DR. RAHUL S LAHOTI MD Scholar Dissertation submitted to
145
“A COMPHRENSIVE STUDY OF ULUKHAL SANDHI W.S.R TO HIP JOINT AND IT’S APPLIED ANATOMY” BY DR. RAHUL S LAHOTI MD Scholar Dissertation submitted to the RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA, BANGALORE. In partial fulfillment of the requirements for the degree of AYURVEDA VACHASPATI In RACHANA SHARIR Under The Guidance of Dr. SOURABHEE KOREGAVE MD (AYU) PROFESSOR & H. O. D Department of PG studies in RACHANA SHARIR CO-GUIDE Dr. RAHUL NITINALIAS RUGE MD (Ayu) Asso. Professor Department of PG studies in RACHANA SHARIR LATTHE EDUCATION SOCIETY'S ACHARYA DESHABUSHAN AYURVEDIC MEDICAL COLLEGE AND HOSPITAL, BEDKIHAL DIST- BELAGAVI 2017-2020
DR. RAHUL S LAHOTI MD Scholar Dissertation submitted to
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12
Asthis are 360 according to vedvadi but in shalyatantra these are
figured 300. Of these 300 bones, 120 are
found in shakha (extremities), 117 in kshroni, Prushtha, Parshva,
Urah and remaining 63 are located in
Greeva-pradesha. Thus 120 + 117 + 63 = 300, total number of Asthi
is three hundred (23).
Asthi prakara (types):
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In the Ayurvedic science the Asthi are classified into five-group
viz.
Kapala, Ruchaka, Taruna, Valaya and Nalakasthi (23) (24).
i) Kapalasthi – Asthi at the places of Janu, Nitamba, Ansa, Ganda,
Talu,
Shankh, and Sheerah.
iii) Tarunasthi – Asthi located at Ghrana, Karna, Greeva, and
Akshikosh.
iv)Valayasthi – Asthi found in Parshva, Prushtha, and Urah.
v) Nalakasthi – Remaining Asthi; (long bones).
All the five types of Asthi are named after their external
appearance.
Mamsa (muscles) is bound to these bones with the help of Sira and
Snayu.
13
NITAMBA:-
¦ m. (-)
1. A woman's buttock's.
2. The buttocks or posteriors in general, or as it is sometimes
applied, to the circumference of the hip and
loins.
Monier-Williams
m. the shoulder L.
m. a partic. Position of the hands in dancing Cat.
According to the meaning of nitamba the bone over the nitamb
pradesh is shroni phalak. Shroniphalak asthi
which is related to vankshan sandhi.
Meaning of shroniphalak is
2. The hip- bone.
Monier-Williams
/ -- n. The hip and loins L.
/ -- n. The hip-bone
1. The hip and loins, or the hip only.
14
2. The hip- bone, the os ilium. E. the same, and fruit, aff. of
comparison, or
a plank; also n. (-) |
Shroniphalak asthi is made up of jaghankapal(), bhagasthi()
and
kukundarasthi(). On prusth bhag of shroniphalak the fusion all of
this forms a
vankshanodukhal(). Where the head of urvasthi() forms vankshan
sandhi.
Urvasthi ()
It is a type of nalakasthi means long bone present over lower limb.
Urvasthi are 2 in no. Head of urvasthi is
circular in nature and it is present inner side. In central part of
head it consists depression which gives
attachment to ligament of vamkshan sandhi.
ULUKHAL SANDHI
||
-Vachaspatyam
The mortar which goes up and down and the structure which look like
a mortar used for freeing rice from
husk by pounding it with pestle (29).
: |
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-Amarkosh
As we separate the husk and bran layers of the grain by pounding it
with instrument called mortor and pestle,
mortor is where we add grains and pestle is used for pounding the
grains in rapid motion is ulukhalam (30).
15
According to shabdsagar
1) A wooden mortar used for freeing rice from the husk, by pounding
it with pestle.
2) Any mortar E. for up, and what goes, affix : also ulukhal.
According to monierwilliams
1) Udukhal n. A wooden mortar used for pounding rise and separating
the husk.
2) Udukhal n. bdellium L.
Synonyms
“, ::|”
The structure which seems like a wooden mortar which used for
freeing rice grains from husk, by pounding
it with pestle is called Ulukhal (33).
According to Haranchandra
“ : , |”
According to haranchandra ulukhal word is derived from wooden
mortar because it seems like the structure
of wooden mortar and its activity. He also correlated to the when
arrow is released from the bow by a archer
the bow string comes back to its position same as the ulukhal
sandhi has all kriya (movement) and comes to
its anatomical position (33).
Types of ulukhal sandhi
“ , ::, : |”
-| : : |
Gananathsen
There are three types of ulukhal sandhi are explained (33)
1) kaksha sandhi
2) Vankskhansandhi
3) Dashnesandhi
Kaksha sandhi:-
In this type of Sandhi one bone has mortar like structure which
unites with pestle like head of another
bone.It is bahuchala()type of sandhi. It is also known as
amsasandhi. It is made up of amsapita of
amsaphalakasthi, head of pragandasthi.
According to apte
-1)The groin.
According to monier williamas
2) -The thigh joint.
In this type of Sandhi one bone has mortar like structure which
unites with pestle like head of another bone.
It is bahuchala ()type of sandhi. In Vankshana Sandhi vankshan is
made up of three bones of
shronipahalak ( jaghankapal, bhagasthi and kukundarasthi) which
seems like vankshanulukhal (mortar)
which unites with head of urvasthi.
Dashane sandhi:-
In this type of Sandhi one bone has mortar like structure which
unites with pestle like head of another bone.
It is sthira () type of sandhi. According to ghanekar tika it does
not consist any movements so this
sandhi not comes -under the ulukhal group it comes under sthira
sandhi. According to gananathsen
commenttary this sandhi is one type of ulukhal sandhi which is
sthira sandhi.
17
According to susuhruta:-
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Katikataruna and nitamba are the two maramas which are explained
related to vankshan sandhi. This each
marmas are 2 in no.This marma are kalantarharani marmas (37).
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Kateekataruna Marmas are located one on either side of the lower
part of the PrushtaVamsha over the
ShroniKaandas (pelvic bones).
They are 2 in number and are located one on either side of the low
back on the pelvic bones. That is exactly
ischial notch (37) (38).
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Nitambmarmas are located one on either side of the lower part of
the PrushtaVamsha above the
ShroniKaandas (pelvic bones).
They are 2 in number and are located one on either side of the low
back on the pelvic bones. That is exactly
ala of ileum (37) (38).
Applied anatomy of ulukhal(vankshan)sandhi:-
- . 15
Causes of fracture patan, pidan, prahar etc are the causes of
bhagna (39).
Types of bhagna according to asthi:-
“ , |
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Tarunasthi bends easliy, nalakasthi gets fracture into single or
more pieces, kapalasthi gets separated
(vibhajan) like mirror ruchakasthi and valayasthi gets cracked
(39).
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There are two types of bhagna described 1) Sandhimukta 2)
Kandbhagna.
19
According to sharangdhar
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Sharanghdhar explained 8 types of bhagna (40) 1) Bhagnprustha, 2)
Vidarita, 3) Vivartita, 4) Vishlishta,
5) Tiryakshipta 6) Adhogat, 7) Urdhwag, 8) Sandhibhang.
According to Bhavprakash:-
In uttarkand bhavprakash has also explained Sandhibhagn as one of
type in 48 chapter in chikitsaprakarnam
bhagnaadhikar (41).
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There six types of sandhimukta are explained 1) Utpista, 2)
Visilista, 3) Vivartita, 4)Avakshipta
5)Atikisipta, and 6) Tiryaksipta (39).
Lakashanas of sandhimukta:-
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Incapability of extension, flexion, movement, circumduction and
rotation (immobility, considered in respect
of the natural movements of the joint), of the dislocated limb,
which becomes extremely painful and cannot
bear the least touch. These are said to be the general symptoms of
a dislocation (39).
VISHESH LAKSHANAS OF TYPES SANDHIMUKTA:-
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Utpista:-In case of a friction of a joint by two articular
extremeties (Utplishtam) a swelling is found to
appear on either side of the articulation attended with a variety
of pain at night(39).
Visilista:-A little swelling accompanied by a constant pain and
disordered function of the dislocated joint,
marks the case of simple-looseness (Vislishtam) of the articulation
(39).
Vivartita:-While pain and unevenness of the joint owing to the
displacement of the connected bones
distinguish a case of Vivartitam (lateral displacement) (39).
Avakshipt:-An excruciating pain, and looseness of the dislocated
bone arc the symptoms which characterise
a case in which a dislodged bone is seen to drop or hang down from
its joint (Adhah-kshiptam) (39).
Atikisipta:-In a case of abnormal projection (Ati-kshiptam\ the
dislocated bone is removed away from its
joint which becomes extremely painful (39).
Tiryakisipta:-A case of oblique dislocation (Tiryak-kshiptam) is
marked by the projection or displacement
of the bone on one side accompanied by a sort of intolerable pain
(39).
Types of kandbhagna:-
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Fractures (kandbhagn) of shaft of the bones are karkatak,
ashvakarna, churnita, picchita, asthichallita,
kandbhagn, majjaanugata, atipatita, vakra, chinna, patita, sphutita
are the twelve types of kandbhagnas
explained by the susrutacharaya (39).
Lakshana of kandbhagna:-
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A violent swelling (about the seat of fracture) with throbbings or
pulsations, abnormality in the position (of
the fractured limb), which cannot bear the least touch, crepitus
under pressure, a looseness or dropping of the
limb, the presence of a variety of pain and a sense of discomfort
in all positions these are in brief the general
symptoms of kandbhagna (39).
Visheshlakshanas of kandbhagn:-
Karkatam:-The case where a fractured bone, pressed or bent down at
its two articular extremities, bulges
out at the middle so as to resemble the shape of a knot (Granthi),
is called Karkatam. (39).
Ashvakarna:-The case where the fractured bone projects like the ear
of a horse is called As'vakarnam (39).
Churnita:-The fractured bone is found to be shattered into
fragments in a case of the Chumitam or
comminuted kind which can be detected both by palpation and
crepitation (39).
Picchita:-A smashed condition of the fractured bone marks a case of
the PicUoMtim kind which is often
found to be marked by a great swelling (39).
Asthichallit:-The case where the covering or skin of the bone
(periosteum) is cast or splintered off is called
the Asthi-chchalUtatn (39).
Kandbhagna:-The case where the completely broken or severed bone?
Are found to project through the
local skin, is called Killdabhaganam (compound) (39).
Majjanugat:-The case where a fragment of the fractured or broken
bone is found to pierce into the bone and
dig out the marrow, is called JVEljjaaugatam, (Impacted fracture)
(39).
Atipatitam:-The case where the fractured bone droops or hangs down
is called Ati-patitam (39).
Vakram: - The case where the unloosened bone (from its position) is
bent down in the form of an arch is
called Vakram (39).
Chinna:-The case where only one articular extremity of the bone is
severed is called Chhinnan (39).
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Patit:-The case where the bone is slightly fractured and pierced
with a large number of holes, is called
Patitam, an excruciating pain being the leading indication
(39).
Slhutitam: The case where the bone largely cracked and swollen
becomes painful as if stuffed with the
bristles of a Suka insect is called Sphutitam (39).
Rajyakshma:-
In rajyakshma Dhatukshay is one of the reason of samprapti . There
is dhatwagni Mandya of rasa, rakta,
Mamsa, meda, shukra. Ultimately deterioration of immune system is
known as Rajyakshma.
After hetusevan there is deficiency of rasa dhatu. Rajyakshma is
manifested by vitiation of vata and
kaphapradhan Tridosha. Madhyam rogamarg constitutes the head,
heart, bladder, and other marmasthan,
asthi sandhi etc. Vata and kaphadoshas get aggravated with pitta
dosha and spread all over the joints of body
and other marmasthan, urdhwa, ardha, tiryakbhaga which obstructs
the strotas then leads to improper
dhatupak which leads to Rajyakshma (41).
Types of rajyakshma
1) According to causes: - There are 4 types. They are Vegaavrodha,
kshyaj, sahsaj, vishamaashanjanya.
2) According to samprapti: - They are of 2 types. They are anulom
and pratilom.
3) According to severity of lakshan: - They are of 3 types. They
are trirupa, shadhrupa, ekadashrupa.
Sandhigatavata:-
Sandhigata Vata means a condition in which Vata or Vayu is located
in the joints and destructs the joints.
Sandhigata vata are of two types Dhatukshayjanya or
strotoavarodhjanya. They are also called as upsthambit
or Nirupasthambit (42).
After the hetusevan there is vitiation of vata dosh which follows
the RukshataParushta and kharta of strotas
and vitiated vata is lodged in sandhi of the joints or after hetu
sevan it causes the kaphaprakopa and
amadoshutappti that followed by strotoavarodh and vitiated vata is
lodged in sandhi.
23
yohopravrittisavedana (42).
Amavata:-
Amavata is a painful condition which has been explained by
acharayas in samhita. The disease initially
manifests as a gut disorder with symptoms of indigestion and
anorexia. Later the disease is seen to encroach
all the tissues, mainly bones, muscles and joints and multiple
organs to cause a symptom complex. This
condition is often compared to Rheumatoid arthritis (42).
Due to hetusevan that is vataprakop and amotpatti forms samvata
which forms Ama which travels whole
body through dhamni. While traveling through dhamni ama becomes
more vitiated due to sthanikdoshas.
Vata pushesh vitiated ama in shleshmasthan that are mainly bony
joints and muscles. The ama on further
vitiation by vata and kapha enters the circulation and later gets
associated with morbid pitta. This gives the
combination a corrosive nature and they tend to destroy any tissue
or organ with which they come into
contact. The vitiated ama and vata get lodged in various joints,
mainly in the low back, pelvis and hips and
causes stiffness of the body along with severe pain.
Vatrakta:-
Vatarakta disease explained in ayurvedic text involving vitiation
of vata and rakta.When a person takes
excessive foods and exposes to lifestyle activities which aggravate
Vata and also is used to long distance
rides on animals like elephants, camels, horses, the vata gets
severely aggravated by its own causes. On the
other hand rakta or blood gets vitiated by the consumption of
lavana, amla, katu, kshara etc causes
mentioned in samhita. The vitiated rakta quickly blocks the
passages of vayu and interferes with its smooth
movements. The vata, whose passages are blocked by rakta further
undergoes vitiation and further
contaminates the rakta or blood. The blood vitiated by vayu later
burns the whole blood in the body. The
blood contaminated by vitiated Vayu leaves its place and gravitates
towards the foot. This vicious
amalgamation of vitiated vata and rakta is called vatarakta. Later
the pitta and kapha join this amalgamation
and make the clinical picture of the disease even more
complicated.The symptoms are first manifested in the
24
small joints of the foot. Later it gradually spreads to the upper
portions of the body causing itching, pain and
numbness etc symptoms in all the joints of the hands and foot. The
other joints of the body are also involved
in the painful picture. In association of kapha, this vatarakta
spreads all through the body in quick time like a
poison (66).
Definition:
Joint is a junction between two or more bones or cartilages. The
sites where two skeletal elements come
together are termed joints. It is a device to permit movements
however; immovable joints are primarily
meant for growth and may permit molding during childbirth (44)
(45).
Classification of joints:
A) Structural classification:
1) Fibrous joints:
3) Synovial joints:
b) Sellar or saddle joints
c) Condylar or bicondylar joints
d) Ellipsoid joint
g) Plane joints.
B) Functional classification:
2) Amphiarthrosis – are slightly movable joints, like cartilaginous
joints.
3) Diarthrosis – are freely movable joints like synovial
joints.
C) Regional classification:
Fibrous Joints:-
The articulating surfaces of the bones are joined by fibrous
tissue, and thus very little movement is possible.
The sutures of the vault of the skull and the inferior tibiofibular
joints are examples of fibrous joints. Solid
joints are connections between skeletal elements where the adjacent
surfaces are linked together either by
fibrous connective tissue or by cartilage, usually fibrocartilage.
Movements at these joints are more
restricted than at synovial joints (44) (45).
Fibrous joints include sutures, gomphoses, and syndesmoses.
Sutures occur only in the skull where adjacent bones are linked by
a thin layer of connective tissue termed
a sutural ligament (44) (45).
Gomphoses occur only between the teeth and adjacent bone. In these
joints, short collagen tissue fibers in
the periodontal ligament run between the root of the tooth and the
bony socket (44) (45).
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Syndesmoses are joints in which two adjacent bones are linked by a
ligament. Examples are the
ligamentum flavum, which connects adjacent vertebral laminae, and
an interosseous membrane, which links,
for example, the radius and ulna in the forearm (44) (45).
Cartilaginous Joints:-
Cartilaginous joints can be divided into two types: primary and
secondary (44) (45).
Primary cartilaginous joint:-A primary cartilaginous joint is one
in which the bones are united by a plate
or a bar of hyaline cartilage. Thus, the union between the
epiphysis and the diaphysis of a growing bone and
that between the 1st rib and the manubrium sterni are examples of
such a joint. No movement is possible (44)
(45).
Secondary cartilaginous joint:-A secondary cartilaginous joint is
one in which the bones are united by a
plate of fibrocartilage and the articular surfaces of the bones are
covered by a thin layer of hya-line cartilage.
Examples are the joints between the vertebral bodies and the
symphysis pubis. A small amount of movement
is possible (44) (45).
Synovial joints are connections between skeletal components where
the elements involved are separated by a
narrow articular cavity. In addition to containing an articular
cavity, these joints have a number of
characteristic features. First, a layer of cartilage, usually
hyaline cartilage, covers the articulating surfaces of
the skeletal elements. In other words, bony surfaces do not
normally contact one another directly. A second
characteristic feature of synovial joints is the presence of a
joint capsule consisting of an inner synovial
membrane and an outer fibrous membrane (44) (45).
The synovial membrane attaches to the margins of the joint surfaces
at the interface between the cartilage
and bone and encloses the articular cavity. The synovial membrane
is highly vascular and produces synovial
fluid, which percolates into the articular cavity and lubricates
the articulating surfaces. Closed sacs of
synovial membrane also occur outside joints, where they form
synovial bursae or tendon sheaths. Bursae
often intervene between structures, such as tendons and bone,
tendons and joints, or skin and bone, and
27
reduce the friction of one structure moving over the other. Tendon
sheaths surround tendons and also reduce
friction (44) (45).
The fibrous membrane is formed by dense connective tissue and
surrounds and stabilizes the joint. Parts of
the fibrous membrane may thicken to form ligaments, which further
stabilize the joint. Ligaments outside the
capsule usually provide additional reinforcement (44) (45).
Another common but not universal feature of synovial joints is the
presence of additional structures within
the area enclosed by the capsule or synovial membrane, such as
articular discs (usually composed of
fibrocartilage), fat pads, and tendons. Articular discs absorb
compression forces, adjust to changes in the
contours of joint surfaces during movements, and increase the range
of movements that can occur at joints.
Fat pads usually occur between the synovial membrane and the
capsule and move into and out of regions as
joint contours change during movement. Redundant regions of the
synovial membrane and fibrous
membrane allow for large movements at joints.
Descriptions of synovial joints based on shape and movement.
Synovial joints are described based on shape
and movement:
based on the shape of their articular surfaces, synovial joints are
described as plane (flat), hinge, pivot,
bicondylar (two sets of contact points), condylar (ellipsoid),
saddle, and ball and socket;
based on movement, synovial joints are described as uniaxial
(movement in one plane), biaxial (movement
in two planes), and multiaxial (movement in three planes).
Hinge joints are uniaxial, whereas ball and socket joints are
multiaxial.
Plane joints: In plane joints, the apposed articular surfaces are
flat or almost flat, and this permits the
bones to slide on one another. Examples of these joints are the
sternoclavicular and acromioclavicular joints
(44) (45).
Hinge joints: Hinge joints resemble the hinge on a door, so that
flexion and extension movements are
possible. Examples of these joints are the elbow, knee, and ankle
joints (44) (45).
28
Pivot joints: In pivot joints, a central bony pivot is surrounded
by a bony–ligamentous ring, and rotation is
the only movement possible. The atlanto axial and superior
radioulnar joints are examples (44) (45).
Condyloid joints: Condyloid joints have two distinct convex
surfaces that articulate with two concave
surfaces. The movements of flexion, extension, abduction, and
adduction are possible together with a small
amount of rotation. The metacarpophalangeal joints or knuckle
joints are examples (44) (45).
Ellipsoid joints: In ellipsoid joints, an elliptical convex
articular surface fits into an elliptical concave
articular surface. The movements of flexion, extension, abduction,
and adduction can take place, but rotation
is impossible. The wrist joint is example (44) (45).
Saddle joints: In saddle joints, the articular surfaces are
reciprocally concavo convex and resemble a
saddle on a horse’s back. These joints permit flexion, extension,
abduction, adduction, and rotation. The
example of this type of joint is the carpometacarpal joint of the
thumb (44) (45).
Ball-and-socket joints: In ball-and-socket joints, a ball-shaped
head of one bone fits into a socket like
concavity of another. This arrangement permits free movements,
including flexion, extension, abduction,
adduction, medial rotation, lateral rotation, and circumduction.
The shoulder and hip joints are examples (44)
(45).
Ball and socket joint: - It is type of synovial joint. In ball and
socket joint, a ball shaped head of one
bone fits socket like structure of another. This arrangement permit
free movements. They are:-
Flexion is a movement that takes place in a sagittal plane. For
example, flexion of the elbow joint
approximates the anterior surface of the forearm to the anterior
surface of the arm. It is usually an anterior
movement, but it is occasionally posterior, as in the case of the
knee joint (46).
Extension means straightening the joint and usually takes place in
a posterior direction (46).
Abduction is a movement of a limb away from the midline of the body
in the coronal plane (46).
29
Adduction is a movement of a limb toward the body in the coronal
plane. In the fingers and toes, abduction
is applied to the spreading of these structures and adduction is
applied to the drawing together of these
structures (46).
Rotation is the term applied to the movement of a part of the body
around its long axis. Medial rotation is
the movement that results in the anterior surface of the part
facing medially. Lateral rotation is the
movement that results in the anterior surface of the part facing
laterally (46).
Circumduction is the combination in sequence of the movements of
flexion, extension, abduction, and
adduction.The Shoulder joint and hip joint are the example of ball
and socket joint (46).
Stability of Joints
The stability of a joint depends on three main factors: the shape,
size, and arrangement of the articular
surfaces; the ligaments; and the tone of the muscles around the
joint (46).
Articular Surfaces
The ball-and-socket arrangement of the hip joint and the mortise
arrangement of the ankle joint are good
examples of how bone shape plays an important role in joint
stability. Other examples of joints, however, in
which the shape of the bones contributes little or nothing to the
stability include the acromioclavicular joint,
the calcaneocuboid joint, and the knee joint (46).
Ligaments
Fibrous ligaments prevent excessive movement in a joint, but if the
stress is continued for an excessively
long period, then fibrous ligaments stretch. For example, the
ligaments of the joints between the bones
forming the arches of the feet will not by themselves support the
weight of the body. Should the tone of the
muscles that normally support the arches become impaired by
fatigue, then the ligaments will stretch and the
arches will collapse, producing flat feet (46).
30
Elastic ligaments, conversely, return to their original length
after stretching. The elastic ligaments of the
auditory ossicles play an active part in supporting the joints and
assisting in the return of the bones to their
original position after movement (46).
Muscle Tone
In most joints, muscle tone is the major factor controlling
stability. For example, the muscle tone of the short
muscles around the shoulder joint keeps the hemispherical head of
the humerus in the shallow glenoid cavity
of the scapula. Without the action of these muscles, very little
force would be required to dislocate this joint.
The knee joint is very unstable without the tonic activity of the
quadriceps femoris muscle. The joints
between the small bones forming the arches of the feet are largely
supported by the tone of the muscles of
the leg, whose tendons are inserted into the bones of the feet
(46).
Nerve Supply of Joints
The capsule and ligaments receive an abundant sensory nerve supply.
A sensory nerve supplying a joint also
supplies the muscles moving the joint and the skin overlying the
insertions of these muscles, a fact that has
been codified as Hilton’s law (46).
Joints are meeting points of two bones.
BONES: -
Bone is a living tissue capable of changing its structure as the
result of the stresses to which it is subjected.
Like other connective tissues, bone consists of cells, fibers, and
matrix. It is hard because of the calcification
of its extracellular matrix and possesses a degree of elasticity
because of the presence of organic fibers. Bone
has a protective function; the skull and vertebral column, for
example, protect the brain and spinal cord from
injury; the sternum and ribs protect the thoracic and upper
abdominal viscera. It serves as a lever, as seen in
the long bones of the limbs, and as an important storage area for
calcium salts. It houses and protects within
its cavities the delicate blood-forming bone marrow (47)
(48).
31
Bone exists in two forms: compact and cancellous. Compact bone
appears as a solid mass; cancellous bone
consists of a branching network of trabeculae. The trabeculae are
arranged in such a manner as to resist the
stresses and strains to which the bone is exposed (47) (48).
Classification of Bones
Bones may be classified regionally or according to their general
shape. Bones are grouped as follows based
on their general shape: long bones, short bones, flat bones,
irregular bones, and sesamoid bones (47) (48).
Long Bones
Long bones are found in the limbs (e.g., the humerus, femur,
metacarpals, metatarsals, and phalanges). Their
length is greater than their breadth. They have a tubular shaft,
the diaphysis, and usually an epiphysis at each
end. During the growing phase, the diaphysis is separated from the
epiphysis by an epiphyseal cartilage. The
part of the diaphysis that lies adjacent to the epiphyseal
cartilage is called the metaphysis. The shaft has a
central marrow cavitycontaining bone marrow. The outer part of the
shaft is composed of compact bone that
is covered by a connective tissue sheath, the periosteum (47)
(48).
The ends of long bones are composed of cancellous bone surrounded
by a thin layer of compact bone. The
articular surfaces of the ends of the bones are covered by hyaline
cartilage (47) (48).
Short Bones
Short bones are found in the hand and foot (e.g., the scaphoid,
lunate, talus, and calcaneum). They are
roughly cuboidal in shape and are composed of cancellous bone
surrounded by a thin layer of compact bone.
Short bones are covered with periosteum, and the articular surfaces
are covered by hyaline cartilage (47) (48).
Flat Bones
Flat bones are found in the vault of the skull (e.g., the frontal
and parietal bones). They are composed of thin
inner and outer layers of compact bone, the tables, separated by a
layer of cancellous bone, the diploë. The
scapulae, although irregular, are included in this group (47)
(48).
Irregular Bones
32
Irregular bones include those not assigned to the previous groups
(e.g., the bones of the skull, the vertebrae,
and the pelvic bones). They are composed of a thin shell of
com-pact bone with an interior made up of
cancellous bone (47) (48).
Sesamoid Bones
Sesamoid bones are small nodules of bone that are found in certain
tendons where they rub over bony
surfaces. The greater part of a sesamoid bone is buried in the
tendon, and the free surface is covered with
cartilage. The largest sesamoid bone is the patella, which is
located in the tendon of the quadriceps femoris.
Other examples are found in the tendons of the flexor pollicis
brevis and flexor hallucis brevis. The function
of a sesamoid bone is to reduce friction on the tendon; it can also
alter the direction of pull of a tendon.
In relation to hip joint there is pelvic bone. It is also known as
hip bone (47) (48).
Pelvic bone (Hip bone)
The pelvic bone is irregular in shape and has two major parts
separated by an oblique line on the medial
surface of the bone (49).
The pelvic bone above this line represents the lateral wall of the
false pelvis, which is part of the
abdominal cavity (49).
The pelvic bone below this line represents the lateral wall of the
true pelvis, which contains the pelvic
cavity (49).
The linea terminalis is the lower two-thirds of this line and
contributes to the margin of the pelvic inlet.
The lateral surface of the pelvic bone has a large articular
socket, the acetabulum, which, together with the
head of the femur, forms the hip joint (49).
Inferior to the acetabulum is the large obturator foramen, most of
which is closed by a flat connective tissue
membrane, the obturator membrane. A small obturator canal remains
open superiorly between the membrane
and adjacent bone, providing a route of communication between the
lower limb and the pelvic cavity. The
posterior margin of the bone is marked by two notches separated by
the ischial spine:
33
the lesser sciatic notch.
The posterior margin terminates inferiorly as the large ischial
tuberosity. The irregular anterior margin of the
pelvic bone is marked by the anterior superior iliac spine, the
anterior inferior iliac spine, and the pubic
tubercle (49).
Each pelvic bone is formed by three elements: the ilium, pubis, and
ischium. At birth, these bones are
connected by cartilage in the area of the acetabulum; later, at
between 16 and 18 years of age, they fuse into
a single bone (49).
Ilium
Of the three components of the pelvic bone, the ilium is the most
superior in position. The ilium is separated
into upper and lower parts by a ridge on the medial surface.
Posteriorly, the ridge is sharp and lies immediately superior to
the surface of the bone that articulates with
the sacrum. This sacral surface has a large L-shaped facet for
articulating with the sacrum and an expanded,
posterior roughened area for the attachment of the strong ligaments
that support the sacro-iliac joint.
Anteriorly, the ridge separating the upper and lower parts of the
ilium is rounded and termed the arcuate
line.
The arcuate line forms part of the linea terminalis and the pelvic
brim. The portion of the ilium lying
inferiorly to the arcuate line is the pelvic part of the ilium and
contributes to the wall of the lesser or true
pelvis.
The upper part of the ilium expands to form a flat, fan shaped
“wing,” which provides bony support for the
lower abdomen, or false pelvis. This part of the ilium provides
attachment for muscles functionally
associated with the lower limb. The anteromedial surface of the
wing is concave and forms the iliac fossa.
The external (gluteal) surface of the wing is marked by lines and
roughenings and is related to the gluteal
region of the lower limb.
34
The entire superior margin of the ilium is thickened to form a
prominent crest (the iliac crest), which is the
site of attachment for muscles and fascia of the abdomen, back, and
lower limb and terminates anteriorly as
the anterior superior iliac spine and posteriorly as the posterior
superior iliac spine.
A prominent tubercle, the tuberculum of the iliac crest, projects
laterally near the anterior end of the crest;
the posterior end of the crest thickens to form the iliac
tuberosity.Inferior to the anterior superior iliac spine
of the crest, on the anterior margin of the ilium, is a rounded
protuberance called the anterior inferior iliac
spine. This structure serves as the point of attachment for the
rectus femoris muscle of the anterior
compartment of the thigh and the iliofemoral ligament associated
with the hip joint. A less prominent
posterior inferior iliac spine occurs along the posterior border of
the sacral surface of the ilium, where the
bone angles forward to form the superior margin of the greater
sciatic notch (49).
Pubis
The anterior and inferior part of the pelvic bone is the pubis. It
has a body and two arms (rami).
The body is flattened dorsoventrally and articulates with the body
of the pubic bone on the other side at
the pubic symphysis. The body has a rounded pubic crest on its
superior surface that ends laterally as the
prominent pubic tubercle.
The superior pubic ramus projects posterolaterally from the body
and joins with the ilium and ischium at
its base, which is positioned toward the acetabulum. The sharp
superior margin of this triangular surface is
termed the pecten pubis (pectineal line), which forms part of the
linea terminalis of the pelvic bone and the
pelvic inlet. Anteriorly, this line is continuous with the pubic
crest, which also is part of the linea terminalis
and pelvic inlet. The superior pubic ramus is marked on its
inferior surface by the obturator groove, which
forms the upper margin of the obturator canal.
The inferior ramus projects laterally and inferiorly to join with
the ramus of the ischium (49).
Ischium
The ischium is the posterior and inferior part of the pelvic bone.
It has:
35
a large body that projects superiorly to join with the ilium and
the superior ramus of the pubis, and
a ramus that projects anteriorly to join with the inferior ramus of
the pubis.
The posterior margin of the bone is marked by a promi-nent ischial
spine that separates the lesser sciatic
notch, below, from the greater sciatic notch, above.
The most prominent feature of the ischium is a large tuberosity
(the ischial tuberosity) on the posteroinferior
aspect of the bone. This tuberosity is an important site for the
attachment of lower limb muscles and for
supporting the body when sitting (49).
Proximal femur
The femur is the bone of the thigh and the longest bone in the
body. Its proximal end is characterized by a
head and neck, and two large projections (the greater and lesser
trochanters) on the upper part of the shaft.
The head of the femur is spherical and articulates with the
acetabulum of the pelvic bone. It is characterized
by a nonarticular pit (fovea) on its medial surface for the
attachment of the ligament of the head.
The neck of the femur is a cylindrical strut of bone that connects
the head to the shaft of the femur. It
projects superomedially from the shaft at an angle of approximately
125°, and projects slightly forward. The
orientation of the neck relative to the shaft increases the range
of movement of the hip joint.
The upper part of the shaft of the femur bears a greater and lesser
trochanter, which are attachment sites for
muscles that move the hip joint (49).
Greater and lesser trochanters
The greater trochanter extends superiorly from the shaft of the
femur just lateral to the region where the
shaft joins the neck of the femur. It continues posteriorly where
its medial surface is deeply grooved to form
36
the trochanteric fossa. The lateral wall of this fossa bears a
distinct oval depression for attachment of the
obturator externus muscle.
The greater trochanter has an elongate ridge on its anterolateral
surface for attachment of the gluteus
minimus and a similar ridge more posteriorly on its lateral surface
for attachment of the gluteus medius.
Between these two points, the greater trochanter is palpable.
On the medial side of the superior aspect of the greater trochanter
and just above the trochanteric fossa is a
small impression for attachment of the obturator internus and its
associated gemelli muscles, and
immediately above and behind this feature is an impression on the
margin of the trochanter for attachment of
the piriformis muscle.
The lesser trochanter is smaller than the greater trochanter and
has a blunt conical shape. It projects
posteromedially from the shaft of the femur just inferior to the
junction with the neck. It is the attachment
site for the combined tendons of psoas major and iliacus muscles
(49).
Extending between the two trochanters and separating the shaft from
the neck of the femur are the
intertrochanteric line and intertrochanteric crest.
Intertrochanteric line
The intertrochanteric line is a ridge of bone on the anterior
surface of the upper margin of the shaft that
descends medially from a tubercle on the anterior surface of the
base of the greater trochanter to a position
just anterior to the base of the lesser trochanter. It is
continuous with the pectineal line (spiral line), which
curves medially under the lesser trochanter and around the shaft of
the femur to merge with the medial
margin of the linea aspera on the posterior aspect of the femur
(49).
Intertrochanteric crest
The intertrochanteric crest is on the posterior surface of the
femur and descends medially across the bone
from the posterior margin of the greater trochanter to the base of
the lesser trochanter. It is a broad smooth
37
ridge of bone with a prominent tubercle (the quadrate tubercle) on
its upper half, which provides attachment
for the quadratus femoris muscle (49).
Hip joint
The hip joint is a synovial articulation between the head of the
femur and the acetabulum of the pelvic bone.
The joint is a multiaxial ball and socket joint designed for
stability and weight-bearing at the expense of
mobility. Movements at the joint include flexion, extension,
abduction, adduction, medial and lateral
rotation, and circumduction (50).
When considering the effects of muscle action on the hip joint, the
long neck of the femur and the angulation
of the neck on the shaft of the femur must be borne in mind. For
example, medial and lateral rotation of the
femur involves muscles that move the greater trochanter forward and
backward, respectively, relative to the
acetabulum. The articular surfaces are spherical with a marked
congruity; this limits the range of movement
but contributes to the considerable stability of the joint. In the
anatomical position, the anterior/superior part
of the femoral head is not covered by the acetabulum. This is
because the axes of the femoral head and of the
acetabulum are not in line with each other. The axis of the femoral
head points superiorly, medially and
anteriorly, while the axis of the acetabulum is directed
inferiorly, laterally and anteriorly (50).
The articular surfaces of the hip joint are:
the spherical head of the femur, and
the lunate surface of the acetabulum of the pelvic bone.
Acetabulum
The large cup-shaped acetabulum for articulation with the head of
the femur is on the lateral surface of the
pelvic bone in the region where the ilium, pubis, and ischium
fuse.
The margin of the acetabulum is marked inferiorly by a prominent
notch (acetabular notch).The wall of the
acetabulum consists of nonarticular and articular parts:
38
The nonarticular part is rough and forms a shallow circular
depression (the acetabular fossa) in central and
inferior parts of the acetabular floor—the acetabular notch is
continuous with the acetabular fossa.
The articular surface is broad and surrounds the anterior,
superior, and posterior margins of the acetabular
fossa. The smooth crescent-shaped articular surface (the lunate
surface) is broadest superiorly where most of
the body’s weight is transmitted through the pelvis to the femur.
The lunate surface is deficient inferiorly at
the acetabular notch.
The acetabular fossa provides attachment for the ligament of the
head of the femur, whereas blood vessels
and nerves pass through the acetabular notch.
The cup-shaped acetabulum is a little below the middle third of the
inguinal. The acetabulum almost entirely
encompasses the hemispherical head of the femur and contributes
substantially to joint stability.
The nonarticular acetabular fossa contains loose connective tissue.
The lunate surface is covered by hyaline
cartilage and is broadest superiorly. Except for the fovea, the
head of the femur is also covered by hyaline
cartilage.
The rim of the acetabulum is raised slightly by a
fibrocartilaginous collar (the acetabular labrum).
Inferiorly,
the labrum bridges across the acetabular notch as the transverse
acetabular ligament and converts the notch
into a foramen .The part of the labrum that bridges the acetabular
notch does not have cartilage cells and is
called the transverse acetabular ligament. If forms a foramen
through which vessels and nerves may enter the
joint. The acetabular labrum is triangular in section. The base is
attached to the acetabular rim and the apex
is free (50).
Femoral head-
The femoral head is ovoid or spheroid but not completely congruent
with the reciprocal acetabulum. The
ligament of the head of the femur is a flat band of delicate
connective tissue that attaches at one end to the
fovea on the head of the femur and at the other end to the
acetabular fossa, transverse acetabular ligament,
and margins of the acetabular notch. The ligament is
extra-articular and contains a tiny branch of the
obturator artery partly responsible for the vascular supply of the
femoral head. The femoral head and neck
39
also receive arterial supply from the capsular vessels, arising
from the medial and lateral circumflex arteries
(50).
Capsule –
The synovial membrane attaches to the margins of the articular
surfaces of the femur and acetabulum, forms
a tubular covering around the ligament of the head of the femur,
and lines the fibrous membrane of the joint.
From its attachment to the margin of the head of the femur, the
synovial membrane covers the neck of the
femur before reflecting onto the fibrous membrane .The fibrous
membrane that encloses the hip joint is
strong and generally thick. Medially, it is attached to the margin
of the acetabulum, the transverse acetabular
ligament, and the adjacent margin of the obturator foramen.
Laterally, it is attached to the intertrochanteric
line on the anterior aspect of the femur and to the neck of the
femur just proximal to the intertrochanteric
crest on the posterior surface (50).
Ligaments
Three ligaments reinforce the external surface of the fibrous
membrane and stabilize the joint: the
iliofemoral, pubofemoral, and ischiofemoral ligaments.
Iliofemoral ligament-The iliofemoral ligament is anterior to the
hip joint and is triangular shaped. Its apex
is attached to the ilium between the anterior inferior iliac spine
and the margin of the acetabulum and its base
is attached along the intertrochanteric line of the femur. Parts of
the ligament attached above and below the
intertrochanteric line are thicker than the part attached to the
central part of the line. This results in the
ligament having a Y appearance.
Pubofemoralligament- The pubofemoral ligament is anteroinferior to
the hip joint. It is also triangular in
shape, with its base attached medially to the iliopubic eminence,
adjacent bone, and obturator membrane.
Laterally, it blends with the fibrous membrane and with the deep
surface of the iliofemoral ligament.
Ischiofemoralligament- Theischiofemoral ligament reinforces the
posterior aspect of the fibrous
membrane. It is attached medially to the ischium, just
posteroinferior to the acetabulum, and laterally to the
greater trochanter deep to the iliofemoral ligament.
40
The fibers of all three ligaments are oriented in a spiral fashion
around the hip joint so that they become taut
when the joint is extended. This stabilizes the joint and reduces
the amount of muscle energy required to
maintain a standing position (50).
Muscles
The hip joint is surrounded by a large number of muscles. According
to their function these are divided into
six groups:
(1) flexors,
(2) extensors,
(3) abductors,
(4) adductors,
Flexor muscles
The flexor muscles of the hip joint are anterior to the axis of
flexion and extension.
The iliopsoas is the most powerful of the flexors. It originates at
the lumbar vertebrae and the
corresponding intervertebral discs of the last thoracic and all the
lumbar vertebrae, the superior two-
thirds of the bony iliac fossa and the iliolumbar and ventral
sacroiliac ligaments. The insertion is to the
lesser trochanter. Although its main function is flexion, it is
also a weak adductor and lateral rotator.
The distal part of the muscle is palpable just deep to the inguinal
ligament, where it lies bordered by
the sartorius muscle laterally and the femoral artery medially
(50).
The sartoriusis mainly a flexor of the hip, originating at the
anterior superior iliac spine and inserting
at the proximal part of the medial surface of the tibia.
Consequently the muscle acts on two joints, with
the accessory function of lateral rotation and abduction of the hip
as well as flexion and medial rotation
of the knee. At the surface, the muscle divides the anterior aspect
of the thigh into a medial and a lateral
41
femoral triangle. During active flexion, abduction and lateral
rotation at the hip and 90° flexion at the
knee, the muscle becomes prominent and is easily palpable
(50).
The rectus femoris combines movements of flexion at the hip and
extension at the knee. Its origin is
at the anterior inferior iliac spine, a groove above the acetabulum
and the fibrous capsule of the hip
joint and inserts into the common quadriceps tendon at the proximal
border of the patella. The origin
can be palpated only in a sitting position because of tension in
the overlying structures. The tendon and
muscle belly are bordered medially by the sartorius muscle, and
laterally by the tensor fasciae latae
and the vastuslateralis, the largest part of the quadriceps
(50).
The tensor fasciae latae originates at the outer surface of the
anterior superior iliac spine, and inserts
into the proximal part of the iliotibial tract – a strong band
which thickens the fascia lata at its lateral
aspect. Thus the course of the tensor is dorsal and distal. Acting
through the iliotibial tract the muscle
extends and rotates the knee laterally. It may also assist in
flexion, abduction and medial rotation of
the hip. In the erect posture, it helps to steady the pelvis on the
head of the femur. The muscle can be
palpated easily during resisted flexion and abduction of the hip
with the knee extended (50).
A number of other muscles are also active during flexion of the hip
joint but only via their accessory
function. These are the pectineus, adductor longus and brevis, and
the most anterior fibres of the
adductor magnus and the glutei (medius and minimus) (50).
Extensor muscles:-
Gluteus maximus
The most important extensor is the gluteus maximus which takes
origin from the posterior gluteal line
and crest of the ilium, the lower part of the sacrum, the coccyx
and the sacrotuberousligament, and
runs in a lateral and caudal direction. Three-quarters of the
muscle inserts at the proximal part of the
iliotibial tract and the other part into the gluteal tuberosity of
the femur. It is a strong extensor. The
lower fibres also have a function in lateral rotation and adduction
and the upper fibres assist in powerful
abduction. In standing, the muscle is inactive and remains so
during the forward bending at the hip
joint. However, in conjunction with the hamstrings, it is active in
raising the trunk after stooping (50).
42
Hamstrings: semimembranosus, semitendinosus and biceps
femoris
These muscles are also important extensors of the hip. Because the
muscles cross two joints, their
efficiency at the hip depends on the (extended) position of the
knee. Their origins are from the upper
area of the ischial tuberosity (50).
The semimembranosus inserts at the posterior aspect of the medial
condyle of the tibia. An additional
attachment is to the posterior capsule of the knee joint.
Throughout its extent the muscle is partly
overlapped by the semitendinosus and is therefore only palpable on
each side of the latter (50).
The semitendinosus inserts at the proximal part of the medial
surface of the tibia, behind the
attachments of the sartorius and gracilis. Both muscles have
accessory functions in medial rotation and
adduction of the thigh, and in flexion and medial rotation of the
knee joint (50).
The tendon of the biceps femoris splits round the fibular
collateral ligament and inserts into the lateral
side of the head of the fibula. The accessory function of this
muscle is lateral rotation and adduction of
the thigh, and flexion and lateral rotation of the knee (50).
The collective origin of these muscles at the tuberosity of the
ischium is best palpated in the side-
lying position or supine lying, with the hip flexed to 90°. This
position moves the gluteus maximus
upwards so permitting direct palpation of the tuberosity. Palpation
of the muscle bellies is performed
in prone lying, with the knee flexed to less than 90° and during
slight contraction of the muscles.
Resisted medial rotation of the lower leg makes semitendinosus and
semimembranosus prominent.
Resisted lateral rotation of the lower leg tenses the biceps and
also makes the tendon visible and
palpable at the lateral and distal part of the thigh (50).
Abductor muscles
The main abductor muscle is the gluteus medius. It originates from
the external surface of the ilium,
just below the iliac crest. Insertion is on the lateral surface of
the greater trochanter of the femur. The
muscle is partially covered by two other muscles: anteriorly the
tensor fasciae latae, posteriorly the
gluteus maximus (50).
43
The gluteus medius stabilizes the pelvis in the transverse
direction. Standing on one limb, strong action
of the gluteus medius, powerfully assisted by gluteus minimus and
tensor fasciae latae, keeps the pelvis
horizontal. This stabilization of the pelvis is essential for
normal walking. In mild or moderate
weakness of these muscles (50).
The other important abductors are the gluteus minimus, the tensor
fasciae latae and the upper part of
the gluteus maximus.
The lateral aspect of the hip is covered by a wide muscular fan
made up of two muscle bellies:
anteriorly the tensor fasciae latae, posteriorly the superficial
fibres of the gluteus maximus. Both insert
into the anterior and posterior borders of the iliotibial tract at
its proximal aspect. Because of the
triangular shape and the anatomical and functional similarity to
the deltoid muscle of the shoulder joint,
these muscles are sometimes known as the ‘deltoid of the
hip’.
The iliotibial tract is a long and strong band, which is part of
the fascia lata and attached to the anterior
aspect of the lateral tibial condyle. This structural arrangement
permits the muscles to influence the
stability of the extended knee joint and thus help to maintain the
erect posture.
The iliotibial tract overrides the greater trochanter, where it is
vulnerable to strain (50).
Adductor muscles
The adductors lie medial to the central axis of the hip joint.
Although the adductor magnus is the most
powerful it is clinically not important. The adductor longus is
more easily strained. Its origin is at the
anterior aspect of the pubis at the junction of the pubic crest and
symphysis, and it inserts at the middle
third of the lineaaspera of the femur. During resisted adduction
the adductor longus is the most
prominent muscle of the adductor group and forms the medial border
of the femoral triangle. Its
accessory function is flexion of the hip (50).
Other adductors are the pectineus, adductor magnus, quadratus
femoris, external obturator and
the greatest part of the gluteus maximus. Another adductor is the
gracilis, the most superficial of
the adductor group. It arises broadly from the inferior ramus of
the pubis. The muscle belly lies just
dorsal to the adductor longus. The tendon of this biarticular
muscle passes across the medial condyle
44
of the femur, posterior to the tendon of the sartorius, and is
attached to the upper part of the medial
surface of the tibia. Because of this course it is also a flexor
and medial rotator of the knee (50).
Finally, the semitendinosus, semimembranosus and biceps femoris
also assist in adduction of the hip.
There is a strong functional relationship between the abdominal
muscles and the adductors of the hip
joint. ‘Adductor tendinitis’ and ‘rectus abdominus tendinitis’ are
often seen simultaneously (50).
Lateral rotator muscles
When the resisted lateral rotation test is painful, the
quadratusfemoris should be sought first because
the lesion is usually in this muscle. This flat quadrilateral
muscle arises from the upper part of the
lateral border of the tuberosity of the ischium and inserts just
distally from the intertrochanteric crest
of the femur (50).
Other lateral rotators of the hip that cross the joint posteriorly,
such as the piriformis, the obturator
muscles, pectineus, the posterior fibres of the adductor magnus,
the gluteus maximus and the posterior
fibres of gluteus medius, are clinically unimportant . The long
head of biceps also laterally rotates the
thigh when the hip is extended (50).
Anteriorly, the sartorius and iliopsoas have only an accessory
function during lateral rotation (50).
Medial rotator muscles
The medial rotators that cross the hip anteriorly are the tensor
fasciae latae and the anterior fibres of
gluteus medius and minimus. Posteriorly, semimembranosus and
semitendinosus have an accessory
function in medial rotation when the hip is extended (50).
Bursae
The gluteal bursae are situated deeply, just above and behind the
greater trochanter underneath the
gluteus medius and maximus.
the greater trochanter and the iliotibial tract.
45
The psoas bursa, also called the bursa iliopectinea, lies deep to
the iliopsoas muscle at the floor of the
femoral triangle and just in front of the hip joint, with which it
may communicate.
The ischial bursa lies distally at the tuberosity just covered by
the edge of the gluteus maximus. In a
flexed, i.e. sitting, position the muscle is pulled up slightly so
that in bursitis pain results because of
compression of the inflamed bursa between the seat and the
tuberosity (50).
RELATIONS OF HIP JOINT:-
Anterior Relations:-
Tendon of iliopsoas separated from the joint by a bursa and femoral
vein, femoral artery and femoral
nerve.
Posterior Relations:-
The joint, from below upward ,is related to the following muscles
,tendon of obturator externus
covered by the qudratus femoris, obturator internus and gemelli,
piriformis,sciatica nerve and the
glueteus maximus muscle.
Superior Relations:-
Reflected head of rectus femoris covered by the gluteus minimus,
gluteus medius and partly by
gluteus maximus
Inferior Relations:-
Lateral fibres of the pectineus and the obturator externus. In
addition there are gracilis, adductors
longus, brevis, magnus and hamstring muscles (62).
Vascular supply:-
Vascular supply to the hip joint is predominantly through branches
of the obturator artery, medial and lateral
circumflex femoral arteries, superior and inferior gluteal
arteries, and the first perforating branch of the deep
artery of the thigh. The articular branches of these vessels form a
network around the joint. The joint is
innervated by articular branches from the femoral, obturator, and
superior gluteal nerves, and the nerve to
the quadratusfemoris.
46
The largest branch of the femoral artery in the thigh is the deep
artery of the thigh (profundafemoris artery),
which originates from the lateral side of the femoral artery in the
femoral triangle and is the major source of
blood supply to the thigh. The deep artery of the thigh immediately
passes:
posteriorly between the pectineus and adductor longus muscles and
then between the adductor longus and
adductor brevis muscles, and
then travels inferiorly between the adductor longus and adductor
magnus, eventually penetrating through
the adductor magnus to connect with branches of the popliteal
artery behind the knee.
The deep artery of the thigh has lateral and medial circumflex
femoral branches and three perforating
branches (51) (52).
The medial circumflex femoral artery normally originates proximally
from the posteromedial aspect of the
deep artery of the thigh, but may originate from the femoral
artery. It passes medially around the shaft of the
femur, first between the pectineus and iliopsoas and then between
the obturator externus and adductor brevis
muscles. Near the margin of the adductor brevis the vessel gives
off a small branch, which enters the hip
joint through the acetabular notch and anastomoses with the
acetabular branch of the obturator artery. The
main trunk of the medial circumflex femoral artery passes over the
superior margin of the adductor magnus
and divides into two major branches deep to the quadratus
One branch ascends to the trochanteric fossa and connects with
branches of the gluteal and lateral
circumflex femoral arteries.
The other branch passes laterally to participate with branches from
the lateral circumflex femoral artery,
the inferior gluteal artery, and the first perforating artery in
forming an anastomotic network of vessels
around the hip (51) (52).
Lateral circumflex femoral artery
The lateral circumflex femoral artery normally originates
proximally from the lateral side of the deep artery
of the thigh, but may arise directly from the femoral artery. It
passes deep to the sartorius and rectus femoris
and divides into three terminal branches:
One vessel (ascending branch) ascends laterally deep to the tensor
fasciae latae muscle and connects with
a branch of the medial circumflex femoral artery to form a channel,
which circles the neck of the femur and
supplies the neck and head of the femur.
One vessel (descending branch) descends deep to the rectus femoris,
penetrates the vastuslateralis muscle,
and connects with a branch of the popliteal artery near the
knee.
One vessel (transverse branch) passes laterally to pierce the
vastuslateralis and then circles around the
proximal shaft of the femur to anastomose with branches from the
medial femoral circumflex artery, the
inferior gluteal artery, and the first perforating artery to form
the cruciate anastomosis around the hip (51) (52).
Perforating arteries
The three perforating arteries branch from the deep artery of the
thigh as it descends anterior to the adductor
brevis muscle—the first originates above the muscle, the second
originates anterior to the muscle, and the
third originates below the muscle. All three penetrate through the
adductor magnus near its attachment to the
lineaaspera to enter and supply the posterior compartment of the
thigh. Here, the vessels have ascending and
descending branches, which interconnect to form a longitudinal
channel, which participates above in
forming an anastomotic network of vessels around the hip and
inferiorly anastomoses with branches of the
popliteal artery behind the knee (51) (52).
Obturator artery-
The obturator artery originates as a branch of the internal iliac
artery in the pelvic cavity and enters the
medial compartment of the thigh through the obturator canal. As it
passes through the canal, it bifurcates into
an anterior branch and a posterior branch, which together form a
channel that circles the margin of the
obturator membrane and lies within the attachment of the obturator
externus muscle. Vessels from the
anterior and posterior branches supply adjacent muscles and
anastomose with the inferior gluteal and medial
48
circumflex femoral arteries. In addition, an acetabular vessel
originates from the posterior branch, enters the
hip joint through the acetabular notch, and contributes to the
supply of the head of the femur (51) (52).
Inferior gluteal artery:-
The inferior gluteal artery is a large terminal branch of the
anterior trunk of the internal iliac artery. It passes
between the anterior rami S1 and S2 or S2 and S3 of the sacral
plexus and leaves the pelvic cavity through
the greater sciatic foramen inferior to the piriformis muscle. It
enters and contributes to the blood supply of
the gluteal region and anastomoses with a network of vessels around
the hip joint (51) (52).
Superior gluteal artery
The superior gluteal artery originates from the posterior trunk of
the internal iliac artery in the pelvic cavity.
It leaves the pelvic cavity with the superior gluteal nerve through
the greater sciatic foramen above the
piriformis muscle. In the gluteal region, it divides into a
superficial branch and a deep branch:
The superficial branch passes onto the deep surface of the gluteus
maximus muscle.
The deep branch passes between the gluteus medius and minimus
muscles. In addition to adjacent
muscles, the superior gluteal artery contributes to the supply of
the hip joint.
Branches of the artery also anastomose with the lateral and medial
femoral circumflex arteries from the
deep femoral artery in the thigh, and with the inferior gluteal
artery (51) (52).
Nerves
The femoral nerve arises mainly from the second and third lumbar
spinal nerves. It passes down between the
psoas major and iliacus muscles, then behind the inguinal ligament
to enter the thigh. At this proximal level,
the nerve lies just lateral to the femoral artery. Muscular
branches supply the iliacus, pectineus, sartorius
and quadriceps muscles. The skin on the front of the thigh is
supplied by several cutaneous branches.
The lateral cutaneous nerve of the thigh arises from the second and
third lumbar spinal nerves. It passes
behind or through the inguinal ligament about 1 cm medial to the
anterior superior iliac spine. At the
49
proximal part of the sartorius it divides into two branches to
supply the anterolateral part of the thigh as far
as the knee.
The obturator nerve arises mainly from the third and fourth lumbar
spinal nerves. It enters the thigh through
the obturator foramen. Some cutaneous branches are given to the
skin on the medial side of the thigh,
whereas another branch supplies the capsule of the hip joint.
Muscular branches are distributed to the
pectineus, adductor longus, gracilis, adductor brevis, external
obturator and adductor magnus.
The sciatic nerve, the largest nerve in the body, arises from the
fourth and fifth lumbar and first and second
sacral spinal nerves. It passes out of the pelvis through the
greater sciatic foramen below the piriformis
muscle. On its medial side it is accompanied by the inferior
gluteal artery and the posterior cutaneous nerve
of the thigh. The nerve descends just medial to the midpoint of a
line joining the greater trochanter of the
femur and the tuberosity of the ischium. Muscular branches are
distributed to the semimembranosus (51) (52).
MOVEMENTS:-
Addiction and abduction occurs around an anteroposterior
axis.
Medial and lateral rotation occurs around vertical axis.
Circumduction is a combination of the foregoing movements.
In general, all the axes pass through the center of the head of the
femur, but none of them is fixed
because the head is not quite spherical.
Flexion is limited by the contact of the thigh with the anterior
abdominal wall. Similarly, adduction is
limited by the contact with the opposite limb. The range of the
other movements is different from one
another: Extension 15°, abduction 50°, medial rotation 25°, and
lateral rotation 60° (63).
Muscles of the posterior compartment of thigh
50
Mucles Origin Insertion Innervation Function
Muscles of the gluteal region (spinal segments in bold are the
major segments innervating the muscle)
Muscles Origin Insertion Innervation Function
Piriformis Anterior surface of
ischial spine
ischial
tuberosity
the ischium
ilium
ilium
(L5, S1, S2)
sacrotuberous
ligament
Muscles of the anterior compartment of thigh (spinal segments in
bold are the major segments
innervating the muscle)
Psoas major Posterior
Muscle Origin Insertion Innervation Function
Gracilis A line on the
external surfaces
57
1) Referred Pain from the Hip Joint
The femoral nerve not only supplies the hip joint but, via the
intermediate and medial cutaneous nerves of
the thigh, also supplies the skin of the front and medial sides of
the thigh. It is not surprising, therefore, for
pain originating in the hip joint to be referred to the front and
medial side of the thigh. The posterior division
of the obturator nerve supplies both the hip and knee joints. This
would explain why hip joint disease
sometimes gives rise to pain in the knee joint (53).
2) Congenital Dislocation of the Hip
The stability of the hip joint depends on the ball-and-socket
arrangement of the articular surfaces and the
strong ligaments. In congenital dislocation of the hip, the upper
lip of the acetabulum fails to develop
adequately, and the head of the femur, having no stable platform
under which it can lodge, rides up out of
the acetabulum onto the gluteal surface of the ilium (53).
Treatment of congenital Dislocation of hip joint:-
If a baby is younger than 6 months and detected congenital
dislocation of hip joint it is likely to fitted pablik
harness pressure to hip joint in the socket. The baby should wear
pavlik harness pressure for 6-12 weeks it
depends upon age severity of condition. If pavlik harness treatment
remain unsuccessful then surgery needed
closed reduction or open reduction. If baby is more than or equal
18 months then and is not responding the
treatment then femoral or pelvic osteotomies is required to
reconstr