Posterior Pelvis and Thigh

what travels through the greater sciatic notch ABOVE the piriformis muscle?

what travels through the greater sciatic notch ABOVE the piriformis muscle?

superior gluteal nerve
superior gluteal artery
piriformis muscle

what travels through the greater sciatic notch BELOW the piriformis muscle?

(POPS IQ):
Pudendal nerve
Nerve to Obturator internus
Posterior femoral cutaneous nerve
Sciatic nerve
Inferior gluteal nerve and artery
Nerve to Quadratus femoris

what travels through the lesser sciatic notch?

Tendon of obturator internus

Internal pudendal vessels

Pudendal nerve

Nerve to obturator internus

gluteal sulcus

AKA gluteal folds

creases under the buttcheeks

intergluteal cleft

crack of the butt

SIJ

sacroiliac joint

Articulation of the auricular or ear-shaped part of the sacrum and the ilium

Plane synovial joint

Has some syndesmosis qualities posteriorly

A small amount of glide, but not much movement

*landing from jumping can cause issues

sacrospinous ligament

border for greater sciatic foramen and top part for the lesser sciatic foramen (splits these)

ligament that travels from the sacrum to the ischial spine

what's special about pudendal nerve?

it travels out through the greater sciatic foramen and then comes back in through the lesser sciatic foramen

trochanteric bursa

Between the TFL/IT band and gluteus maximus

For people who have issues with this, sidelying hurts (lie on your back)

Need this padding

gluteofemoral bursa

Between IT band, femur, and vastus lateralis

ischial bursa

On ischial tuberosity

Separates inferior part of gluteus maximus from ischial tuberosity

PADDING

gluteus maximus

proximal attachment: ilium posterior to posterior gluteal line; dorsal surface of sacrum and coccyx; and sacrotuberous ligament

distal attachment: most fibers end in iliotibial tract, which inserts into lateral condyle of tibia; some fibers insert on gluteal tuberosity of femur

innervation: inferior gluteal nerve

action: extends thigh and assists in its lateral rotation; steadies thigh and assists in rising from sitting position

gluteus medius

proximal attachment: external surface of ilium between anterior and posterior gluteal lines

distal attachment: lateral surface of greater trochanter of femur

innervation: superior gluteal nerve

action: abduct and medially rotate thigh; keep pelvis level when opposite leg is raised

gluteus minimus

proximal attachment: external surface of ilium between anterior and inferior gluteal lines

distal attachment: anterior surface of greater trochanter of femur

innervation: superior gluteal nerve

action: abduct and medially rotate thigh; keep pelvis level when opposite leg is raised

Trendelenburg Test

stand on one leg

the abductors are firing on the leg you are standing on in order to keep the pelvis level

Trendelenburg is when the abductors are unable to maintain the pelvis level (the abductors on the side the foot is planted on the ground)

Superior gluteal nerve innervates these muscles (gluteus medius and gluteus minimus)

piriformis

proximal attachment: anterior surface of 2nd-4th sacral segments; superior margin of greater sciatic notch and sacrotuberous ligament

distal attachment: superior border of greater trochanter of femur

innervation: branches of anterior rami of S1, S2

action: laterally rotate extended thigh; abduct flexed thigh; steady femoral head in acetabulum (stabilizes hip joint)

triceps coxae

superior gemelli
obturator internus
inferior gemelli

*all have common distal attachment on the greater trochanter of the femur

superior gemelli

proximal attachment: ischial spine

distal attachment: medial surface of greater trochanter (trochanteric fossa) of femur

innervation: nerve to obturator internus

action: laterally rotate extended thigh; abduct flexed thigh; steady femoral head in acetabulum (stabilizes hip joint)

obturator internus

tiny little tendon you will see; as though you cut a shoelace in half

proximal attachment: pelvic surface of ilium and ischium; and obturator membrane

distal attachment: medial surface of greater trochanter (trochanteric fossa) of femur

innervation: nerve to obturator internus

action: laterally rotate extended thigh; abduct flexed thigh; steady femoral head in acetabulum (stabilizes hip joint)

inferior gemelli

proximal attachment: ischial tuberosity

distal attachment: medial surface of greater trochanter (trochanteric fossa) of femur

innervation: nerve to quadratus femoris

action: laterally rotate extended thigh; abduct flexed thigh; steady femoral head in acetabulum (stabilizes hip joint)

quadratus femoris

proximal attachment: lateral border of ischial tuberosity

distal attachment: quadrate tubercle on intertrochanteric crest of femur and area inferior to it

innervation: nerve to quadratus femoris

action: laterally rotates thigh; steadies femoral head in acetabulum

obturator externus

proximal attachment: margins of obturator foramen and obturator membrane

distal attachment: trochanteric fossa of femur

innervation: obturator nerve

action: laterally rotates thigh; steadies head of femur in acetabulum

thomas test

Hip Flexion Contractures/Shortening

Patient supine, lumbar flat, one leg off of the end of the table with other leg flexed, patient pulling knee to chest

he test can also be performed with the starting position of both knees fully flexed to the chest and slowly lowering the leg being tested to see if the leg makes it to the table.

If a contracture is present the leg will raise off of the table. Lack of Full hip extension with knee flexion less than 45° indicates iliopsoas tightness. If full hip extension is reached in this position but knee flex of 80 degrees or more is not reached, it would indicate rectus femoris tightness. If any hip external rotation is observed it may indicate ITB tightness.

ober test

tightness of IT band or TFL

Patient sidelying on non-effected side with LE flexed at hip & knee to reduce lumbar lordosis. Affected knee held in 90 flexion while pelvis is stabilized. Passive abduction of the thigh and then in line with body.


Lifted leg should drop past midline. IF leg remains abducted beyond neutral or 10 degrees of adduction, this indicates TFL and/or ITB tightness.

trendelenburg test

stand on one leg

if the pelvis is unlevel and moves inferiorly on the leg that is off the ground, that would be a positive trendelenburg indicating the hip abductors (gluteus medius and gluteus minimus) are weak on the side where the leg is planted on the floor

faber test

SI joint or Hip joint issues

Patient supine. Foot on opposite knee (Flexion, Abduction, EX Rotation of thigh at hip = FABER) Apply slight downward pressure to this limb.

Looking for patient to report pain at the hip/SI joint

If they have pain, you would be suspicious of hip/SIJ issues

ortolonni test

Infants (sometimes have subluxing hip issues/dislocate)

you'll feel the femur out of the socket

Physical examination:
asymmetrical thigh/inguinal folds
flex hips and knees in supine, abduct thighs (pull anteriorly then abduct)

resistance to abduction - adductor spasm

Ortolani's sign - audible clunk or click

Treatment: place hips in abducted position via brace (Pavlik Harness, triple diapers) -- pressure of femoral head in acetabulum promotes growth and deepening of socket with time
OR
surgical correction

straight leg test

Patient is positioned supine and the clinician lifts the patient's affected leg by the posterior ankle while keeping the knee in a fully extended position.

The clinican continues to lift the patient's leg by flexing at the hip until pain is illicited or end range is reached.

Neurologic pain which is reproduced in the leg and low back between 30-70 degrees of hip flexion is a positive result of lumbar disc herniation at the L4-S1 nerve roots.

In order to make this test more specific, the ankle can be dorsiflexed and the cervical spine flexed. This increases the stretching of the nerve root and dura.

Pain at less than 30 degrees of hip flexion might indicate acute spondylolithesis, gluteal abscess, disc protrusion or extrusion, tumor of the buttock, an acute dural inflammation, a malingering patient, or the sign of the buttock.

Pain at greater than 70 degrees of hip flexion might indicate tightness of the hamstrings, gluteus maximus, hip capsule or a pathology of the hip or sacroiliac joints.

hip joint type

ball (head of femur) and socket (acetabulum of inominate) = multiaxial synovial ball and socket joint

hip joint - function

transmits weight from body (spine and pelvis) to lower extremities

hip joint - capsule

ligamentum teres (ligament to head of femur via fovea)

fat pad in acetabulum

partial vacuum within joint

Joint Capsule: Attaches to labrum, acetabular rim and medial to the greater trochanter at both the intertrochanteric line anteriorly and intertrochanteric crest posteriorly

covers entire femoral head and neck (trochanters are extracapsular)

iliofemoral ligament

Y ligament (of bigelow)

reinforces hip anterorly

PREVENTS HYPEREXTENSION during standing

Strongest ligament in the body. Crosses joint anteriorly from AIIS to intertrochanteric line of femur (between the greater and lesser trochanters). It splits before inserting on the femur and therefor looks like a "Y".

pubofemoral ligament

limits abduction and some hyperextension

crosses hip joint on the medial inferior side. Passes posteriorly and inferiorly from the medial aspect of the acetabular rim and superior ramus of the pubis to the neck of the femur

ischiofemoral ligament

reinforced hip joint posteriorly

has anterior attachment

prevents hyperextension

Crosses the hip joint posteriorly attaching on ischial portion of acetabular rim. Passes superolateral to insert on the femoral neck. Reinforces the hip posteriorly. Has anterior attachment, winds around the neck of the femur. Most commonly injured.

movements of the hip joint

Flexion & extension

Abduction & adduction

Medial & lateral rotation

Circumduction

which ligaments are taut during external rotation of the hip?

superior iliofemoral and pubofemoral

which ligaments are taut during internal rotation of the hip?

ischiofemoral ligament

which ligaments are tightened during abduction of the hip?

pubofemoral and ischiofemoral ligaments

which ligaments are tightened during adduction of the hip?

superior iliofemoral ligament

TRUE OR FALSE: all ligaments of the hip are taut in hip extension and relaxed in hip flexion.

TRUE

Which hamstring is not innervated by tibial division of sciatic nerve?

biceps femoris - short head (common fibular division of sciatic nerve)

What do the hamstrings do?

extend at the hip and flex at the knee

Which hamstring is the exception of extending at the hip?

Short head of biceps femoris - proximal attachment is on the femur so it CANNOT extend the hip. It can only flex the knee

To test for femoral nerve problem, what would you do?

Seated, extend the leg at the knee and put resistance - assessing quads and femoral nerve

What gives blood supply to the neck and head of the femur?

medial circumflex femoral artery

What could happen if decreased blood supply to neck and head of femur?

Avascular necrosis (AVN) - bone death at neck and head of the femur

What are ways to disrupt the blood supply at the neck and head of the femur?

Dislocation, etc. which disrupts medial circumflex artery

What artery lies at the fovea of the head of the femur?

Branch of obturator artery (near the fovea of the head of the femur)

What is the angle of inclination (related to the femur)?

Drive a line down the fovea and the shaft of the femur and measure that angle

What is the normal range for the angle of inclination for adults?

125-130 degrees

What is the normal range for the angle of inclination for children?

150 degrees

coxa

hip

genu

knee

What is it called when there is a decreased angle of inclination? (less than 125 degrees)

coxa vara (shorter leg)

*directing femur toward midline which brings knees inward

Less force required by Abductors to resist gravity during single leg stance

What is it called when there is an increased angle of inclination? (greater than 130 degrees)

coxa valga (longer leg)

*directing femur away from midline which increases stress at medial knee (bow legged)
*increased risk of dislocation of the head of the femur

Shortens moment arm of abductors, decreasing mechanical advantage
^ stress at medial knee

What is angle of torsion?

Line from axis of hear and neck to femoral condyles (in transverse plane) and take angle measurement

What is considered normal angle of torsion?

15 degrees, normal twist of the femur

What is it called when the angle of torsion is less than 15 degrees?

RETROVERSION

How does patient present when angle of torsion is less than 15 degrees?

Toe-out when hip is aligned

*with children, get them to stop sleeping on their stomach because it could increase the issue when sleeping on stomach with toes out to the sides (issue usually corrects itself in children)

What is it called when the angle of torsion is greater than 15 degrees?

EXCESSIVE ANTEVERSION

How does patient present when angle of torsion is greater than 15 degrees?

Toe-in when hip is aligned

TRUE OR FALSE: What happens at the hip will likely have issues at the knee.

TRUE

Q Angle

measure ASIS to middle of patella

In females, Q angle will be larger because female hips are wider

genu vara/varum

decrease in angle at the knee

genu valga/valgum

increase in angle at the knee

What does SCFE stand for?

Slipped capital femoral epiphysis

What is slipped capital femoral epiphysis?

SCFE, or skiffy

Femoral cap where the epiphyseal plate is is not staying put

Fracture through the growth plate

May have coxa vara if slow developing

Shearing force with abduction and ER

Happens more commonly in males 10-17 yrs of age

How does pt. present with SCFE?

The patient may report:
hip pain
medial thigh pain
knee pain

an acute or insidious onset of a limp

decreased range of motion of the hip

on plain radiographs, the femoral head is seen displaced, posteriorly and inferiorly in relation to the femoral neck and within the confines of the acetabulum.

Treatment is primarily operative internal fixation

congenital dislocation of hip

Genetic and environmental components

More common in girls than boys (~8:1)

Ligamentous laxity

In utero positioning

Breech presentation at birth

Severity from subluxation to dislocation

acquired/traumatic dislocation of hip - posterior

Hip dislocation is easiest with femur flexed and a force applied anteriorly to the tibia- or through the tibia. The head of the femur is driven posteriorly out of the acetabular socket and can disrupt the blood supply to the head and neck of the femur (medial circumflex artery) and possibly traumatize the sciatic nerve if driven far enough out (knee strikes dashboard in car accident)

Fibrous capsule ruptures inferiorly and posteriorly when femur driven rearward

Femoral head lies posterior to acetabulum

Potential damage to sciatic nerve

acquired/traumatic dislocation of hip - anterior

Violent injury (hit by car, fall) forcing hip into extension, abduction, lateral rotation

Femoral head lies inferior to acetabulum

Frequently fractures acetabular margin

acquired/traumatic dislocation of hip - central

Again, violent injury - blow to lateral aspect of hip, esp. with hip in abduction

Femoral head driven deeper into acetabulum

Comminuted fracture of acetabular wall

treatment for dislocation of hip

Depends on type & severity of dislocation & presence of fracture

Closed or open reduction

Immobilization

Compensatory methods for resuming activities under precautions

Remobilization & strengthening

factors that affect fracture site of femur

age
sex
condition
mode of injury

Legg-Calve-Perthes Disease

juvenile arthritis

childhood hip disorder initiated by a disruption of blood flow to the head of the femur. Due to the lack of blood flow, the bone dies (osteonecrosis or avascular necrosis) and stops growing
Loss of blood supply- age of onset is less than 10 yrs of age. More often in males. Hip pain- vague and in the groin. Can revascularize over time.
This weakened bone gradually breaks apart and can lose its round shape. The body eventually restores blood supply to the ball, and the ball heals. But if the ball is no longer round after it heals, it can cause pain and stiffness. The complete process of bone death, fracture and renewal can take several years.

signs and symptoms of legg-calve-perthes disease

Limping
Pain or stiffness in the hip, groin, thigh or knee
Limited range of motion of the hip joint

Legg-Calve-Perthes disease usually involves just one hip. Both hips are affected in some children, usually at different times.

avascular necrosis of the femur (AVN)

a pathologic process that results from interruption of blood supply to the bone.

AVN of the hip is poorly understood, but this process is the final common pathway of traumatic or nontraumatic factors that compromise the already precarious circulation of the femoral head

Head of femur will change over time

Blood supply via obturator artery, most coming from medial and lateral circumflex arteries

Lack hip extension, and ER; Groin pain with weight bearing and even at rest, limited ROM and weakening secondary to disuse

LOTs of hip replacements

conditions associated with AVN

Hip dislocation
Decompression sickness
Sickle cell disease
Radiotherapy
Gaucher's disease (genetic disorder)
Corticosteroid high-dose therapy
Possibly other conditions e.g. diabetes

labral tear

Fibrocartilage ring in the acetabulum that helps with stability

Deepens the socket

Tears can cause interarticular snapping clunk in patient- giving way sensation

Pain in sensation especially in flexion

Medial anterior pain reported - feel like deep tooth ache
Might feel snapping

femoral acetabular impingement (FAI)

Mechanical abutment of femoral head in the acetabulum

CAM: Abnormal head shape is too large, abuts up in the acetabulum
Pincer: acetabulum has too much coverage on the head so the labrum gets pinched- like a birds beak

FAI occurs because the hip bones do not form normally during the childhood growing years. It is the deformity of a cam bone spur, pincer bone spur, or both, that leads to joint damage and pain. When the hip bones are shaped abnormally, there is little that can be done to prevent FAI.

snapping hip syndrome

Iliopsoas subluxes over the greater trochanter, or iliopectineal eminence or femoral head
Lateral IP band moving over greater trochanter
Intra articular: snapping labral tear, loose bodies, cartilage defect
Painful in flexion

hip fracture treatment

Closed or open reduction
Pain management
Precautions
Approaches similar to dislocation

ORIF

open reduction internal fixation

means hardware (plates/screws) were placed in the bone

complications of hip fractures

Infection
Avascular necrosis of the femoral head
Nonunion
Degenerative joint disease of hip
Chronic pain

total hip replacement

Head & neck of femur removed

Joint disarticulated

Metal prosthesis inserted in femur

Acetabulum replaced with metal or plastic cup in THR, not in partial HR

cemented vs. non-cemented
full vs. partial
determines surgical approach

precautions following THA (or THR total hip replacement) surgery

No hip flexion beyond 90o

No hip rotation

No adduction beyond neutral (No crossing of legs)

weight bearing restrictions (none, partial, full)

varies by surgical approach

why is titanium a good metal for replacements?

attracts bone to grow around it

list muscles of the levator ani (pelvic floor)

iliococcygeus
pubococcygeus
puborectalis

What does superior gluteal nerve innervate?

gluteus medius and gluteus minimus

What does inferior gluteal nerve innervate?

gluteus maximus

What muscles are innervated by nerve to obturator internus?

obturator internus and superior gemelli

What muscles are innervated by nerve to quadratus femoris?

Quadratus femoris and inferior gemelli

piriformis syndrome

12% of population, the common fibular nerve pierces the piriformis, which may predispose it to entrapment

cause issues with the common fibular division of sciatic nerve when piriformis contracts