Anatomy of the Hip

What articulates in the hip joint ?

The acetabulum of the pelvis and the head of the femur

What type of joint is the hip joint ?

Diarthrodial ball and socked synovial joint

What are the degrees of freedom in the hip joint?

Flexion/extension
Abduction/adduction
Medial/lateral rotation

Is the hip the largest joint in the body?

No it's the second largest one

What is the function of the hip joint?

Connects the pelvis to the LE
Transmit weight between axial and appendicular skeleton

What type of disease usually mosy commonly affects it ?

Arthritis

What is the difference between the femur or the humerus?

The neck of the femur

Why does thefemur head has a neck?

For more stability because it needs to provide maximum stability in addition to high
motility

How ?
The neck gives the mobility by the diaphisis in addition the head is constraint in
the acetabulum

Anatomy of the Hip 1

 How does the anatomy of the Hip joint affects the knee ?
The difference between the anatomical and mechanical axes which Increases
the stress on the medial side of the knee

How it is anatomically fixed?

The medial epicondyle of the femur is bigger than the right which corrects the
anatomical axis of the hip/femur to decrease the stress on the medial side

Does this fix come with a disadvantage ?

Yes since it increases the risk of osteoarthritis on the medial side because now
we have a bigger surface of contact

What is the shape of the femoral head ?

2/3 of a perfect sphere

What is the head covered with ?

Cartilage except the fovea

What is the function of the ligamentum teres ?

Nutrition

Is the acetabulum complete ?

Non inferiorly it is covered by the acetabular ligament

What area of the hip joint beseer feya osteoarthritis aktar shi ?
Articular surfaces between the acetabulum and head

Why is the knee joint more at risk than hip in osteoarthritis

Shape of the joint open joint

Less stability

Where is the acetabulum located and what shape is it ?

Located in the lateral aspect of the pelvis and it's concave

How does it face ?

Lateral anterior and inferiorly

What makes it more deep ?

Anatomy of the Hip 2

 A ring of fibrocartilage called the acetabular labrum

Can this cartilage cause problems ?

Yes it can get impinged bl hip joint

What surface of the acetabulum doesn't articulate with the hip head ?

Central portion

Where does the major weight bearing forces are transmitted ?

The horseshoe shaped thicker in the lateral region articular cartilage

How does the femoral head projects ?

Posteriorly medially and superiorly

How is the goal of mobility with stability for functional tasks achieved ?
Because of the shapes of the articulating surfaces of the hip joint and the reinforcing
properties of the capsule ligaments and hip musculature

What is the shape of the neck of the femur ?

Concave

Why ?

If any abnormality happens and the concave bseer fi callus formation it causes
friction bl labrum tb3 2el acetabulum causing impingement

What bundles create the iliofemoral ligament?

Superior and inferior illiofemoral bundles

Where is the origin and insertion of the iliofemoral ligament?

O: ASIS
I: Intertrochanteric line

In what direction does the iliofemoral ligament gets tight?

Both bundles in extension

Superior illiofemoral bundle

Adduction

Anatomy of the Hip 3

 Inferior illiofemoral bundle
Abduction

What are the origin and insertion of the Pubofemoral ligament?

O: Superior Pubic Ramus
I: Intertrochanteric line

In what direction does the pubofemoral ligament gets tight ?

Extension

Abduction

What are the origin and insertion of the ischio-femoral ligament ?

O acetabulum
I greater trochanter

In what direction does the ischio-femoral ligament gets tight ?

Hyperextension

Why?

Because of its spirl orientation

Why all/most ligaments in the hip joint prevent hyperextension ?

Because the line of gravity passes posteriorly to the hip joint thus the hip extensors
are always in function so to avoid hyperextension

What is the closed packed position of the hip joint ?

20° of extension with minimal medial rotation and abduction

Why ?

Since the ligaments ate tight in extension thus maximum stability

What us the loose packed position of the hip joint ?

30 flexion
30 abduction and slight lateral rotation

Define the capsular pattern

Anatomy of the Hip 4

 It's a sequence of movement that is affected upon a malfunction of any sort

What is the capsular pattern in the hip joint ?

Flexion, abduction medial rotation

Is this order fixed ?

No it may vary

When our pt has a problem in the hip (inflammation/arthritis) which position does
they take?
The lose packed position

Why ?

Since it decreases the pain

What does congruence of the joint mean ?

The surface coverage of the articulating surfaces

In which position is their less congruency and which more ??

Closed packed position less

Open packed position more

How can u describe the relationship between congruency and the open and closed
packed position?
Inversely proportional

What is an example of the loose packed/full congruent position?

Quadrupled position

What position is the one with the greatest risk of dislocation occurance ?

Flexion and abduction

Describe the intrauterine position ?

Hip flexion ext rotation

Knee flexion int rotation

What is the angle of inclination?

It's between the femoral neck and medial side of the shift

Anatomy of the Hip 5

 What is the normal degree of it?

125°

At birth ?

140-150°

Why does it decrease with age ?

Due to the weight bearing with walking

What happens to the neck shaft ankle of inclination in coxa vara ?

Decrease <120

What happens if there's unilateral coxa vara ?

A limb shorter than the other

What does this lead to ?

Genu varus or bow knees

What are the causes of coxa vara ?

Congenital

Slipped upper femoral epiphysis

Fractures

Bone softening disease like rickets

What are the mechanical effects of coxa vara ?

It leafs to a lengthened moment arm of the abductors → improving their mechanical

advantages → contract less vigorously to stabilise the pelvis—> Less force needed
JRF

Is this mechanical affect always negative?

No like in pts with CP or OA

It makes easier on them to walk since they need less force

To what direction does the JRF displaces ?

Medially

What are the signs and symptoms of coxa vara ?

Anatomy of the Hip 6

 Painless limp

Short limb

Deformity: adduction and ext rotation

Limited abduction

Hip flexion contractures

excessive lordosis

Limited hip extension

Why do we have limited abduction ?

Since the decrease in the angle/axis causes tight adduction which decreases the
range

Why do we have excessive lordosis?

Due to the contractures in the hip flexors which leads to anterior pelvic tilt which
causes hyper-lordosis

Why do we have inured hip extension?

Contracture of the hip flexor

On what doe sthe treatment of the coxa vara depends ?

On the neck shaft angle

How ?
If angle >110 Conservative treatment

If angle <110 we have to intervene surgically

What does the Conservative treatment entails ?

Lift in the sgoe

Stretching of the hip abductors

Stretching of the lateral rotators

Improve hip posture

What does the unconservative treatment entail ?

Anatomy of the Hip 7

 We usually treat them post op

Subtrochanteric or Intertrochanteric osteotomy with screw and plates

Afte that we use

1. Hip Spica (6-8) weeks

2. Active ROM ex.

3. Active side lying hip abduction

4. Standing hip hiking ex trendelenburg

When is three point gait allowed ?

Upon achieving full ROM post op

When is full WB allowed ?

Negative trendelenburg sign

Describe the trendelenburg sign

When standing on one leg there is an adduction moment at the hip tending to cause
the pelvis to drop on the unsupported side hip or pelvic drop

What prevents this drop

Gluteus medium stabilising the pelvis on the stance side

Anatomy of the Hip 8

 What is the definition of coxa valga ?
When the neck shaft inclination angle is greater than 130°

What happens if there's unilateral coxa valga ?

We observe a limb longer than the other

What are the causes of coxa valga ?

Trauma

Congenital

Dislocation

Spastic paralysis

In what case do we have to strengthen the hip abductors more ?

Coxa valga

Anatomy of the Hip 9

 Why ?
Since the increase of the angle causes the increase of the lever arm thus
decreasing the mechanical advantage of the abductors which will lead to them
contracting more to stabilise the pelvis thus increasing JRF

What is the mechanical effect of cixa valga ?

Shortens lever arm of the hip abductors—> decrease the mechanical advantages—
> have to contract more to stabilise the pelvis —> increase JrF

What happens to the JRF upon cixa valga ?

Lateral displacement which leads to a decrease in the weight bearing area

Decreasing in the weight bearing area causes what ?

Increase bl stress thus degenerative changes in the articular cartilage

What are the signs and symptoms of coxa valga ?

Painless limp

Longer limb on the involved side

Adductor tightness

Weak abductors

Upward pelvic obliquity

Altered pelvic mechanics

Why do we have weak abductors ?

They need more force to work that they're not equipped to perform

Why do we have upward pelvic tilt

Because of the angle difference tightness and weakness surrounding it

What does it cause ?

Sometimes it causes scoliosis in the lumbar region

What does the altered pelvic mechanics cause?

Back pain and sacroiliac joint dysfunction

What is the treatment of coxa valga?

Anatomy of the Hip 10

 Stretching adductor

Strengthening abductors

Balance ex

Free ex to improve posture

General leg ex

Treat LBP and sacroiliac dysfunction

Severe cases are treated with osteotomy to correct leg length difference and
restore normal mechanics

What is the torsion angle ?

It's the angle between the axis of the femoral neck and the axis of the femoral
condyles and the twists between them

What is the normal degree of torsion angle ?

Anatomy of the Hip 11

 10-15° of anteroversion to the frontal plane

What might be associated with excessive anteroversion ?

Congenital dislocation

Why is the anteroversion or retroversion an abnormal thing ?

Since upon anteroversion the femoral head coverage decreases

And upon retroversion the femoral head coverage increases

Why do children with anteroversion walk in the toe in gait ?

Since the coverage of the head of the femur decreases the stability feels less so
they walk in toe in gait to increase the coverage of the head befoot kello la jowa

Which age is the most common this problem shows ?

3-18

What is an indication if medial rotation of the femur on the tibia ?

Squinting patella

Why does the patella take this position?

To compensate for the anteroversion

What is an indication if lateral rotation of the femur or the tibia ?

Forg eyes/grasshopper eyes

Why does the patella assume this position ?

To compensate the retroversion

pt with knee or ankle problems what other joint should we inspect?

Hip joint because a problem in the hip joint might cause a problem in the knee and
ankle

What happens in anteroversion?

Causes the shaft of the femur to be medially rotated

What is the related posture ?

Subtler pronation

Anatomy of the Hip 12

 Lateral patellar subluxation

Medial tibial torsion

Medial femoral torsion

What are the compensating postures ?

L. Tibial torsion

L. Rotation at knee, tubua femur or pelvis

Lumbar rot at the same side

In anteroversion is there a congenital genu valgum?

No only mechanical and pes planus

What happens in retroversion?

The shaft of the femur rotates laterally

What test do we use to measure hip anteroversion?

Craig's test

What are the mechanical effects of anteroversion?

Op. is true for retroversion

Increased range of int rotation

Decreased range of ext rotation

W/Frog sitting is the position of comfort

Excessive toe in gait

Which nerve root primarily innervates the Hip joint ?

L3

Where does the irritation show ?

L3 dermatlme can refer to the ground and down the thigh to the knee

How can the sciatic nerve get entrapped and where ?

Due to the tightness of the piriformis at the Midline between the greater trochanter
and ischeal tuberosity

Anatomy of the Hip 13

 How can the obturator nerve be damaged or affected ?
Uterine pressure and damage during labor

How can the femoral nerve be damaged and why ?

During reduction of congenital dislocation of the hip

Fracture of the Upper femur or pelvis
Pressure during forceps labor and delivery

If a pt comes with referred pain into the hip and buttock region what are the
possibilities that we have to eliminate?

Lumbar Spine
SIJ and Hip

Anatomy of the Hip 14