1
Q
Anterior and posterior Relations of hip joint
A
Hip joint is a synovial ball and socket joint between the acetabulum of the pelvis and the head of the femur. The acetabular labrum (made of fibrocartilage) is attached to the peripheral edge of the acetabulum. There is a deep depression on the head of the femur for the attachment of the ligament of the head of the femur (ligamentum teres)
2
Q
What is the function of the labrum
A
Joint capsule is attached around labrum and passes literally like a sleeve, to attach to the neck of the femur and then the capsule fibres turn back to attach to around the head of the femur. They hold down the arteries that run up from distal to proximal to supply most of the head of the femur.
3
Q
Ligaments that reinforce joint capsule
A
4
Q
Strongest ligament that reinforces hip capsule
A
iliofemoral (prevents hyperextension)
5
Q
Is joint capsule tight in extension or flexion
A
In general, the hip joint capsule is tight in extension and more relaxed in flexion.
6
Q
What are the hip flexors and their nerve and blood supply
A
- Muscles = Iliopsoas
- Femoral nerve
- Ilioplumbar branch of internal iliac artery
7
Q
Hip Extensors
A
- Gluteus maximus, Hamstrings
- Inferior gluteal nerve
- Deep femoral artery (hamstrings)
- Inferior gluteal and superior gluteal artery (gluteus maximus)
8
Q
Hip adductors
A
- Medial thigh muscle = adductor magnus/longus/brevis
- Obturator nerve
- Longus – profunda femoris artery/deep femoral artery + obturator artery
- Magnus – deep femoral artery branches
- brevis – deep femoral artery
9
Q
Hip Abductors
A
- Gluteus medius/minimus, TFL, Obturator internus, gemelli, piriformis
- Superior gluteal nerve
- Gluts – superior gluteal artery
- TFL – latera; circumflex femoral artery
- Gemelli – inferior gluteal
- Piriformis – superior gluteal, inferior gluteal, gemellar branches of internal pudendal artery
10
Q
Hip internal rotators
A
- Gluteus Minimus, medius, TFL
- Superior gluteal nerve
- Glut s- superior gluteal artery
- TFL – Lateral cirmflex femorla artery
11
Q
Hip External rotators
A
- Gluteus maximus, Piriformis, obturator internis, gemelli
- Superior gluteal nerve
- Gluteus max – superior gluteal artery
- Piriformis – superior/inferior gluteal, gemellar branches internal pudendal
- Gemelli. Ifneiro gluteal artery
12
Q
Which direction of hip dislocation is the most common and why?
A
Posterior because anterior ligaments are stronger
13
Q
Which structure at risk following hip dislocation
A
Nerve injury – sciatic nerve is most commonly affected
14
Q
In what position is affected limb likely to be in posteiror hip dislocation
A
Flexion, adduction and internal rotation with shortening of the leg.
15
Q
WHat is this?
A
Fracture of the neck of the femur
16
Q
What does this show
A
OA of the hip
17
Q
What main factors stabilise the hip joint
A
- Acetabulum – deep to prevent slipping
- Acetabular labrum - increase depth. Long articular surface for stability
- Iliofemoral, pubofemoral, ischiofemoral ligament very strong and thickened joint capsule and spiral orientation so tighter when joint extended
- Anteiror ligsments stronger so medial flexors fewer and weaker and vise versa
18
Q
What is Trendelenburg’s test
A
= Place their hands on your outstretched hands (for stability) and ask them to stand on the leg your examining, lifting the contralateral leg off the ground for 30 seconds. Feel for drop in pelvis on contralateral side.
19
Q
Trendelenburg’s sign
A
Contralateral side (normal side) will sag down/ indicates weakness sin hip abductor muscles (gluteus Medius and gluteus minimums)
20
Q
What is a common complication of fracture of the neck.. How do you treat fractured femoral head? How do you treat the complication
A
Post op complications are pain, bleeding, length llength discrepancies and potential NV damage. Long term complications – joint dislocation, aseptic loosening, peri-prosthetic fracture and deep infection/prosthethic joint infection.
21
Q
What can be done for an arthritic hip
A
= Initial management – Adequate pain control to ensure ongoing mobility and QoL. Lifestyle mods including weight loss, regular exercise and smoking cessation. Physiotherapy to slow disease progression.
= Long term management – if conservative don’t work them surgical intervention. Hip replacement (total or hemiarthroplasty). Common post-op complications including TE disease, bleeding, dislocation, infection, loosening of prosthesis and leg length discrepancy.
= Surgical approaches : Posterior approach, anterolateral approach, anterior approach.
22
Q
Shenton’s line:
A
Imaginary curved line along inferior border of superior pubic ramus. Should eb continuous and smooth
23
Q
NV supply of the hip
A
- Medial + lateral circumflex femoral arteries (branches of profunda femoris artery-deep femoral artery). Anastomose at base femoral neck to form ring where smaller branches arise.
- Medial circumflex femoral artery – majority and damage to this can result in avascular necrosis of femoral head.
- Artery to head of femur + superior/inferior gluteal arteries = provide additional supply.
- Sciatic, femoral and obturator nerves (also innervate knee hence referred pain either way)
24
Q
2 Types dislocaiton of the hips
A
- COngenital - DDH when acetabulum shallow because of failure to develop properly in utero
- Acquired dislocation - relatively uncommon and usually from trauma or complication of total hip replacement or hemiarthroplasty. Posterior (msot common) vs anterior.
25
Damage to superior gluteal nerve
Innervates gluteus medius and minimius. They will become paralysed so pelvis unsteady and get Trendelenburg sign ((pelvic drop on unsupported leg)
26
Tensor Fascia Lata
gluteal muscles acting as flexor, abductor and internal rotator of hip, Innervated by superior gluteal nerve. When stimulated, tensor fasciae lata tautens iliotibial band and braces the knee.
27
Fascia
= sheet/band of fibrous tissue lying deep to skin. It lines, invests, and separates structures within the body. 3 main types
28
Iliotibial Tract: (iliotibial band or IT band)
* Longitudinal thickening of fascia lata, strengthened by fibres form gluteus maximus.
* Located laterally in thigh, extending from iliac tubercle to lateral tibial condyle.
* **3 main functions**:
* Movement. Extensor, abductor, lateral rotator of hip with additional role in providing lateral stabilisation to knee joint
* Compartmentalisation – deepest aspect of ITT extends centrally to form lateral IM septum of thigh and attaches to femur.
* Muscular sheath – forms sheath around tensor fascia lata muscle.
* Fascia lata graft – popular choice for tissue graft as iliotibial tract procides particularly high concentration of CT fibres and can be surgically harvested whilst leaving most fibres intact.
29
Neck of femur fracture - when is it common, classification, blood uspply
* Typically, from low energy injuries like frail in frail older people or high energy injuries like road traffic collision or fall from height and often associated with other significant injuries.
* Anywhere from subcapital region of femoral head to 5cm distal to less trochanter.
**Intracapsula**r: from subcapital region to basocervical region of femoral neck, immediately proximal to trochanters
**Extra-capsular**: outside capsule. Inter-trochanteric (between GTrochanter + LTrochanter) or Sub-trochanteric (LTrochanter to 5cm distal to point)
* Blood supply – retrograde predominately thorugh medial circumflex femoral artery (directly on intra-capsular femoral neck)
* Displaced intra-capsular fractures – disrupt blood supply so avascular necrosis even if hip is flexed so need joint replacement.
30
Clinical signs of neck of femur fracture
* Trauma, often low energy then pain and inability to weight bear.
* Pain predominately in groin, thigh or commonly in elderly, referred to knee
* Leg shortened + externally rotated due to pull of short external rotators, with pain on pin rolling the leg and axial loading
* Distal NV deficits rare in isolated neck of femur fractures but full NV exam needed.
31
Invetsiagtions of neck of femur fracture
* Plain film radiograph imaging – AP and lateral views and AP pelvis. If suspicious patho fracture then full length femoral radiographs.
* Routine bloods, FBC, U&Es, coag screen, G&S, possible creatinine kinase
* Urine dip, CXR, EXG for older people especially for pre and peri operative management.
32
Management of neck of femur frcture
* A-\>E approach, analgesia
* No operative – rare
* Post op complications are pain, bleeding, length llength discrepancies and potential NV damage.
* Long term complications – joint dislocation, aseptic loosening, peri-prosthetic fracture and deep infection/prosthethic joint infection.
33
OA fo the hip summary
* Degenerative joint disease – loss of articular cartilage, associated with periarticular bone response.
* RF = systemic (age, obesity, female, etc) or local (hsitory trauma, muscle weakness etc)
* CLinical = pain (weight bearing aggrevates it) improves with rest, stiff, antalgic gait, passive mvoement painful in severe, possible trendelenburgs
* Ix - narrowing joint space, osteophyte formation, sclerosis of subchondral bon, subchondral bone cysts
* Classify progression -WOMAC (combien stiffness, pain, function)
* lifetsyle mods, physio, smoking cessation. and if dont work conservative then surgical.
34
What type fracture
Left sub capital
35
Types Femoral fractures
36
What are the borders of pelvic inlet and outlet?
37
The obturator foramen is almost completely closed by the obturator membranes. Why is it not completely closed?
Leaves small canal for obturator artery, vein, nerve
38
What structures are transmitted through the greater sciatic foramen?
Piriformis muscles divides it:
* Suprapiriform foramen – superior gluteal nerve/ artery/ vein
* Intrapiriform foramen – sciatic nerve, pudendal nerve, inferior gluteal Nerve/ artery/ vein, posterior femoral cutaneous nerve, nerve to obturator internus, nerve to quadratus femoris.
39
What type of joint is the sacroiliac joint?
Diarthrodial synovial joint. Surrounded by fibrous capsule containing joint space filled with synovial fluid between articular surfaces.
40
What are the marked differences between the female and typical male pelvis? What are the reasons for this?
in a male pelvis, the coccyx is projected inwards and immovable compared to a female pelvis that is flexible and straighter which helps women in the delivery process. The female sacrum is wider, shorter, and has less curves. Thus, it provides more space in the pelvic cavity compared to a male’s who has a longer and narrower sacrum. The pelvis is connected to the bones in the lower extremities particularly the femur. The femur is attached to the acetabulum which is located at the pelvis. The acetabulum has a very significant difference between a male and female pelvis. A male acetabulum is much larger than a female acetabulum. The sciatic notch in the female pelvis is wider than that of a male pelvis. The pelvic inlet in a female pelvis is slightly oval in shape while a male pelvis has a heart-shaped pelvic inlet.
41
Pelvic diaphragm muscles + levator ani labelled
42
What is the nerve supply of the levator ani?
Pudendal nerve, perineal nerve acting together
43
Perineal spaces, perineal membrane and perineal body labelled with glands:
44
Why is the perineal body important?
Central attachment for perineal muscles and Critical for maintaining the integrity of the pelvic floor, especially in females. The perineal body may rupture during vaginal delivery which widens the borders of lavatory ani muscles of both sides.
45
What is the function of the vestibular glands?
The Bartholin’s glands (greater vestibular glands) are important organs of the female reproductive system. Mucoid secretion that aids in vaginal and vulvular lubrication.
46
What is an episiotomy?
Cut (incision) through area between vaginal opening and your anus (perineum). Done to make vaginal opening larger for childbirth.
47
Ischioanal fossae (used to be ischiorectal) – these lie deep to skin of anal triangle. What is the anococcygeal body?
Ischioanal fossae is space filled with fat lateral to anal canal and just below pelvic diaphragm. Anococcygeal body is a fibrous median raphe in the floor of pelvis, which extends between coccyx and margin of anus.
48
Blood supply and venous drainage of perineum?
Internal iliac vein.
Internal pudendal artery (branch of internal iliac).
49
Lymphatic drainage of perineum?
Upper medial group of superficial inguinal lymph nodes.
50
Identify the external urethral opening, vagina, uterine cervix, fornices:
51
What structure is an important relation of posterior fornix and why is this important?
Posterior fornix is shaped to allow body to catch and retain ejaculated seme at back of vagina
52
What is the perineum?
between the thighs, most inferior part of pelvic outlet. Separated from pelvic cavity superiorly by the pelvic floor. Carries structures that support urogenital and GI systems so important in micturition, defecation, sexual intercourse and childbirth.
53
What are the 2 areas of perineum?
* Anal triangle
* Urogenital triangle
54
What is the structure of pelvic floor?
* Funnel shaped, attaches to walls of lesser pelvis, separating pelvic cavity from perineum.
* Few gaps to allow urination + defecation: Urogenital hiatus (passage of urethra and vagina), rectal hiatus (passage of anal canal). Between the urogenital hiatus and anal canal is a fibrous node (perineal body) which joins the pelvic floor to perineum.
55
WHta is the funciton of the pelvic floor?
* Important role to play in correct functioning of pelvic and abdominal viscera
* Support abdomino pelvic viscera though tonic contraction
* Resistance to increase in intra-pelvic/abdominal pressure during activities like coughin or lifting heavy objects
* Urinary and faecal continence – muscle fibres have sphincter action on the rectum and urethra. Relax to allow urination and defecation.
56
WHta muscles make up the levator ani?
* Pubococcygeus - Fibres travek around margin of urogenital hiatus and run posteromedial
* Puborectalis - U shaped sling from bpdies of pubic bones.
* Iliococcygeus - Thin muscle fibres.
57
Whta is pelvic floor dysfunction
* Abnromal fucntioning of pelvic floor muscles
* In women, this can result in loss of structual support to these organs: Urinary inconctinece, fecal incontinence, genitourinary prolapse, pelvic pain, sexual dysfunction.
58
Whta is the anaotmcial course of th epudendal nerve
* formed from sacral plexus (ventral rami of psinal nerves S2,3,4)
* Descends + passes between piriformis and ischiococcyeys msucles
* Leaves pelvis through greater sciatic formaen and crsses sacrospinous ligament and re-enters pelvis in lesser sciatic formen.
59
Function of pudendal nerve
**Motor Function**
* Innervates muscles of perineum and pelvic floor:
* Innervated external urethral sphincter.
**Sensory Function:**
* Sensation to external genitalia of both sees and skin around an8us, anal canal and perineum through its branches.
* Inferior rectal nerve – innervates perianal skin + lower ¼ of anal canal
* Perineal nerve – innervates skin of perineum, labia minor and majora or posterior scrotum
* Dorsal nerve of penis or clitoris – innervates kin of penis or clitoris. Thus, responsible for afferent component of penile an dlcitoral erection.
60
Pudendal nerve block
- Form of analgesic occasionally given before vaginal childbirth, episiotomy and other minor vaginal procedures.
* Patient in lithotomy position and ischial spine palpated transvaginal. Local anaesthetic injected into tissues around ischial spine. Then completed on opposite side.
* As the pudendal nerve is accompanied by internal pudenal artery, it is essential to aspirate before injected local anaesthetic to ensure its not gone into systemic
61
fetal skull and the way it rotates in birth
62
63
Function of round ligament of uterus
Support an anchor uterus. During pregnancy these stretch (wider and longer) to support growing uterus.
64
Normal position of uterus
Anteverted, where uterus tips forward. (Retroverted is slightly posteriorly angled)
65
What is an ectopic pregnancy and why is it dangerous and what’s the diagnosis
Fertilised egg implants itself outside of the womb, usually in one of the fallopian tubes. Can cause fallopian tube to burst open and this can lead to life threatening bleeding. Transvaginal US to diagnose.
66
Which nerve is found deep to ovary
= Obturator nerve?
67
Which arteries supply uterus and ovary
Ovarian artery (direct ranch of abdominal aorta)
68
What structures are closely related to uterine arteries
Ureter goes under uterine artery at one point. (Water under bridge) therefore in hysterectomy important to not cut Ureter or damage it.
69
Where do ovarian arteries come from? What is lymphatic drainage of uterus and ovary
= Ovarian arteries generally arise from anterolateral aspect of Abdominal aorta caudal to origin of renal arteries at level of L2 vertebra. They may arise from renal, suprarenal, inferior phrenic, superior mesenteric, lumbar, common iliac or internal iliac arteries. Para aortic for ovaries. Aortic or lumbar nodes. External iliac LNs from uterine body and sometimes the uterine fundus.
70
What kind of tissue is the glans penis made up of?
Corpus spongiosum but glans penis is covered (uncircumcised men) with mucosa. The prepuce covering.
71
What is the function of Bulbospongiosus?
Acts to expel remaining urine from the urethra after the bladder has completed its emptying. In males it also aids in the final stages of erection by compressing veins within bulb of penis to maintain tumescence.
72
What is the function of Ischiocavernous?
Provide extra rigidit of erected penis by compressing penile crus during rigid phase of erection.
73
The urogenital hiatus lies within which muscle
Located in anterior pelvic floor.
74
What vessels must sperm travel through to reach the prostate
## Footnote
Leave testes -\> through epididmys -\> ductus deferens -\> ejaculatory duct -\> urethra.
75
The Tunica _____ comprises the testicular capsule and mediastinum
Tunica albuginea
76
What is the function of the fundiform ligament
? It is a specialisation or thickening of superifical (Scarpas) fascia extending from linea alba of lower abdominal wall. Supports pendulous part of penis in front of pubis.
77
Roughly how long is the epididymis? Why might this be?
4-6m, it is coiled
78
The septum of the penis is continuous with what other tissue?
Septum of penis is median partition within glans, which extends to tunica albuginea and attached to frenulum, urethra and ventral aspect of ventral meatus.
79
The Dartos muscle is continuous with which layer of abdo wall?
This is the thin rugated fascial muscle of scrotum made of smooth muscle. It is continuous with Colles fascia of perineum and Scarpas fascia of abdomen.
80
What is name of channel that testis descends through to reach scrotum
Inguinal canal
81
What is name of plexus of veisn supplying testis? Where might these veins arise?
Pampiniform plexus (loose network of small veisn found within male spermatic cord).
82
The tunica vaginalis has parietal and visceral layer. What structure might this be derived from?
Tunica vaginalis is pouch of serous membrane that covers testes. Derived from saccus vaginalis of pertinoneum which in the fetus preceded the descent of testis from abdomen in to scrotum.
83
Name the layers of tissue surrounding the testis from superficial to deep.
Tunica vaginalis (outermost tissue) which has visceral, cavum vaginale and parietal layer. Then tunica albuginea (thick and protective), then first thin layer is tunica vasculosa -\>
84
Layers of scrotum
Skin, Dartos fascia + muscle, External spermatic fascia, Cremasteric fascia, Internal spermatic fascia, Tunica vaginalis, Tunica albuginea.
85
what is the blood supply and lymphatic drainage of the penis:
Dorsal arteries of the penis, deep arteries of the penis, bulbourethral artery. These are all branches of the internal pudendal artery. This vessel arises from the anterior division of the internal iliac artery.
Venous blood drained by paired veins. Cavernous spaces by deep dorsal vein of penis -\> prostatic venous plexus. Superficial dorsal veins -\> superficial structures of penis like skin and connective tissue.
86
Nerve supply of penis:
S2-S4 spinal cord segments and spinal ganglia. Sensory and sympathetic innervation to skin and glans penis is by dorsal nerve of penis (branch of pudendal nerve). PS is carried by cavernous nerves from the per-prostatic nerve plexus and is responsible for vascular changes which cause erection.
87
What nerves control erection and ejaculation
* Erection: PS nerves from S2-S4 join to form pelvic plexus. PS discharge causes erection.
* Ejaculation: Sympathetic nerves originate from T11-L2. Causes ejaculation and detumescence.
* Somatic nerves: Supplied by dorsal penile and pudendal nerves. Efferent signals are relayed from Onufs nucleus (S2-S4) to innervate ischiocavernous and bulbocarvernous muscles.
* Autonomic discharge to penis will trigger veno-occlusive mechanism which triggers arterial blood into penile sinusoidal spaces as this increases, so does volume so compression of subtunical venous plexus with reduced venous return. During detumescence phase the arteriolar constriction will reduce arterial inflow and allow venous return to normalise
88
What are the narrowest parts of the urethra (male):
Narrowest is where it opens in the navicular fossa of the glans penis at external urethral meatus. Membranous urethra is narrowest.
89
Which part of male urethra is commonly blocked and why
Benign prostatic hyperplasia. (Prostatic urethra)
90
What is blood supply to prostate gland
Prostatic arteries (mainly from infernal iliac arteritis). Some branches may also arise form internal pudendal and middle rectal arteries.
91
What is the venous drainage of prostate gland and why is this important clinically
Prostatic venou plexus, draining into internal iliac veins. However venous plexus also connects psoteirorly by network of veins, including Batson Venous plexus, to internal vertebral venous plexus. Prostate carcinoma also commonly spready via Batson venous plexus to vertebral bodies and cause skeletal metastasis.
92
What is the function of the prostatic fluid
Prostate secretes proteolytic enzymes into the seme, which act to break down clotting factors in the ejaculate. This allows the semen to remain in a fluid state, moving throughout the female reproductive tract for potential fertilisation.
93
What is the function of the seminal fluid
: Supports activities of sperm by providing energy and immune defence, along with contributions to their motility, transportation, capacitation and fertilising ability.
94
What type of innervation results in contraction of the ductus deferens smooth muscle
Sympathetic nerves from pelvic plexus.
95
What is the blood supply to testis
Main via paired testicular arteries (directly from AA) and descend down abdomen, pass into scrotum via inguinal canal contained within spermatic cord. Also by branches of cremasteric artery (from inferior epigastric artery) and artery of vas deferences (from inferior vesical) which give anastomoses to main testicular arteries.
96
Where do the left and right testicular veins drain:
Testicular veins are formed form pampiniform plexus in scrotum. Left testicular cein drains in to left renal vein while right testicular veins drains directly into IVC.
97
What is a varicocele
Gross dilation of the veins draining the testes. The left testicle more commonly affected as vein is longer. A large variocele can look and feel like a bag of worms within scrotum. Not a disease.
98
What is torsion of the testis:
Testicle rotates, twisting spermatic cord that brings blood to scrotum. The reduced blood flow causes sudden and often severe pain and swelling. Mostly between 12-18.
99
What is the processus vaginalis and why is it associated with inguinal hernias
: Processus vaginalis is the peritoneal tunnel through which the testes migrate from retroperitoneum toward scrotum in embryological development. Indirect inguinal hernia is the protursuion of abdominal organ into patent processus vaginalis extending into inguinal canal. In indirect inguinal hernias they are caused by the failure of the processus vaginalis to regress.
100
What is the lymphatic drainage of the testis and scrotum:
Testis is Lumbar and para-aortic nodes, along lumbar vertebrae. Scrotum drains into nearby superficial inguinal nodes.
101
What is a hydrococele and how can this be distinguished from a haematocele:
* Hydrocoele – collection of serous fluid within tunica vaginalis. The congenital form is mostly due to failure of processus vaginalis to close and adult often associated with inflammation or trauma and rarely, testicular tumours.
* Haematocoele – collection blood in tunica vaginalis. Can be distinguished form hydrocoele by transillumination (where light applied to testicular swelling) as due to dense nature of blood, light cant pass through.
102
Where is the innervation of the scrotum derived from:
Anterior (+ anterolateral) scrotum – Anterior scrotal nerves from genital branch of genitofemoral nerve and ilioinguinal nerve
Posterior scrotum – Posterior scrotal nerves from perineal branches of pudendal nerve and posterior femoral cutaneous nerve.
103
Describe the cremasteric reflex
Superficial reflex in males which is elicited when inner part of thigh is stroked. Stroking causes cremaster muscle to contract and pull up ipsilateral testicle toward inguinal canal.
104
What is an indirect inguinal hernia + is it more commen in N/F and the causes:
When abdominal content pushed down along inguinal canal. More in males. Bowel enters inguinal canal via deep inguinal ring. Arise from incomplete closure of processus vaginalis, an outpouching of peritoneum allowing for embryonic testicular descend, therefore usually deemed congenital in origin. Lateral to inferior epigastric vessels.
105
What is a direct inguinal hernia and what can cause one:
Bowel enters inguinal canal directly through weakness in posterior wall of canal, termed Hesselbachs triange. Mostly in older patients, often secondary to abdominal wall laxity or significant increase in intra-abdominal pressure.
Anatomy - y4
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