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65 Cards in this Set

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Hip joint
Synovial ball and socket joint; articulation of head of femur within the actebabulum of pelvis
Hip flexors
1. Iliopsoas (iliacus + psoas)
2. Rectus femoris
3. Sartorius

Anterior compartment muscles
The femoral nerve innervates all of the hip flexors
Flexion of hip vs. extension of hip
Flexion = thigh moves forward
Extension = thigh moves backward
Internal rotation of hip vs external rotation
Internal rotation = foot turns inward

External rotation = foot turns outward
Iliopsoas
2 muscles: iliacus + psoas

A: Hip flexion
N: femoral nerve; ventral rami L1-L3
O: L1-L5; iliac crest
I: lesser trochanter of femur
Iliopsoas
Quadriceps muscles
1. Vastus lateralis
2. Vastus intermedius
3. Vastus medialis
4. Rectus femoris

A: hip flexion (rectus femoris only); knee extension
N: femoral nerve (L2-L4)
O: RF- AIIS; VL- linea aspera; VI-femur; VM- linea aspera
I: Tibial tuberosity
Sartorius
A: Hip flexion & external rotation; knee flexion
N: femoral nerve (L2-L4)
O: ASIS
I: medial to the tibial tuberosity
Muscles of the thigh
Hip extensors
1. Gluteus maximus
2. Hamstring muscles

Posterior compartment muscles
Gluteus maximus
A: Hip extension when hip is flexed; ADD lower fibers; ABD upper fibers
N: inferior gluteal nerve (L5-S2)
O: sacrum & ilium
I: gluteal line & IT band
Hamstring muscles
1. Biceps femoris
2. Semitendinous
3. Semimembranosus

A: hip extension and knee flexion
N: branches of the sciatic nerve (L5, S1, S2): tibial nerve does all three; peroneal nerve does just the short head of the biceps femoris
O: ischial tuberosity
I: BF - head of the fibula; ST - medial to the tibial tuberosity; SM - medial tibial condyle
Hamstrings
Hip adductors
1. Gracilis
2. Adductor longus
3. Adductor brevis
4. Adductor magnus
5. Pectineus

Medial compartment muscles
Hip adductors
Gracilis
A: hip adduction
N: obturator nerve (L2-L4)
O: pubis
I: medial to the tibial tuberosity
Adductor longus
Adductor brevis
Adductor magnus
A: hip adduction
N: obturator nerve (L2-L4)
O: AL & AB - pubis; AM - ischium
I: linea aspera
Pectineus
A: hip adduction, flexion & IR
N: femoral nerve; 20% obturator nerve
O: pubis
I: linea aspera
Hip abductors
1. Gluteus medius
2. Gluteus minimus
Gluteus medius
A: hip abduction
N: superior gluteal nerve (L4 - S1)
O: ilium
I: greater trochanter
Gluteus minimus
A: hip abduction
N: superior gluteal nerve (L4 - S1)
O: ilium
I: greater trochanter
Superior & inferior gluteal nerves
Tensor fasciae lata
A: abduction, flexion, IR of hip
N: superior gluteal (L4 - S1)
O: iliac crest
I: IT band (lateral aspect of proximal tibia)
Trendelenburg’s sign or gait
Caused by weakness of hip abductors (gluteus medius and minimus)

Normal: when wieght is borne by one limb, the muscles on the supported side fix (contract to isometrically resist adduction) the pelvis so that it does not sag to the unsupported side

If the right gluteus minimus and medius muscles are paralyzed, the unsupported left side (sound side) of the pelvis falls (sags) instead of rising to stay level
External hip rotators
1. Piriformis
2. Superior gamellus
3. Inferior gamellus
4. Obturator internus
5. Quadratus femoris
6. Obturator externus (anterior muscle)

A: external hip rotation (stabilizes pelvis during gait by resisting internal rotation)
N: ventral rami L1-S2
O: PI- sacrum; SG & IG - ischium; OI - obturator foramen; QF ischium
I: greater trochanter
External hip rotators
Obturator externus
A: external rotator of the hip
N: obturator nerve (post. branch)
O: obturator foramen
I: greater trochanter
Anterior compartment of thigh
Femoral a.
Femoral n.
Medial compartment of thigh
Obturator a.
Obturator n.
Posterior compartment of thigh
Profunda femoris art
Perforationg vessels
Sciatic n
Muscle compartment of the lower extremity
Thigh muscles
Lateral cutaneous femoral nerve
L2-L4
Cutaneous anterior and lateral thigh
Crosses ASIS and can be compressed there meralgia parasthetica
Femoral nerve
Sensory to anteromedial thigh via ant/intermed cut. nerves
L2-L4
Motor to psoas, articularis genu, and anterior thigh muscles (quads + sartorius)
Obturator nerve
L2-L4
Sensory to inferomedial thigh
Anterior branch: medial thigh compartment (add longus & brevis, gracilis, and pectineus)
Posterior branch: obturator externus, adductor magnus
Sciatic nerve
L2-S3
Hamstrings by tibial division,
short head of biceps by common fibular (peroneal)
Bifurcates into tibial nerve and peroneal nerves just above pop fossa
Muscles that extend the knee
Quadriceps

1. Rectus femoris
2. Vastus lateralis
3. Vastus intermedius
4. Vastus

All insert onto the patella

Rectus is the only one that crosses the hip too (and thus flexes it)

N: femoral
A: femoral (LCFA - RF, VL, VI; Profunda - VM)
Flexion of the knee
Flexion:
Sartorius - ASIS
Gracilis - Inferior pubic ramus
Semitendinosus - IT
Semimembranosus - IT
Biceps Femoris- IT (Long Head & Short Head)
Popliteus - LFC
Gastrocnemius - MFC/LFC
Plantaris LFC
Tibial nerve (L4 - S3)
Tibial nerve innervates the muscles of the posterior thigh (hamstrings) and posterior leg (calf muscles)

EXCEPT:
-Short head of biceps femoris (common peroneal n)
-Sartorius (femoral n)
-Gracilis (obturator n)
The one muscle of the medial thigh compartment that crosses the hip and knee joint is?
The gracilis

A: adduction & flexion of hip; flexion & internal rotation of knee
N: obturator nerve (L2, L3)
O: inferior pubic ramus
I: tibia (medial tuberosity)
The short head of the biceps femoris is innervated by?
The common peroneal (fibular) nerve?

The long head is the tibial nerve
Pes anserina
Insertion of the sartorius, gracilis, semitendinosus onto the antero-medial surface of the tibia
ACL
Anterior cruciate ligament

Comes off the posterior portion of the lateral femoral condyle, and crosses in front of the PCL in the intercondylar notch to attach to the middle of the anterior tibia at the intercondyloid eminance

Primary restraint to anterior tibial translation, ie it prevents the tibia from moving forward relative to the femur
ACL
PCL
Posterior cruciate ligament

originates at the AL aspect of the medial femoral condyle in the intercondylar notch and attaches to the posterior intercondylar area of the middle of the tibia

Primary restraint to posterior tibial translation, ie it prevents the tibia from moving back relative to the femur
PCL
ALC and PCL
MCL
Medial collateral ligament

Extends from the femur to the tibial metaphysis

Primary restraint to valgus (inward stress)

Has superficial and deep fibers; deep fibers attach to the meniscus

A mild sprain of the superficial fibers will not cause the joint to swell, but a sprain of the deep fibers will also affect the meniscus and cause joint effusion

So if you have a swollen joint, that r/o a superficial sprain
LCL
Lateral collateral ligament

Femur to fibula

Stabilizes the lateral side of the joint to varsus (outside) stress
Menisci of knee
Medial and lateral
Fibrocartilage discs
98% type I collagen
Vascularized peripherally but not in middle (deep injury will not heal)
Load bearing
Gluteal tears
Older patient, +/- trauma
Trendelenberg's sign due to weakness or paralysis of gluteus medius and minimus muscle; inability to abduct the hip and the unsupported (sound) side of the hip falls

Tx:

Non-Operative -
PT
NSAIDs
Injections (cortisone)

Operative
Debridement
Repair
Greater trochanteric pain syndrome
Greater trochanteric bursitis

Bursa becomes inflammed due to mechanical irritation; can be associated with other pathology around the hip

Localized tenderness over the greater trochanter

Tx: injections, PT, bursectomy
Gerdy's tubercle
Lateral tubercle of the tibia where the IT band and tensor fascia latae insert
Internal snapping hip
Interna Coxa Sultans

Pain in groin associated with popping

Popping reproduced when extending the hip from a flexed, externally rotated position

Iliopsoas snapping over the pelvic brim or femoral head, or lesser trochanter of the femur

Diagnosed with physical exam or dynamic ultrasound

tx: NSAIDs and PT, surgical release
Meralgia Paresthetica
Compression of the lateral cutaneous femoral nerve (L2-L4) that causes pain & sensory deficitis; usually worsened with leg extension

Tender over inguinal ligament by ASIS

Tight pants & belts; construction workers; thin, young & healthy; obese or pregnant

Diagnosis - physical exam is usually sufficient; EMG; selective nerve injections

tx: correct underlying disorder- lose weight, deliver baby, different clothes

NSAIDs, neurolysis (release fibers over the nerve), transection (leaves patch withou sensation)
Piriformis syndrome
Compression of the sciatic nerve by the piriformis (hypertrophy, extension bands, ect.)

Lower back, buttock, posterior thigh pain; worse with sitting, squatting, stairs

Pain with flexion, adduction, IR

Pace Sign - pain and weakness with resisted ABD when seated

Sometimes the sciatic nerve splits before the piriformis, with the tibial branch passing under the piriformis and the peroneal branch passing through

Buzz words- cyclist, runners; buttock pain, localized tenderness; reproduced pain with flexion, ADD, IR; studies and further work up negative;

diagnosis of exclusion

tx: NSAIDs, muscle relaxants; PT: stretching and strengthening, muscle balance, gluteus strengthening; local injections; surgical- Piriformis release
Hamstring tear
Mechanism - Activities of quick acceleration/deceleration
Waterskiing - Hip flexion/knee extension

History
Tightness
Pop

Exam
Ecchymosis
Tenderness at ischial tuberosity
May have palpable defect

Radiographs
Normal
Avulsion in skeletally immature
MRI

Treatment
Non-Operative
Return to sports 4-6 weeks
Operative
Direct repair
Slipped Capital Femoral Epiphysis
Presentation can be (a) unstable - inability to bear weight, acute onset of severe pain, or (worse prognosis)osseous necrosis; or (b) stable - limp, +/- pain

Pain - groin; may be isolated referred pain to the knee (usually to the medial side)

Radiographs
AP view - Kleins line will help detect slipped epiphysis; frog legs lateral view - abduction of hip joint, can make it easier to see

Tx: surgery - in situ pinning (rod); Reorientation Osteotomies - wedge osteotomy, remove wedge, reposition femur, insert screw
Slipped Capital Femoral Epiphysis
Legg-Calve-Perthes Disease
Idiopathic osseous necrosis of the femoral head

LCPD usually occurs in children aged 4-10 years. The disease has an insidious onset and may occur after an injury to the hip. In the vast majority of instances, the disorder is unilateral

Males:females = 5:1

Presentation: limp, pain, loss of motion

Over the age of 8 years old the prognosis is worse; younger children tend to do well with this

50% do well with conservative treatment

Delayed DJD from aspherical joint – if severe --> early arthritic changes

Tx: medical is to keep hip contained --> maintaining the femur abducted and internally rotated so that the femoral head is held well inside the rounded portion of the acetabulum or surgery -->
femoral/pelvic osteotomies
Blood supply to femoral head
Hip dysplasia
Shallow acetabulum (socket)

Types:

Infantile
Adult
Developmental dysplasia of the hip (infantile type)
Displacement of the femoral head from the acetabulum causing disruption of normal hip development

Common findings:
Left hip (fetal positioning?)
Female sex predominence (5:1)
Breech delivery
First born
Positive family history
White or Navajo Indian race

Screening exam:
Barlow's
Ortolani's - click in hip adduction
Galeazzi's sign - look at knee height (is one lower than the other?)
Leg lengths & skin folds - look for assymetry
Hip motion

Radiology:
Ultrasound if < 3 months because epiphysis not there when born, shows up in 4-6 months

Hilgenreiner’s line
Perkin’s line
Shenton’s line

Tx: Containment
Pavlik harness – pclced to abduct, flex and externally rotate to bring head into acetabalum
Closed reduction and casting
Open reduction
Pelvic and femoral osteotomies
Hilgreiner's line - From an anteroposterior radiograph of the hips, a horizontal line (Hilgenreiner line) is drawn between the triradiate epiphyses.

Perkin line - Next, lines are drawn perpendicular to the Hilgenreiner line through the superolateral edge of the acetabulum (Perkin line), dividing the hip into 4 quadrants.

The proximal medial femur should be in the lower medial quadrant, or the ossific nucleus of the femoral head, if present (usually observed in patients aged 4-7 mo), should be in the lower medial quadrant. The acetabular index is the angle between the Hilgenreiner line and a line drawn from the triradiate epiphysis to the lateral edge of the acetabulum. Typically, this angle decreases with age and should measure less than 20° by the time the child is 2 years old.

Shenton line - a line drawn from the medial aspect of the femoral neck to the inferior border of the pubic rami (assesses obturator foramen). The line should create a smooth arc that is not disrupted. If disrupted, it indicates some degree of hip subluxation is present.
Adult form of hip dysplasia
The most common cause of hip arthritis in adults

Shallow acetabulum -> reduced joint contact area -> overload of the anterosuperior joint surface (more pressure on a smaller area) -> cartilage breakdown

The first sign of hip dysplasia in an adolescent or young adult is usually hip pain, or occasionally clicking and popping

Radiographic findings:

1. Central edge angle 25 -40 degrees - AP radiograph - angle formed by a line drawn from center of femoral head to outer edge of the acetabular roof, and  a verticle line drawn thru center of femoral head; - angles greater than 25 deg are considered normal;- less than 20 deg indicates severe dysplasia

2. Shentons line

3. Tonnis angle (Acetabular Index) <10 degrees is normal; increased in hip dysplasia

Surgical treatment reserved for symptomatic dysplasia;
-Joint preserving acetabular osteotomies

Goal: improve quality of life and alter progression of the disease
The acetabular index is the angle formed between Hilgenreiner line (a horizontal line through the upper margin of the radiolucent triradiate cartilage) and a tangential line to the lateral ossific margin of the roof of the acetabulum