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Introduction to Hip and Knee Dr Haroon Zaffar (FY1)Bones of the hip FemursFemur – proximal end Important points to remember - Femoral head – articulates with acetabulum to form hip joint - Greater Trochanter – attachement site for gluteal muscles - Lesser trochanter - attachment site for iliopsoas - Intertrochanteric line - Intertrochanteric crestFemur – shaft Important points to remember - Linea aspera - adductor muscles attach into here - Pectineal line - pectineus muscle inserts here - Gluteal tuberosity - gluteal maximus inserts here - Supracondylar linesFemur – distal end Important points to remember - Lateral and medial epicondyle – collateral ligaments originate from here - Intercondylar fossa – ACL and PCL knee ligaments attach hereTibia Important points to remember - Tibial plateau - Intercondylar eminence and tubercles - Tibial tuberosity - Medial malleousFibula Important points to remember - Lateral malleolus - Neck – lateral and posterior aspect - common fibular nerve What two movements can cause fracture of the lateral malleolus ? - External rotation of ankle - Eversion of ankleHip bonesHip bone - Ilium Important points to remember Anterior superior iliac spine – sartorius muscle originates from here Anterior inferior iliac spine – rectus femoris muscle originates from here Iliac fossa – illiacus muscle originatesHip bone - Pubis Important points to remember Adductor muscles originate from pubis bone Inferior pubic rami – Gracilis muscle originates here Obturator foramen – the obturator externus originates hereHip bone - ischium Important points to remember Ischial tuberosity – posterior muscles of thigh originate from hereHip joint Important points to remember - Ball and socket joint - Intracapsular Ligament – Ligament of head of femur (encloses obturator artery) - Extracapsular – Iliofemoral, ischiofemoral and pubofemoralHip joint – Blood supply Blood supply - Medial and lateral circumflex arteries (branch of deep femoral artery) - Medial artery responsible for most of arterial supply - Damage can lead to avascular necrosisKnee joint – ligaments ACL – prevents anterior dislocation of tibia onto femur (note meniscus attaches to PCL – prevents posterior dislocation of tiba onto femur Collateral ligaments – prevents excessive lateral and medial movementKnee joint – ligaments ACL – prevents anterior dislocation of tibia onto femur (note meniscus attaches to PCL – prevents posterior dislocation of tiba onto femur Collateral ligaments – prevents excessive lateral and medial movementMuscles of the Thigh – Anterior compartment I Spot Pretty Queen – Extensors of Knee Iliopsoas muscle Sartorius Pectineus Quadriceps FemorisMuscles of the Thigh – Anterior compartment Iliopsoas (psoas major and iliacus) - Psoas major – originates from lumber vertebrae - Iliacus – originates from iliac fossa - Both insert into lesser trochanter of femur - Flexion of thigh at hip jointMuscles of the Thigh – Anterior compartment Sartorius - Originates from anterior iliac spine - inserts to tibia - Hip flexion and Knee flexion Pectinus - Originates from pubis bone - Inserts into pectineal line - Adduction and flexion of hip jointMuscles of the Thigh – Anterior compartment Quadriceps femoris (3 vastus, 1 rectus femoris) - Rectus femoris – originates from anterior iliac spine - Vastus medial – originates from intertrochanteric line - Vastus intermediate – originates from anterior surface of femur - Vastus lateral – originates from greater trochanter - ALL MUSCLES INSERT INTO PATELLA VIA QUARICEPS TENDONWhat muscles in the anterior compartment of the thigh flex at the hip joint ? Iliopsoas Sartorius Pectineus Rectus femorisWhat muscles in the anterior compartment of the extend at knee joint ? Quadriceps femoris – medial, lateral and intermediate and rectus femorisWhat muscles in the anterior compartment of the thigh flexes at the knee joint? SartoriusMuscles of the Thigh – Medial compartment Give Obama Three Apples Gracilis Obturator externa Three Adductor Adductor Magnus Adductor Brevis Adductor LongusMuscles of the Thigh – Medial compartment Gracilis Originates from inferior pubic ramus Inserts into medial surface of proximal tibia Adduction at hip and flexion at knee Obturator externus Originates from obturator foramen Inserts into posterior aspect of greater trochanter Adduction of hip and lateral rotationMuscles of the Thigh – Medial compartment Adductors Magnus Originates from inferior rami of pubis and rami of ischium. Attaches to linea aspera and medial supracondylar line of femur Adduction, extension and flexion at the hip Brevis and Longus Orginates from pubis bone Attaches to linea aspera AdductionMuscles of the Thigh – Posterior compartment By Sydney Street Biceps femoris Semitendinosus SemimembranousMuscles of the Thigh – Posterior compartment Biceps femoris (Long and short head) Long head originates from ischial tuberosity Short head originates from the linea aspera Both heads insert into head of fibula Knee flexion and hip extension. Lateral rotation Semitendanous Originates from ischial tuberosity Attaches to medial surface of tibia Knee flexion and hip extension, Medial rotation Semimembranous Originates from ischial tuberosity Attached to medial tibial condyle Knee flexion and hip extension, Medial rotationMuscles of the Thigh – Nerve supply - Medial – Obturator - Anterior – Femoral - Posterior - SciaticMuscles of the gluteal region - Superficial muscles Gluteus maximus Originates from posterior aspect of ilium, sacrum and coccyx Inserts into iliotibial tract and gluteal tuberosity of femur Extension of thigh and lateral rotation Inferior gluteal nerve supply Gluteus medius Originates from posterior surface of ilium Inserts into greater trochanter of femur Abduction of thigh and medial rotation Superior gluteal nerve Gluteus minimus Originates from ilium Inserts into greater trochanter of femur Abduction of thigh and medial rotation Superior gluteal nerveMuscles of the gluteal region - Superficial muscles Tensor fascia lata Originates from anterior iliac crest Inserts into iliotibial band (attaches to lateral condyle of tibia) Asist gluteus medius and minimus with abduction and medial rotation Superior gluteal nerve Iliotibial tract - Strong band of connective tissue - Attaches iliac crest to tibia - Gluteus maximus and the tensor fascia lata attach to the tract - Helps stabilise the extended knee jointMuscles of the gluteal region - Deep muscles Piriformis Quadratus Femoris Originates from ischial tuberosity Originates from anterior aspect of sacrum Attaches to intertrochanteric crest Inserts into greater trochanter of femur Lateral rotation Lateral rotation and abduction Nerve to the quadratus femoris Nerve to the piriformis Obturator internus Originates from pubis and ischium at the obturator foramen Inserts into greater trochanter of femur Lateral rotation and abduction Nerve to the obturator internus (L5-S2) Gemelli Originates from superior – ischial spine, inferior – ischial tuberosity Inserts into greater trochanter of femur Lateral rotation and abduction Superior - Nerve to the obturator internus Inferior – Nerve to the quadratus femorisQuestion 1 Abdulkarim a 22-year-old male presents to the emergency room with pain in the left knee following a twisting injury during a rugby match. He states that it has gradually swollen over the past 24 hours, and he is unable to fully extend it. On examination you note tenderness over the medial joint line, a joint effusion, and the joint is held in a flexed position. There is no laxity on valgus stress test. What is the most likely diagnosis? A) Medial meniscal tear B) Lateral meniscus tear C) ACL tear D) PCL tear E) Medial collateral ligament tear Answer – A) Medial meniscal tear History of rotational injury Gradual swelling – meniscal injury Rapid joint swelling – ACL/PCL tearQuestion 2 Dwight a 75-year old male presents to the emergency room after being involved in a head-on car crash. He complains of severe pain in his left knee. On examination of the lower limbs, you note that the tibia displaces posteriorly on application of a force. What is the most likely diagnosis? A) Patellar dislocation B) Capsular tear C) Meniscal tear D) ACL tear E) PCL tear Answer E) PCL tear History of hyperextension injury Posterior sag on examination Positive posterior drawer testQuestion 3 A 75-year-old man is seen in the clinic with a 3-month history of right- sided hip pain that is worse when going up and down stairs along with morning stiffness lasting 30 minutes. He has a past medical history of COPD for which he was recently given a 5-day course of prednisolone following an acute exacerbation. He smokes 15 cigarettes daily and has been drinking 38 units a week after breaking up with his long-term partner 3 weeks ago. An x-ray is performed. What is the most likely cause of this patient presentation ? A) Avascular necrosis B) Osteoarthritis of the hip C) Osteonecrosis of the hip D) Iliotibial band syndrome E) Osteoporosis of the hip Answer B) Osteoarthritis of the hip LOSS – loss of joint space, osteophytes, subchondral sclerosis, subchondral cystsQuestion 4 A 43-year-old man presents to the GP with an unusual and 'wonky' walk since a sports accident he was involved in three weeks ago. During the examination, the GP asks the patient to stand on his left leg. Upon doing so, a slight pelvic drop is noted on the right side. Given the examination findings, what is the most likely affected nerve? A) Left inferior gluteal nerve B) Left obturator nerve C) Left superior gluteal nerve D) Right inferior gluteal nerve E) Right superior gluteal nerve Answer C) left superior gluteal nerve Superior gluteal nerve - gluteus medius and minimus Inferior gluteal nerve - gluteus maximus Trendelenburg signQuestion 5 During a block dissection of the groin, the sartorius muscle is identified. What is the nerve supply to this muscle? A) Obturator nerve B) Femoral nerve C) Sciatic nerve D) Sueprior Gluteal nerve E) Piriformis nerve Answer 2) Femoral nerve Sartorius is in anterior compartmentMuscles of the Thigh – Nerve supply - Medial – Obturator - Anterior – Femoral - Posterior - SciaticQuestion 6 Danish 72-year-old man is getting his leg chopped off. The posterior compartment muscles are divided. Which one of the following muscles does not lie in the posterior compartment of the thigh? A) Biceps femoris B) Semitendinosus C) Quadratus femoris D) Semimembranosus E) None of the above Answer – C) Quadratus femoris Deep gluteal muscleMuscles of the Thigh – Posterior compartment By Sydney Street Biceps femoris Semitendinosus SemimembranousQuestion 7 A 19-year-old man is playing rugby when he suddenly notices a severe pain at the posterolateral aspect of his right thigh. Which one of the following muscle groups is most likely to have been injured? a) Semimembranosus b) Semitendinosus c) Biceps femoris d) Gastrocnemius e) Soleus Answer: C) Biceps femorisQuestion 8 A 34-year-old man attends the accident and emergency department complaining of pain around the lateral aspect of the knee. The pain started two hours ago, during a game of hockey, whereby the anteromedial aspect of the patient's extended knee was struck by a hockey stick. The doctor orders a knee x-ray which identified an avulsion fracture of the fibular head. What muscle is the most likely cause of this patient's avulsion fracture? A) Sartorius B) Soleus C) Semitendanosus D) Biceps femoris E) Fibularis brevis Answer D) biceps femoris Head of fibula is insertion site for both long and short head of biceps femorisQuestion 9 A 20-year-old man was involved in a road traffic collision between 2 cars both going approximately 60 miles per hour. Once stabilised, the doctor performs a secondary survey. On examination, the patient's right leg is adducted, flexed and internally rotated. He is diagnosed with a dislocation of the hip. What type of dislocation is most likely and why? A) Anterior dislocation as the acetabulum is shallow anteriorly B) Anterior dislocation as the ischiofemoral ligament is strongest C) Posterior dislocation as the acetabulum is shallow anteriorly D) Posterior dislocation as the the ischiofemoral ligament is strongest E) Posterior dislocation as the the pubofemoral ligament is strongest Answer D) Posterior dislocation as the the ischiofemoral ligament is strongest Prevents hyperextension of hip