Pelvis, Hip, Anterior/Posterior Gluteal Region, Fracture Concepts

Functions of the pelvic girdle

bearing load of upper body, transferring load to lower body, provide muscle attachments (walking, posture, abdominal wall), protects viscera, support for pregnancy, forms pelvic floor, attachment site for genitalia

Difference between male and female pelvises?

Female pelvises are more circular, shallower, wider, shorter/less curved, and bones are lighter and thinner

Ilium bony landmarks

anterior/posterior superior iliac spine (ASIS, PSIS), anterior/posterior inferior iliac spine (AIIS, PIIS), iliac crest, anterior/posterior/inferior gluteal lines

Ischium bony landmarks

ischial tuberosities, ischial ramus, ischial spine, greater sciatic notch, lesser sciatic notch, greater sciatic foramen

Femur bony landmarks

greater/lesser trochanters, intertrochanteric crest, trochanteric fossa, gluteal tuberosity, quadrate tubercle, linea aspera, pectinal line, epicondyles, adductor tubercle, condyles, intercondylar notch

What is a typical angle of inclination of the femur?

125 degrees

What is coxa valga?

femur head and shaft angle greater than 125 degrees, knees bend outward (genu varum)

What is coxa vara?

femur head and shaft angle less than 125 degrees, knees bend further inward (genu valgum)

What is a sacroiliac (SI) joint?

articulation of the auricular (ear-shaped) surfaces of the sacrum and the ilium

What type of joints form the SI joint?

synovial (anterior), syndesmosis (posterior)

SI joint characteristics

capable of slight gliding and rotary movements, little mobility due to ligaments, transmits the weight of most of the body to the hip joints

What are the sacral ligmanets?

sacroiliac (anterior, posterior, interosseous), sacrotuberous, sacrospinous, iliolumbar

Which ligament separates the greater and lesser sciatic foramen?

sacrospinous ligament

Which two bones form the obturator foramen?

ischium and pubis

Where does the trochanteric bursa lie?

between gluteus maximus from greater trochanter

Where does the gluteofemoral bursa lie?

between iliotibial tract and superior portion of proximal vastus lateralis attachment

Where does the ischial bursa lie?

between inferior gluteus maximus and ischial tuberosity

Which bursa is often absent?

ischial bursa

Which muscles prevent contralateral hip drop (Trendelenberg Sign)?

Gluteus medius and minimus

What does the Trendelenberg Sign look like?

Drop in pelvis on side of raised leg

Largest muscle of the pelvic/gluteal region

gluteus maximus

Under which muscle does the sciatic nerve exit?

piriformis

Which muscles form the triceps coxae?

superior gemellus, obturator internus, inferior gemellus

What is the short, flat, rectangular muscle inferior to the triceps coxae?

quadratus femoris

What is the largest nerve in the body?

Sciatic nerve

What is piriformis syndrome?

common fibular nerve pierces the piriformis

What are the two branches of the sciatic nerve?

tibial nerve, common fibular nerve

Pubis bony landmarks

pubic symphysis, pubic crest, pubic tubercle, pectin pubis, obturator crest, foramen, and membrane (fills foramen), superior/inferior rami

Attachment sites of the sacrospinous ligament

sacrum to ischial spine

Attachment sites of the sacrotuberous ligament

sacrum to ischial tuberosity

What is the role of the retinaculum?

support patella from the sides

Superior border of the femoral triangle

inguinal ligament

Medial border of the femoral triangle

adductor longus

Lateral border of the femoral triangle

sartorius

Floor of the femoral triangle

pectineus and iliopsoas

Contents of the femoral triangle

femoral vein, artery, nerve (medial to lateral)

What is the adductor canal?

narrow tunnel of fascia that houses femoral vessels (femoral artery/vein, saphenous n, n to vastus medialis

Anterior/lateral borders of adductor canal

vastus medialis

Medial border of adductor canal

sartorius

Posterior border of adductor canal

adductor magnus and longus

Roof of adductor canal

apex of femoral triangle

Floor of adductor canal

adductor hiatus

What is the adductor hiatus?

foramen near adductor magnus tendon where femoral vessels pass from anterior to posterior into popliteal fossa

What type of joint is the hip joint?

ball and socket

Which arteries supply the femoral head?

Deep femoral artery (medial/lateral circumflex arteries)

Nerve supply to the hip joint

femoral nerve, obturator nerve, superior gluteal nerve, nerve to quadratus femoris

Hip joint capsule properties

covers entire femoral head, thinner and looser posteroinferiorly, deeper circular fibers form collar around neck, fat pad in acetabulum

Hip joint ligaments

iliofemoral (Y ligament), pubofemoral, ischiofemoral, ligamentum teres

What is the normal angle of torsion of the hip?

15 degrees

What happens when the angle of torsion is above 15 degrees?

anteversion (toe-in)

What happens when the angle of torsion is below 15 degrees?

retroversion (toe-out)

Causes of labral tears

trauma, torsional/twisting movements, unknown causes

Labral tear Sx

anterior hip/groin pain, clicking/locking, gives way, normal ROM, px with hip flexion, adduction, IR and SLR

Labral tear Rx

NSAIDs, rest, protected WB, surgical repair

OA causes

uknown, trauma, infection, hemarthrosis, osteonecrosis

OA Sx

gradual px onset, altered gait, limited internal rotation/extension, general hip weakness

OA Rx

NSAIDs, decrease WB, assistive devices, strengthening, hip resurfacing, hip replacement

Bursitis causes

trauma, friction

Bursitis Sx

lateral hip px, increased px over greater trochanter (especially when lying down on affected side), px w/ abduction, rotations

Bursitis Rx

remove irritating cause, heat, stretching, strengthening, steroid injection

Piriformis syndrome Sx

px in butt, restricted rotations, sciatic nerve px, increased px w/ sitting

Piriformis syndrome Rx

stretching, ice, massage, NSAIDs, botox to nerve

Congential hip dislocation causes

ligamentous laxity, in utero positioning, breech presentation at birth, more common in males (8:1), unilateral (L>R) or bilateral

Congenital hip dislocation dx

physical examination, ultrasound

Congential hip dislocation rx

positioning/bracing, splints, increased pressure promotes growth and deepening of acetabulum, surgical correction

Acquired posterior hip dislocation causes

trauma causes fibrous capsule to rupture inferiorly and posteriorly, moving femoral head posterior to acetabulum

Acquired anterior hip dislocation causes

trauma forcing hip into extension, abduction, lateral rotation

Acquired central hip dislocation causes

trauma forces hip deeper into acetabulum

Acquired hip dislocation rx

closed or open reduction, immobilization, compensatory methods for resuming activity, remobilization, strengthening

S/Sx of a fracture

px, tenderness, deformity, edema, ecchymosis, loss of general function and mobility

First stage of fracture healing

hematoma formation

Details of hematoma formation

BVs penetrate to form hematoma, occurs in 48-72 hours, can last 1-2 weeks

Second stage of fracture healing

cellular proliferation

Details of cellular proliferation

osteogenic cells proliferate, osteoblasts and osteoclasts differentiate, form fibrocartilage collar around fx

Third stage of fracture healing

callus formation

Details of callus formation

osteoblasts replace cartilage with bone

Fourth stage of fracture healing

ossification

Details of ossification

thickened deposition of calcium, osteoblasts move to the site

Fifth stage of fracture healing

consolidation and remodeling

Details of consolidation and remodeling

callus resorbed, woven bone transforms into mature bone, reshaping occurs in response stresses which can last months or years

Fracture healing times

Child: 4-6 weeks

Adolescent: 6-8 weeks

Adult: 10-18 weeks

Fracture treatments

reduction (open/closed), fixation

Closed reduction

nonoperative realignment, weights applied to fracture to realign (traction)

Open reduction

surgical intervention, ORIF, replacement, external fixation

Fixation

casting/bracing, rods, pins, screws, wires

Fracture risk factors

trauma, falls, spontaneous fractures, osteoporosis, pathologic fractures, radiation effects

Types of hip/femoral head fractures

subcapital neck, transcervical neck, intertrochanteric, subtrochanteric, fracture of greater/lesser trochanter

Hip fracture complications

infection, avascular necrosis of femoral head, nonunion/fusion, degenerative joint disease of hip, chronic pain

Avascular necrosis of femoral head is synonymous with…

hip dislocation, decompression sickness, sickle cell disease, radiotherapy, Gaucher’s disease, corticosteroid high-dose therapy

Total hip replacement details

head and neck of femur removed, joint may be disarticulated, metal/ceramic prosthesis inserted in femur, acetabulum replaced with cement or plastic cup (only THR)

What passes through the greater sciatic notch?

sciatic nerve, piriformis, sacral plexus

What passes through the lesser sciatic notch?

nerves and BVs

Why does the angle of inclination change with aging?

Angle is greatest at birth, lessens as we start WB

What are the 5 deep gluteal nerves?

sciatic, superior gluteal, inferior gluteal, n to quadratus femoris, n to obturator internus

Of the 5 deep gluteal nerves, which one exits superiorly to the piriformis?

superior gluteal nerve

Where does the sciatic nerve split?

halfway down the thigh

The quads insert into the patella via which tendon?

quad tendon

What does the patella tendon connect?

patella to tibial tuberosity

Your patient comes to you saying that they have a tight IT band and want you to stretch it. What do you tell them?

ITB is a fasica, can’t be stretched itself. Tightness can be a result of tight TFL or gluteus maximus, stretch those instead

Your patient has severe lordosis. What muscles are tight?

iliopsoas, erector spinae