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Anatomy

Lower Limb

Question 125 of 180

A 65 year old lady is brought to ED after falling off a ladder. The acetabulum is fractured at its posterosuperior margin by dislocation of the hip joint. Which of the following bones is most likely to be involved:

Answer:

The acetabulum is formed by the fusion of the three bones, the ilium superiorly, the ischium posteroinferiorly and the pubis anteromedially.

The hip joint is a multiaxial synovial ball and socket joint occurring between the head of the femur and the acetabulum of the pelvis.

Table: Anatomical Overview of the Hip Joint

Joint Hip
Type Synovial ball and socket joint
Articulations Head of femur with acetabulum of pelvis
Stabilising factors Acetabular labrum, thickened fibrous capsule, extracapsular ligaments (iliofemoral, ischiofemoral, pubofemoral), medial rotator muscles (effectively ‘pull’ head of femur into acetabulum)
Movements Flexion/Extension, Abduction/Adduction, Medial/Lateral rotation, Circumduction
Blood supply Branches of obturator artery, medial and lateral circumflex branches of profunda femoris artery and superior and inferior gluteal arteries
Innervation Femoral nerve, obturator nerve, superior gluteal nerve and nerve to the quadratus femoris

Joint articulations

The acetabulum is formed by the fusion of the three bones, the ilium, the ischium and the pubis.

By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Hip Joint. (Image by Henry Vandyke Carter [Public domain], via Wikimedia Commons)

The rim of the acetabulum is raised slightly by the fibrocartilaginous acetabular labrum which increases its depth, improving stability of the joint. The acetabular labrum continues inferiorly as the transverse acetabular ligament which bridges the acetabular notch and converts the notch into a foramen for the passage of nutrient vessels and nerves.

Ligaments

The intracapsular ligament of the head of femur (ligamentum teres) runs from the fovea on the head of the femur at one end to the acetabular fossa and the transverse acetabular ligament on the other. It carries a small acetabular branch of the obturator artery.

There are three main stabilising extracapsular ligaments; the iliofemoral (the largest and strongest ligament), the pubofemoral and the ischiofemoral ligament.

  • The iliofemoral ligament is anterosuperior to the hip joint, attached proximally to the ilium just below the anterior inferior iliac spine and distally to the intertrochanteric line of the femur. This ligament specifically prevents hyperextension and lateral rotation of the hip joint whilst standing.
  • The pubofemoral ligament is anteroinferior to the hip joint, attached to the pelvis at the iliopubic eminence and adjacent bone and blending distally with the articular capsule. This ligament prevents excessive abduction and extension of the femur at the hip joint.
  • The ischiofemoral ligament is posterior to the hip joint, attached medially to the ischium and laterally to the greater trochanter. This ligament prevents excessive extension and medial rotation of the femur at the hip joint.

By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Intracapsular Ligament of Head of Femur. (Image by Henry Vandyke Carter [Public domain], via Wikimedia Commons)

Modified by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia Commons

Hip Joint Ligaments (Anterior View). (Image modified by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia Commons)

 

By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Hip Joint Ligaments (Posterior View). (Image by Henry Vandyke Carter [Public domain], via Wikimedia Commons)

Blood supply

The hip joint receives its blood supply primarily from branches of the obturator artery, the medial and lateral circumflex arteries (branches of the profunda femoris artery) and the superior and inferior gluteal arteries. The articular branches of these vessels form a network around the joint.

Innervation

The hip joint is innervated by articular branches from the femoral nerve (anteriorly), obturator nerve (inferiorly), superior gluteal nerve (superiorly), and the nerve to the quadratus femoris (posteriorly).

Joint movements

The hip joint allows the movements of flexion and extension, abduction and adduction, medial and lateral rotation and circumduction.

Table: Movements of the Hip Joint

Movement Muscles Involved
Flexion Sartorius, Iliacus, Psoas major, Pectineus, Rectus femoris
Extension Hamstrings, Gluteus maximus
Abduction Gluteus maximus, medius and minimus, Obturator internus, Gemelli, Piriformis, Sartorius
Adduction Adductor longus, magnus and brevis, Gracilis, Pectineus
Medial rotation Gluteus medius and minimus, Adductor longus, magnus and brevis, Semitendinosus and Semimembranosus
Lateral rotation Obturator externus, Sartorius, Iliacus, Psoas major, Biceps femoris, Piriformis, Gluteus maximus, Obturator internus, Gemelli, Quadratus femoris

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l

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