anatomy of groin
DESCRIPTION
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MOB TCD
Groin
Professor Emeritus Moira O’Brien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
Groin
• Lower half of anterior abdominal wall• Proximal portion of the thigh• Pain in the groin may be due to local
structures • Referred from other areas e.g. the
spine or ureter• Pain may be acute or chronic• Quality of pain• Rest or movement
MOB TCD
Hip and Groin Pain
• Spinal problems such as disc lesions
• Intra-abdominal problems
• Gynecological disorders
• Urological problems
• Urinary tract infection
• Pelvic inflammatory conditions
• Genital swelling or inflammation
• Epididymis, hydrocele, variocele
MOB TCD
• Os coxae (hip bone) femur
• Pubic symphysis
• Hip joint
• Femoral artery
• Femoral vein
• Long saphenous vein
• Inguinal lymph glands
• Nerves
• Muscles
• Bursae
• Hernia
Groin MOB TCD
Cutaneous Nerves MOB TCD
• Proximal group parallel to inguinal ligament
• Enlarged tender inguinal glands
• Part of a generalised lymphadenopathy
• Secondaries
Inguinal Glands MOB TCD
• Proximal group• Lesions in local structures• Skin of lower anterior abdominal
wall• Gluteal region • Skin of scrotum or labia• Distal superficial glands• Skin of leg area drained by long
saphenous vein• All drain to deep inguinal glands
along femoral vein
Inguinal Glands MOB TCD
• Lower five intercostal nerves• Subcostal nerve T12• 10th intercostal nerve is at the level of
the umbilicus• Iliohypogastric nerve L1• Ilioinguinal nerve L1
Skin of Anterior Abdominal Wall MOB TCD
• Subcostal nerve T 12• Iliohypogastric nerve L1• Ilioinguinal nerve L1• Femoral branch of the genitofemoral
nerve L1,2• Lateral cutaneous nerve of the thigh
L2,3• Femoral nerve L2,3,4• Obturator nerve L2,3,4
Cutaneous Nerves of Thigh MOB TCD
• Superficial fatty layer• Membranous layer of superficial fascia• Below umbilicus• Continuous with Colles’ fascia in the
perineum
Anterior Abdominal Wall MOB TCD
• Intercostal vessels• Skin above umbilicus:
superficial veins and lymphatics drain to axilla
• Skin below umbilicus:
superficial veins and lymphatics drain to long saphenous vein
• Superficial inguinal glands
Blood Supply and Lymphatics MOB TCD
• External oblique• Internal oblique• Transversus• Rectus abdominus• Pyramidalis• Nerves and vessels • Lie between internal oblique and
transversus
Abdominal Muscles MOB TCD
• Origin • Outer surfaces lower borders lower
eight ribs• Interdigitating serratus anterior• Latissimus dorsi
External Oblique MOB TCD
• Inserted into anterior half of anterior two thirds outer lip of iliac crest
• Aponeurosis in inguinal region passes anterior to rectus muscle
• Forms the inguinal ligament• Lacunar ligament• Reflected portion of inguinal
ligament
Insertion – External Oblique MOB TCD
• Inguinal ligament: aponeurosis is folded back from anterior superior iliac spine to pubic tubercle to form inguinal ligament
• Lacunar ligament:
triangular, attached to pectineal line, lateral free border medial margin of femoral ring
Inguinal and Lacunar Ligaments MOB TCD
• Pubic crest• Gap for superficial ring• Pubic bone • Linea alba • Anterior wall of the
rectus sheath• Zyphoid process
Insertion – External Oblique MOB TCD
• Muscular origin• Lateral two thirds of
inguinal ligament• Anterior two thirds
intermediate lip of iliac crest
• Lumbar fascia• Muscular fibres arch over
contents of inguinal canal anterior to rectus muscle
Internal Oblique MOB TCD
• Into the costal margin, upper three as fleshy fibres
• Next three as aponeurotic• Inserted into linea alba• Between zyphoid and half way between
umbilicus and pubic symphysis, aponeurosis splits
• Anterior fuses with external oblique• Posterior with transversus
Insertion – Internal Oblique MOB TCD
• Half way between umbilicus and pubic symphysis
• Aponeurosis of the internal oblique and transversus fuse to form conjoint tendon
• Anterior portion of rectus sheath• Inserted into pectineal line behind
superficial inguinal ring
Internal Oblique – Conjoint Tendon MOB TCD
• Origin• Lateral one third of inguinal ligament• Anterior two thirds of inner lip of iliac
crest• Lumbar fascia• Lower border and inner surfaces lower
six ribs interdigitating with diaphragm
Transversus Abdominus MOB TCD
• Into zyphoid, linea alba• Half way between umbilicus and
pubic symphysis• Fuses with posterior lamella of
the internal oblique • Below forms conjoint tendon• Inserted into pectineal line
behind superficial inguinal ring
Insertion – Transversus Abdominus MOB TCD
• Segmental muscle• Two heads• Anterior pubic symphysis• Pubic crest• Inserted anterior aspect
of 5,6,7th costal cartilages • Adhesions anterior• Segmental blood and
nerve supply from intercostals
Rectus Abdominus MOB TCD
• Lines deep aspect of transversus abdominus
• Fuses with inguinal ligament• Continuous with iliac fascia• Except in region femoral
vessels• Forms anterior wall of femoral
sheath
Transversalis Fascia MOB TCD
• Intramuscular canal • Deep inguinal ring• Superficial ring• Transmits spermatic cord in male • Round ligament in female
Inguinal Canal MOB TCD
• Triangular opening in aponeurosis of external oblique
• Base pubic crest• Superior crus to pubic crest• Inferior attached to pubic tubercle• External spermatic fascia arises from
its margins
Superficial Inguinal Ring MOB TCD
• Oval opening 2.5 cm• Above the middle of inguinal ligament• Inferior epigastric artery medial to
ring
Deep Inguinal Ring MOB TCD
• Anterior wall• External oblique • Whole anterior wall• Lateral half• Internal oblique
Inguinal Canal MOB TCD
• Posterior wall• Transversalis fascia• Whole of wall• Medial half conjoint tendon• Medial quarter, reflected portion
of inguinal ligament
Inguinal Canal MOB TCD
• Roof• Arching fibres of internal oblique • Transversus as they arise from the
inguinal ligament
Roof of Inguinal Canal MOB TCD
• Floor• Inguinal ligament
medial half• Lacunar ligament
Floor of Inguinal Canal MOB TCD
• Vas deferens• Testicular artery• Pampiniform plexus of veins• Remains of processus vaginalis• Genital branch of genitofemoral nerve• Lymphatics from testes• Cremaster artery
Passing through Deep Ring Male
MOB TCD
• Everything that went through deep ring• Plus:• Ilioinguinal nerve• Internal spermatic fascia• Cremaster muscle and fascia
Passing through Superficial Ring Male
MOB TCD
• Round ligament of uterus• Remains of processus vaginalis• Genital branch of genitofemoral
nerve• Lymphatics from uterus, region of
cornu
Passing through Deep Ring Female
MOB TCD
• Everything that went through deep ring:
• Plus ilioinguinal nerve
Passing through Superficial Ring Female
MOB TCD
• Contraction of the abdominal muscles increases the obliquity of the inguinal canal
• Protecting the two ringsLytle, 1945
Inguinal Canal MOB TCD
• Pain aggravated by an increase in intraabdominal pressure
• Hernia• Inguinal or femoral hernia• Entrapment of the ilioinguinal nerve
Increase in Intra Abdominal Pressure
MOB TCD
• Chronic pain in the groin in an athlete
• May be due to a hernia or a potential hernia
Hernia MOB TCD
• Sudden severe pain in lower abdomen
• Associated with lifting a heavy object
• Common history of a direct inguinal hernia
Inguinal Hernia MOB TCD
• Passes through• Deep inguinal ring• May extend to pass through
the superficial ring into the scrotum
• Congenital or acquired • Congenital inside the tunica
vaginalis (serous membrane, covers part of testes)
• Acquired outside
Indirect Inguinal Hernia MOB TCD
• Direct inguinal hernia• Enters through posterior wall of the
inguinal canal• Leaves through superficial inguinal ring• Above and medial to pubic tubercle
Direct Inguinal Hernia MOB TCD
• Inguinal above and medial to pubic tubercle
• Femoral below and lateral
Inguinal Versus Femoral Hernia MOB TCD
Femoral Ring MOB TCD
• Enters through femoral ring• Enters femoral canal• Medial compartment of femoral
sheath• More common in women
Femoral Hernia MOB TCD
Femoral Hernia MOB TCD
• Swelling is soft and diffuse
• Empties on minimal pressure
• Refills on release• Cough impulse is
present
Saphenous Varix MOB TCD
• Common cause of chronic groin pain in field sports
• Particularly soccer players• Pain on any sudden change of
movement, sneezing, coughing
Gilmore’s Groin MOB TCD
• Trying to sprint will increase the pain • Pain is worse getting out of bed the
day after a match or a training session
Gilmore’s Groin MOB TCD
• Pain is increased by external rotation
• Or hyperextension of hip• Pain is localised to lower
anterior abdominal wall• Adductor or perineal region
Gilmore’s Groin MOB TCD
• Torn external oblique aponeurosis
• Torn conjoint tendon• A dehiscence between conjoint
tendon and the inguinal ligament• The absence of a hernial sac• Superficial inguinal ring on the
affected side is dilated and tender
• Cough impulse
Gilmore’s Groin MOB TCD
• Treatment is surgical • 90% return to sport• Strengthen lower abdominal
muscles
Gilmore’s Groin Surgery MOB TCD
1. Plication of the transversalis fascia in ‘shouldice hernia repair’
2. Repair of torn conjoint tendon
3. Approximation of conjoint tendon to the inguinal ligament
4. Repair of the external oblique
5. Reconstitution of the superficial inguinal ring
Gilmore’s Groin Surgery MOB TCD
• Dermatomes• Entrapment of nerves• Pierce muscle• Pierce fascia• Repetitive movements
Anatomy of Nerve Injuries MOB TCD
• Must know the course of nerve• Dermatomes• Entrapment of nerves• Pierce muscle• Pierce fascia• Repetitive movements
Anatomy of Nerve Injuries MOB TCD
• Nerves supply
• Skin
• Muscles (group)
• Tendons
• Bones
• Joints
• Blood vessels
Dermatomes and Myotomes MOB TCD
• External forces • Fibro-osseous tunnels, tether the
nerve
• Oedema
• Callus formation as a result of a fracture
• External compression due to specific movements
• Mechanical compression
• Compartment syndromes
• The nerve is tender at the site of compression
Extrinsic Factors MOB TCD
• Fibrous bands• Accessory muscles• Spurs• Narrow notches• Anatomical variations of the nerve itself
Extrinsic Factors MOB TCD
Lumbo-Sacral Plexus MOB TCD
• Affects branches of lumbar or sacral plexuses
• Pierces muscle• Pierces fascia• Increase in compartment
pressure• Compressed by external
pressure
Entrapment Syndromes in Lower Limb
MOB TCD
• Lower five intercostal nerves• Subcostal nerve T12• 10th intercostal nerves at the level of
the umbilicus• Iliohypogastric nerve L1• Ilioinguinal nerve L1
Skin of Anterior Abdominal Wall MOB TCD
• Subcostal nerve T 12• Iliohypogastric nerve L1• Ilioinguinal nerve L1• Femoral branch of the
genitofemoral nerve L1,2• Lateral cutaneous nerve of the
thigh L2,3• Femoral nerve L2,3,4• Obturator nerve L2,3,4
Cutaneous Nerves of Thigh MOB TCD
Cutaneous Nerves MOB TCD
• Branch of lumbar plexus• Lateral border of psoas• Anterior to quadratus lumborum• Neurovascular plane between internal
oblique and transversus• Lateral cutaneous supplies upper part of
buttock
Ilio-Hypogastric Nerve L1 MOB TCD
• Pierces internal oblique above anterior superior iliac spine
• Pierces aponeurosis of external oblique an inch above superficial ring
• Supplies skin over lower part of rectus sheath
• Can be trapped piercing aponeurosis
Ilio-Hypogastric Nerve MOB TCD
• Ilio-inguinal nerve• L1 branch of lumber plexus• Lateral border of psoas• Anterior to quadratus lumborum• Neurovascular plane between
internal oblique and transversus
Ilio-Inguinal Nerve MOB TCD
• Pierces internal oblique 4 cm medial to
• Anterior superior iliac spine
• Enters inguinal canal• Leaves through superficial
ring
• Supplies the skin of the medial part of the thigh
• Adjoining portion of the scrotum and labia
Ilio-Inguinal Nerve MOB TCD
• May be trapped post surgery, due to adhesions
• Poor tone in abdominal muscles
• Pain increased by increased tension in the anterior abdominal wall
• Hyperextension of hip• Tenderness 4 cm from
anterior superior iliac spine
Ilio-Inguinal Nerve MOB TCD
• Pain increased• Increased tension in the anterior
abdominal wall• Hyperextension of hip• Tenderness 4 cm medial to anterior
superior iliac spine
Ilio-Inguinal Nerve Entrapment MOB TCD
• Iliohypogastric in 5.6%• Ilioinguinal 90.7%• Union of branches of ilioinguinal
and genital branch of the genitofemoral nerve 13%
• Genitofemoral passing through superficial inguinal ring 35.2%
• Piercing inguinal ligament 5.6%• Femoral branch 13% Akita et al., 1999
CutaneousNerves MOB TCD
• Lumbar plexus L1,2• Anterior aspect of the psoas• Genital branch enters the deep
inguinal ring• Femoral branch lies on the lateral
side of femoral artery in the femoral sheath
Genitofemoral Nerve MOB TCD
• Enters thigh on lateral aspect of femoral artery in femoral sheath
• Pierces anterior wall of the sheath
• Supplies skin a hands breath below the inguinal ligament
Femoral Branch Genitofemoral MOB TCD
• Union with ilioinguinal nerve on anterior aspect of spermatic cord
• Supplies ventral aspect of scrotum and adductor region
• Cutaneous branch on the dorsal-caudal aspect
• May also supply dorsal scrotumAkita et al., 1999
Genitofemoral Nerve MOB TCD
Genitofemoral Nerve MOB TCD
• The lateral cutaneous nerves of the thigh L2,3
• Lumbar plexus in psoas• Lateral aspect of psoas• Pierces inguinal ligament• Lies in fibrous tunnel• Divides into two• Pierces deep fascia
Lateral Cutaneous Nerve MOB TCD
• A centimeter medial to anterior superior iliac spine
• Crosses the lateral angle of femoral triangle
• Divides into two• Pierces deep fascia• Anterolateral aspect of the thigh• Anterior portion of gluteal region
Lateral Cutaneous Nerve of Thigh MOB TCD
• Entrapment in the fascial tunnel• Injured in the thigh by asymmetric bars
in gymnastics • Causes meralgia paraesthetica• Post laparoscopic surgery
Lateral Cutaneous Nerve of Thigh MOB TCD
• The largest branch of the lumbar plexus• Lateral aspect of psoas• Passes under the inguinal ligament• Outside femoral sheath• 2 cm below• Divides into terminal branches• Muscular • Articular• Cutaneous
Femoral Nerve L2,3,4 MOB TCD
Muscular branches• Rectus femoris• Vastus medialis• Vastus lateralis• Vastus intermedius• Sartorius, pectineus
Cutaneous • Medial cutaneous nerves of thigh• Intermediate cutaneous nerves of thigh• Saphenous
Articular branches to hip and knee joints
Femoral Nerve MOB TCD
• Dancers may stretch the nerve by prolonged hyperextension of the hip
• Compress the nerve under the inguinal ligament
• The nerve may also be compressed due to a haematoma following a partial tear of the iliacus
O’Brien, 1997
Femoral Nerve MOB TCD
Femoral nerve
Saphenous
Femoral Nerve MOB TCD
• The obturator nerve L2-3-4• Lumbar plexus in psoas• Medial aspect of psoas• Side wall of pelvis under peritoneum• Leaves through obturator foramen• Divides into anterior and posterior
divisions
Obturator Nerve MOB TCD
• Supplies the parietal peritoneum on side wall of the pelvis
• It is related to the ovary• Pathology in the ovary or
endometriosis may result in referred pain to the hip, knee or medial side of the high
Obturator Nerve MOB TCD
• The anterior division of the obturator leaves pelvis
• Anterior to obturator externus
• Descends in front of adductor brevis
• Behind pectineus and adductor longus
obturator nerve
Anterior Divison Obturator MOB TCD
• Adductor longus • Adductor brevis• Gracilis• It gives an articular twig to the
hip joint• Skin on the medial side of the
thigh
Anterior Divison Obturator MOB TCD
Obturator Nerve MOB TCD
• It may be entrapped as it leaves the pelvis • Pierces and supplies the obturator externus • Causing spasm of the adductor muscles
Posterior Divison Obturator MOB TCD
• Supplies adductor portion of adductor magnus, above hiatus
• Articular twig to knee joint and cruciate ligaments
• Causing spasm of the adductor muscles• It may be entrapped as it leaves the pelvis or
between fascial planes
Posterior Divison Obturator MOB TCD
obturator nerve fascial planes
Obturator Nerve MOB TCD
• Pressure on obturator nerve• Pain on inner aspect of thigh
relieved by flexion of hip• Increased by extension,
adduction and medial rotation
Howship Rhomberg Sign MOB TCD
Obturator Nerve MOB TCD
Psoas Muscle MOB TCD
Sacral Plexus MOB TCD
Pudendal Nerve MOB TCD
• Compression of pudendal nerve in cyclists due to saddle
• History of change of saddle• Compressing dorsal nerve of
penis
Pudendal Nerve MOB TCD
Psoas Muscle MOB TCD
• Iliac fossa and iliac crest• Inserts into psoas• Major• Nerve L23• Psoas bursa
Iliacus MOB TCD
• Upper half of anterior inferior iliac spine• Area above actetabulum• Inserted into quadriceps tendon• Flexes hip• Extends knee• Femoral nerve
Rectus Femoris Muscle MOB TCD
• Synovial ball and socket joint• Multiaxial• Three degrees of freedom• Movement in three planes• Close pack extension and
medial rotation• Least pack semiflexion
Hip Joint MOB TCD
• One of most stable joints in the body
• Articular surface of hip joint are reciprocally curved
• Superior surface of femur and acetabulum sustain greatest pressure
Hip Joint MOB TCD
• Y shaped epiphyseal cartilage• Start to ossify at 12• Fuse 16-17• Acetabular notch is inferior• Nonarticular fossa, thin related
medially to obturator internus• Pad of fat, proprioceptive nerves
Acetabulum MOB TCD
• Semilunar articular surface covered with hyaline cartilage
• Deepened by labrum acetabulare
• Wedge shaped fibrocartilage
Articular Surface of Hip Joint MOB TCD
• Head of femur 2/3rd of sphere• Pit for ligamentum teres• Covered with articular cartilage• Cartilage thicker posterior superior• Epiphyseal line for head
intracapsular
Articular Surface MOB TCD
• Trabeculae develop along lines of stress
• Calcar femorale is the cortical bone on inferior aspect of neck
• Neck is cancellous bone
Femur MOB TCD
• Proximally attached• Margins of the acetabular fossa • Base of labrum• Distally, anterior to the
intertrochanteric line• Inferiorly, femoral neck close to
lesser trochanter
Capsule of Hip MOB TCD
• Posterior• Free border, finger’s breadth
from trochanteric crest due to insertion of obturator externus
• Into trochanteric fossa and• Root greater trochanter
Capsule of Hip MOB TCD
• Strongest superiorly• Anteromedially, deep fibres
reflected head of rectus femoris• Iliopsoas is anterior• Lateral deep fibres of gluteus
minimus
Capsule of Hip MOB TCD
• Fibres of capsule reflected along neck to articular margin called retinacular fibres
• Blood supply to head run under retinacular fibres
Retinacular Fibres MOB TCD
• Labrum acetabulare• Transverse ligament• Ligament of head• Iliofemoral ligament• Pubofemoral ligament• Ischiofemoral ligament• Zona orbicularis
Ligaments of Hip MOB TCD
• Transverse ligament is part of the labrum
• Ligamentum teres is triangular • Its base is attached to transverse
ligament and the apex to the pit on the head of femur
• Blood supply to epiphysis from obturator artery
• Only supplies a flake of bone in elderly
Ligaments of Hip MOB TCD
• Thickening of capsule• Lower half of anterior inferior
iliac spine and adjoining acetabulum
• Distally• Upper and lower parts of
inter trochanteric line
Iliofemoral Ligaments MOB TCD
• One of strongest ligaments in body
• Tightens in extension• Helps maintain erect posture• Facet on anterior aspect of
neck• Prevents hyperextension • Fulcrum reducing hip
Iliofemoral Ligaments MOB TCD
• Superior pubic ramus• Inferior part of inter trochanteric
line and upturned part• Relatively weak• Prevents abduction• Bursa between it and iliofemoral
Pubofemoral Ligament MOB TCD
• Ischium to posterior part of joint (weak)
• Circular fibres called zona orbicularis
• Centre of gravity in front of head
• Synovial under obturator externus
Ischiofemoral Ligament MOB TCD
• Lines inner portion of capsule and nonarticular structures
• Ligament of head• Fat in acetabular fossa• May communicate with psoas
bursa • Bursa under obturator externus
Synovial Membrane MOB TCD
• Trochanteric bursa• Posterolateral aspect of
greater trochanter gluteofemoral
• Vastus lateralis ischial bursa• Ischial tuberosity
Bursa Under Glueus Maximus MOB TCD
• Child: obturator artery via ligamentum teres supplies epiphysis
• Elderly: main supply via retinacular vessels from trochanteric and cruciate anastamoses
• Medial and lateral circumflex femoral vessels
Blood Supply to Head of Femur MOB TCD
• Superior gluteal supplies the upper part of the acetabulum
• Inferior gluteal supplies the inferior and posterior and the capsule
• Transverse and ascending branches of lateral circumflex femoral artery
• Transverse and ascending branch of medial circumflex femoral
• Cruciate and trochanteric anastomosis
Blood Supply MOB TCD
• Fractures of neck may cause avascular necrosis, extra capsular arteries enter the trochanter at the base of neck
• Medial and lateral circumflex femoral vessels and superior gluteal
Blood Supply MOB TCD
• Femoral nerve• Obturator nerve• Superior gluteal nerve• Nerve to quadratus femoris• Posterior dislocation may
damage sciatic• Pain in hip referred to knee
Nerve Supply MOB TCD
• One of the most stable joints• Congenital dislocations is
common• 1.5 per 1000 live births• Female : Male = 8:1 • Ultrasound best method of
detecting
Stability of Hip MOB TCD
• Rectus femoris• Adductor longus • Pectineus• Psoas, iliacus• Femoral sheath• Femoral nerve
Anterior Relations MOB TCD
• Obturator externus• Passes inferior and then posterior to
joint • Superior gluteal nerve• Inferior gluteal nerve• Sciatic nerve• Posterior cutaneous nerve thigh• Nerves to obturator internus and
quadratus femoris• Pudendal nerve
Inferior and Posterior Relations MOB TCD
• Gluteus minimus • Gluteus medius• Superior gluteal vessels and nerves
between• Iliotibial tract• Superficial three quarters of gluteus
maximus
Lateral Relations MOB TCD
• Piriformis • Superior gemellus• Obturator internus• Inferior gemellus• Quadratus femoris• Adductor magnus• Obturator externus• Gluteus maximus
Posterior Relations MOB TCD
• Limited by anterior abdominal wall• Psoas• Iliacus• Pectineus• Adductor longus and brevis• Rectus femoris
Movements: Flexion MOB TCD
• Hamstrings first 10°1. Long head of biceps
2. Semitendinosus
3. Semimembranosus
• 123, extended knee ++• Adductor magnus• Gluteus maximus most efficient when hip is
flexed 45 °
Movements: Extension MOB TCD
• Obturator nerve• Adductor longus• Adductor brevis• Adductor magnus• Can flex or extend depending on
position of hip
Movements: Adduction MOB TCD
• Gluteus medius• Gluteus minimus• Standing on leg, gluteus medius
and minimus abduction
• By preventing adduction
Movements: Abduction MOB TCD
• Iliopsoas • Adductors• Anterior fibres of gluteus medius
Movements: Medial Rotation MOB TCD
• Obturator internus• Piriformis• Superior gemmelus• Obturator internus • Inferior gemmelus• Quadratus femoris
Movements: Lateral Rotation MOB TCD
Trendelenburg Tests MOB TCD
Fractured Neck of Femur MOB TCD
• Apophysitis • Avulsion fractures• After 13 years• 11-40% of all hip and
pelvic fracturesBoyd et al., 1997
• Anterior superior iliac spine
• Anterior inferior iliac spine
• Ischial tuberosity commonest
Hip Problems in Children MOB TCD
Hip Problems MOB TCD
• 5-10 year old child• Aching pain in hip• Limp• Limitation of movement• Perthe’s• Osteochondritis of head of femur
Pain in a Child MOB TCD
• One of the most stable joints• Congenital dislocations is
common• 1.5 per 1000 live births• Female : Male = 8:1 • Ultrasound best method of
detecting
Stability of Hip MOB TCD
• Femoral version is the angular difference between axis of femoral neck and transcondylar axis of the knee
• Femoral anteversion ranges from 30º - 40º at birth
• Decreases progressively 15º at skeletal maturation
• Adults• Anteversion• Average of 8º in men and
14º in women• Most common cause of
in-toeing • If associated with internal
tibial torsion may lead to patellofemoral subluxation due to an increase in the Q-angle
Femoral Anteversion MOB TCD
• Young, healthy athletes do get cancer!
• Fortunately most tumors are benign!
• Bone pain at night
• Tumor till proved otherwise
Renstrom, 2008
Tumors and Neoplasms MOB TCD
• Chronic
• Secondary to acetabular dysplasia
• Part of ‘rim lesion’ complexRenstrom, 2008
•
Hip Joint Labral Tear MOB TCD
• Labrum tears and cartilage loss are common in patients with mechanical symptoms in the hip
• In young, active patients with a complaint of groin pain
• The diagnosis of a labrum tear should be suspected and investigated as radiographs and the history may be nonspecific for this diagnosis
Burnett et al., 2006
Labrum Tears and Cartilage Loss MOB TCD
• MR arthrogram has an accuracy of 91% for labral tears
Chan et al., 2005
• Sensitivity labral tear
• MR 25%,
• MRA 92%Toomayan et al., 2006
MR – Arthrography (MRA) MOB TCD
• The acetabulum covers too much of the femoral head
• Secondary to ‘retroversion’ of the socket • Or a ‘profunda’ socket that is too deep• Most of the time, the cam and pincer forms
exist together• Female, 30-40 yearsRenstrom, 2008
Pincer Impingement MOB TCD
• Loss of roundness contributes to abnormal contact between the head and socket
• Male, 20-30 yearsRenström, 2008
Cam Impingement MOB TCD
Renström, 2008
Cam Impingement MOB TCD
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