JOINT AND IT’S APPLIED ANATOMY”
BY
Dissertation submitted to the
BANGALORE.
In partial fulfillment of the requirements for the degree of
AYURVEDA VACHASPATI
PROFESSOR & H. O. D
CO-GUIDE
Asso. Professor
LATTHE EDUCATION SOCIETY'S
2017-2020
KARNATAKA, BANGALORE.
HOSPITAL BEDKIHAL-SHAMANEWADI-591214.
Declaration by the Candidate
This is to certify that the dissertation entitled “A COMPHRENSIVE STUDY
OF ULUKHAL SANDHI W.S.R TO HIP JOINT AND IT’S APPLIED
ANATOMY” is a bonafide and genuine research work done by me under the guidance
of Dr. SOURABHEE KOREGAVE MD (Ayu) Associate professor, Department of
PG studies in RACHANA SHARIR.
Signature of the Candidate
Dr. RAHUL S LAHOTI
KARNATAKA, BANGALORE.
HOSPITAL BEDKIHAL-SHAMANEWADI-591214.
Declaration by the candidate
I hereby declare that the Rajiv Gandhi University of Health Sciences,
Karnataka shall declare the rights to preserve, use and disseminate this
dissertation/ thesis in print or electronic format for academic/ research purpose.
Place: Bedkihal Signature of the candidate
Date: 28/4/2020 Dr. RAHUL S LAHOTI
© Rajiv Gandhi University of Health Sciences, Karnataka
ACKNOWLEDGEMENT
The value of help cannot be ever scaled. But no milestone can be reached without the help and support of
our beloved and respected ones. Still an ocean is nothing but a vast collection of small drops. Since the
ocean of my acknowledgements, cannot be put forth here. I am trying to express this in the form of some
drops of my deep and sincere feeling.
I manifest immense pleasure, to express my deep sense of sincere gratitude towards my honorable teacher.
Research guide, Dr. Sourabhee Koregave, Proffesor and HOD Dept of Sharir-Rachana, ADAM college,
bedkihal for her benevolent guidance, encouragement, kind heartedness, invaluable suggestions, moral
support, untiring help, expertise contribution and full involvement in the conduction and preparation of this
research work and during my on-going post graduate studies.
II must record my heavy debt of gratitude to Dr. Rahul Ruge, Associate professor. Dept of Sharir Rachana
ADAM college bedkihal for his continuous inspiration and constant encouragement during the course of
study. I am obliged to him for his timely help and the courage he provided whenever needed. What I have
achieved today is only because of his persistent and intellectual concerns, constant inspiration and parental
attitude.
I gratefully count the extrapolative suggestions, invaluable help, guidance of Dr. Ranjeet Mohite Dept. of
Sharir Rachana, who has been ever prepared to take keen interest in my research work.
Wormiest and sincere gratitude towards Dr. Pradnya Rokade, Lecturer, Dept of Sharir Rachana for his
valuable hints and eminent advice.
I am very grateful to Dr. Mrs. Ketkale mam, Lecturer, Dept of Sharir Rachana, for her support in this
academic period and guidelines for constant improvement.
I accord my gratitude and esteem for Dr. Nilesh Chougule sir Principal of ADAM college bedkihal, for
providing all requisite facilities for successful study of this topic.
All above teachers helped me whenever I found any difficulty due to which I could complete this work in
stipulated time and with enthusiasm. Hence I again thank them from my heart and feel myself happy to
remain in their debts.
I like to express my deep gratitude towards my friends. Dr Amol Desai sir, Lecturer, Dept of KC ADAM
college bedkihal, for their timeless assistance, keen interest, long co-operation, genuine support which
enabled me to complete this work and their moral support was there in every work.
I feel unique pleasure in extending sincere thanks to my friends, department colleagues Vd. Mosin and
Arpita and Vd pradnya for their ever willing cooperation and moral support during the study period.
I am heartily grateful to my senior friends Dr Abhay khot and Dr Sandesh Arekar for their valuable guidance
and motivation right from synopsis submission.
I am also thankful to my friends Vd. Arpita tonage and Mosin Karimkhan timely help for getting
photographs of dissection.
The acknowledgement would be incomplete if I would not express my deep sense of gratitude towards,
college Library from where I get books on regular intervals which were more helpful to complete
dissertation.
Last but not least, I deem it my immense pleasure to put on record my deep sense of gratitude, indebtedness
and responsibility towards my beloved Aai, Baba, dear brother manik, Sisters Akanksha for their affection,
blessings, encouragement, exuberance for completion of this work, which cannot be expressed in words.
Lastly I gratefully record my thanks for all above specified and those who directly or indirectly helped me
and with this may their auspicious blessings be showered over me for life long.........
- Vd Rahul s Lahoti
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LIST OF TABLES
1
Muscles of the gluteal region (spinal segments in bold are the
major segments innervating the muscle)
50-53
2
53
3
54-55
4
55-57
Not Necessary for this study.
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ABSTRACT
The sandhi word is derived from the root Sam+dha+ki which means sandhanmiti. Holding together, joining,
and binding. Where two or more articular surface of bone are joined together is known as sandhi.
The sandhi are essential for locomotion and various movements of body. Injury to these structures may lead
to many complication and even end up with morbidity. Ulukhal sandhi is a synovial joint. It is a
Chesthavanta joint. Hip joint is a type of Ulukhal sandhi is present at iliac region and it is multiaxial joint.
The structure of this joint is made to give stability to human body. The injuries to this joint leads to serious
conditions which may lead to death. Many vital structure are present at the hip joint. It is not easy to
dislocate this joint if dislocation appears the pain is unbearable. Diseases of hip joint are explained in
ayurvedic classic and there severity and there lakshanas. This all ayurvedic diseases can be correlated to
modern aspect.
The references of Ulukhal Sandhi are available in the Ayurvedic classics, but they are scattered and are not
available in a single place. Only few gross anatomical features described in relation to its applied aspects are
present in the Samhita’s. Hence to fulfill these lacunae in the subject and to study the comprehensive study
of Ulukhal Sandhi With special reference to hip joint and it’s applied aspect is present work of this study is
chosen.
1
INTRODUCTION
Ayurveda can bring happiness to both, the diseased and the healthy individual, but only if it is understood in
the most proper way. Ayurveda differs from other sciences in that it treats the patient and not the symptoms,
in other words it teaches us how to live and how to make other people’s life worth living.
“ , ||”
. . 1/15
According sushruta ayurveda is that science in which “life” (knowledge of life) is present (understood) by
which life is attain.
“ |
|”
. . 6/19
Unless a Vaidya has a comprehensive knowledge of the whole body parts, he is unable to acquire the exact
learning of delightful Ayurveda for the universe. It has set up for itself a very lofty and ideal positive health,
perfect to the minutest detail “The patient is the center of medical universe around which all our work
revolve and towards which all our efforts trend”.
The body being the base of a healthy life needs to be given thorough consideration and for this, it is
necessary that we have a profound knowledge of the human body. This knowledge no doubt, should be as
vivid as possible,with a maximum clarification of concepts, explanation of terms, definition of obscure
entities and thus helping to produce clear image of that science.
The precise knowledge of body parts is useful for health maintenance and improvement. If body
constituents are known properly then the factors helpful for up- gradation of health can be easily understood.
2
“Sharir” provides thorough information about these constituents of the body. So the study of “sharir” is
inevitable in any medical science.
Sharir does not refer to anatomy or physiology but it is in compact the total science of biology .It forms the
base of medicine and surgery.
Let the science be any, it has its own theories and principles. Ayurveda, the science of life, has also its
theories based upon Dhosh , Dhtu and ,Mala called DhoshDhatuMalasidhhant.The combination of sharer ,
indriya, satva and atma is known as AYU . Ayurveda, is sanskrita word, derived from two roots ayur means
life and veda which knowledge. Ayurveda describes Life from birth to death and life after death . The
combination of physical as well as mental health is called healthy individual.
The main aim of ayurveda is to protect the health of healthy individuals and to treat the diseased person to
make him free from disease, both by physically and mentally. Atharvaveda conatins detail information
regarding the disease and medicine. A human form is thought to be the most useful among all types of births.
A human body is a medium for all kind of knowledge and is the only source of Dharma (duty), Artha
(economy), Kama (sex), and Moksha (deliverance). A human body provides a strong base for all these four
‘Purushartha’. Therefore nothing can be more prestigious other than a body which knows no aging and no
death.
It needs following of the rules and regulations explained in the swasthvruuta.daily routine behavior changing
in lifestyles according to different seasons. Trayoupstahmbha that are Ahar , nidra and brahma charya ,
exercise, sadvruttaacharana , achararasayan , yoga asana pranayam use of abyanga, gandush, nasya .
Ayurveda is the prevention of disease by the following the various measures and promotion of the life,
which is devided in eight branches called asthangayurveda.
In Ayurvedic literature Atreya, Dhanvantari and all other communities have made it important the
knowledge of body to have undoubtedly for the sake of knowledge. The definition of Sandhi in various
Ayurvedic grammatical literature are given as “the union” or “to unite” or “the meeting point of two or more
3
structures.” Regarding this Aacharya Sushruta has quoted that although there are numerous Sandhi in our
body which cannot be counted so only Asthi Sandhi should be considered while enumerating Sandhis.
In our Ayurvedic classics different Aacharyas have mentioned different numbers of Sandhi. According to
Aacharya Sushruta Sandhis are 210 in number, which are responsible for various movements, and are
distributed throughout the body. In Ayurvedic Samhitas the description of anatomy of Sandhi in detail is not
found .It is observed that the incidence of joints disorders are increasing in today’s world. It is the burning
problem for both families and society. A thorough knowledge of the structure and function of the joint is
required to diagnose and treat the diseases of joints.
Joints (articulations) are unions between two or more bones or rigid parts of the skeleton. Joints exhibit a
variety of forms and functions. They are constructed to allow for different degrees and types of movement.
4
OBJECTIVES OF THE STUDY:-
To correlate the structure ulukhal sandhi (ball and socket joint) & hip joint.
To elaborate more knowledge about ulukhal sandhi.
To analyze anatomical as well as surgical importance & applied anatomy of hip joint.
5
-San.shabdhkaustubh
Sandhi is the union of two things, Union, Fusion, Joint of the body, Leisure, Space between
two things (1).
- Vachaspatyam, vol 4
- . ..6
The exact meaning of sandhi is a meeting point or place, but in anatomy it is meant for bony articulations.
Sometimes ‘Sandhan’ is also used as synonymous to ‘Sandhi’ as described in the following (2) (3).
“ |”
-. . 5/8
According to charakacharya Sandhis are the “Moolsthana” of ‘Majjavaha srotasa’(4).
“|”
6
The meeting point of two or more ‘Asthi’ is termed as ‘Sandhi’ (5).
“ |”
. . 5/55
The meeting point of two or more ‘Asthi’ is termed as ‘Sandhi’ (6).
“ : ||”
- 5/37
According to Sharangadhara Samhita, sandhis are also the meeting place of any two structures in the body.
Such sandhis are held together by Kapha (7).
“ :|
||”
-. .5/33
The description of sandhis (joints) is made only in regard of Asthi. Because the number of joints of Peshi,
Snayu and Sira are innumerous (8).
Sandhi-Sankhya:
-. . 5/27
According to Sushruta accounts 210 total Asthi-sandhi out of which 68 in ‘Shakha’, 59 in ‘Koshta’, and 83
in ‘Greeva’ and above part (9).
“ |”
-. 4
“ |”
-.
Acoording to bhavprakash, The human body consist 210 sandhis (12).
Sandhis of Koshta:
-. 5/19
According to susruta, Out of 59 sandhis in ‘Koshta’, three are present at ‘Katikapal’, 24 in
‘Prushthavansha’ (vertebral column), 24 in ‘Parshva’ and 8 in the chest region (13).
Sandhis of Greeva and above region (head and neck).
, : ,
,
,:
, ,
: ,
: ||
- . 5/31
According to susruta, Greeva contains 8 Sandhis as mentioned earlier in the chest region, 3
8
in kantha, Hridaya-Kloma related tube consist of 18 sandhis, 32 in peg and socket, 1 each in Kakalak and
nose, 2 in eyelids, 1 in Ganda, Karna and Shankha on each side, 2 in Hanu (mandible) (14).
Sandhi-prakara:
: :||
: ||”
- . 5/19
There are two types of Sandhi, first is ‘Movable’ and other is ‘Immovable’. Sandhis at the places of
extremity, mandibular region and lumber region are movable sandhi. Remaining are immovable Sandhis (14).
Main classification is of two types. 1. Based on Kriya 2. Based on Rachana.
1. KriyanusarVargeekaran (Based onMovement): The Sandhis are of two types.
i. Cheshtavanta Sandhi ii. Sthira Sandhi
The Sandhis which are situated in the Shakhas, Hanu and Kati are Cheshtavanta Sandhi whileall the
remaining Sandhi comes under the Sthira in nature (14).
The Cheshtavanta Sandhis are further classified into two types based on their extent of movement.
They are-
1. Bahuchala (freely movable) 2. Alpachala (slightly movable)
The Sandhi of Shakhas, Hanu and Kati are of Bahuchala variety and the Sandhi of Prushtha etc. are
Alpachala variety (14).
-. 5/31
:,
::,
: :,
:,
|
: ||”
-. 5/32, . . 5/77. 3/242
2. Rachananusar Sandhi Vargeekaran (Based on structure): Based on the structure Aacharya Sushruta
had described eight types of Sandhi. Kora, Ulukhala, Samudga, Pratara, Tunnasevani, Wayastunda,
‘Mandal’, and Shankhawarta (15) (16) (17).
Sandhi.
These are as follows:
1) Kora sandhi – As per the description of Haranchandra in commentary of Sushrut Samhita, Kapat etc. is
taken for Nibandhan of a special devise called Kora is known that the Kabja (hinge) . The Kora Sandhi is
seen in the following region- Anguli, Manibandha, Gulpha, Janu and Kurpara
2) Ulukhala sandhi- These types of Sandhi look like stone grinder used in the kitchen in olden days that’s
why it is named so. The Ulukhala variety of joints is found at Kaksha, Vankshana and Dashana
3) Samugda sandhi-This variety of Sandhi looks like a box. This variety of Sandhi looks like a box. These
Samudga Sandhis is seen at Ansapeeth, Guda, Bhaga and Nitamba
10
4) Pratara sandhi – According to Dalhana, the articulating surfaces of this variety of joint are flat in nature
and floating, supported by cushion and friction is seen in between the articulating surfaces. In Sushruta’s
opinion this variety of joints are located at Greeva and Prushthavansha.
5) Tunnasevani – The commentator Gananath Sen has opined that articulating surfaces resembles dentate
edges which are supported and stucked together or embedded into one other. This type of Sandhi is found at
Sirakapala and Katikapala
6) Wayastunda – According to Gananatha Sen the Hanu which is situated within Shankhasthi is considered
as Vayastunda Sandhi. Even Sushruta has got similar opinion about Vayastunda Sandhi
7) Mandal sandhi – According to Dalhana the Sandhi, which are oval or round are called as Mandala
Sandhi. This type of Sandhi is present in Kantha, Hrudaya and Netra
8) Shankhavarta-According to Haranachandra, these are circular in nature which resembles the circles of a
snail or Shankha. According to Sushruta they are found in Shrotra and Shringataka
The above mentioned types are based on structures at the place of sandhi.
Sandhi are the structure which are meeting point of two asthi. Asthis are
ASTHI
- Sans. Shabd kaustubh
“ – () ; |”
A remnant of body which lies inside the mamsa is called as ‘Asthi’ (19).
- Vachaspatyam, Vol-I
11
||”
Asthi is a sharir-dhatu, one from Rasadi saptadhatu (20).
It is a toughest quintessence dhatu, which supports the body (20).
Asthi are strong, stable and having cavity filled with majja (bone morrow) (20).
ASTHI PARYAY
- . .
Medoj, Asthi-dhatu, Kulya and Keekasa are the synonyms of Asthi.
|
ASTHI SANKHYA (NUMBER)
“ ;
|


: , ||”
- . . 5/18
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):
;

||”
- . . 5/20
“ |

|
: ||”
- . . 5/72
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).
: |
||
-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:-
||”
-. .6/16
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).
,

-..
||”
- . . . 4/18
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).

-..
tu ||
: ||”
- . . . 4/18
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:-
“ , |
, ||”
- - . . 15
Tarunasthi bends easliy, nalakasthi gets fracture into single or more pieces, kapalasthi gets separated
(vibhajan) like mirror ruchakasthi and valayasthi gets cracked (39).
“ |
, ||”
- . . 25/4
There are two types of bhagna described 1) Sandhimukta 2) Kandbhagna.
19
According to sharangdhar
||
: …………….||
-.. 7/8
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).
-..15/5
There six types of sandhimukta are explained 1) Utpista, 2) Visilista, 3) Vivartita, 4)Avakshipta
5)Atikisipta, and 6) Tiryaksipta (39).
Lakashanas of sandhimukta:-
“||”
-. 15/6
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:-
20
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:-
, , , , ||”
- . . 15/8
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:-
||”
21
-. 15/9
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.
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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
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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
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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).
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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).
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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).
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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).
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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
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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:
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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.
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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:
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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.
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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
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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).
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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).
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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
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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.
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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.
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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
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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
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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
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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