1. Clinical anatomy of the lower limb :
hip joint, knee joint
Semmelweis University, Faculty of Medicine
Department of Human Morphology and Developmental Biology
Dr. Csáki Ágnes
2015

2. Sobota - Atlas of Human Anatomy
Hip joint: summary
Sobota - Atlas of Human Anatomy
Mechanism: free (ball and socket) joint
Acetabular labrum - enarthrosis
Strong capsule and ligaments, zona orbicularis
Limited movements compared to shoulder joint.
Dislocated rarely, bones break before dislocation
Movements: (ante)flexion:130° (flexed knee!) ; extension (retroflexio):0-10° ;
rotation:90° ; abduction:40° ; adduction:0° in extension

3. lig. capitis femoris (round lig.)
Socket and head
Caput femoris
Facies lunata
Labrum acetabulare
lig. capitis femoris (round lig.)
Ligaments inside:
Minimal mechanichal role
Blood supply of the head of femur
Lig. transversum acetabuli

4. Hip joint: ligaments Lig. iliofemorale Lig. pubofemorale
Lig. ischiofemorale
Forrás: Sobota - Atlas of Human Anatomy
Strongest ligaments of the body, relaxed in anteflexion, limitation of retroflexion.
Deeper parts: zona orbicularis

5. Blood supply of the head and neck of femur
Arteries located immediately under the periosteum: often damage in case of cervical fracture of femur.
In this case, the only supply to the head is the artery in the round ligament (lig. capitis femoris – from obturator artery).
avascular necrosis
importance of quick reposition and fixation

6. Angle of inclination:Centrum-Collum-Diaphysis angle
(CCD-angle)

7. CCD-angle changes with the age
3 weeks
9 years
15 years
Old age

8. Normal X-ray
acetabulum
trochanter major
head
neck
trochanter minor

9. Acetabulum fracture

10. Hip dysplasia, hip dislocation
Causes: intrauterine developmental defect of acetabular fossa, not deep enough, can dislocate to relatively small forces.
(twins, oligohydramnion, ??)
Screening (physical examination, ultrasound)

11. Hip dysplasia, hip dislocation
Treatment: conservative:
Pavlik Harness
(anteflexio, abductio)
Force on the head of the femur deepens the socket!
Surgical intervention is usually avoided.
Larger angle bw head and neck in children!

13. Arthrosis, hip dysplasia, untreated case
arthrosis, Pinguin walk, walking disability
bony spurs, damaged cartilage

14. hip joint implant

15. Roser-Nélaton’s line
Auguste Nélaton 
( )
Wilhelm Ferdinand
Roser
 (1817 – 1888)
Spina iliaca anterior superior
Trochanter major
Tuber ischiadicum
The tip of the greater trochanter does not rise above a line which joins the superior anterior iliac spine to the ischial tuberosity. In case of fracture of the neck or hip dislocation, these three points no longer lie on a straight line.

16. Hip dislocation

17. Trendelenburg-sign Positive sign: the healthy side depressed .
Friedrich
Trendelenburg 
(1844 – 1924) .
Positive sign: the healthy side depressed
Hip dislocation or palsy of gluteus medius
Normal: negative

18. Femoral neck fractures
Medial
neck fracture
1 year mortality 20-35%!
Especially in elderly osteoporotic (female) patients.
Cadaver position!
(extremity shorter, rotated outwards)
Problems with the blood supply of the head: avascular necrosis
Quick reposition, mobilization important
(necrosis, other side-effects)
Intertrochanteric fracture
Lateral
neck fracture
Subtrochanteric fracture
Sobota - Atlas of Human Anatomy

19. Lateral neck fracture

20. Medial neck fracture

21. Intertrochanteric fracture

22. Intramuscular injection
Triangular technique
(trochanter major, anterior superior iliac spine, iliac crest)
NOT to hit: superior gluteal
a., v., n.
Sobota - Atlas of Human Anatomy

23. Lesser sciatic foramen :
Gluteal region
Suprapiriform hiatus :
superior gluteal a., v., n.
Infrapiriform hiatus:
inferior gluteal a., v., n.
sciatic n.
posterior femoral cut. n.
internal pudendal a., v.
pudendal n.
Piriformis m.
Obturator int
Lesser sciatic foramen :
internal pudendal a., v.
pudendal n.
Sobota - Atlas of Human Anatomy

24. Risks of gluteal intramuscular injection

25. Sobota - Atlas of Human Anatomy
Knee joint: summary
Tibiofemoral and patellofemoral joints
Mechanism: trochoginglymus !!!
Originally two joints: 4 collateral ligaments!
Incongruent surfaces: equalized by menisci
Great workload, frequently damaged, especially the ligaments and the menisci.
Sobota - Atlas of Human Anatomy
Movements: flexion:130° ; extension:0-5° ;
rotation:50° (only at flexed knee!!!)

26. Patella
Functions primarily as an anatomic pulley for the quadriceps muscle.
It increases the lever arm of the extensor mechanism allowing for more effective knee flexion
and thus increase quadriceps strength by 33–50%. 
it acts as a “spacer” and protects the tendon by reducing the friction and compressive stress and minimizes the concentration of stress by transmitting forces evenly to the underlying bone

27. Ligaments Patellar ligament Medial collateral lig.
Lateral collateral lig.
Oblique popliteal lig.
Medial and lateral cruciate lig.
Meniscofemoral lig.
Transverse lig. of knee

28. Collateral ligaments
Streched and therefore work only at extended knee. If the joint is flexed to at least 30 degrees, they do not limit any movements (rotation is possible).
Test at extended knee (try to open the joint medially or laterally).
At a flexion more than 30 degrees the cruciate ligaments take over the same functions.
Sobota - Atlas of Human Anatomy

29. Cruciate ligaments
Some parts are streched at every position, with greater workload at flexed kneed – higher chance of damage (skiing).
Limit medial and lateral opening, rotation, antero-posterior movements.
Test: drawer sign.
Anterior drawer sign: ant. cruciate lig. injury.
Posterior drawer sign: post. cruciate lig. injury
Sobota - Atlas of Human Anatomy

30. Intracapsular but extrasynovial position of the crutiate ligaments
Stratum synoviale
Stratum fibrosum

31. Menisci
The meniscus serves as a shock-absorption system, assists in lubricating the knee joint, and limits the ability to flex and extend the joint.
Incongruent surfaces.
Fixed but also mobile structures, obtain different positions at different stages of movements.
Medial meniscus is more fixed – damaged more often.
Symptoms: pain, „stop of movement”
Sobota - Atlas of Human Anatomy
Passive movements of menisci

32. Forrás: Sobota - Atlas of Human Anatomy

33. Meniscal tear
ismost commonly caused by twisting or over-flexing the knee joint.
Arthroscopic removal of damaged part: in case of central injury

34. Arthroscopy

35. Arthroscopic reconstruction: at peripheral injury (blood supply!)

36. Genicular arteries
A. descendens genus

37. Angle of inclination acts on the weight-bearing line of the leg
Normal
Coxa valga
Coxa vara
Genu varum
Genu valgum

38. Normal knee

39. Pain around the knee

40. Osgood–Schlatter disease generally occurs in boys and girls aged 9–16 coinciding with periods of growth spurts
Intense knee pain is usually the presenting symptom that occurs during activities such as running, jumping and
especially ascending or descending stairs and during kneeling. Imbalance in the process of ossification,
between the breakdown and building of bone tissue

41. Growth cartilage or epipahyseal plate
A child’s knee
Growth cartilage or epipahyseal plate

42. The quadriceps femoris m. pulls the proximal piece up.
Fracture of patella
The quadriceps femoris m. pulls the proximal piece up.

44. Prosthesis of cartilaginous surface
Cartilage (in joint) does not regenerate!

45. Mosaicplasty

46. Popliteal fossa Borders: m. semitendinosus et semimembranosus
m. biceps femoris
m. gastrocnemius medialis et lateralis
Base:
femur (popliteal surface), m. adductor magnus, capsule of knee joint, m. popliteus
Two access: adductor canal (a.v. femoralis) and flexor muscles (sciatic n.)
Deep outflow under the origin of soleus m.
Covered superficially by popliteal fascia.
Contents: popliteal a., v., tibial n. , common peroneal n. (sciatic n.), lesser saphenous v., lymph vessels, med. and lat. cut. surral nerve. (surral n.), collateral arteries/veins of the knee.
Palpatable popliteal artery!
Sobota - Atlas of Human Anatomy

47. https://www.youtube.com/watch?v=BYwVaKkRdF4 Oblique scar
Longitudinak scar

48. Literature
Szentagothai J, Réthelyi M: Funkcionális anatómia, Medicina, 1989
Sobota - Atlas of Human Anatomy, 20th edition, Urban and Schwarzenberger, 1993
Renner Antal: Traumatológia, 2nd edition, Medicina, Budapest, 2003
Vízkelety Tibor: Az ortopédia tankönyve, 2nd edition, Semmelweis Kiadó, 1999
Radiologic images:

49. Femoral triangle (iliopectineal fossa)
Borders:
m. iliopsoas, m. pectineus (iliopectineal fascia)
fascia lata (sapheneal hiatus – cribriform plate
Connections:
subinguinal hiatus : femoral a., v., genitofemoral n. (femoral br.), lymph vessels
sapheneal hiatus : greater saphenous v. genitofemoral n. (femoral br.), lymph vessels
adductor canal : femoral a., v.
Femoral nerve runs under the iliopectineal fascia!!!
Sobota - Atlas of Human Anatomy

50. Femoral artery in superficial position – risk of injury!!!
Sobota - Atlas of Human Anatomy
Palpatable femoral artery!
First aid!!
Regions supplied by spf. and deep inguinal lymph nodes:
lower extremity, inferior superficial part of abdominal wall, external genital organs (NOT THE TESTIS!!!)
drain further to the pelvic nodes near the. Iliac artery.
Lymph node enlargement is fairly common, mostly caused by banal infection.

51. Subinguinal hiatus Lacuna musculonervosa: lateral cutaneus femoral n.
m. iliopsoas
femoral n.
Lig. lacunare
Lacuna vasorum:
femoral a., v.
genitofemoral n. (femoral br.)
Lacuna lymphatica (herniosa):
lymph vessels
Inner opening of femoral canal!!
(anulus femoralis)
Sobota - Atlas of Human Anatomy
Femoral canal: septum femorale, l. lymphatica, femoral triangle (iliopectineal fossa), saphenous hiatus
Femoral herniation (especially common in females)