MOB TCD

Groin

Professor Emeritus Moira O’Brien

FRCPI, FFSEM, FFSEM (UK), FTCD

Trinity College

Dublin

Groin

• Lower half of anterior abdominal wall• Proximal portion of the thigh• Pain in the groin may be due to local

structures • Referred from other areas e.g. the

spine or ureter• Pain may be acute or chronic• Quality of pain• Rest or movement

MOB TCD

Hip and Groin Pain

• Spinal problems such as disc lesions

• Intra-abdominal problems

• Gynecological disorders

• Urological problems

• Urinary tract infection

• Pelvic inflammatory conditions

• Genital swelling or inflammation

• Epididymis, hydrocele, variocele

MOB TCD

• Os coxae (hip bone) femur

• Pubic symphysis

• Hip joint

• Femoral artery

• Femoral vein

• Long saphenous vein

• Inguinal lymph glands

• Nerves

• Muscles

• Bursae

• Hernia

Groin MOB TCD

Cutaneous Nerves MOB TCD

• Proximal group parallel to inguinal ligament

• Enlarged tender inguinal glands

• Part of a generalised lymphadenopathy

• Secondaries

Inguinal Glands MOB TCD

• Proximal group• Lesions in local structures• Skin of lower anterior abdominal

wall• Gluteal region • Skin of scrotum or labia• Distal superficial glands• Skin of leg area drained by long

saphenous vein• All drain to deep inguinal glands

along femoral vein

Inguinal Glands MOB TCD

• Lower five intercostal nerves• Subcostal nerve T12• 10th intercostal nerve is at the level of

the umbilicus• Iliohypogastric nerve L1• Ilioinguinal nerve L1

Skin of Anterior Abdominal Wall MOB TCD

• Subcostal nerve T 12• Iliohypogastric nerve L1• Ilioinguinal nerve L1• Femoral branch of the genitofemoral

nerve L1,2• Lateral cutaneous nerve of the thigh

L2,3• Femoral nerve L2,3,4• Obturator nerve L2,3,4

Cutaneous Nerves of Thigh MOB TCD

• Superficial fatty layer• Membranous layer of superficial fascia• Below umbilicus• Continuous with Colles’ fascia in the

perineum

Anterior Abdominal Wall MOB TCD

• Intercostal vessels• Skin above umbilicus:

superficial veins and lymphatics drain to axilla

• Skin below umbilicus:

superficial veins and lymphatics drain to long saphenous vein

• Superficial inguinal glands

Blood Supply and Lymphatics MOB TCD

• External oblique• Internal oblique• Transversus• Rectus abdominus• Pyramidalis• Nerves and vessels • Lie between internal oblique and

transversus

Abdominal Muscles MOB TCD

• Origin • Outer surfaces lower borders lower

eight ribs• Interdigitating serratus anterior• Latissimus dorsi

External Oblique MOB TCD

• Inserted into anterior half of anterior two thirds outer lip of iliac crest

• Aponeurosis in inguinal region passes anterior to rectus muscle

• Forms the inguinal ligament• Lacunar ligament• Reflected portion of inguinal

ligament

Insertion – External Oblique MOB TCD

• Inguinal ligament: aponeurosis is folded back from anterior superior iliac spine to pubic tubercle to form inguinal ligament

• Lacunar ligament:

triangular, attached to pectineal line, lateral free border medial margin of femoral ring

Inguinal and Lacunar Ligaments MOB TCD

• Pubic crest• Gap for superficial ring• Pubic bone • Linea alba • Anterior wall of the

rectus sheath• Zyphoid process

Insertion – External Oblique MOB TCD

• Muscular origin• Lateral two thirds of

inguinal ligament• Anterior two thirds

intermediate lip of iliac crest

• Lumbar fascia• Muscular fibres arch over

contents of inguinal canal anterior to rectus muscle

Internal Oblique MOB TCD

• Into the costal margin, upper three as fleshy fibres

• Next three as aponeurotic• Inserted into linea alba• Between zyphoid and half way between

umbilicus and pubic symphysis, aponeurosis splits

• Anterior fuses with external oblique• Posterior with transversus

Insertion – Internal Oblique MOB TCD

• Half way between umbilicus and pubic symphysis

• Aponeurosis of the internal oblique and transversus fuse to form conjoint tendon

• Anterior portion of rectus sheath• Inserted into pectineal line behind

superficial inguinal ring

Internal Oblique – Conjoint Tendon MOB TCD

• Origin• Lateral one third of inguinal ligament• Anterior two thirds of inner lip of iliac

crest• Lumbar fascia• Lower border and inner surfaces lower

six ribs interdigitating with diaphragm

Transversus Abdominus MOB TCD

• Into zyphoid, linea alba• Half way between umbilicus and

pubic symphysis• Fuses with posterior lamella of

the internal oblique • Below forms conjoint tendon• Inserted into pectineal line

behind superficial inguinal ring

Insertion – Transversus Abdominus MOB TCD

• Segmental muscle• Two heads• Anterior pubic symphysis• Pubic crest• Inserted anterior aspect

of 5,6,7th costal cartilages • Adhesions anterior• Segmental blood and

nerve supply from intercostals

Rectus Abdominus MOB TCD

• Lines deep aspect of transversus abdominus

• Fuses with inguinal ligament• Continuous with iliac fascia• Except in region femoral

vessels• Forms anterior wall of femoral

sheath

Transversalis Fascia MOB TCD

• Intramuscular canal • Deep inguinal ring• Superficial ring• Transmits spermatic cord in male • Round ligament in female

Inguinal Canal MOB TCD

• Triangular opening in aponeurosis of external oblique

• Base pubic crest• Superior crus to pubic crest• Inferior attached to pubic tubercle• External spermatic fascia arises from

its margins

Superficial Inguinal Ring MOB TCD

• Oval opening 2.5 cm• Above the middle of inguinal ligament• Inferior epigastric artery medial to

ring

Deep Inguinal Ring MOB TCD

• Anterior wall• External oblique • Whole anterior wall• Lateral half• Internal oblique

Inguinal Canal MOB TCD

• Posterior wall• Transversalis fascia• Whole of wall• Medial half conjoint tendon• Medial quarter, reflected portion

of inguinal ligament

Inguinal Canal MOB TCD

• Roof• Arching fibres of internal oblique • Transversus as they arise from the

inguinal ligament

Roof of Inguinal Canal MOB TCD

• Floor• Inguinal ligament

medial half• Lacunar ligament

Floor of Inguinal Canal MOB TCD

• Vas deferens• Testicular artery• Pampiniform plexus of veins• Remains of processus vaginalis• Genital branch of genitofemoral nerve• Lymphatics from testes• Cremaster artery

Passing through Deep Ring Male

MOB TCD

• Everything that went through deep ring• Plus:• Ilioinguinal nerve• Internal spermatic fascia• Cremaster muscle and fascia

Passing through Superficial Ring Male

MOB TCD

• Round ligament of uterus• Remains of processus vaginalis• Genital branch of genitofemoral

nerve• Lymphatics from uterus, region of

cornu

Passing through Deep Ring Female

MOB TCD

• Everything that went through deep ring:

• Plus ilioinguinal nerve

Passing through Superficial Ring Female

MOB TCD

• Contraction of the abdominal muscles increases the obliquity of the inguinal canal

• Protecting the two ringsLytle, 1945

Inguinal Canal MOB TCD

• Pain aggravated by an increase in intraabdominal pressure

• Hernia• Inguinal or femoral hernia• Entrapment of the ilioinguinal nerve

Increase in Intra Abdominal Pressure

MOB TCD

• Chronic pain in the groin in an athlete

• May be due to a hernia or a potential hernia

Hernia MOB TCD

• Sudden severe pain in lower abdomen

• Associated with lifting a heavy object

• Common history of a direct inguinal hernia

Inguinal Hernia MOB TCD

• Passes through• Deep inguinal ring• May extend to pass through

the superficial ring into the scrotum

• Congenital or acquired • Congenital inside the tunica

vaginalis (serous membrane, covers part of testes)

• Acquired outside

Indirect Inguinal Hernia MOB TCD

• Direct inguinal hernia• Enters through posterior wall of the

inguinal canal• Leaves through superficial inguinal ring• Above and medial to pubic tubercle

Direct Inguinal Hernia MOB TCD

• Inguinal above and medial to pubic tubercle

• Femoral below and lateral

Inguinal Versus Femoral Hernia MOB TCD

Femoral Ring MOB TCD

• Enters through femoral ring• Enters femoral canal• Medial compartment of femoral

sheath• More common in women

Femoral Hernia MOB TCD

Femoral Hernia MOB TCD

• Swelling is soft and diffuse

• Empties on minimal pressure

• Refills on release• Cough impulse is

present

Saphenous Varix MOB TCD

• Common cause of chronic groin pain in field sports

• Particularly soccer players• Pain on any sudden change of

movement, sneezing, coughing

Gilmore’s Groin MOB TCD

• Trying to sprint will increase the pain • Pain is worse getting out of bed the

day after a match or a training session

Gilmore’s Groin MOB TCD

• Pain is increased by external rotation

• Or hyperextension of hip• Pain is localised to lower

anterior abdominal wall• Adductor or perineal region

Gilmore’s Groin MOB TCD

• Torn external oblique aponeurosis

• Torn conjoint tendon• A dehiscence between conjoint

tendon and the inguinal ligament• The absence of a hernial sac• Superficial inguinal ring on the

affected side is dilated and tender

• Cough impulse

Gilmore’s Groin MOB TCD

• Treatment is surgical • 90% return to sport• Strengthen lower abdominal

muscles

Gilmore’s Groin Surgery MOB TCD

1. Plication of the transversalis fascia in ‘shouldice hernia repair’

2. Repair of torn conjoint tendon

3. Approximation of conjoint tendon to the inguinal ligament

4. Repair of the external oblique

5. Reconstitution of the superficial inguinal ring

Gilmore’s Groin Surgery MOB TCD

• Dermatomes• Entrapment of nerves• Pierce muscle• Pierce fascia• Repetitive movements

Anatomy of Nerve Injuries MOB TCD

• Must know the course of nerve• Dermatomes• Entrapment of nerves• Pierce muscle• Pierce fascia• Repetitive movements

Anatomy of Nerve Injuries MOB TCD

• Nerves supply

• Skin

• Muscles (group)

• Tendons

• Bones

• Joints

• Blood vessels

Dermatomes and Myotomes MOB TCD

• External forces • Fibro-osseous tunnels, tether the

nerve

• Oedema

• Callus formation as a result of a fracture

• External compression due to specific movements

• Mechanical compression

• Compartment syndromes

• The nerve is tender at the site of compression

Extrinsic Factors MOB TCD

• Fibrous bands• Accessory muscles• Spurs• Narrow notches• Anatomical variations of the nerve itself

Extrinsic Factors MOB TCD

Lumbo-Sacral Plexus MOB TCD

• Affects branches of lumbar or sacral plexuses

• Pierces muscle• Pierces fascia• Increase in compartment

pressure• Compressed by external

pressure

Entrapment Syndromes in Lower Limb

MOB TCD

• Lower five intercostal nerves• Subcostal nerve T12• 10th intercostal nerves at the level of

the umbilicus• Iliohypogastric nerve L1• Ilioinguinal nerve L1

Skin of Anterior Abdominal Wall MOB TCD

• Subcostal nerve T 12• Iliohypogastric nerve L1• Ilioinguinal nerve L1• Femoral branch of the

genitofemoral nerve L1,2• Lateral cutaneous nerve of the

thigh L2,3• Femoral nerve L2,3,4• Obturator nerve L2,3,4

Cutaneous Nerves of Thigh MOB TCD

Cutaneous Nerves MOB TCD

• Branch of lumbar plexus• Lateral border of psoas• Anterior to quadratus lumborum• Neurovascular plane between internal

oblique and transversus• Lateral cutaneous supplies upper part of

buttock

Ilio-Hypogastric Nerve L1 MOB TCD

• Pierces internal oblique above anterior superior iliac spine

• Pierces aponeurosis of external oblique an inch above superficial ring

• Supplies skin over lower part of rectus sheath

• Can be trapped piercing aponeurosis

Ilio-Hypogastric Nerve MOB TCD

• Ilio-inguinal nerve• L1 branch of lumber plexus• Lateral border of psoas• Anterior to quadratus lumborum• Neurovascular plane between

internal oblique and transversus

Ilio-Inguinal Nerve MOB TCD

• Pierces internal oblique 4 cm medial to

• Anterior superior iliac spine

• Enters inguinal canal• Leaves through superficial

ring

• Supplies the skin of the medial part of the thigh

• Adjoining portion of the scrotum and labia

Ilio-Inguinal Nerve MOB TCD

• May be trapped post surgery, due to adhesions

• Poor tone in abdominal muscles

• Pain increased by increased tension in the anterior abdominal wall

• Hyperextension of hip• Tenderness 4 cm from

anterior superior iliac spine

Ilio-Inguinal Nerve MOB TCD

• Pain increased• Increased tension in the anterior

abdominal wall• Hyperextension of hip• Tenderness 4 cm medial to anterior

superior iliac spine

Ilio-Inguinal Nerve Entrapment MOB TCD

• Iliohypogastric in 5.6%• Ilioinguinal 90.7%• Union of branches of ilioinguinal

and genital branch of the genitofemoral nerve 13%

• Genitofemoral passing through superficial inguinal ring 35.2%

• Piercing inguinal ligament 5.6%• Femoral branch 13% Akita et al., 1999

CutaneousNerves MOB TCD

• Lumbar plexus L1,2• Anterior aspect of the psoas• Genital branch enters the deep

inguinal ring• Femoral branch lies on the lateral

side of femoral artery in the femoral sheath

Genitofemoral Nerve MOB TCD

• Enters thigh on lateral aspect of femoral artery in femoral sheath

• Pierces anterior wall of the sheath

• Supplies skin a hands breath below the inguinal ligament

Femoral Branch Genitofemoral MOB TCD

• Union with ilioinguinal nerve on anterior aspect of spermatic cord

• Supplies ventral aspect of scrotum and adductor region

• Cutaneous branch on the dorsal-caudal aspect

• May also supply dorsal scrotumAkita et al., 1999

Genitofemoral Nerve MOB TCD

Genitofemoral Nerve MOB TCD

• The lateral cutaneous nerves of the thigh L2,3

• Lumbar plexus in psoas• Lateral aspect of psoas• Pierces inguinal ligament• Lies in fibrous tunnel• Divides into two• Pierces deep fascia

Lateral Cutaneous Nerve MOB TCD

• A centimeter medial to anterior superior iliac spine

• Crosses the lateral angle of femoral triangle

• Divides into two• Pierces deep fascia• Anterolateral aspect of the thigh• Anterior portion of gluteal region

Lateral Cutaneous Nerve of Thigh MOB TCD

• Entrapment in the fascial tunnel• Injured in the thigh by asymmetric bars

in gymnastics • Causes meralgia paraesthetica• Post laparoscopic surgery

Lateral Cutaneous Nerve of Thigh MOB TCD

• The largest branch of the lumbar plexus• Lateral aspect of psoas• Passes under the inguinal ligament• Outside femoral sheath• 2 cm below• Divides into terminal branches• Muscular • Articular• Cutaneous

Femoral Nerve L2,3,4 MOB TCD

Muscular branches• Rectus femoris• Vastus medialis• Vastus lateralis• Vastus intermedius• Sartorius, pectineus

Cutaneous • Medial cutaneous nerves of thigh• Intermediate cutaneous nerves of thigh• Saphenous

Articular branches to hip and knee joints

Femoral Nerve MOB TCD

• Dancers may stretch the nerve by prolonged hyperextension of the hip

• Compress the nerve under the inguinal ligament

• The nerve may also be compressed due to a haematoma following a partial tear of the iliacus

O’Brien, 1997

Femoral Nerve MOB TCD

Femoral nerve

Saphenous

Femoral Nerve MOB TCD

• The obturator nerve L2-3-4• Lumbar plexus in psoas• Medial aspect of psoas• Side wall of pelvis under peritoneum• Leaves through obturator foramen• Divides into anterior and posterior

divisions

Obturator Nerve MOB TCD

• Supplies the parietal peritoneum on side wall of the pelvis

• It is related to the ovary• Pathology in the ovary or

endometriosis may result in referred pain to the hip, knee or medial side of the high

Obturator Nerve MOB TCD

• The anterior division of the obturator leaves pelvis

• Anterior to obturator externus

• Descends in front of adductor brevis

• Behind pectineus and adductor longus

obturator nerve

Anterior Divison Obturator MOB TCD

• Adductor longus • Adductor brevis• Gracilis• It gives an articular twig to the

hip joint• Skin on the medial side of the

thigh

Anterior Divison Obturator MOB TCD

Obturator Nerve MOB TCD

• It may be entrapped as it leaves the pelvis • Pierces and supplies the obturator externus • Causing spasm of the adductor muscles

Posterior Divison Obturator MOB TCD

• Supplies adductor portion of adductor magnus, above hiatus

• Articular twig to knee joint and cruciate ligaments

• Causing spasm of the adductor muscles• It may be entrapped as it leaves the pelvis or

between fascial planes

Posterior Divison Obturator MOB TCD

obturator nerve fascial planes

Obturator Nerve MOB TCD

• Pressure on obturator nerve• Pain on inner aspect of thigh

relieved by flexion of hip• Increased by extension,

adduction and medial rotation

Howship Rhomberg Sign MOB TCD

Obturator Nerve MOB TCD

Psoas Muscle MOB TCD

Sacral Plexus MOB TCD

Pudendal Nerve MOB TCD

• Compression of pudendal nerve in cyclists due to saddle

• History of change of saddle• Compressing dorsal nerve of

penis

Pudendal Nerve MOB TCD

Psoas Muscle MOB TCD

• Iliac fossa and iliac crest• Inserts into psoas• Major• Nerve L23• Psoas bursa

Iliacus MOB TCD

• Upper half of anterior inferior iliac spine• Area above actetabulum• Inserted into quadriceps tendon• Flexes hip• Extends knee• Femoral nerve

Rectus Femoris Muscle MOB TCD

• Synovial ball and socket joint• Multiaxial• Three degrees of freedom• Movement in three planes• Close pack extension and

medial rotation• Least pack semiflexion

Hip Joint MOB TCD

• One of most stable joints in the body

• Articular surface of hip joint are reciprocally curved

• Superior surface of femur and acetabulum sustain greatest pressure

Hip Joint MOB TCD

• Y shaped epiphyseal cartilage• Start to ossify at 12• Fuse 16-17• Acetabular notch is inferior• Nonarticular fossa, thin related

medially to obturator internus• Pad of fat, proprioceptive nerves

Acetabulum MOB TCD

• Semilunar articular surface covered with hyaline cartilage

• Deepened by labrum acetabulare

• Wedge shaped fibrocartilage

Articular Surface of Hip Joint MOB TCD

• Head of femur 2/3rd of sphere• Pit for ligamentum teres• Covered with articular cartilage• Cartilage thicker posterior superior• Epiphyseal line for head

intracapsular

Articular Surface MOB TCD

• Trabeculae develop along lines of stress

• Calcar femorale is the cortical bone on inferior aspect of neck

• Neck is cancellous bone

Femur MOB TCD

• Proximally attached• Margins of the acetabular fossa • Base of labrum• Distally, anterior to the

intertrochanteric line• Inferiorly, femoral neck close to

lesser trochanter

Capsule of Hip MOB TCD

• Posterior• Free border, finger’s breadth

from trochanteric crest due to insertion of obturator externus

• Into trochanteric fossa and• Root greater trochanter

Capsule of Hip MOB TCD

• Strongest superiorly• Anteromedially, deep fibres

reflected head of rectus femoris• Iliopsoas is anterior• Lateral deep fibres of gluteus

minimus

Capsule of Hip MOB TCD

• Fibres of capsule reflected along neck to articular margin called retinacular fibres

• Blood supply to head run under retinacular fibres

Retinacular Fibres MOB TCD

• Labrum acetabulare• Transverse ligament• Ligament of head• Iliofemoral ligament• Pubofemoral ligament• Ischiofemoral ligament• Zona orbicularis

Ligaments of Hip MOB TCD

• Transverse ligament is part of the labrum

• Ligamentum teres is triangular • Its base is attached to transverse

ligament and the apex to the pit on the head of femur

• Blood supply to epiphysis from obturator artery

• Only supplies a flake of bone in elderly

Ligaments of Hip MOB TCD

• Thickening of capsule• Lower half of anterior inferior

iliac spine and adjoining acetabulum

• Distally• Upper and lower parts of

inter trochanteric line

Iliofemoral Ligaments MOB TCD

• One of strongest ligaments in body

• Tightens in extension• Helps maintain erect posture• Facet on anterior aspect of

neck• Prevents hyperextension • Fulcrum reducing hip

Iliofemoral Ligaments MOB TCD

• Superior pubic ramus• Inferior part of inter trochanteric

line and upturned part• Relatively weak• Prevents abduction• Bursa between it and iliofemoral

Pubofemoral Ligament MOB TCD

• Ischium to posterior part of joint (weak)

• Circular fibres called zona orbicularis

• Centre of gravity in front of head

• Synovial under obturator externus

Ischiofemoral Ligament MOB TCD

• Lines inner portion of capsule and nonarticular structures

• Ligament of head• Fat in acetabular fossa• May communicate with psoas

bursa • Bursa under obturator externus

Synovial Membrane MOB TCD

• Trochanteric bursa• Posterolateral aspect of

greater trochanter gluteofemoral

• Vastus lateralis ischial bursa• Ischial tuberosity

Bursa Under Glueus Maximus MOB TCD

• Child: obturator artery via ligamentum teres supplies epiphysis

• Elderly: main supply via retinacular vessels from trochanteric and cruciate anastamoses

• Medial and lateral circumflex femoral vessels

Blood Supply to Head of Femur MOB TCD

• Superior gluteal supplies the upper part of the acetabulum

• Inferior gluteal supplies the inferior and posterior and the capsule

• Transverse and ascending branches of lateral circumflex femoral artery

• Transverse and ascending branch of medial circumflex femoral

• Cruciate and trochanteric anastomosis

Blood Supply MOB TCD

• Fractures of neck may cause avascular necrosis, extra capsular arteries enter the trochanter at the base of neck

• Medial and lateral circumflex femoral vessels and superior gluteal

Blood Supply MOB TCD

• Femoral nerve• Obturator nerve• Superior gluteal nerve• Nerve to quadratus femoris• Posterior dislocation may

damage sciatic• Pain in hip referred to knee

Nerve Supply MOB TCD

• One of the most stable joints• Congenital dislocations is

common• 1.5 per 1000 live births• Female : Male = 8:1 • Ultrasound best method of

detecting

Stability of Hip MOB TCD

• Rectus femoris• Adductor longus • Pectineus• Psoas, iliacus• Femoral sheath• Femoral nerve

Anterior Relations MOB TCD

• Obturator externus• Passes inferior and then posterior to

joint • Superior gluteal nerve• Inferior gluteal nerve• Sciatic nerve• Posterior cutaneous nerve thigh• Nerves to obturator internus and

quadratus femoris• Pudendal nerve

Inferior and Posterior Relations MOB TCD

• Gluteus minimus • Gluteus medius• Superior gluteal vessels and nerves

between• Iliotibial tract• Superficial three quarters of gluteus

maximus

Lateral Relations MOB TCD

• Piriformis • Superior gemellus• Obturator internus• Inferior gemellus• Quadratus femoris• Adductor magnus• Obturator externus• Gluteus maximus

Posterior Relations MOB TCD

• Limited by anterior abdominal wall• Psoas• Iliacus• Pectineus• Adductor longus and brevis• Rectus femoris

Movements: Flexion MOB TCD

• Hamstrings first 10°1. Long head of biceps

2. Semitendinosus

3. Semimembranosus

• 123, extended knee ++• Adductor magnus• Gluteus maximus most efficient when hip is

flexed 45 °

Movements: Extension MOB TCD

• Obturator nerve• Adductor longus• Adductor brevis• Adductor magnus• Can flex or extend depending on

position of hip

Movements: Adduction MOB TCD

• Gluteus medius• Gluteus minimus• Standing on leg, gluteus medius

and minimus abduction

• By preventing adduction

Movements: Abduction MOB TCD

• Iliopsoas • Adductors• Anterior fibres of gluteus medius

Movements: Medial Rotation MOB TCD

• Obturator internus• Piriformis• Superior gemmelus• Obturator internus • Inferior gemmelus• Quadratus femoris

Movements: Lateral Rotation MOB TCD

Trendelenburg Tests MOB TCD

Fractured Neck of Femur MOB TCD

• Apophysitis • Avulsion fractures• After 13 years• 11-40% of all hip and

pelvic fracturesBoyd et al., 1997

• Anterior superior iliac spine

• Anterior inferior iliac spine

• Ischial tuberosity commonest

Hip Problems in Children MOB TCD

Hip Problems MOB TCD

• 5-10 year old child• Aching pain in hip• Limp• Limitation of movement• Perthe’s• Osteochondritis of head of femur

Pain in a Child MOB TCD

• One of the most stable joints• Congenital dislocations is

common• 1.5 per 1000 live births• Female : Male = 8:1 • Ultrasound best method of

detecting

Stability of Hip MOB TCD

• Femoral version is the angular difference between axis of femoral neck and transcondylar axis of the knee

• Femoral anteversion ranges from 30º - 40º at birth

• Decreases progressively 15º at skeletal maturation

• Adults• Anteversion• Average of 8º in men and

14º in women• Most common cause of

in-toeing • If associated with internal

tibial torsion may lead to patellofemoral subluxation due to an increase in the Q-angle

Femoral Anteversion MOB TCD

• Young, healthy athletes do get cancer!

• Fortunately most tumors are benign!

• Bone pain at night

• Tumor till proved otherwise

Renstrom, 2008

Tumors and Neoplasms MOB TCD

• Chronic

• Secondary to acetabular dysplasia

• Part of ‘rim lesion’ complexRenstrom, 2008

•

Hip Joint Labral Tear MOB TCD

• Labrum tears and cartilage loss are common in patients with mechanical symptoms in the hip

• In young, active patients with a complaint of groin pain

• The diagnosis of a labrum tear should be suspected and investigated as radiographs and the history may be nonspecific for this diagnosis

Burnett et al., 2006

Labrum Tears and Cartilage Loss MOB TCD

• MR arthrogram has an accuracy of 91% for labral tears

Chan et al., 2005

• Sensitivity labral tear

• MR 25%,

• MRA 92%Toomayan et al., 2006

MR – Arthrography (MRA) MOB TCD

• The acetabulum covers too much of the femoral head

• Secondary to ‘retroversion’ of the socket • Or a ‘profunda’ socket that is too deep• Most of the time, the cam and pincer forms

exist together• Female, 30-40 yearsRenstrom, 2008

Pincer Impingement MOB TCD

• Loss of roundness contributes to abnormal contact between the head and socket

• Male, 20-30 yearsRenström, 2008

Cam Impingement MOB TCD

Renström, 2008

Cam Impingement MOB TCD

“BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”