D. J. (Daniel John) Cunningham.

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When the capsule of the hip joint has been carefully cleaned
it will be seen that the fibres which compose it run in two
different directions. The majority pass longitudinally from
the hip bone to the femur. There are, however, other fibres
which lie more or less at right angles to the longitudinal
fibres. They constitute the zona orbicularis and are seen to



Anterior inferior
spine of ilium



Labrum glenoidale
Head of femur




Pubo-capsular ligament



Obturator
membrane



Pubo-capsular ligament
FIG. 140. Dissection of Hip Joint from the front.

advantage only on the posterior aspect of the capsule, where
they were noted during the dissection of the gluteal region
(p. 304). The longitudinal fibres are most massed on the
front of the joint.

Certain thickened portions of the capsule, with more or
less distinct attachments, are described under special names.
They are :



1. Ilio-femoral ligament.

2. Pubo-capsular ligament.



3. Ischio-capsular ligament.

4. The zona orbicularis.



HIP JOINT



327



Ligamtntum Ilio-femorale. The ilio- fern oral ligament is
placed over the front of the articulation, and constitutes the
thickest and most powerful part of the capsule. Proximally
it is attached to the anterior inferior spine of the ilium and
to the depressed surface immediately lateral to that spine.

V. circumflexa ilium superficialis Fascia cribrose



V. saphena magna
Subinguinal lymph gland '
V. epigastrica superficialis



Pectineal part of fascia lata
N. obturatorius ramus anterior I



N. obturatorius ramus posterior | |
\ \



V. feinoralis

Margo falciformis
A. femoralis
Iliac fascia
| N. femoralis
| | Psoas bursa
| | | Iliac part of fascia lata
| M. rectus femoris




Tractus ilio-
tibialis
Capsula articular's



Mm. biceps femoris et semitendinosus



Trochanter major
M. semimembranosus . Collum femoris

A. circumflexa femoris medialis on M. ' Capsula articularis

obdurator externus I N. cutaneus femoris posterior
N. ischiadiacus (peroneal and tibial parts)

FIG. 141. Dissection of an oblique transverse Section through upper part of
Thigh showing the relation of the Fascia to the Muscles.



Distally it is attached to the intertrochanteric line of the
femur. At its upper or iliac end it is a single mass of
fibres, but as it passes distally, it divides into a lateral and
a ma&z/band (Fig. 140).

The lateral and shorter band is implanted into the upper
part of the intertrochanteric line and to the adjacent part of
the greater trochanter. It is sometimes called the ilio-
1218



328 THE INFERIOR EXTREMITY

trochanteric band. The more medial and longer band is
almost vertical, and its distal end is attached to the lower
part of the intertrochanteric line. The interval between the
two diverging bands is occupied by a thinner portion of the
capsule which is perforated by an articular twig from the
ascending branch of the lateral femoral circumflex artery.
The ilio-femoral ligament is sometimes called the Y-shaped
ligament^ but, in making use of this term, remember that
the shape it presents is that of an inverted Y.

Ligamentum Pubocapsulare (O.T. Pubo-femoral Ligament).
The pubo-capsular ligament is the name applied to fasciculi
which spring from the pubic bone and the obturator mem-
brane, and join the lower and anterior aspect of the capsule.
In cases where the bursa under the ilio-psoas is continuous
with the cavity of the joint, the aperture of communication
is placed between this band and the ilio-femoral ligament.

Ligamentum Ischiocapsulare (O.T. Ischio-femoral Ligament).
The ischio-capsular ligament is a comparatively weak band
which springs from the ischium, below the acetabulum, and
passes upwards and laterally, anterior to the tendon of the
obturator externus. It terminates in the capsule.

Zona Orfa'cu/aris(O.T. Orbicular Ligament}. The zonaorbi-
cularis is composed of circular fibres, which are most distinct
on the posterior aspect of the capsule. It encircles the neck of
the femur posteriorly and below, but is lost as it is traced an-
teriorly towards the upper and anterior parts of the capsule.

The dissector has already noted the close connection
which is exhibited between the capsule of the hip joint and
the tendons of the glutaeus minimus, and the reflected head of
the rectus femoris. Reinforcing fibres are contributed to the
capsule by both of those tendons.

Movements permitted at the Hip Joint. Before the capsule of the
joint is opened the range of movement which is permitted at the hip joint
should be tested. Flexion, or forward movement, is very free, and is
checked by the anterior surface of the thigh coming into contact with the
abdominal wall. Extension, or backward movement, is limited by the
ilio-femoral ligament. That powerful ligament has a most important part to
play in preserving the upright attitude with the least possible expenditure
of muscular exertion. In the erect posture the line of gravity falls slightly
behind the line joining the central points of the two hip joints. In the
upright attitude the ilio-femoral ligaments are tense, and prevent the pelvis
from rolling backwards on the heads of the femora. Abduction, or lateral
movement of the limb, is checked by the pubo-capsular ligament. Adduction,
or medial movement (e.g. as in crossing one thigh over the other), is limited



HIP JOINT 329

by the proximal portion of the ilio-femoral ligament and the upper part
of the capsule. Rotation medially tightens the ischio-capsular ligament, and
is therefore, in a measure, restrained by it. Rotation laterally is limited by
the lateral portion of the ilio-femoral ligament. In circumduction^ which
is produced by combination of the movements of flexion, abduction, exten-
sion, and adduction, different parts of the capsular ligament are tightened
at different stages of the movement.

The flexor nmscles of the hip joint are chiefly (i) the ilio-psoas, (2)
the rectus femoris, (3) the pectineus, (4) the adductors longus and brevis
and the pubic fibres of the adductor magnus ; the extensors are (i) the
glutaeus maximus, (2) the hamstrings, (3) the ischial fibres of the adductor
magnus, (4) the posterior fibres of the glutaeus medius, (5) the posterior
fibres of the glutaeus minimus; the adductor muscles are (i) the three
adductors, (2) the gracilis, (3) the pectineus, (4) the obturator externus,
(5) the lowest fibres of the glutaeus maximus, (6) the quadratus femoris ;
the abductors are (i) the upper part of the glutaeus maximus, (2) the
tensor fasciae latse, (3) the glutoeus medius, (4) the glutoeus minimus.

The medial rotators are (i) the ilio-psoas, (2) the anterior part of the
glutaeus medius, (3) the anterior part of the glutaeus minimus, (4) the tensor
fasciae latse ; the lateral rotators are (i) the two obturator muscles, (2)
the gemelli, (3) the piriformis, (4) the quadratus femoris, (5) the three
adductors, (6) the pectineus, (7) the inferior fibres of the glutseus maximus,
(8) the ilio-psoas.

It must be noted that the obturator muscles, the piriformis, and the
gemelli, which act as lateral rotators when the body is erect, become
abductors when the joint is flexed, and that the ilio-psoas is a flexor
of the hip joint and a medial rotator of the thigh until flexion is almost
complete, then it becomes a lateral rotator.

Dissection. The hip joint should now be opened. Make
one incision along the upper border and another along the medial
border of the ilio-femoral ligament in order to isolate that band
from the rest of the capsule, then remove all other parts of the
capsule. The object of this dissection is to enable the dissector
to appreciate the great strength of the ilio-femoral ligament.
It is fully a quarter of an inch thick, and a strain varying from
250 Ibs. to 750 Ibs. is required for its rupture (Bigelow). It is
very rarely torn asunder in dislocations, and consequently the
surgeon is enabled in most cases to reduce the displacement by
manipulation. The ilio-femoral ligament may now be removed.

Labrum Glenoidale (O.T. Cotyloid Ligament). The labrum
glenoidale is a firm fibro-cartilaginous ring, which is fixed to the
brim or margin of the acetabulum ; it bridges across the notch,
in the lower margin of the acetabulum, and thus completes
the circumference of the cavity, deepens it, and at the same
time narrows its mouth to a slight extent. The labrum
glenoidale fits closely upon the head of the femur, and, acting
like a sucker, exercises an important influence in retaining it in
place. Both surfaces of the labrum are covered with synovial
membrane ; its free margin is thin, but it is much thicker at
its attachment to the acetabular brim.



33



THE INFERIOR EXTREMITY



Ligamentum Transversum Acetabuli. The transverse
ligament consists of transverse fibres which bridge across
the acetabular notch, and are attached to its margins. It
lies between the labrum glenoidale laterally and the bottom
of the notch medially, but a space is left between the medial



Ischial spine



Labrum glenoidale




Capsule of
joint dividec
and thrown
laterally



Transverse ligament



Retinacula



FIG. 142. Dissection of Hip Joint from behind. The bottom of the
acetabulum has been removed to show the ligamentum teres.



margin of the ligament and the bottom of the incisura
through which vessels and nerves enter the joint. The
lateral margin of the ligament is attached to the labrum
glenoidale.

Ligamentum Teres Femoris. The ligamentum teres is
not round, as its name might lead one to expect, but
is somewhat flattened and fan -like in shape. Its narrow



PLATE XXIV




Lesser trochanter

FIG. 144. Radiograph of the Hip Joint of an adult.
(Dr. R. Knox.)



PLATE XXV



Sacro-iliac joint



Jpine of ischiun



Superior ramn
of pubi



Inferior ram us
of ischium




Unossified

cartilage

between

greater

trochanter



Lesser trochanter



FIG. 145. Radiograph of the Hip Region of a child.

The rami of the pubis and ischium have fused. The epiphyseal line
of the lesser trochanter is visible.



PLATE XXVI



Sacro-iliac
joint



Epiphyseal
line between
the head and .

the neck of
the femur



Unossified
I cartilage
between
ilium and
ischium



\




Body of
pubis



Lesser, trocbanter Tuberosity of ischium

FIG. 146. Radiograph of the Hip Region of a child n years old.

The epiphysis of the lesser trochanter has not yet appeared. The inferior
rami of the pubis and ischium have fused.



PLATE XXVII



Ilium



Head of

femur

Unossified

cartilage

between the

head and the

neck of the

femur

Greater

trochanter




Lesser
trochanter



FIG. 147. Radiograph ot the Hip Region of a child.

The.epiphysis of the lesser trochanter has not yet appeared, but the
inferior rami of the pubis and ischium have fused.



PLATE XXVIII



Sacro-iliac
joint



Unossified

cartilage

between

ilium and

ischium



Pubis



.Head of

I femur
Unossified

. cartilage
between the
head and the
neck of the

| femur

\ Greater
trochanter



Ramus of j
ischium



.Lesser
trochanter



FIG. 148. Radiograph of the Hip Region of a child.

The epiphysis of the lesser trochanter has not yet appeared, and the

inferior rami of the pubis and ischium have not yet united.



PLATE XXIX




Unossified
cartilage
between
ilium and
pubis and
ischium



Pubis




Ischium



FIG. 149. Radiograph of the Hip Region of a child.

The epiphysis of the greater trochanter has just appeared. The
inferior rami of the pubis and ischium have not yet united.



PLATE XXX



Ilium



Sacro-iliac
joint



Ischium



Head of fem



Femi




FIG. 150. Radiograph of the*Hip Region of a child.

The gaps between the various segments of the bones indicate the
sizes of the intervening cartilage segments.



HIP JOINT 331

femoral extremity is implanted into the fovea capitis femoris,
whilst its flattened acetabular end is bifid, and is fixed to the
margins of the acetabular notch, and also to the transverse
ligament. This attachment can be defined by the removal
of the synovial layer and some areolar tissue. The liga-
mentum teres is surrounded by a prolongation of the synovial
layer, and a small artery runs along it to the head of the
femur.

It is difficult to understand the part which the ligamentum
teres plays in the mechanism of the hip joint. It presents
very different degrees of strength in different subjects. It
becomes very tense when the thigh is slightly flexed and
then adducted.

The Interior of the Joint and the Synovial Stratum. A
mass of soft fat occupies the non-articular bottom of the
acetabulum. Upon this the ligamentum teres is placed, and
blood-vessels and nerves enter it by passing through the
notch under cover of the transverse ligament. The vessels
are derived from the medial femoral circumflex and the
obturator arteries, and the nerves are twigs from the anterior
branch of the obturator nerve, from the accessory obturator,
when it is present, and from the nerve to the rectus femoris
muscle. A nerve-twig is also supplied to the posterior
part of the joint by the nerve to the quadratus femoris.

The synovial stratum lines the inner surface of the fibrous
stratum of the capsule. From the fibrous stratum it is reflected
on to the neck of the femur, and it clothes the bone as far
as the margin of the articular cartilage which covers the head.
Along the line of reflection some fibres of the fibrous stratum
proceed proximally on the neck of the femur and raise the
synovial layer in the form of ridges. These fibres are termed
the retinacula or cervical ligaments.

The retinacitla are of some surgical importance. In intracapsular
fracture of the neck of the femur they may escape rupture, and they
may then, to some extent, help to retain the fragments in apposition.
Hence examinations of this class of fracture must be conducted gently,
lest by rupturing this ligamentous connection the fragments be perma-
nently displaced.

At the acetabular attachment of the capsule the synovial
membrane is reflected on to the labrum glenoidale and
invests both its surfaces. It also covers the articular surface
of the transverse ligament and the cushion of fat which



332 THE INFERIOR EXTREMITY

occupies the bottom of the cavity. Lastly, it gives a tubular
investment to the ligamentum teres.

Removal of the Limb. The limb must now be removed from the trunk
by dividing the ligamentum teres. It should then be taken to one of the
tables set aside for the dissection of separate parts. Before proceeding to
the dissection of the leg the attachments of the various muscles to the
femur should be revised. The bulk of the muscles may be removed, but
a small portion of each should be left, so that the attachments may again
be revised, should it be found necessary to do so, at a later period.



THE LEG.

Surface Anatomy. Before the dissection of the leg is
commenced, the relations of the tibia and fibula to the
surface should be carefully investigated. The sharp anterior
crest or shin of the tibia does not form a projection visible
to the naked eye, but, nevertheless, it is subcutaneous and
can be felt very distinctly when the finger is passed along it.
It extends from the tuberosity of the tibia to the anterior
border of the medial malleolus, pursuing a slightly sinuous
course, and in its distal part it is rounded off and indistinct.

The broad flat medial surface of the body of the tibia is
also subcutaneous, distal to the level of the insertion of the
sartorius, and the medial border of the bone which forms its
posterior boundary can be followed by the finger throughout
its entire length from the medial condyle, to the posterior
border of the medial malleolus. It indicates the position of
the great saphenous vein and the saphenous nerve.

The fibula, on the whole, is more deeply placed. The head
is easily distinguished below and posterior to the lateral
condyle of the tibia; the trunk of the peroneal nerve lies
behind it. The proximal half of the body of the bone
is concealed by the surrounding muscles and cannot be
palpated satisfactorily. The distal end of the bone, which
forms the lateral malleolus, and the distal part of the body,
proximal to the malleolus, are subcutaneous in a triangular area
which will be found to be bounded anteriorly by the peronseus
tertius, and by the peronaeus longus and brevis muscles
posteriorly.

The two malleoli form marked projections in the region of
the ankle. The medial malleolus is the broader and more



THE LEG 333

prominent of the two ; it does not pass so far distally,
but its anterior border is situated more anteriorly than the
lateral malleolus. This is due to its greater breadth ; because,
when examined from behind, the posterior borders of the two
projections are seen to occupy very nearly the same transverse
plane.

On the posterior aspect of the leg the prominence known
as the " calf of the leg " is visible. This is largely due to the
fleshy bellies of the gastrocnemius muscle. Distal to the calf,
and immediately proximal to the heel, the powerful tendo
calcaneus can be felt. Anterior to that tendon a slight hollow
is apparent on each side of the limb.

The skin will be reflected from the dorsum of the foot
during the dissection of the leg ; therefore the present oppor-
tunity should be seized for studying the surface anatomy of the
foot, The individual tarsal bones cannot be recognised through
the integument which covers the dorsum of the foot ; but if
the foot is powerfully extended, the head of the talus will
be brought into view, in the shape of a slight prominence,
which lies below and anterior to the ankle joint. The
margins of the foot require careful study, because it is by
the recognition of certain bony projections in them that
the surgeon is enabled to determine the point at which to
enter the knife when he is called upon to perform partial
amputation of the foot. Examine the medial margin first.
Begin posteriorly, at the projection formed by the medial process
of the calcaneus, and proceed forwards. About one inch
below the medial malleolus the medial edge of the sustenta-
culum tali may be recognised, and about one inch, or a little
more, anterior to that, is the tubercle of the navicular. Then
comes the first cuneiform bone, which is succeeded by
the first metatarsal bone. None of these bony points can
be said to form visible prominences on the surface. In
order to distinguish them the medial margin of the foot must
be carefully palpated. On the lateral margin of the foot the
tuberosity on the base of the fifth metatarsal bone stands out
as a distinct landmark. Posterior to it is the cuboid, and
still more posterior the lateral surface of the calcaneus, which
is almost completely subcutaneous. When present in a well-
developed form, the trochlear process (O.T. peroneal tubercle)
on this surface may be distinguished, about one inch distal
and a little anterior to the lateral malleolus. If the foot is



334



THE INFERIOR EXTREMITY



strongly inverted the anterior end of the calcaneus will be
seen to project on the surface.

Subdivision of the Leg into Regions. In the dissection of
the leg four distinct regions may be recognised, viz. :

1. An anterior crural region, in which are placed those structures which

lie anterior to the interosseous membrane, and between the two
bones of the leg.

2. A medial crural region, corresponding to the subcutaneous or medial

surface of the body of the tibia.

3. A lateral crural region, which includes the parts in relation to the

lateral surface of the fibula.

4. A posterior crural region, in which are placed the parts, on the back

of the leg, which lie posterior to the interosseous membrane and the
two bones of the leg.



ANTERIOR CRURAL REGION AND DORSUM OF FOOT.

The anterior crural region should be dissected first,
and it is usual to conjoin with this the dissection of the
dorsum of the foot. The following parts are exposed :



1. Superficial veins.

2. Cutaneous nerves.

3. Deep fascia, with its inter -

muscular septa, the transverse
ligament of the leg, the lig.
laciniatum, and the cruciate
ligament of the leg.

4. Tibialis anterior.

5. Extensor digitorum longus.

6. Peronoeus tertius.



7. Extensor hallucis longus.

8. Anterior tibial vessels.

9. Perforating branch of the pero-

neal artery.

10. Deep peroneal nerve.

11. Recurrent articular branch

from the common peroneal
nerve.

12. Extensor digitorum brevis.

13. Dorsalis pedis vessels.



Dissection. Reflection of Skin. To place the limb in a
convenient position for the dissection of this region, a block
should be introduced beneath the knee, and the foot should be
extended and fastened firmly to the table by means of hooks.
The skin should be reflected from the tibial and peroneal (medial
and lateral] crural regions at the same time. Incisions : (i)
a vertical cut along the median line of the leg and dorsum of the
foot to the base of the middle toe ; (2) a transverse incision across
the ankle joint ; (3) a transverse incision across the dorsum
of the foot at the roots of the toes.

The four flaps of skin, thus mapped out (10, n, 12, 13, Fig. 104),
must now be raised from the subjacent fatty tissue, and the
superficial veins and nerves dissected out.

Superficial Fascia. The superficial fascia of the front and
the medial and lateral sides of the leg and the dorsum of
the foot presents no peculiar features; and it contains as
a rule only a moderate amount of fat, in which lie the
cutaneous veins and nerves.



THE LEG



335



The veins which will be met with in it during the
dissection are :



1. The dorsal digital veins of the

toes.

2. The dorsal venous arch.



3. The distal part of the great

saphenous vein.

4. The distal part of the small

saphenous vein.



The cutaneous nerves or their branches which should be
secured as they pass through the superficial fascia are :



1. N. cutaneus surse lateralis.

2. N. suralis.

3. N. saphenus.



4. N. peronseus superficialis.

5. N. peronseus profundus.



Dissection. The lateral cutaneous nerve of the calf was
displayed in the dissection of the popliteal space, arising from the
common peroneal nerve or in common with the peroneal anasto-
motic branch. Trace it now to its termination on the antero-
lateral aspect of the leg.

After the lateral cutaneous nerve of the calf has been traced
to its termination, the cutaneous veins should be dissected, for, on
the dorsum of the foot, they lie more superficially than the nerves,
and in other situations they serve as guides to the positions of
some of the nerves. Commence with the dorsal venous arch
of the foot. It lies opposite the anterior parts of the bodies of
the metatarsal bones and is usually visible, after the skin has
been reflected, in at least part of its extent. Follow it medially
to the medial border of the foot, where it joins with the medial
dorsal digital vein of the great toe to form the commencement
of the great saphenous vein. Next follow the great saphenous
vein upwards, in front of the medial malleolus and obliquely
across the medial surface of the distal third of the tibia to the
medial border of the tibia. The remainder of the great saphenous
vein will be displayed when the medial sural region is dissected,
therefore do not follow it further at present, but secure the
distal part of the saphenous nerve, which lies close to it, and
follow the nerve to the middle of the medial border of the foot,
where it ends. When the dissection of the saphenous nerve
is completed follow the dorsal venous arch laterally to the
lateral margin of the foot, where it unites with the lateral dorsal
digital vein of the little toe to form the small saphenous vein.
Follow the small saphenous vein backwards below the lateral
malleolus and there secure the sural nerve, which lies adjacent
to the vein. Follow the sural nerve forwards. About the
middle of the lateral border of the foot it gives a twig of com-
munication, to a branch of the lateral division of the superficial
peroneal nerve, and then continues onwards to the lateral part
of the dorsal aspect of the little toe. Follow it to its termination.
Now clean the dorsal digital veins which join the convex anterior
border of the dorsal venous arch. They are four in number,
one opposite each interdigital cleft. Follow them to the clefts,
and trace their tributaries into the toes. The terminal part
of the superficial peroneal nerve must now be secured. If either
the communicating twig from the saphenous nerve to the most



Online LibraryD. J. (Daniel John) CunninghamCunningham's manual of practical anatomy (Volume 1) → online text (page 33 of 44)