Week 2 Hip & Knee

Front 1

Hip joint

Back 1

Synovial ball and socket joint; articulation of head of femur within the actebabulum of pelvis

Front 2

Hip flexors

Back 2

1. Iliopsoas (iliacus + psoas)
2. Rectus femoris
3. Sartorius

Anterior compartment muscles
The femoral nerve innervates all of the hip flexors

Front 3

Flexion of hip vs. extension of hip

Back 3

Flexion = thigh moves forward
Extension = thigh moves backward

Front 4

Internal rotation of hip vs external rotation

Back 4

Internal rotation = foot turns inward

External rotation = foot turns outward

Front 5

Iliopsoas

Back 5

2 muscles: iliacus + psoas

A: Hip flexion
N: femoral nerve; ventral rami L1-L3
O: L1-L5; iliac crest
I: lesser trochanter of femur

Front 6

Iliopsoas

Back 6

Front 7

Quadriceps muscles

Back 7

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

Front 8

Sartorius

Back 8

A: Hip flexion & external rotation; knee flexion
N: femoral nerve (L2-L4)
O: ASIS
I: medial to the tibial tuberosity

Front 9

Muscles of the thigh

Back 9

Front 10

Hip extensors

Back 10

1. Gluteus maximus
2. Hamstring muscles

Posterior compartment muscles

Front 11

Gluteus maximus

Back 11

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

Front 12

Hamstring muscles

Back 12

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

Front 13

Hamstrings

Back 13

Front 14

Hip adductors

Back 14

1. Gracilis
2. Adductor longus
3. Adductor brevis
4. Adductor magnus
5. Pectineus

Medial compartment muscles

Front 15

Hip adductors

Back 15

Front 16

Gracilis

Back 16

A: hip adduction
N: obturator nerve (L2-L4)
O: pubis
I: medial to the tibial tuberosity

Front 17

Adductor longus
Adductor brevis
Adductor magnus

Back 17

A: hip adduction
N: obturator nerve (L2-L4)
O: AL & AB - pubis; AM - ischium
I: linea aspera

Front 18

Pectineus

Back 18

A: hip adduction, flexion & IR
N: femoral nerve; 20% obturator nerve
O: pubis
I: linea aspera

Front 19

Hip abductors

Back 19

1. Gluteus medius
2. Gluteus minimus

Front 20

Gluteus medius

Back 20

A: hip abduction
N: superior gluteal nerve (L4 - S1)
O: ilium
I: greater trochanter

Front 21

Gluteus minimus

Back 21

A: hip abduction
N: superior gluteal nerve (L4 - S1)
O: ilium
I: greater trochanter

Front 22

Superior & inferior gluteal nerves

Back 22

Front 23

Tensor fasciae lata

Back 23

A: abduction, flexion, IR of hip
N: superior gluteal (L4 - S1)
O: iliac crest
I: IT band (lateral aspect of proximal tibia)

Front 24

Trendelenburg’s sign or gait

Back 24

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

Front 25

External hip rotators

Back 25

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

Front 26

External hip rotators

Back 26

Front 27

Obturator externus

Back 27

A: external rotator of the hip
N: obturator nerve (post. branch)
O: obturator foramen
I: greater trochanter

Front 28

Anterior compartment of thigh

Back 28

Femoral a.
Femoral n.

Front 29

Medial compartment of thigh

Back 29

Obturator a.
Obturator n.

Front 30

Posterior compartment of thigh

Back 30

Profunda femoris art
Perforationg vessels
Sciatic n

Front 31

Muscle compartment of the lower extremity

Back 31

Thigh muscles

Front 32

Lateral cutaneous femoral nerve

Back 32

L2-L4
Cutaneous anterior and lateral thigh
Crosses ASIS and can be compressed there meralgia parasthetica

Front 33

Femoral nerve

Back 33

Sensory to anteromedial thigh via ant/intermed cut. nerves
L2-L4
Motor to psoas, articularis genu, and anterior thigh muscles (quads + sartorius)

Front 34

Obturator nerve

Back 34

L2-L4
Sensory to inferomedial thigh
Anterior branch: medial thigh compartment (add longus & brevis, gracilis, and pectineus)
Posterior branch: obturator externus, adductor magnus

Front 35

Sciatic nerve

Back 35

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

Front 36

Muscles that extend the knee

Back 36

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)

Front 37

Flexion of the knee

Back 37

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

Front 38

Tibial nerve (L4 - S3)

Back 38

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)

Front 39

The one muscle of the medial thigh compartment that crosses the hip and knee joint is?

Back 39

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)

Front 40

The short head of the biceps femoris is innervated by?

Back 40

The common peroneal (fibular) nerve?

The long head is the tibial nerve

Front 41

Pes anserina

Back 41

Insertion of the sartorius, gracilis, semitendinosus onto the antero-medial surface of the tibia

Front 42

ACL

Back 42

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

Front 43

ACL

Back 43

Front 44

PCL

Back 44

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

Front 45

PCL

Back 45

Front 46

ALC and PCL

Back 46

Front 47

MCL

Back 47

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

Front 48

LCL

Back 48

Lateral collateral ligament

Femur to fibula

Stabilizes the lateral side of the joint to varsus (outside) stress

Front 49

Menisci of knee

Back 49

Medial and lateral
Fibrocartilage discs
98% type I collagen
Vascularized peripherally but not in middle (deep injury will not heal)
Load bearing

Front 50

Gluteal tears

Back 50

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

Front 51

Greater trochanteric pain syndrome

Back 51

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

Front 52

Gerdy's tubercle

Back 52

Lateral tubercle of the tibia where the IT band and tensor fascia latae insert

Front 53

Internal snapping hip

Back 53

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

Front 54

Meralgia Paresthetica

Back 54

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)

Front 55

Piriformis syndrome

Back 55

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

Front 56

Hamstring tear

Back 56

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

Front 57

Slipped Capital Femoral Epiphysis

Back 57

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

Front 58

Slipped Capital Femoral Epiphysis

Back 58

Front 59

Legg-Calve-Perthes Disease

Back 59

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

Front 60

Blood supply to femoral head

Back 60

Front 61

Hip dysplasia

Back 61

Shallow acetabulum (socket)

Types:

Infantile
Adult

Front 62

Developmental dysplasia of the hip (infantile type)

Back 62

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

Front 63

Back 63

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.

Front 64

Adult form of hip dysplasia

Back 64

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

Front 65

Back 65

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