Hip and Thigh Fractures

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24 Hip and Thigh Fractures

Anatomy of the Hip and Thigh

image

Hip Joint and Ligaments

image

Femur

Femur

• Parts and landmarks: head; fovea (for round ligament); neck; greater trochanter; lesser trochanter; intertrochanteric line, crest, and fossa; pectineal line; gluteal tuberosity; linea aspera; shaft (body); popliteal surface; adductor tubercle; medial epicondyle; lateral epicondyle; medial condyle; lateral condyle; intercondylar fossa; patellar surface

Coxal (Hip) Bones

• Ilium, ischium, and pubis are fused in adults. (See Chapter 17, Pelvic Fractures, for more bone information.)
• Coxal bone epiphyseal plates intersect in the center of the acetabulum.
• Acetabulum

image Peripheral lunate surface lined with hyaline cartilage
image Fat within central acetabular fossa surfaced with synovial membrane

Hip Joint

• Synovial ball-and-socket, deepened by circumferential, fibrocartilaginous acetabular labrum
• Synovial membrane

image Runs from edges of acetabular hyaline cartilage
image Along inside of fibrous capsule
image Extends to distal neck and periphery of articular cartilage of head

• Round ligament (ligamentum teres) of head of femur

image Intraarticular, covered by synovium
image Runs from fovea to transverse acetabular ligament

• Transverse acetabular ligament: spans acetabular notch, extending rim for a complete socket
• (Collateral) ligaments: spiraling thickenings of fibrous joint capsule, passing from acetabular rim to intertrochanteric line or trochanters

image Iliofemoral (Bigelow): anterior-superior, Y-shaped, very strong, prevents hyperextension by screwing femoral head tightly into acetabulum
image Pubofemoral: anterior-inferior, prevents hyperabduction
image Ischiofemoral: posterior, weakest of three

• Retinacula

image Retinacular fibers surround neck proximal to head, binding down nutrient arteries to head.
image Anatomical basis for head ischemia with neck fracture

image

Thigh: Serial Cross Sections

Compartments of the Thigh

• Circumferential deep fascia of lower limbs

image Like strong elastic stockings
image Limits expansion of muscles during contraction, important in upright gait

• Fascia lata: investing deep fascia of thigh

image Attaches proximally to inguinal ligament, pubic rim, Scarpa’s fascia, iliac crest, sacrum, coccyx, sacrotuberous ligament, ischial tuberosity
image Attaches to exposed bone at knee and to crural fascia
image Strengthened laterally by vertical-running fibers of iliotibial tract, a conjoint aponeurosis of gluteus maximus and tensor fascia lata

• Intermuscular septa separate groups of muscles in thigh.

image Septa attach to linea aspera and fascia lata.
image Lateral intermuscular septum strongest

• Gluteal compartment

image Primarily hip joint abductor and rotator muscles: gluteus maximus, medius, and minimus; piriformis, superior and inferior gemellus, quadratus femoris
image Vessels: superior and inferior gluteal (internal iliac branches) arteries and veins
image Nerves: superior and inferior gluteal nerves and branches from sciatic roots, nerve to quadratus femoris

• Anterior compartment

image Hip flexor and knee extensor muscles: sartorius, rectus femoris; vastus lateralis, medialis, and intermedius (quadriceps femoris)
image Vessels: femoral and deep femoral arteries and veins
image Nerves: femoral nerve; posterior divisions of lumbar plexus

• Posterior compartment

image Hip extensor and knee flexor muscles: semitendinosus, semimembranosus, biceps femoris
image Vessels: perforating branches of deep femoral and popliteal arteries and veins
image Nerves: sciatic nerve, tibial and fibular divisions

• Medial compartment

image Hip adductor muscles: adductor longus, brevis, minimus, and magnus
image Vessels: branches of obturator arteries and veins
image Nerves: obturator nerve, accessory obturator (when present), anterior division of lumbar plexus

Vessels and Nerves

image

Arteries of Thigh

image

Arteries of Femoral Head

Arterial Supply to the Thigh and Hip Joint

• Femoral artery (continuation of external iliac supply)

image Primary source of blood for lower extremity
image Gives off deep femoral (profunda femoris) proximally to supply deep compartments
image Travels anteriorly initially under sartorius (in subsartorial canal; Hunter’s)
image Continues as popliteal artery after passing through hiatus of adductor magnus posteriorly into popliteal fossa

• Femoral artery branches

image Superficial epigastric artery
image Superficial external pudendal artery
image Deep external pudendal artery
image Deep femoral (profunda femoris) artery

image Lateral femoral circumflex artery
image Medial femoral circumflex artery
image Perforating branches

image Descending genicular artery
image Popliteal artery (continues as posterior tibial artery of leg)

• Obturator artery (from internal iliac)

image Artery to head of femur

• Hip joint is supplied by anastomotic branches of medial and lateral femoral circumflex and artery to head of femur (from obturator artery).
• Artery to head of femur runs along ligament of head; artery might contribute little blood to joint after adulthood.
• Immediate blood supply to hip joint provided by retinacular arteries, branches of circumflex vessels
• Retinacular arteries from medial circumflex usually provide more blood and pass beneath unattached posterior border of joint capsule.
• Lateral circumflex retinacular arteries must pass through thick iliofemoral ligament and are fewer and smaller than medial branches.
• Circumflex arteries can variably arise directly from femoral artery proper.

Veins of the Hip and Thigh

• Run parallel to femoral artery and its major branches: valved; arterial counterpulsation effect pumps blood heartward
• Femoral vein tributaries (external iliac drainage)

image Greater and lesser saphenous: superficial drainage of thigh and leg
image Lateral circumflex: from hip joint
image Medial circumflex: from hip joint
image Deep femoral (profunda femoris)
image Distal femoral vein proper, drains popliteal vein (leg)

image

Sciatic Nerve

Nerves of the Hip and Thigh

• Hilton’s law: nerves supplying a joint also innervate muscles acting across it, as well as skin over distal insertions of those muscles
• Sciatic nerve (L4-S1)

image Dominant nerve supply for lower extremity
image Runs posterior, medially in deep thigh, separated from femur by adductor magnus
image To posterior (extensor) compartment of thigh (hamstrings) and compartments in leg and foot
image Tibial (anterior) and fibular (peroneal; posterior) divisions

• Obturator nerve (L2-L4)

image To hip adductors

• Femoral nerve (L2-L4)

image To hip flexors/knee extensors

• Gluteal nerves (L4-S1)

image To hip extensors, abductors, and rotators

Clinical Correlates

Compartment Syndromes

• Relatively rare because large volume is required to cause pathological increase in tissue pressure
• Compartment fascia blends with deep fascia of muscles and can allow extravasation of blood.
• Predisposing factors: vascular injury, severe blunt trauma to thigh, systemic hypotension, external compression of thigh, coagulopathy, deep vein thrombosis
image

Intracapsular Femoral Neck Fracture

Hip Fractures

• Risk highest in older white women
• Risk factors include osteoporosis, inactivity, smoking, dementia, and psychotropic medications.
• Most fractures result from falls onto greater trochanter or from twisting injury of lower extremity.
• 12%-36% 1-year mortality rate in elderly
• Broad classification into 2 types: femoral neck (intracapsular) and intertrochanteric fractures

Intracapsular Fractures

• May be compression-type or tension-type
• Tension-type typically occur on superior neck, more commonly in athletes or military trainees.
• Compression-type fractures typically occur along inferior neck, more commonly in elderly persons with osteoporosis.
• Pathological bone lesions and metastases can also cause fractures.
• High risk of avascular necrosis of femoral head in intracapsular fractures, owing to damage to retinacular arteries running on the neck
image

Fractures of Shaft and Distal Femur

Shaft and Distal Femur Fractures

Diaphyseal Fractures

• Typically occur with twisting injury in osteoporosis or with metastatic lesions
• Usually treated surgically in adults
• Classified by location
• Subtrochanteric fractures

image Begin below lesser trochanter but can extend proximally into piriform fossa or intertrochanteric region
image Region contains cancellous bone with reduced vascularity; risk of delayed healing, failure of fixation

• Shaft fractures

image Spiral oblique or transverse
image Treatment guided by pattern, amount of comminution, associated injuries
image Falls, vehicle accidents, and gunshot wounds can cause vascular damage, compartment syndromes, knee injuries, and axial fractures.
image Occasionally accompanied by femoral neck fracture

• Distal fractures

image Occur within 9 cm of articular surface
image Gastrocnemius can flex and posteriorly displace distal fragment.
image Extraarticular or intraarticular
image Intraarticular may be unicondylar or bicondylar

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24 Hip and Thigh Fractures

Anatomy of the Hip and Thigh

image

Hip Joint and Ligaments

image

Femur

Femur

• Parts and landmarks: head; fovea (for round ligament); neck; greater trochanter; lesser trochanter; intertrochanteric line, crest, and fossa; pectineal line; gluteal tuberosity; linea aspera; shaft (body); popliteal surface; adductor tubercle; medial epicondyle; lateral epicondyle; medial condyle; lateral condyle; intercondylar fossa; patellar surface

Coxal (Hip) Bones

• Ilium, ischium, and pubis are fused in adults. (See Chapter 17, Pelvic Fractures, for more bone information.)
• Coxal bone epiphyseal plates intersect in the center of the acetabulum.
• Acetabulum

image Peripheral lunate surface lined with hyaline cartilage
image Fat within central acetabular fossa surfaced with synovial membrane

Hip Joint

• Synovial ball-and-socket, deepened by circumferential, fibrocartilaginous acetabular labrum
• Synovial membrane

image Runs from edges of acetabular hyaline cartilage
image Along inside of fibrous capsule
image Extends to distal neck and periphery of articular cartilage of head

• Round ligament (ligamentum teres) of head of femur

image Intraarticular, covered by synovium
image Runs from fovea to transverse acetabular ligament

• Transverse acetabular ligament: spans acetabular notch, extending rim for a complete socket
• (Collateral) ligaments: spiraling thickenings of fibrous joint capsule, passing from acetabular rim to intertrochanteric line or trochanters

image Iliofemoral (Bigelow): anterior-superior, Y-shaped, very strong, prevents hyperextension by screwing femoral head tightly into acetabulum
image Pubofemoral: anterior-inferior, prevents hyperabduction
image Ischiofemoral: posterior, weakest of three

• Retinacula

image Retinacular fibers surround neck proximal to head, binding down nutrient arteries to head.
image Anatomical basis for head ischemia with neck fracture

image

Thigh: Serial Cross Sections

Compartments of the Thigh

• Circumferential deep fascia of lower limbs

image Like strong elastic stockings
image Limits expansion of muscles during contraction, important in upright gait

• Fascia lata: investing deep fascia of thigh

image Attaches proximally to inguinal ligament, pubic rim, Scarpa’s fascia, iliac crest, sacrum, coccyx, sacrotuberous ligament, ischial tuberosity
image Attaches to exposed bone at knee and to crural fascia
image Strengthened laterally by vertical-running fibers of iliotibial tract, a conjoint aponeurosis of gluteus maximus and tensor fascia lata

• Intermuscular septa separate groups of muscles in thigh.

image Septa attach to linea aspera and fascia lata.
image Lateral intermuscular septum strongest

• Gluteal compartment

image Primarily hip joint abductor and rotator muscles: gluteus maximus, medius, and minimus; piriformis, superior and inferior gemellus, quadratus femoris
image Vessels: superior and inferior gluteal (internal iliac branches) arteries and veins
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