower edge of the gluteus medius up and the artery and
superior gluteal nerve will be seen coming out between it and the pyri-formis. To ligate the
sciatic and internal pudic arteries an incision parallel to the one just described but about 7.5
cm. (3 in.) lower is made through the gluteus maximus, and just below the edge of the
pyriformis from without inward will be found the great sciatic nerve, lesser sciatic nerve,
sciatic artery, and the internal pudic nerve and internal pudic artery crossing the spine of the
ischium.

Fig. 507. - View of the outer surface of the bones of the hip showing Roser-Nelaton line (a-d).
Bryant's triangle (a b c), iliotrochanteric line, (a c) and the iliotrochanteric angle (b a c).

Bursae

Covering the tuberosity of the ischium is a bursa which sometimes suppurates and forms a
sinus. It can readily be excised. These sinuses are often bilateral.
Fig. 508. - Ligation of the gluteal, internal pudic, and sciatic arteries.

 
The Hip-Joint

The hip-joint, like the shoulder, is a ball-and-socket joint, and, like it, moves in all directions.
The main function of the shoulder is mobility, but the functions of the hip are mobility and
support. To give the necessary support and security, the band-like ligaments uniting the
bones are strong and the extent of the movements is restricted. Macalister ("Text Book of
Human Anatomy," p. 179) points out that while the shoulder has 118 degrees of motion
around a sagittal axis, abduction and adduction, the hip has only 90 degrees; around a
coronal axis, flexion and extension, the shoulder has 170 degrees and the hip only 140
degrees. In the vertical axis the shoulder rotates 90 degrees, while the hip rotates only 45
degrees. In the upright position the centre of gravity falls in front of the axis of rotation of the
hip-joint.

The head of the femur is 5 cm. (2 in.) in diameter and forms 5/7 of a sphere. Below and
behind its centre is the depression for the attachment of the ligamentum teres. The
acetabulum is much deeper than the glenoid cavity of the shoulder-joint and its depth is
increased by the cotyloid ligament around its edge. This makes the joint air-tight and holds
the femur in place by suction, hence it is called by Allis ("An inquiry into the difficulties
encountered in the reduction of dislocations of the hip," Philadelphia, 1896) the sucker
ligament. The acetabulum is incomplete at its lower anterior edge, forming the cotyloid notch.
The cotyloid ligament bridges over this notch, and its deeper part loses its cartilaginous cells,
becomes fibrous, and is called the transverse ligament.

Beneath the transverse ligament pass vessels, nerves, fatty tissue, and the extremity of the
ligamentum teres, which is attached to the ischium just outside.

Running up in the floor of the acetabulum from the cotyloid notch is a depression in which is
lodged the ligamentum teres and a pad of fat called the Haversian gland. The ligamentum
teres is composed of synovial and connective tissue. It is not strong and ruptures at about 14
kilos; the small artery it contains affords nourishment for itself alone, only a very small amount
of blood going to the head of the femur. Bland Sutton regards it as a vestigial structure and a
regression of the pectineus muscle. It is too weak to add much to the strength of the joint, and
the view of Allis that its function is to distribute the synovial fluid and act as a lubrieating agent
is probably correct. The great pressure to which the articulating surfaces of the hip-joint are
subjected requires special lubrication and this is furnished by the ligamentum teres and
Haversian gland.
Fig. 509. - Anterior view of the ligaments of the hip-joint.

Like other joints, the hip has a capsular ligament which is strengthened by bands or
ligaments. These ligaments are the iliofemoral, pubofemoral, and ischiofemoral.

 
The Hip-Joint. Continued

Iliofemoral Ligament (Bertins' Ligament Or Y Ligament Of Bigelow)

This is the strongest ligament in the body. The single stem of the Y ligament is attached to the
upper edge of the rim of the acetabulum just below the anterior inferior spine. Its two
branches are attached below to the anterior intertrochanteric line. Its upper edge is reinforced
by a band from the ilium to the trochanter, the iliotrochanteric band, and one from the
reflected tendon of the rectus, the tendinotrochanteric band (Henry Morris) (Fig. 509).

The pubofemoral ligament, also called the pectineofemoral ligament, runs outward into the
capsule from the horizontal ramus of the pubes. It is quite weak.

Ischiofemoral Ligament

Allis describes this ligament as follows: "It arises from the ischial portion of the rim of the
socket and sends its fibres to the capsule to be blended with them. As its fibres extend
upward they separate like two fingers or terminal processes, the one extending forward to the
base of the oblique (posterior) line, the other running backward to the digital fossa (Fig. 510)".

It will be observed that this makes it a posterior Y ligament with a distinct bony attachment for
its two arms (like the external lateral ligament of the elbow - see page 283). The web of the
two arms is half way down the posterior surface of the neck of the femur.

Capsular Ligament

The capsule of the joint is composed of a thin sac strengthened by the band-like ligaments
just described. Wherever there is no reinforcing band the capsule is weak. The posterior and
lower portion is weaker than the anterior and upper portion. There is a weak spot between the
arms of the iliofemoral ligament anteriorly, a branch of the circumflex artery usually entering
here. Between the pubofemoral and inner edge of the iliofemoral ligament is another weak
point. A bursa here separates the iliopsoas from the joint and often communicates with the
joint. A third weak spot is on the lower posterior part of the neck between the two branches of
the ischiofemoral ligament (Fig. 511). Injections into the joint protrude very markedly at this
point. The weakest part of the joint is the lower anterior, below the pubofemoral ligament and
opposite the cotyloid notch; the strongest part is the upper anterior part.
Fig. 510. - The ischiofemoral or posterior y-ligament. The stem of the Y is attached at the
base of the tuberosity of the ischium and one branch is seen going toward the greater
trochanter and the other toward the lesser, leaving a weak spot between them half-way down
the neck of the bone.
Fig. 511. - Hip-joint distended with wax; the capsule ends posteriorly half-way down the neck
and is seen distended by the injection material protruding between the two arms of the
ischiofemoral ligament.