The hip joint and gluteal region

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Anterior inferior iliac spine

Iliofemoral (Bigelow's) ligament

Greater trochanter Pubofemoral ligament -

Lesser trochanter

Fig.46.1

The front of the hip joint

Fig.46.1

The front of the hip joint

Iliofemoral Ligament Bigelow

Origins of rectus femoris Iliofemoral ligament Fat pad

Articular cartilage

Fig.46.2

The structures around the acetabulum

Ligamentum teres

Pubofemoral ligament

Transverse ligament

Ischiofemoral ligament

Obturator membrane

Fig.46.2

The structures around the acetabulum

Labrum acetabulare

Cut edge of capsular ligament

Sacrospinous ligament

Sacrotuberous ligament

• Type: the hip is a synovial ball and socket joint. The articulation is between the rounded femoral head and the acetabulum which, like the shoulder, is deepened at its margins by a fibrocartilaginous rim—the labrum acetabulare. The central and inferior parts of the acetabulum are devoid of articulating surface. This region is termed the acetabular notch from which the ligamentum teres passes to the fovea on the femoral head. The inferior margin below the acetabular notch is completed by the transverse acetabular ligament.

• Capsule: the capsule of the hip joint is attached above to the acetabular margin, including the transverse acetabular ligament. The capsule attaches to the femur anteriorly at the trochanteric line and to the bases of the trochanters. Posteriorly the capsule attaches to the femur at a higher level—approximately 1 cm above the trochanteric crest. The capsular fibres are reflected from the lower attachment upwards on the femoral neck as retinacula. These fibres are of extreme importance as they carry with them a blood supply to the femoral head. • Stability: the stability of the hip is dependent predominantly on bony factors. Ligamentous stability is provided by three ligaments:

(a) Iliofemoral ligament (Bigelow's ligament)—is inverted, Yshaped and strong. It arises from the anterior inferior iliac spine and inserts at either end of the trochanteric line. This ligament prevents hyperextension at the hip.

(b) Pubofemoral ligament—arises from the iliopubic junction and passes to the capsule over the trochanteric line where it attaches.

(c) Ischiofemoral ligament—fibres arise from the ischium and some encircle laterally to attach to the base of the greater trochanter. The majority of the fibres, however, spiral and blend with the capsule around the neck of the femur—the zona orbicularis.

Fig.46.3

The superficial muscles of the gluteal region

Gluteus medius

Aponeurosis covering erector spinae

Tensor fasciae latae Gluteus maximus

Iliotibial tract Gracilis

Adductor magnus Semitendinosus Biceps femoris Vastus lateralis

Fig.46.3

The superficial muscles of the gluteal region

• Synovium: the synovial membrane lines the capsule of the hip joint and is reflected back along the femoral neck. It invests the ligamentum teres as a sleeve and attaches to the articular margins. A psoas bursa occurs in 10% of the population. This is an outpouching of synovial membrane through a defect in the anterior capsular wall under the psoas tendon.

• Blood supply (Fig. 46.6): the femoral head derives its blood supply from three main sources:

1 Vessels which pass along the neck with the capsular retinacula and enter the head through large foramina at the base of the head.

These are derived from branches of the circumflex femoral arteries via the cruciate and trochanteric anastomoses. This is the most important supply in the adult.

2 Vessels in the ligamentum teres which enter the head through small foramina in the fovea. These are derived from branches of the obturator artery.

3 Through the diaphysis via nutrient femoral vessels.

• Nerve supply: is from branches of the femoral, sciatic and obturator nerves.

Gluteus medius

Gluteus maximus

Femoral insertion of gluteus maximus

Internal pudendal nerve and artery

Vastus lateralis

Biceps femoris Semimembranosus Semitendinosus

Gluteus maximus

Obturator Internus

Fig.46.4

The deeper structures in the gluteal region after the removal of gluteus maximus and medius

Gluteus medius

Gluteus minimus Superior gluteal artery and nerve Inferior gluteal nerve Piriformis

Obturator internus and gemelli Inferior gluteal artery Quadratus femoris Posterior cutaneous nerve of thigh Sciatic nerve

Adductor magnus

Opening in adductor magnus Biceps (short head) Biceps (long head)

Sciatic nerve

Semimembranosus tendon

Gastrocnemius

Fig.46.4

The deeper structures in the gluteal region after the removal of gluteus maximus and medius

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