Netter's Concise Orthopaedic Anatomy 2nd Edition

7 Pelvis • MUSCLES

Transverse Section: Pubic Crest, Femoral Heads, Coccyx

Superior portion of pubic symphysis Interior of urinary bladder
Co Spermatic cord
Adductor longus muscle
Beginning of urethra
Body of pubis
Prostate gland with
prostatic urethra Pectineus muscle
Psoas muscle and tendon
Femoral vein
Iliacus muscle
Femoral artery
Head of femur
Femoral nerve
Neck of femur
Sartorius muscle
Gluteus
medius Iliopsoas muscle
muscle
Gluteus Rectus femori
minimus muscle
tendon
Greater Tensor
trochanter fasciae latae
muscle
Inferior Gluteus
gemellus medius
muscle muscle
Right sciatic nerve Obturator
Gluteus maximus muscle artery, vein,
and nerve
Obturator internus muscle
Acetabular fossa
Sacrotuberous ligament
Lunate (articular)
Ejaculatory ducts surface of
acetabulum
Perineal flexure (termination of Left sciatic nerve
rectum, beginning of anal canal) Internal pudendal artery and vein

Tip of coccyx Pudendal nerve

Fat body of ischioanal fossa

Levator ani muscle (puborectalis)

MRI pelvis Femoral
artery
Adductor
longus Sartorius
Anterior
wall Tensor
fasciae latae
Femoral Gluteus
head medius

Obturator Rectus
internus femoris
Posterior Iliopsoas
wall
Urinary
Gluteus bladder
maximus
Coccyx

240 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

NERVES • Pelvis 7

Diaphragm (cut) L1 White and gray rami
Subcostal nerve (T12) communicantes
L2 Subcostal nerve (T12)
Sympathetic trunk L3 Iliohypogastric nerve
Iliohypogastric nerve L4 Ilioinguinal nerve
Transversus abdominis
Ilioinguinal nerve muscle
Genitofemoral nerve (cut) Quadratus lumborum muscle
Psoas major muscle
Lateral cutaneous
nerve of thigh Gray rami communicantes
Genitofemoral nerve
Femoral nerve
Obturator nerve Iliacus muscle
Psoas major muscle (cut)
Lumbosacral trunks Lateral cutaneous nerve of thigh
Inguinal ligament (Poupart)
Femoral nerve
Genital branch and
Femoral branch of
genitofemoral nerve

Obturator nerve

LUMBAR PLEXUS Schema T12
Subcostal nerve (T12) L1
Lumbar plexus comprises the ventral White and gray rami
rami of L1-L4. Two divisions: anterior communicantes L2
(innervates flexors), posterior (exten- Ventral
sors). Plexus formed within the psoas Iliohypogastric nerve rami of
muscle.
Ilioinguinal nerve L3 spinal
Anterior Division nerves
Genitofemoral nerve
Subcostal (T12): Inferior to 12th rib L4
Lateral femoral
Sensory: Subxyphoid region cutaneous nerve L5
Motor: None Gray rami
communicantes Lumbosacral trunk
Iliohypogastric (L1): Under psoas,
pierces abdominal muscles Muscular branches
to psoas and iliacus
Sensory: Above pubis muscles
Motor: Posterolateral buttocks
Transversus abdominis Femoral nerve
Internal oblique Accessory obturator
nerve (often absent)
Obturator nerve

Ilioinguinal (L1): Under psoas, pierces abdominal muscles Obturator (L2-4): Exits via obturator canal, splits into ant.
Sensory: Inguinal region, anterosuperior thigh & post. division (can be injured by retractors placed
Motor: None behind the transverse acetabular ligament [TAL])

Genitofemoral(L1-2): Pierces psoas lies on anterior Sensory: Inferomedial thigh via cut. br. of obturator n.
surface of psoas muscle Motor: External oblique
Sensory Scrotum or labia majora
Motor: Cremaster Obturator externus (posterior division)

Accessory Obturator (L2-4): Inconsistent

Sensory: None
Motor: Psoas

Posterior Division

Lateral Femoral Cutaneous (FFCN) (L2-3): runs on ilia- Femoral (L2-4): Lies between psoas major and iliacus
cus, crosses inferior to ASIS (can be compressed
there: meralgia paresthetica) Sensory: None (in pelvis)
Motor: Psoas
Sensory: None (in pelvis) Iliacus
Motor: None Pectineus

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 241

7 Pelvis • NERVES

Schema L4 Lumbosacral trunk

Anterior division L5
Posterior division Gray rami communicantes

Superior gluteal nerve S1
Inferior gluteal nerve S2 Pelvic splanchnic nerves (parasympathetic to
Nerve to piriformis
inferior hypogastric [pelvic] plexis)
Tibial nerve S3
Sciatic nerve Common fibular
S4
(peroneal) nerve S5 Coccygeal nerve

Nerve to quadratus femoris (and inferior gemellus) Perineal branch of 4th sacral nerve

Nerve to obturator internus (and superior gemellus) Nerve to levator ani and coccygeus
(ischiococcygeus) muscles
Lumbosacral trunk Pudendal nerve
Psoas major muscle Perforating cutaneous nerve
Superior gluteal artery and nerve Posterior femoral cutaneous nerve
Obturator nerve
Iliacus muscle L5 Sympathetic trunk
Inferior gluteal artery L4 Gray rami communicantes
Nerve to quadratus femoris Pelvic splanchnic nerves (cut)
Internal pudendal artery S1 (parasympathetic to inferior
Nerve to obturator internus S2 hypogastric [pelvic] plexus)
Pudendal nerve S3 Piriformis muscle
Obturator internus muscle
Superior pubic ramus S4
Piriformis muscle S5
Coccygeus (ischiococcygeus) muscle
Nerve to levator ani muscle Co

Levator ani muscle Sacral splanchnic nerves (cut)
(sympathetic to inferior
Topography: medial and slightly hypogastric [pelvic] plexus)
anterior view of hemisected pelvis

LUMBOSACRAL PLEXUS

Lumbosacral plexus comprises the ventral rami of L4-S3(4). Two divisions: Anterior (innervates flexors), posterior (exten-
sors). Plexus lies on anterior piriformis muscle.

Anterior Division

Nerve to quadratus femoris (L4-S1): Exits greater Pudendal (S2-4): Exits greater then re-enters pelvis through
sciatic foramen lesser sciatic foramen

Sensory: None Sensory: Perineum:
Motor: Quadratus femoris via perineal nerve (scrotal/labial br.)
via inferior rectal nerve
Inferior gemelli via dorsal nerve to penis/clitoris

Nerve to obturator internus (L5-S2): Exits greater Motor: Bulbospongiosus: perineal nerve
sciatic foramen Ischiocavernosus: perineal nerve
Urethral sphincter: perineal nerve
Sensory: None Urogenital diaphragm: perineal nerve
Motor: Obturator internus Sphincter ani externus: inferior rectal nerve

Superior gemelli

Nerve to coccygeus (S3-4): directly innervates muscle

Sensory: None
Motor: Coccygeus

Levator ani

242 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

NERVES • Pelvis 7

Gluteus maximus muscle (cut) Iliac crest
Superior gluteal nerve Gluteus medius muscle (cut)
Gluteus minimus muscle
Sciatic nerve Piriformis muscle
Inferior gluteal nerve Superior gemellus muscle

Posterior cutaneous nerve of thigh Tensor fasciae latae muscle

Nerve to obturator internus Gluteus medius muscle (cut)
(and superior gemellus)
Obturator internus muscle
Pudendal nerve
Nerve to quadratus
Ischial spine femoris (and inferior
gemellus) supplying
Sacrospinous ligament articular branch to
hip joint
Perforating
cutaneous nerve
Sacrotuberous ligament

Inferior anal (rectal) nerve Greater trochanter of femur

Dorsal nerve of Intertrochanteric crest
penis/clitoris

Perineal nerve Inferior gemellus muscle
Quadratus femoris muscle
Posterior scrotal/ Gluteus maximus muscle (cut)
labial nerves
Sciatic nerve
Perineal branches of Posterior cutaneous nerve of thigh
posterior cutaneous Inferior cluneal nerves
nerve of thigh

Ischial tuberosity

Semitendinosus muscle
Biceps femoris muscle (long head)
(covers semimembranosus muscle)

LUMBOSACRAL PLEXUS

Posterior Division Both Divisions

Superior Gluteal (L4-S1): Exits greater sciatic foramen Posterior Femoral Cutaneous (S1-S3): Exits via greater
above the piriformis sciatic foramen, under piriformis, medial to sciatic
Sensory: None nerve
Motor: Gluteus medius
Sensory: Inferior buttocks: via inferior cluneal nerves
Gluteus minimus Posterior perineum: perineal branches
Tensor fasciae latae Posterior thigh (see Chapter 8)

Inferior Gluteal (L5-S2): Exits greater sciatic foramen Motor: None
Sensory: None
Motor: Gluteus maximus Sciatic (L4-S3): Largest nerve in body. Two components:
tibial (ant. division) and peroneal (post. division). Exits
Nerve to Piriformis (S2): Directly innervates muscle greater sciatic foramen under piriformis. Anatomic vari-
Sensory: None ants include exiting through or above piriformis. Re-
Motor: Piriformis flecting short ERs will protect sciatic in posterior ap-
proach to hip.

Sensory: None (in pelvis; see Chapters 8-10)
Motor: None (in pelvis; see Chapters 8-10)

Other Nerves (Nonplexus)

Superior Cluneal (L1-3): Branches of dorsal rami. Medial Cluneal (S1-3): Branches of dorsal rami
Sensory: Superior 2⁄3 of buttocks Sensory: Sacral and medial buttocks

• Piriformis muscle is the landmark in gluteal region. Most nerves exit inferior to it. POP’S IQ is a mnemonic: Pudendal,
N. to Obturator internus, Posterior cutaneous, Sciatic, Inferior gluteal, N. to Quadratus femoris.

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 243

7 Pelvis • ARTERIES Abdominal aorta Internal iliac artery
Posterior division
Median sacral artery Right Common iliac Anterior division
Left arteries
Iliolumbar artery External iliac artery
Umbilical artery (patent part)
Lateral sacral arteries Obturator artery
Middle rectal artery
Superior Uterine artery
gluteal artery Vaginal artery
Inferior vesical artery
Piriformis muscle Superior vesical arteries

Inferior Medial umbilical ligament
gluteal artery (occluded part of umbilical artery)
Internal pudendal artery
Coccygeus Pubic symphysis
(ischiococcygeus)
muscle Sagittal section
Sacrotuberous ligament

Obturator fascia (of
obturator internus muscle)

Internal pudendal artery
in pudendal canal (Alcock’s)

Levator ani muscle (cut edge)

ARTERY COURSE COMMENT/SUPPLY
Common iliacs
Median sacral AORTA
Internal iliac
External iliac Branch at L4, run along anterior spine Blood supply to pelvis & lower extremities

Obturator Descends along anterior spine & sacrum Anastomoses with lateral sacral arteries
Inferior gluteal
Multiple visceral COMMON ILIAC ARTERY

branches Under ureter toward sacrum, then divides Supplies most of pelvis & pelvic organs
Divides into anterior & posterior divisions
Superior gluteal
Iliolumbar On ant. surface of psoas to inguinal ligament Does not supply much of the pelvis
Lateral sacral
INTERNAL ILIAC

Anterior Division

Through obturator foramen w/obturator nerve Fovea artery (ligamentum teres) branches

Exits greater sciatic foramen under piriformis Supplies gluteus maximus muscle

Umbilical Supplies bladder (via sup. vesical arteries)
Uterine/vaginal (females) Supplies uterus & vagina (via vaginal br.)
Inferior vesical (males) Supplies bladder, prostate, ductus deferens
Middle rectal Anastomoses w/sup. & inf. rectal arteries
Internal pudendal Runs with pudendal nerve
Inferior rectal art. branches from this artery

Posterior Division

Exits greater sciatic foramen above piriformis In sciatic notch, can be injured in posterior column
fractures or pelvic ring injuries

Runs superiorly toward iliac fossa Supplies ilium, iliacus, & psoas muscles

Run along sacrum, anterior to the sacral roots Supplies sacrum/sacral muscles/nerves
Anastomoses w/median sacral art. (aorta)

244 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

ARTERIES • Pelvis 7

Deep circumflex iliac artery Deep dissection External iliac artery and vein
Superficial circumflex artery Superficial epigastric artery
Lateral femoral cutaneous nerve
Deep artery of thigh
Sartorius muscle (cut) Femoral artery and vein (cut)
Pectineus muscle (cut)
Iliopsoas muscle Superficial external pudendal artery

Obturator canal
Obturator externus muscle
Adductor longus muscle (cut)

Ascending, transverse and Anterior branch and
descending branches of Posterior branch of
Lateral circumflex obturator nerve
femoral artery
Medial circumflex Adductor brevis muscle
femoral artery

Iliac crest Gluteus medius m. (reflected)
Posterior superior iliac spine Gluteus minimus m.
Superior gluteal a. and n.
Inferior gluteal a. and n. Piriformis m.
Superior and
Sacrospinous lig. inferior gemellus mm.
Obturator internus m.
Sacrotuberous lig. Gluteus maximus m. (reflected)

Sciatic n.

Posterior femoral cutaneous n. Trochanteric bursa
Ischial tuberosity Quadratus femoris m.

Medial femoral circumflex a.

ARTERY COURSE COMMENT/SUPPLY

EXTERNAL ILIAC ARTERY Supplies anterolateral abdominal wall
muscles
Deep circumflex iliac Runs laterally under internal oblique to Supplies anterior abdominal wall muscles
iliac crest Terminal branch of external iliac artery

Inferior epigastric Runs superiorly in transversalis fascia Supplies superficial abdominal tissues
Supplies superficial abdominal tissues
Femoral artery Continuation of EIA under inguinal ligament Supplies subcutaneous tissues in the pu-

FEMORAL ARTERY bic region and the scrotum/labia majus
Gives off circumflex (2) & perforating
Superficial circumflex iliac In subcutaneous tissues toward ASIS branches
Runs under quadratus femoris; can be in-
Superficial epigastric In subcutaneous tissues toward umbilicus
jured in posterior approach to hip
Superficial & deep external Medially over the adductors & spermatic At risk in anterolateral approach to hip

pudendal cord to inguinal and genital regions

Profunda femoris (deep Between adductor longus & pectineus/
artery of thigh) adductor brevis

Medial circumflex B/w pectineus & psoas, then posterior to
femoral femoral neck under quadratus femoris

Lateral circumflex femoral Runs laterally deep to sartorius & rectus

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 245

7 Pelvis • DISORDERS

Osteitis pubis Contusion
on iliac
crest

Inflamed bursa
adjacent to
ischial tuberosity

Ischial tuberosity and hip pointer

Sacroiliitis

DESCRIPTION Hx & PE WORKUP/FINDINGS TREATMENT

• Inflammation or degenera- OSTEITIS PUBIS 1. Activity modification
tion of pubic symphysis 2. Rest, NSAIDs
Hx: Anterior pelvic pain, XR: AP pelvis (ϩ/Ϫ inlet & 3. Fusion if symptoms are
• Etiology: repetitive micro- sports or trauma outlet views)
trauma (sports) or fracture PE: Symphysis pubis is CT/MR: Not usually neces- refractory to conserva-
tender to palpation sary for diagnosis tive care
• Inflammation or degenera-
tion of sacroiliac joint SACROILIITIS 1. Rest, NSAIDs
2. Injection can be diag-
• Infection can also occur Hx: Low back pain XR/CT: SI joints, ϩ/Ϫ DJD
here PE: SIJ tender to palpa- Bone Scan: r/o infection nostic & therapeutic
tion, ϩ FABER test; in- LABS: CBC, ESR, CRP if in- (corticosteroid)
• Assoc. w/Reiter’s syndrome jection can help diag- fection is suspected 3. Fusion: rarely indicated
nosis
• Inflammation of bursa of is- 1. Rest
chial tuberosity ISCHIAL BURSITIS 2. NSAIDs
3. Activity modification:
• Often from prolonged sitting Hx: Buttocks pain, sitting XR: Pelvis, r/o tuberosity
• Aka “weaver’s bottom” PE: Ischial tuberosity avulsion decrease sitting or in-
• Mimics hamstring injury tender to palpation; ac- MR: Can evaluate/ r/o crease cushion
tive hamstrings NOT hamstring insertion injury
• Direct trauma to iliac crest painful 1. Rest, NSAIDs
• Common in contact sports 2. Padding to iliac crest
ILIAC CREST CONTUSION (HIP POINTER) 3. Corticosteroid injection
(e.g., football, hockey, etc)
Hx: Trauma, “hip” pain XR: Pelvis, r/o fracture
PE: Iliac crest tender to MR/CT: Usually not neces-
palpation sary for diagnosis

246 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

SURGICAL APPROACHES • Pelvis 7

Iliacus (reflected)

Window #1

Inguinal Window #3
ligament

Window #1 Femoral nerve Fascia
Iliopsoas (external
Inguinal oblique)
ligament
Iliopsoas Spermatic
Fascia Femoral nerve cord
(external Window #2
oblique) External iliac
artery and vein

Spermatic cord

Window #3

External iliac Window #2 External iliac
artery and vein artery and vein
Window #2

Window #1 Retropubic
space of
Iliopsoas Retzius
Femoral nerve
Window #3
Inguinal ligament
Fascia (external Spermatic
oblique) cord

USES INTERNERVOUS PLANE DANGERS COMMENT

• Open reduc- ILIOINGUINAL APPROACH • Good knowledge of abdominal
tion, internal & pelvic anatomy essential to
fixation of ac- 3 windows—interval (access): • Ext. iliac (EI) vessels perform this approach
etabular frac- 1. Lateral to iliopsoas & femoral • Corona mortis (vessel
tures involving • Must detach pelvic insertion
anterior col- nerve (anterior, SIJ, iliac fossa, from obt. art. to EI art.) of abdominal muscles & ilia-
umn of ace- pelvic brim) • Femoral nerve cus muscle for exposure
tabulum 2. Between iliopsoas/femoral nerve • Lateral femoral cuta-
& external iliac artery (pelvic • Use rubber drains around ilio-
brim, lateral superior pubic neous nerve psoas/femoral n. & external il-
ramus) • Inferior epigastric iac vessels to access windows
3. Medial to external iliac artery
& spermatic cord (quadrilateral artery
plate & retropubic space [of • Spermatic cord
Retzius]) • Bladder (use a Foley)

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 247

7 Pelvis • SURGICAL APPROACHES

Quadratus femoris

Joint capsule Gluteal sling
(Gluteus maximus
Gluteus medius insertion cut)
(retracted)
Gluteus maximus
(split)
Gluteal fascia

Sciatic nerve Short external rotators
Ilium (posterior column)
Piriformis Ischium/
posterior wall
of acetabulum

USES INTERNERVOUS PLANE DANGERS COMMENT

• Open reduction, KOCHER-LANGENBECK APPROACH • Heterotopic ossification
internal fixation of is common, prophylaxis
acetabular frac- No internervous plane • Sciatic nerve (e.g., XRT) is often needed.
tures involving • Gluteus maximus (inf. gluteal n.) • Inferior gluteal artery
posterior column • Superior gluteal • Do not take down quadra-
of acetabulum fascia is split in line with its tus femoris due to vascular
fibers; inferior gluteal nerve is vessels & nerve (esp. risk
limit to the split. w/excessive retraction)
• Tensor fasciae latae also split in
line with its fibers

248 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

Topographic Anatomy CHAPTER 8
Osteology
Radiology Thigh/Hip
Trauma
Joints 250
Minor Procedures 251
History 253
Physical Exam 254
Origins and Insertions 258
Muscles 259
Nerves 260
Arteries 261
Disorders 265
Pediatric Disorders 266
Surgical Approaches 270
273
275
279
281

8 Thigh/Hip • TOPOGRAPHIC ANATOMY

Anterior view Inguinal Iliac crest Posterior view
ligament
Iliac crest Gluteus
Hip joint medius
Anterior muscle
superior iliac Sartorius
spine muscle

Tensor fasciae
latae muscle

Vastus Great Gluteus
lateralis muscle saphenous maximus
vein muscle
Rectus femoris
muscle Vastus Greater
medialis trochanter
Rectus femoris muscle of femur
tendon (becoming
part of quadriceps Semitendinosus Ischial
femoris tendon) muscle tuberosity

Iliotibial tract Adductor Gluteal
magnus fold
Patella muscle
Iliotibial
Patellar Gracilis tract
ligament tendon
Bicep femoris muscle
Great Long head
saphenous Short head
vein
Popliteal
fossa

STRUCTURE CLINICAL APPLICATION
Iliac crest Site for “hip pointers”/contusion of lilac crest
Common site for autologous bone graft harvest
Greater trochanter Tenderness can indicate trochanteric bursitis.
Ischial tuberosity Avulsion fracture (hamstrings) or bursitis can occur here.
Iliotibial tract (band) Can snap over greater trochanter of femur, creating “snapping hip” syndrome.
Tightness can cause lateral knee and/or thigh pain.
Quadriceps muscle Atrophy can indicate an injury and/or contribute to knee pain.
• Vastus lateralis
• Vastus medialis Can rupture with eccentric loading. Defect is felt here.
• Rectus femoris Popliteal artery pulse can be palpated here.
• Vastus intermedius (not shown)
Quadriceps tendon
Popliteal fossa

250 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

OSTEOLOGY • Thigh/Hip 8

Anterior view Posterior view

Greater Head Piriformis fossa Greater
trochanter Fovea for Head trochanter
ligament
of head Fovea for
ligament
Neck of head

Lesser trochanter Neck
Intertrochanteric crest
Intertrochanteric line
Calcar
Lesser trochanter

Pectineal line
Gluteal tuberosity

Linea aspera Medial lip
Lateral lip

Shaft (body) Line of attachment of border of Nutrient
synovial membrane foramen
Shaft (body)
Line of reflection of synovial
membrane Popliteal surface

Line of attachment of fibrous
capsule

Line of reflection of fibrous
capsule (unattached)

Lateral epicondyle Adductor tubercle
Medial epicondyle
Lateral epicondyle

Lateral condyle Patellar surface Medial condyle Lateral condyle
Intercondylar fossa

CHARACTERISTICS OSSIFY FUSE COMMENTS

• Long bone characteristics FEMUR
• Proximal femur
Primary 7-8wk 16-18yr • Blood supply
‫ ؠ‬Head: nearly spherical (2⁄3) (Shaft) (fetal) ‫ ؠ‬Head/neck: primarily medial femoral cir-
‫ ؠ‬Neck: anteverted from shaft 19yr cumflex artery (also lateral FCA and of
‫ ؠ‬Greater trochanter: lateral Secondary 18yr ligamentum teres artery)
‫ ؠ‬Lesser trochanter: postero- Distal physis birth 16yr ‫ ؠ‬Shaft: nutrient artery (from profunda fem.)
Head 1yr 16yr
medial Gtr troch 4-5yr • Head vascularity is susceptible to disruption
• Shaft: tubular, bows anteriorly Lsr troch 10yr in fracture or dislocation—leads to AVN

‫ ؠ‬Linea aspera posterior: inser- • Proximal femur bone density decreases with
tion of fascia and muscles age, making it more susceptible to fracture

• Distal femur: 2 condyles • Calcar femorale—vertically oriented dense
‫ ؠ‬Medial: larger, more posterior bone in posteromedial aspect of prox. femur
‫ ؠ‬Lateral: more anterior &
proximal • Piriformis fossa—posteromedial base of gtr
‫ ؠ‬Trochlea: anterior articular trochanter: starting point for femoral nails
depression between condyles
• Neck/shaft angle: 120-135°
• Femoral anteversion: 10-15°
• Distal femur physis: grows approx. 7mm/yr

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 251

8 Thigh/Hip • OSTEOLOGY

Bone Architecture in Relation to Physical Stress

Wolff’s law. Bony structures orient themselves in form and mass
to best resist extrinsic forces (ie, form and mass follow function)

Principal Principal Femoral Calcar
tensile compressive anatomic femorale
group axis
3˚ Vertical
Load 6˚ axis

group Femoral Knee
axis
Greater mechanical
trochanteric 87˚
group axis Tibial
81˚ 87˚ mechanical
axis
Secondary Ward’s
tensile triangle Calcar
group femorale
Secondary
Trabecular configuration compressive
in proximal femur group

Trabecular groups confirm to
lines of stress in weight bearing

GROUP COMMENT

PROXIMAL FEMUR OSTEOLOGY

• Proximal femur comprises several distinct trabecular bone groups that support the head and neck.
• The presence or absence of these groups helps to determine the presence & degree of osteopenia in the prox. femur.
• Malalignment of bone groups determines the fracture type in displaced femoral neck fractures.

Primary compressive From superior femoral head to medial neck, strongest cancellous bone,
supports body weight

Primary tensile From inferior femoral head to lateral cortex

Secondary compressive Oriented along lines of stress in proximal femur

Secondary tensile Oriented along lines of stress in lateral proximal femur

Greater trochanteric group Oriented along lines of stress within the greater trochanter

Ward’s triangle Area of relative few trabeculae within the femoral neck

Anatomic axis LOWER EXTREMITY ALIGNMENT
Mechanical axis Definitions
Knee axis
Vertical axis Line drawn along the axis of the femur
Lateral femoral angle Line drawn between center of femoral head and intercondylar notch
Line drawn along the inferior aspect of both femoral condyles
Knee axis Vertical line, perpendicular to the ground
Mechanical axis Angle formed between the knee axis and the femoral axis

Lateral femoral angle Relationships
Parallel to the ground and perpendicular to vertical axis
Average of 6° from anatomic axis
Approximately 3° from the vertical axis
81° with respect to femoral anatomic axis
87° with respect to femoral mechanical axis

252 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

RADIOLOGY • Thigh/Hip 8

Acetabulum Acetabulum
Fovea Greater
trochanter
Femoral head
Femoral neck Femoral neck
Greater
trochanter Femoral head
Lesser
trochanter Lesser
trochanter
Greater trochanter
Lesser trochanter Hip, AP xray Hip, Lateral xray

Diaphysis Anterior bow
of femur

Diaphysis

Metaphysis

Metaphysis

Femur, AP Femur, Lateral

RADIOGRAPH TECHNIQUE FINDINGS CLINICAL APPLICATION
Fractures, dislocations, arthritis
AP pelvis Supine, beam at symphysis Both hips and pelvis Fractures, arthritis
Fractures, arthritis
AP hip Beam aimed at proximal femur Femoral head, acetabulum
Often needed for preop fx films
Lateral (frog Flex, abd. ER hip, beam at hip Fem. neck, head, acetab. rim Used intraop (fluoro) for ORIF
leg)
Fractures, tumors
Lateral Flex contralateral hip to remove Femoral neck, head, acetabu- Fractures, tumors

(cross-table) it; aim beam across table at lar rim. Ant & post. cortices Intraarticular acetabulum or neck
fractures
hip seen well on lateral Labral tears, AVN, stress fractures

AP femur Supine, beam at mid femur Femur, soft tissues Stress fractures, infection, tumor

Lateral femur Beam laterally at mid femur Femur, soft tissues

See Chapter 7, Pelvis, for views of acetabulum.

OTHER STUDIES

CT Axial, coronal, & sagittal views Articular congruity, fracture
fragments

MRI Sequence protocols vary Labrum, cartilage, cancellous

bone

Bone scan Radioisotope All bones evaluated

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 253

8 Thigh/Hip • TRAUMA

Posterior Dislocation

Anteroposterior view. Anteroposterior radiograph Allis maneuver. Patient supine on table, under
Dislocated femoral head lies posterior shows posterior dislocation anesthesia or sedation. Examiner applies firm
and superior to acetabulum. Femur distal traction at flexed knee to pull head into
adducted and internally rotated; hip acetabulum; slight rotary motion may also
flexed. Sciatic nerve may be stretched help. Assistant fixes pelvis by pressing on
anterior superior iliac spines

Anterior Dislocation

Anterior view. Femoral head in obturator Characteristic position
foramen of pelvis; hip flexed and femur of affected limb. Hip
widely abducted and externally rotated flexed, thigh abducted
and externally rotated.

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT

HIP DISLOCATION

• High-energy trauma (esp. Hx: Trauma, severe pain, Posterior: Thompson: Early reduction essential
MVA, dashboard injury) cannot move thigh/hip I: No or minor post. wall fx (Ͻ6 hr), then repeat
or significant fall PE: Thigh position: II: Large posterior wall fx XR & neuro exam
• Post.: adducted, flexed, IR III: Comminuted acetabular fx Posterior:
• Orthopaedic emergency; • Ant.: abducted, flexed, ER IV: Acetabular floor fx I: Closed reduction and
risk of femoral head AVN • Pain (esp. with motion), V: Femoral head fx abduction pillow
increases with late/de- good neurovascular exam II-V:
layed reduction (sciatic n.) Anterior: Epstein: 1. Closed reduction
XR: AP pelvis, frog lateral I (A, B, C): Superior (open if irreducible)
• Multiple associated inju- (femoral head appears of II (A, B, C): Inferior 2. ORIF( fracture or ex-
ries ϩ/Ϫ fractures different size), femur and A: No associated fx cise fragment/LB)
(e.g., femoral head/neck, knee series B: Femoral head fx Anterior:
acetabulum) CT: R/o fx or bony fragments/ C: Acetabular fx Closed reduction, ORIF
loose bodies (postreduction) if necessary
• Posterior most common
(85%)

COMPLICATIONS: Posttraumatic osteonecrosis (AVN) (reduced risk with early reduction); sciatic nerve injury (posterior
dislocations); femoral artery/nerve injury (anterior dislocations); osteoarthritis; heterotopic ossification

254 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

TRAUMA • Thigh/Hip 8

Type I. Impacted fracture Type II. Nondisplaced fracture

Type III. Partially displaced Type IV. Displaced fracture.
vertical fracture line generally
suggests poorer prognosis

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT

FEMORAL NECK FRACTURE

• Mechanism Hx: Fall, pain, inability to Garden (4 types): Young (high-energy)
‫ ؠ‬Fall by elderly person most bear weight/walk I: Incomplete fracture; • Urgent reduction
common PE: LE shortened, ab- valgus impaction
‫ ؠ‬High-energy injury in young ducted, externally rotated. II: Complete fracture; (CR vs OR)
adults (e.g., MVA) Pain w/“rolling”/log roll nondisplaced • ORIF (3 parallel screws)
extremity III: Complete fracture,
• Intracapsular fractures XR: AP pelvis, cross-table partial displacement Elderly
• Femoral head vascularity at lateral (varus) • Early medical evaluation
MR: If symptomatic with IV: Complete fracture, • Types I & II: ORIF
risk in displaced fractures negative XR (i.e., rule out total displacement
• Associated with osteoporosis occult fracture) (3 screws)
• High morbidity & complication • Types III & IV: hemiar-

rates throplasty
• Medically unstable,

nonoperative

COMPLICATIONS: Osteonecrosis (AVN): incidence increases with fx type (displacement) ϩ/Ϫ late segmental collapse;
nonunion; hardware failure

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 255

8 Thigh/Hip • TRAUMA

Intertrochanteric Fracture of Femur

I. Nondisplaced fracture III. Comminuted displaced fracture

Femoral Shaft Fractures

O I II III IV
Comminution Small cortical Butterfly 50% Large butterfly Severe
discontinuity contact of cortex (zero rotational control) comminution

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT

INTERTROCHANTERIC FRACTURE

• Fall by an elderly per- Hx: Fall, pain, inability to Evans/Jensen: • Early medical evaluation
son most common bear weight/walk • Type IA: Nondisplaced • Early (Ͻ48hr) ORIF
PE: LE shortened, ER. • Type IB: 2 part displaced
• Assoc. w/osteoporosis Pain w/“log rolling” of leg • Type IIA: 3 part, GT ‫ ؠ‬Sliding hip screw/plate
• Occurs along or below XR: AP pelvis/hip cross-table ‫ ؠ‬Cephalomedullary nail
MR: If symptomatic with fragment • Reverse obliquity
intertrochanteric line negative XR (r/o occult • Type IIB: 3 part, LT ‫ ؠ‬Blade plate
• Extracapsular fractures fracture) ‫ ؠ‬Cephalomedullary nail
• Stable vascularity fragment • Nonoperative; medically
• Most heal well with • Type III: 4 part
Reverse obliquity unstable patient
proper fixation

COMPLICATIONS: Nonunion/malunion, decr. ambulatory status, hardware failure, mortality (20% in 1st 6 mo)

FEMORAL SHAFT FRACTURE

• Orthopaedic emergency Hx: Trauma, pain, swelling Winquist/Hansen (5 types): Operative: within 24hr
• High-energy injury deformity, inability to walk/ Stable • Antegrade, reamed,
bear weight 0: No comminution
(e.g., MVA, fall) PE: Deformity, ϩ/Ϫ open I: Minimal comminution locked IM nail
• Associated injuries wound & soft tissue injury; II: Comminuted: Ͼ50% of • Retrograde nail if
check distal pulses
(common) XR: AP/lateral femur; cortices intact needed
• Potential source of Knee: trauma series Unstable • External fixation
Hip: r/o ipsilateral femoral III: Comminuted: Ͻ50% of
significant blood loss neck fx cortices intact ‫ ؠ‬Medically unstable
• Compartment IV: Complete comminution, ‫ ؠ‬High-grade open fx
no intact cortex Traction—if surgery de-
syndrome can occur layed, medically unstable
• Transport patient in patient

traction

COMPLICATIONS: Neurovascular injury/hemorrhagic shock, nonunion/malunion, hardware failure, knee injury (5%)

256 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

TRAUMA • Thigh/Hip 8

Distal Femur Fracture

Transverse supra- Intercondylar (T or Y) Comminuted fracture Fracture of single
condylar fracture fracture extending into shaft condyle (may occur in
frontal or oblique plane)

DESCRIPTION EVALUATION CLASSIFICATION TREATMENT

SUBTROCHANTERIC FRACTURE

• Within 5cm of lesser tro- Hx: Trauma, pain, inability Russell-Taylor: By type:
chanter (LT) to bear weight Type I: no piriformis IA: standard IM nail
PE: Shortened, rotated LE. fossa extension/in- IB: cephalomedullary nail
• Mechanism: No ROM (pain), check volvement IIA: cephalomedullary nail with
‫ ؠ‬Low-energy fall: elderly, neurovascular status A: intact LT trochanteric start point
pathologic fx XR: AP & lateral of femur. B: detached LT IIB: 95° blade plate or cephalo-
‫ ؠ‬High-energy: younger Also, AP pelvis, hip (AP Type II: fracture in- medullary nail with trochanteric
(e.g., MVA) & cross-table lateral), volves piriformis start point
& knee series fossa
• Vascularity is tenuous, can CT: Usually not needed A: intact LT
compromise healing B: detached LT

• Rule out pathologic fx if
fracture occurs with
minimal/no trauma

• High biomechanical
stresses

COMPLICATIONS: Nonunion, malunion, loss of fixation/implant failure, loss of some ambulatory function (esp. in elderly)

DISTAL FEMUR FRACTURE

• Mechanism: direct impact Hx: Trauma, pain, inability AO/Muller: • Nondisplaced/stable:
‫ ؠ‬Young: high energy to bear weight A: Extraarticular ‫ ؠ‬Cast, immobilizer, brace
‫ ؠ‬Elderly: low energy (fall) PE: Swollen, ϩ/Ϫ gross subtypes 1, 2, 3
deformity. Careful pulse B: Unicondylar • Displaced/unstable:
• Articular congruity needed evaluation (Doppler subtypes 1, 2, 3 ‫ ؠ‬Extraarticular: plate or nail
for normal knee function exam if needed) C. Bicondylar ‫ ؠ‬Intraarticular: anatomic re-
XR: AP & lateral knee, fe- subtypes 1, 2, 3 duction of articular surface
• Many associated injuries mur, tibia & locking plate/blade plate
(e.g., tibia fx, knee ligament CT: Evaluate intraarticular
injury) involvement & preop • External fixation: temporarily in
plan open fx, severely swollen soft
• Vascular injuries possible tissues, unstable patient
• Quads/hamstrings: shorten

fx. Gastroc: displace fx pos-
teriorly

COMPLICATIONS: Posttraumatic arthritis, nonunion/malunion, knee stiffness/loss of ROM

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 257

8 Thigh/Hip • JOINTS

Anterior view Posterior view

Anterior Iliofemoral ligament Iliofemoral ligament
superior (Y ligament of Bigelow)
iliac spine Ischiofemoral ligament
Iliopectineal bursa Zona orbicularis
Anterior inferior (over gap in ligaments)
iliac spine Greater
Pubofemoral Ischial trochanter
Greater ligament spine
trochanter
Obturator crest Ischial
tuberosity
Superior
pubic
ramus

Lesser Protrusion Intertrochanteric
trochanter of synovial crest
membrane
Lesser
trochanter

Intertrochanteric line Anterior superior Acetabulum Femoral Labrum Femoral
iliac spine head neck
Joint opened:
lateral view Anterior inferior
iliac spine
Lunate (articular)
surface of Iliopubic eminence
acetabulum Acetabular labrum
Articular (fibrocartilaginous)
cartilage
Fat in acetabular
Greater fossa (covered by
trochanter synovial membrane)

Head of femur Obturator artery
Anterior branch
Neck of femur
Posterior branch
Intertrochanteric Acetabular branch
line
Ligament of Ischial Obturator membrane
head of femur
(cut) Lesser tuberosity Transverse MRI, Hip: coronal

trochanter acetabular ligament

LIGAMENTS ATTACHMENTS COMMENTS

HIP

• The hip is a spheroidal (ball & socket) joint. It has intrinsic stability from osseous, ligamentous, & muscular structures.

Labrum Along acetabular rim except inferiorly Deepens socket, increases femoral head coverage;
can be torn (cause of hip pain)

Transverse Anteroinferior to posteroinferior Covers cotyloid notch in inferior central acetabulum
acetabular acetabulum

Ligamentum teres Fovea (femoral head) to cotyloid notch Small artery to femoral head within this ligament

Capsule Acetabulum to femoral neck Has some discrete thickenings (ligaments)
‫ ؠ‬Iliofemoral Superior: ASIS/ilium to greater trochanter Aka “Y ligament of Bigelow”; provides strong anterior
(2 bands) Inferior: Ilium to intertrochanteric line/LT support, resists extension
‫ ؠ‬Pubofemoral Anterior pubic ramus to intertroch. line Prevents hyperextension of hip, inferior joint support
‫ ؠ‬Ischiofemoral Posterior acetabulum to superior femoral Broad, relatively weak ligament (minimal posterior
neck support). Does not provide complete post. joint cov-

erage, so lateral post. neck is extracapsular

258 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

MINOR PROCEDURES • Thigh/Hip 8

Sites for injection/
aspiration of hip joint

Site for injection/
aspiration of
trochanteric bursa
Trochanteric bursa

STEPS
HIP INJECTION/ASPIRATION
1. Ask patient about allergies
2. Place patient supine, palpate the greater trochanter
3. Prep skin over insertion site (iodine/antiseptic soap)
4. Anesthetize skin locally (quarter size spot)
5. Anterior: Find the point of intersection b/w a vertical line below ASIS and horizontal line from greater trochanter.
Insert 20-gauge (3in) spinal needle upward/slightly medial direction at that point.
Lateral: Insert a 20-gauge (3in) spinal needle superior and medial to greater trochanter until it hits the bone (the
needle should be within the capsule, which extends down the femoral neck). Can “walk” needle up neck into joint.
6. Inject (or aspirate) local or local/steroid preparation into joint. (The fluid should flow easily if needle is in joint.)
7. Dress injection site
TROCHANTERIC BURSA INJECTION
1. Ask patient about allergies
2. Place patient in lateral decubitus position, palpate the greater trochanter
3. Prep skin over lateral thigh (iodine/antiseptic soap)
4. Insert 20-gauge needle (at least 11⁄2 in; 3in in larger patients) into thigh to the bone at the point of most tenderness.
Withdraw needle (1-2mm) so it is just off the bone and in the bursa. Aspirate to ensure needle is not in a vessel.
5. Inject local or local/corticosteroid preparation into bursa. May redirect needle slightly to inject a septated bursa
6. Dress injection site

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 259

8 Thigh/Hip • HISTORY

Osteoarthritis
Characteristic
habitus and
gait

Trauma
Mechanism of injury often by impact
with dashboard, which drives femoral
head backward, out of acetabulum

LFCN entrapment
Numbness and
dysesthesias in
lateral thigh

QUESTION ANSWER CLINICAL APPLICATION
1. Age
Young Trauma, developmental disorders
2. Pain Middle age–elderly Arthritis, fractures
a. Onset
b. Location Acute Trauma, (fracture, dislocation), infection
Chronic Arthritis, labral tear
c. Occurrence Lateral hip/thigh Bursitis, LFCN entrapment, snapping hip syndrome
Buttocks/posterior thigh Consider spine etiology
3. Snapping Groin/medial thigh Hip joint or acetabular etiology (likely not from spine)
4. Assisted ambulation Anterior thigh Proximal femur pathology
Ambulation/WB/motion Hip joint etiology (i.e., not pelvis/spine)
At night Tumor, infection

With ambulation Snapping hip syndrome, loose bodies, arthritis

Cane/crutch/walker Use (and frequency) indicates severity of pain and
condition
5. Activity tolerance Walk distance and activity
cessation Less distance walked and fewer activities no longer
6. Trauma Fall, MVA performed ϭ more severe
7. Activity/work Repetitive use
8. Neurologic symptoms Pain, numbness, tingling Fracture, dislocation, labral tear
9. History of arthritides Multiple joints involved
Femoral stress fracture

LFCN entrapment, spine etiology (e.g., radiculopathy)

Systemic inflammatory disease

260 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

PHYSICAL EXAMINATION • Thigh/Hip 8

Femoral neck fracture Posterior hip dislocation

Typical deformity
injured limb
adducted, internally
rotated and flexed
at hip and knee,
with knee resting
on opposite thigh

Typical deformity
of injured limb in shortened,
externally rotated position

Anterior hip dislocation

Characteristic position
of affected limb. Hip
flexed, thigh abducted
and externally rotated.

Flexion contracture of hip joint

EXAM/OBSERVATION TECHNIQUE CLINICAL APPLICATION

Skin Discoloration, wounds INSPECTION
Position Gross deformity
Shortened, ER Trauma
Gait Adducted, IR Fracture, dislocation
Antalgic (painful) Abducted, ER
Lurch (Trendelenburg) Flexed Femoral neck fracture; intertrochanteric fracture
Lurch Posterior dislocation
Anterior dislocation
Bony structures Hip flexion contracture

Decreased stance phase Knee, ankle, heel (spur), midfoot, toe pain
Lean laterally (on WB side) Gluteus medius weakness
Lean posteriorly (keep hip ext) Gluteus maximus weakness

PALPATION

Greater trochanter/bursa Pain/palpable bursa: infection/bursitis, gluteus
Lesser trochanter medius tendinitis
Snapping—IT band may snap over GT
Snapping— Psoas tendon may snap over LT

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 261

8 Thigh/Hip • PHYSICAL EXAMINATION

Flexion Internal External
rotation rotation

Hip flexion-rotation exercises with patient supine. Hip and knee passively flexed,
then limb rotated laterally and medially as pain permits

Internal rotation 120° 90˚
Limitation of internal rotation of left Flexion
hip. Hip rotation best assessed with
patient in prone position because Extension
any restriction can be detected and
measured easily 0˚

EXAM/OBSERVATION TECHNIQUE CLINICAL APPLICATION

RANGE OF MOTION

Flexion Supine: knee to chest Normal: 120-135°
Thomas test Rule out flexion contracture (see Special Tests, p. 263)

Extension Prone: lift leg off table Normal: 20-30°

Abduction/adduction Supine: leg lateral/medial Normal: Abd: 40-50°, Add: 20-30°

Internal/external rotation Seated: foot lateral/medial Normal: IR: 30°, ER: 50°
Prone: flex knee leg in/out Normal: IR: 30°, ER: 50°

NEUROVASCULAR

Sensory

Genitofemoral nerve (L1-2) Proximal anteromedial thigh Deficit indicates corresponding nerve/root lesion

Obturator nerve (L2-4) Inferomedial thigh Deficit indicates corresponding nerve/root lesion

Lat. femoral cutaneous n. (L2-3) Lateral thigh Deficit indicates corresponding nerve/root lesion

Femoral nerve Anteromedial thigh Deficit indicates corresponding nerve/root lesion

Post. femoral cutaneous n. (S1-3) Posterior thigh Deficit indicates corresponding nerve/root lesion

Motor

Obturator nerve (L2-4) Thigh/hip adduction Weakness ϭ adductor muscle group or nerve/root lesion

Superior gluteal nerve L5) Thigh abduction Weakness ϭ gluteus medius or nerve/root lesion

Femoral nerve (L2-4) Hip flexion Weakness ϭ iliopsoas or nerve/root lesion
Knee extension Weakness ϭ quadriceps or nerve/root lesion

Inferior gluteal nerve (L5-S2) Hip extension Weakness ϭ gluteus maximus or nerve/root lesion

Sciatic: Knee flexion Weakness ϭ biceps long head or nerve/root lesion
Tibial portion (L4-S3) Knee flexion Weakness ϭ biceps short head or nerve/root lesion
Peroneal portion (L4-S2)

Other

Reflex None

Pulses Femoral

262 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

PHYSICAL EXAMINATION • Thigh/Hip 8

Stinchfield test.
Pain with resisted straight
leg raise indicates hip
joint pathology.

Inpingement test. Log roll test.
Pain with hip flexion, adduction, Examiner places hands
and internal rotation indicative of on limb, gently rolls hip
femoroacetabular impingement into internal and external rotation.
and for early arthritis.

15˚

Thomas’ sign
Hip flexion contracture determined with patient supine. Unaffected hip
flexed only until lumbar spine is flat against examining table. Affected hip
cannot be fully extended, and angle of flexion is recorded.

EXAM/OBSERVATION TECHNIQUE CLINICAL APPLICATION

SPECIAL TESTS

Impingement Supine: flex, adduct, IR hip Pain may be indicative of femoral acetabular impingement.

FABER/Patrick Flex, ABduct, ER hip, then Positive if painful. SI joint or hip pathology.
abduct more (figure of 4)

Log roll Supine, hip extended: IR/ER Pain in hip is consistent with arthritis.

Stinchfield Resisted straight leg raise Pain is positive test for hip pathology.

Thomas sign Supine; one knee to chest If opposite thigh elevates off table, flexion contracture.

Ober On side: flex and abduct hip Extend and adduct hip; if stays in abduction, ITB contracture.

Piriformis On side: adduct hip Pain in hip/pelvis indicates tight piriformis (compressing sciatic
nerve).

90-90 straight leg Flex hip & knee 90°, extend Ͼ20° of flexion after full knee extension ϭ tight hamstrings.
knee

Ely’s Prone: passively flex knee If hip flexes as knee is flexed, tight rectus femoris muscle.

Leg length ASIS to medial malleolus A measured difference of Ͼ1cm is positive.

Meralgia Pressure medial to ASIS Reproduction to pain, burning, numbness ϭ LFCN entrapment.

See Chapter 7, Pelvis, for Trendelenburg test.

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 263

8 Thigh/Hip • PHYSICAL EXAMINATION

Ortolani’s (reduction) test “clunk”
With baby relaxed and content
on firm surface, hips and knees
flexed to 90°. Hips examined one
at a time. Examiner grasps baby’s
thigh with middle finger over greater
trochanter and lifts thigh to bring
femoral head from its dislocated
posterior position to opposite
the acetabulum.
Simultaneously, thigh
gently abducted, reducing
femoral head into acetabulum.
In positive finding, examiner
senses reduction by palpable,
nearly audible “clunk”

Allis’ or Galeazzi’s sign

With knees and hips flexed, knee
on affected side lower because
femoral head lies posterior to
acetabulum in this position

Barlow’s (dislocation) test Test for limitation of
Reverse of Ortolani’s test. If femoral head is in abduction. Patient
acetabulum at time of examination, Barlow’s test supine and relaxed on
is performed to discover any hip instability. Baby’s thigh table. Legs gently and
grasped as above and adducted with gentle downward passively abducted to
pressure. Dislocation is palpable as femoral head determine range of
slips out of acetabulum. Diagnosis confirmed motion of each.
with Ortolani’s test Seen in Perthes
disease.

EXAM/OBSERVATION TECHNIQUE CLINICAL APPLICATION

SPECIAL TESTS

Ortolani (peds) Hips at 90°, abduct hips A clunk indicates the hip(s) was dislocated and now reduced

Barlow (peds) Hips at 90°, posterior A clunk indicates the hip(s) is now dislocated, should reduce with
force Ortolani

Galeazzi (peds) Supine: flex hips & knees Any discrepancy in knee height: 1. Dislocated hip, 2. Short femur

264 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

ORIGINS AND INSERTIONS • Thigh/Hip 8

Sartorius muscle

Biceps femoris (long head) Rectus femoris muscle
and semitendinosus muscles Obturator externus
muscle (in piriformis
Pectineus muscle fossa)
Gluteus medius
turator externus muscle Piriformis muscle Obturator muscle
internus Quadratus femoris
Sartorius muscle Adductor muscle

Rectus femoris magnus muscle Iliopsoas muscle
muscle
bturator internus Semimembranosus Gluteus maximus
d superior and muscle muscle
erior gemellus Quadratus
uscles femoris Vastus lateralis muscle

Piriformis Adductor Pectineus muscle Adductor magnus
muscle longus muscle
luteus minimus muscle Vastus Adductor brevis
uscle medialis muscle
Adductor muscle Vastus
Vastus lateralis intermedius muscle
muscle brevis muscle Adductor
longus Biceps femoris muscle
opsoas muscle Quadratus Gracilis muscle muscle (short head)

Vastus medialis femoris Adductor magnus Adductor
muscle muscle muscle magnus muscle

Vastus intermedius Adductor magnus muscle Vastus
muscle lateralis muscle
Gastrocnemius muscle
(medial head) Plantaris muscle

Gastrocnemius muscle
(lateral head)

Popliteus muscle

Origins
Insertions

Semimembranosus
muscle

Popliteus muscle

Articularis genus Adductor Note: Width of zone of attachments to posterior
muscle magnus aspect of femur (linea aspera) is greatly exaggerated
muscle
Iliotibial tract

Biceps femoris Sartorius muscle Pes anserinus
muscle Gracilis muscle
Semitendinosus muscle
uadriceps femoris
uscle (rectus
moris, vastus lateralis,
stus intermedius and
stus medialis via
tellar ligament)

PUBIC RAMI (ASPECT) GREATER TROCHANTER ISCHIAL TUBEROSITY LINEA ASPERA/
POSTERIOR FEMUR
Pectineus (pectineal line/sup) Piriformis (anterior) Inferior gemellus
Adductor magnus (inferior) Obturator internus (anterior) Quadratus femoris Adductor magnus*
Adductor longus (anterior) Superior gemellus Semimembranosus Adductor longus
Adductor brevis (inferior) Gluteus medius (posterior) Semitendinosus Adductor brevis
Gracilis (inferior) Gluteus minimus (anterior) Biceps femoris (LH) Biceps femoris (SH)
Psoas minor (superior) Adductor magnus* Pectineus
Gluteus maximus
Vastus lateralis
Vastus medialis

*Adductor magnus has two origins.

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 265

8 Thigh/Hip • MUSCLES

Superficial dissections Lateral cutaneous nerve of thigh (cut)
Sartorius muscle (cut)
Anterior superior iliac spine Iliopsoas muscle
Femoral nerve,
Inguinal ligament Tensor fasciae latae artery and vein
muscle (retracted)
Pectineus muscle
Iliopsoas muscle
Deep artery
Superficial circumflex Gluteus of thigh
iliac vessels minimus
and medius Adductor
longus muscle
Superficial muscles

epigastric vessels Lateral
circumflex
Superficial and femoral
Deep external artery
pudendal vessels

Femoral sheath Rectus Adductor canal
femoris (opened by re-
Femoral nerve, muscle moval of sartorius
artery and vein muscle)
Vastus
Pectineus lateralis Saphenous nerve
muscle muscle
Nerve to vastus
Deep artery Vastus medialis muscle
of thigh medialis
muscle Adductor
Gracilis magnus muscle
muscle Saphenous nerve
and saphenous Anteromedial
Adductor branch of descending intermuscular
longus genicular artery septum covers
muscle entrance of
femoral vessels to
Sartorius popliteal fossa
muscle (adductor hiatus)

Vastus medialis muscle Sartorius
muscle (cut)
Fascia lata (cut)

Rectus femoris muscle Infrapatellar branch
Vastus lateralis muscle of saphenous nerve
Tensor fasciae latae muscle

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT

Articularis Distal anterior ANTERIOR Pulls capsule supe- May join with vastus
genus femoral shaft riorly in extension intermedialis
Sartorius ASIS Synovial capsule Femoral Flex, ER hip Can avulse from ASIS
(avulsion fracture)
Rectus femoris 1. AIIS Prox. med. tibia Femoral Flex thigh, extend
2. Sup. acetab. rim (pes anserinus) leg Can avulse from AIIS
Vastus lateralis Gtr. trochanter, lat. (avulsion fracture)
linea aspera Quadriceps Extend leg Oblique fibers can
Vastus inter- Proximal femoral affect Q angle
medius shaft Patella/tibial Femoral Extend leg Covers articularis
Vastus medialis Intertrochant. line, tubercle genu
med. linea aspera Extend leg Weak in many patello-
Lateral patella/ Femoral femoral disorders
tibia tubercle

Patella/tibia Femoral
tubercle

Medial patella/ Femoral
tibia tubercle

266 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

MUSCLES • Thigh/Hip 8

Deep circumflex iliac artery Deep dissection

Lateral cutaneous nerve of thigh External iliac artery and vein
Sartorius muscle (cut) Inguinal ligament (Poupart)

Iliopsoas muscle Femoral artery and vein (cut)
Pectineus muscle (cut)
Tensor fasciae latae Obturator canal
muscle (retracted) Obturator externus muscle

Gluteus medius and Adductor longus muscle (cut)
minimus muscles Anterior branch and
Posterior branch of obturator nerve
Femoral nerve
Rectus femoris muscle (cut) Quadratus femoris muscle

Ascending, transverse and Adductor brevis muscle
descending branches of
Lateral circumflex femoral artery Adductor magnus muscle
Gracilis muscle
Medial circumflex femoral artery Cutaneous branch of obturator nerve
Pectineus muscle (cut) Femoral artery and vein (cut)
Deep artery of thigh Articular branch
Perforating branches Saphenous branch
Adductor hiatus
Adductor longus muscle (cut)
Sartorius muscle (cut)
Vastus lateralis muscle
Adductor magnus tendon
Vastus intermedius muscle Adductor tubercle on
medial epicondyle of femur
Rectus femoris muscle (cut)
Infrapatellar branch of
Saphenous nerve Saphenous nerve

Vastus medialis muscle
Quadriceps femoris tendon

Medial patellar retinaculum
Patellar ligament

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT

Obturator Ischiopubic rami, MEDIAL
externus obturator memb
Piriformis fossa Obturator ER thigh Insertion at start
Adductor Body of pubis point of IM nail
longus (inferior)
Adductor Body and inferior Hip Adductors
brevis pubic ramus
Adductor 1. Pubic ramus Linea aspera Obturator Adducts thigh Tendon can ossify
magnus 2. Ischial tub. (mid 1⁄3)
Gracilis Body and inferior
pubic ramus Pectineal line, Obturator Adducts thigh Deep to pectineus
Pectineus linea aspera
Pectineal line of
pubis Linea aspera, 1. Obturator Adducts & flex/ Muscle has two
add. tubercle 2. Sciatic extend thigh separate parts

Prox. med. tibia Obturator Adduct thigh, Used in ligament
(pes anserinus) flex/IR leg reconstruction

Hip Flexors

Pectineal line of Femoral Flex and adducts Part of femoral tri-
femur thigh angle floor

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 267

8 Thigh/Hip • MUSCLES Iliac crest

Deep dissection Gluteal aponeurosis and
gluteus medius muscle (cut)
Superior cluneal nerves
Gluteus maximus muscle (cut) Superior gluteal artery and nerve

Medial cluneal nerves Gluteus minimus muscle
Inferior gluteal artery and nerve
Tensor fasciae latae muscle
Pudendal nerve
Nerve to obturator internus Piriformis muscle
(and superior gemellus)
Gluteus medius muscle (cut)
Posterior cutaneous
nerve of thigh Superior gemellus muscle
Sacrotuberous ligament
Greater trochanter of femur
Ischial tuberosity
Inferior cluneal nerves (cut) Obturator internus muscle

Adductor magnus muscle Inferior gemellus muscle
Gracilis muscle
Sciatic nerve Gluteus maximus muscle (cut)

Muscular branches of sciatic nerve Quadratus femoris muscle
Semitendinosus muscle (retracted)
Semimembranosus muscle Medial circumflex femoral
artery
Sciatic nerve
Articular branch Vastus lateralis muscle
Adductor hiatus and iliotibial tract
Popliteal vein and artery
Superior medial genicular artery Adductor minimus part of
Medial epicondyle of femur adductor magnus muscle

Tibial nerve 1st perforating artery (from
Gastrocnemius muscle (medial head) deep artery of thigh)

Medial sural cutaneous nerve Adductor magnus muscle
Small saphenous vein
2nd and 3rd perforating arteries
(from deep artery of thigh)

4th perforating artery (termination
of deep artery of thigh)

Long head (retracted) Biceps femoris

Short head muscle

Superior lateral genicular artery

Common fibular (peroneal) nerve

Plantaris muscle

Gastrocnemius muscle (lateral head)

Lateral sural cutaneous nerve

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT

Semitendinosus Ischial tuberosity POSTERIOR: HAMSTRINGS Extend thigh, flex Tendon used in lig-
leg ament reconstruc-
Semimembranosus Ischial tuberosity Proximal medial Sciatic tions (ACL)
Ischial tuberosity tibia (pes anse- (tibial) Extend thigh, flex
Biceps femoris: Linea aspera, rinus) leg A border in medial
long head supracondylar Extend thigh, flex approach
Biceps femoris: line Posterior medial Sciatic leg
short head Can avulse front or-
tibial condyle (tibial) Extend thigh, flex igin (avulsion fx)
leg
Head of fibula Sciatic Shares tendon in-
(tibial) sertion with long
head
Fibula, lateral Sciatic
tibia (peroneal)

268 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

MUSCLES • Thigh/Hip 8

Sartorius muscle Fascia lata Branches of femoral nerve
Deep artery and vein of thigh Femoral artery and vein
Adductor longus muscle
Pectineus muscle Great saphenous vein
Iliopsoas muscle
Rectus femoris muscle Obturator nerve (anterior branch)
Adductor brevis muscle
Vastus medialis muscle Obturator nerve (posterior branch)
Lateral cutaneous nerve of thigh Gracilis muscle

Vastus intermedius muscle Adductor magnus muscle
Femur
Sciatic nerve
Vastus lateralis muscle Posterior cutaneous nerve of thigh
Tensor fasciae latae muscle
Semimembranosus muscle
Iliotibial tract Semitendinosus muscle
Gluteus maximus muscle Biceps femoris muscle (long head)

Vastus medialis muscle Medial intermuscular septum of thigh

Rectus femoris muscle

Vastus intermedius muscle

Vastus lateralis muscle Sartorius muscle

Iliotibial tract Nerve to vastus medialis muscle
Saphenous nerve
Lateral intermuscular Femoral artery and vein in adductor
septum of thigh canal

Biceps femoris Short head Great saphenous vein
Adductor longus muscle
muscle Long head

Semitendinosus muscle Gracilis muscle
Semimembranosus muscle Adductor brevis muscle
Deep artery and vein of thigh
Rectus femoris tendon Adductor magnus muscle
Vastus intermedius muscle Posterior intermuscular septum of thigh

Iliotibial tract Sciatic nerve
Vastus medialis muscle
Vastus lateralis muscle Sartorius muscle

Articularis genus muscle Saphenous nerve and descending genicular artery
Great saphenous vein
Lateral intermuscular Gracilis muscle
septum of thigh Adductor magnus tendon

Femur Popliteal vein and artery
Biceps femoris muscle Semimembranosus muscle

Common fibular
(peroneal) nerve

Tibial nerve

Semitendinosus muscle

STRUCTURE RELATIONSHIP
COMPARTMENTS
Anterior Quadriceps: vastus lateralis, vastus intermedius, vastus medius, rectus femoris
Posterior Biceps femoris (long head and short head), semitendinosus, semimembranosus, sciatic nerve
Medial Adductor magnus, adductor longus, adductor brevis, gracilis, femoral artery and vein
FASCIOTOMIES
Lateral incision Release the anterior compartment and posterior compartment
Medial incision Release the medial compartment

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 269

8 Thigh/Hip • NERVES

Obturator nerve Obturator externus muscle
(L2, 3, 4)
Posterior branch Adductor brevis muscle
Articular branch Adductor longus muscle (cut)
Anterior branch Adductor magnus muscle
Posterior branch (ischiocondylar, or
Cutaneous branch “hamstrings,” part supplied
by sciatic [tibial] nerve)
Articular branch Gracilis muscle
to knee joint
Cutaneous
Adductor hiatus innervation

Note: Only muscles
innervated by obturator
nerve shown

LUMBAR PLEXUS

Anterior Division

Obturator (L2-4): exits via obturator canal, splits into anterior and posterior divisions. Can be injured by retractors
placed behind the transverse acetabular ligament.
Sensory: Inferomedial thigh: via cutaneous branch of obturator nerve
Motor: Gracilis (anterior division)

Adductor longus (anterior division)
Adductor brevis (anterior/posterior divisions)
Adductor magnus (posterior division)

270 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

NERVES • Thigh/Hip 8

Genitofemoral nerve T12 Femoral branch
Lateral cutaneous of genitofemoral
nerve of thigh (L2, 3) L1

Femoral nerve (L2, 3, 4) L2 Lumbar plexus
L3

Obturator nerve L4
Iliacus muscle
Lumbosacral
Psoas major muscle
(lower part) trunk Lateral cutaneous

Articular branch nerve of thigh

Sartorius muscle Anterior cutaneous
(cut and reflected) branches of
femoral nerve

Pectineus muscle

Quadriceps Rectus Sartorius Psoas major muscle
femoris femoris muscle
muscle muscle (cut and Genitofemoral nerve
(cut and reflected)
reflected) Lateral cutaneous
Saphenous nerve of thigh
Vastus nerve Femoral nerve
intermedius
muscle Genital branch and
Femoral branch of
Vastus genitofemoral nerve
medialis
muscle Obturator nerve

Vastus
lateralis
muscle

Articularis genus muscle

LUMBAR PLEXUS

Genitofemoral (L1-2): pierces psoas, lies on anteromedial surface of psoas and divides into two branches
Sensory: Femoral branch: proximal anterior thigh (over femoral triangle)

Genital branch: scrotum/labia
Motor: None (in thigh)

Posterior Division

Lateral femoral cutaneous (LFCN) (L2-3): crosses inferior to ASIS (can be compressed at or near ASIS)
Sensory: Lateral thigh
Motor: None

Femoral (L2-4): lies b/w psoas major & iliacus; branches in femoral triangle. Saphenous nerve runs under sartorius.
Sensory: Anteromedial thigh—via anterior/intermediate cutaneous nerves
Motor: Psoas

Pectineus
Sartorius
• Quadriceps

‫ ؠ‬Rectus femoris
‫ ؠ‬Vastus lateralis
‫ ؠ‬Vastus intermedialis
‫ ؠ‬Vastus medialis

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 271

8 Thigh/Hip • NERVES Greater sciatic foramen
Sciatic nerve (L4, 5, S1, 2, 3)
Posterior cutaneous
nerve of thigh Common fibular (peroneal)
(S1, 2, 3) division of sciatic nerve

Inferior cluneal Short head of Cutaneous innervation
nerves biceps femoris muscle
Perineal branches
Long head (cut)
Tibial division of biceps femoris
of sciatic nerve muscle

Long head (cut) of Common fibular Posterior
biceps femoris muscle (peroneal) nerve cutaneous nerve
Adductor magnus muscle of thigh
(also partially supplied Articular
by obturator nerve) branch

Semitendinosus muscle

Semimembranosus
muscle

Tibial nerve

Articular branch

SACRAL PLEXUS

Sciatic nerve: a single nerve with 2 distinct parts; it divides in the distal thigh into tibial & common peroneal nerves

Anterior Division

Tibial (L4-S3): descends (as sciatic) in posterior thigh deep to hamstrings and superficial to adductor magnus muscle
Sensory: None (in thigh)
Motor: Biceps femoris (long head)

Semitendinosus
Semimembranosus

Posterior Division

Common peroneal (L4-S2): descends (as sciatic) in posterior thigh deep to hamstrings and superficial to adductor
magnus
Sensory: None (in thigh)
Motor: Biceps femoris (short head)

Posterior femoral cutaneous nerve (PFCN) (S1-3): through greater sciatic foramen, medial to sciatic nerve
Sensory: Posterior thigh
Motor: None

272 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

Deep circumflex iliac artery ARTERIES • Thigh/Hip 8

Superficial External iliac artery
circumflex iliac artery Inferior epigastric artery
Superficial epigastric artery
Femoral artery Superficial external pudendal artery
Obturator artery
Ascending branch, Deep external pudendal artery
Transverse branch, Medial circumflex femoral artery
Descending branch of Femoral artery
Lateral circumflex
femoral artery Muscular branches

Deep artery of thigh Descending genicular artery
(profunda femoris) Articular branch
Saphenous branch
Perforating branches

Femoral artery passing
through adductor hiatus

ARTERY BRANCHES COMMENT

Obturator Anterior/posterior branches Runs through obturator foramen

FEMORAL ARTERY

In femoral triangle, runs in adductor canal (under sartorius, b/w vastus medialis & adductor longus), then passes poste-
rior through the adductor hiatus and becomes the popliteal artery posterior to the distal femur and knee.

Femoral artery Superficial circumflex iliac Supplies superficial abdominal tissues
(superficial fem. [(SFA]) Superficial epigastric Supplies superficial abdominal tissues
Superficial and deep Supplies subcutaneous tissues in pubic region
external pudendal and scrotum/labia majus
Profunda femoris (deep artery) Primary blood supply to thigh. See below
Descending genicular artery Anastomosis at knee to supply knee
Articular branch
Saphenous branch

Profunda femoris (deep Medial femoral circumflex Supplies femoral neck, under quad. femoris
artery of thigh) Lateral femoral circumflex Supplies femoral neck
Ascending branch Forms anastomosis at femoral neck
Transverse branch To greater trochanter
Descending branch At risk in anteromedial approach to hip
Perforators/muscular branch Supplies femoral shaft and thigh muscles

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 273

8 Thigh/Hip • ARTERIES

Anterior view Posterior view

Subsynovial intracapsular Acetabular Subsynovial intracapsular
arterial ring branch of arterial ring
obturator artery
Retinacular Superior (often minute) Superior Retinacular
Posterior arteries
arteries Anterior Inferior (subsynovial)

(subsynovial) Inferior

Anastomosis be- lliopsoas Medial Anastomosis
tween medial and tendon circumflex
lateral circumflex femoral Ischiofemoral
femoral arteries Medial circumflex artery ligament and
femoral artery joint capsule
Extracapsular ring
Deep artery Lateral Extracapsular
lliofemoral (Y) ligament of thigh circumflex ring
and joint capsule femoral artery
Nutrient artery Nutrient artery
Ascending, of femur of femur
Transverse,
Descending branches of
Lateral circumflex femoral artery

ARTERY COURSE COMMENT/SUPPLY

ARTERIES OF THE FEMORAL NECK

Profunda Femoris

Medial femoral circumflex Between pectineus and psoas, Main blood supply to adult femoral head
(MFCA) then posterior to femoral neck Major contributor to extracapsular ring/anastomosis
under quadratus femoris

Lateral femoral circumflex Deep to sartorius & rectus fem. Less significant blood supply in adult femoral head
Ascending branch Ascends anterior femoral neck Major contributor to extracapsular ring/anastomosis
Transverse branch Across proximal femur to GT Gives partial supply to greater trochanter (GT)
Descending branch Under rectus femoris At risk in anterolateral approach to hip

1st Perforator Ascending branch Can contribute to extracapsular ring/anastomosis

Extracapsular ring—formed at the base of the femoral neck primarily from branches of MFCA and LFCA

Lateral branches From ring, laterally toward GT Supply greater trochanter

Ascending cervical arteries Along extracapsular femoral neck Branch from the extracapsular ring
Intracapsular continuation of cervical arteries
Retinacular arteries Along intracapsular femoral neck Form a second intracapsular ring at base of head

Subsynovial intracapsular arterial ring—formed at the base of the femoral head

Epiphyseal arteries Enter bone at border of articular Will form intraosseous anastomoses
Lateral epiphyseal art. surface In posterosuperior neck Lat. epiphyseal supplies most of WB femoral head

Obturator Artery

Artery of ligamentum teres Thru ligamentum teres to fovea Minimal supply to the adult femoral head
Medial epiphyseal art. Interosseous terminal branches Anastomose with lateral epiphyseal arteries

Other Arteries

Superior & inferior gluteal Can contribute to extracapsular ring/anastomosis

Pediatric femoral head blood supply: 0-4yr MFCA, LFCA, and ligamentum teres artery; 4-8yr: mostly MFCA, minimal
LFCA and ligamentum teres artery; Ͼ8yrs: MFCA is predominant

274 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

Lateral femoral DISORDERS • Thigh/Hip 8
cutaneous nerve
Arrows show the presence
Entrapment of nerve of buttressing and sclerosis
under inguinal ligament in the femoral neck

Coronal MRI reveals bilateral fatigue
fractures (arrows) in the femoral neck

Reprinted with permission from
Resnick D. Kransdorf M. Bone and Joint Imaging,
3rd edition, Elesevier, Philadelphia, 2005.

DESCRIPTION Hx & PE WORKUP/FINDINGS TREATMENT

• Subtle abnormal hip FEMOROACETABULAR IMPINGEMENT 1. NSAIDs, activity modifi-
morphology causes bony cation
abutment. 2 types Hx: Insidious onset, groin XR: AP/lateral of hip
‫ ؠ‬Cam: femoral non- pain, worse with activity Cam: femoral neck 2. Surgical dislocation and
sphericity PE: Decreased ROM (esp. “bump,” ϩ/Ϫ herniation neck and/or acetabular
‫ ؠ‬Pincer: acetabulum IR),ϩ impingement test pit, decreased offset reshaping
overcoverage (flex, add, IR hip) Pincer: increased acetabu-
lar coverage 3. Osteotomy in selected
• Causes early DJD MR: Labral tear, chondral cases
injury
• Excessive loading of hip 4. THA if advanced DJD
• 2 types: tension (superior FEMORAL NECK STRESS (FATIGUE) FRACTURE
• Compression: limited
neck), compression Hx: Increased activity with XR: AP, AP in IR, lateral weight-bearing
(inferior neck) new onset of hip/groin MR: Best study for early
• Common in military pain detection of fracture • Tension: urgent percuta-
recruits PE: ϩ/Ϫ pain with and/or BS: Shows fx subacutely neous pinning (prevent
diminished ROM displacement)
• Nerve trapped near ASIS
• Due to activity (hip ex- MERALGIA PARESTHETICA 1. Remove compressive
entity (e.g., belt, tight
tension), clothing (e.g., Hx: Pain/burning in lateral XR: AP/lateral of hip: rule clothing, etc.)
belt), or repetitive com- thigh out other pathology
pression PE: Decr. sensation on lat- 2. Surgical release: rare
eral thigh, ϩ meralgia
Snapping in hip. 3 types External/Internal:
1. External: ITB over GT SNAPPING HIP (COXA SALTANS) 1. Activity modification, PT
2. Internal: psoas over 2. Consider injection
Hx: Snapping at hip XR: AP/lateral hip: rule out 3. Surgical release: very
femoral head or iliopec- ϩ/Ϫ pain osseous abnormality
tineal eminence (e.g., spur) and hip DJD rare
3. Intraarticular: usually PE: Palpate the tendon (ITB MR: Loose body, labral tear Intraarticular: LB removal
loose body or psoas tendon) then flex US/bursography: Psoas
& extend hip, feeling for tendon 1. NSAIDs, PT (ITB
• Inflammation of bursa snap. (external over GT; stretching)
over greater trochanter internal over LT)
2. Steroid injection
• FϾM, middle age TROCHANTERIC BURSITIS 3. Surgical excision—rare

Hx: Lateral hip pain, cannot XR: AP pelvis, AP/lateral of
sleep on affected side hip: rule out spur, OA,
PE: Point tender at tro- calcified tendons
chanter, pain w/adduction

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 275

8 Thigh/Hip • DISORDERS

Osteoarthritis

Advanced degenerative
changes in acetabulum

Erosion of cartilage and
deformity of femoral head

Radiograph of hip shows
typical degeneration of
cartilage and secondary
bone changes with spurs at
margins of acetabulum

DESCRIPTION Hx & PE WORKUP/FINDINGS TREATMENT

• Loss or damage to ar- OSTEOARTHRITIS 1. NSAIDs/PT
ticular cartilage 2. Injection/activity modi-
Hx: Chronic hip or groin XR: AP pelvic/AP/lateral hip
• Etiology: Primary— pain, increasing over 1. Joint space narrowing fication, cane (in
idiopathic; Secondary— time & with activity 2. Osteophytes opposite hand)
posttraumatic, infection, PE: Decreased ROM (first 3. Subchondral sclerosis 3. Osteotomy (young)
pediatric hip disease IR), ϩ log roll, ϩ/Ϫ flex 4. Bony cysts 4. Arthrodesis (young)
contracture/antalgic gait 5. Total hip arthroplasty

OSTEONECROSIS (AVASCULAR NECROSIS/AVN) Stage:
0-1: Limited WB, obser-
• Necrosis of femoral Hx: Groin pain worse Classification: Modified Ficat vation
head due to vascular with activity 0: Asymptomatic, nl XR, ϩ MR 2: Core decompression
disruption PE: Limited ROM (esp IR 1: Symptomatic, nl XR, ϩ MR 3: Consider vascularized
& abd), antalgic gait 2: XR: sclerosis, no collapse fibula or femoral oste-
• Assoc. w/trauma, ste- XR: AP/lateral: stage- 3: XR: ϩ collapse (crescent otomy
roid or EtOH use, in- specific findings (see 4-6: Total hip arthro-
flammatory disorders. classification) sign) plasty—appropriate for
MRI: Most sensitive study, 4: Flat femoral head, nl ace- most patients. Hip fu-
• MϾF, 30-40’s, 50% shows early changes in sion: in young laborers
bilateral femoral head tabulum
BS: Replaced by MRI 5: Joint narrowing, early DJD
• Greater femoral head 6: Advanced DJD incl. acetab-
involvement, associated ulum
w/poor prognosis

276 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

DISORDERS • Thigh/Hip 8

35° to
45°

Reamers of increasing

size used to enlarge

acetabulum to fit

Reamer of appropriate size inserted acetabular cup of Final position of cup 35° to 45° lateral
and acetabulum reamed to receive
acetabular component preselected size inclination and 15° anteversion

TOTAL HIP ARTHROPLASTY

General Information

• Goals: alleviate pain, maintain personal independence, allow performance of activities of daily living (ADLs).
• Common procedure with high satisfaction rates for primary procedure; revisions are also becoming more common.
• Advances in techniques and materials are improving implant survival; this procedure available to younger pts.

Materials

• Cups (acetabulum) and stems (femur). Usually made of titanium. Stainless steel or cobalt chrome stems may be too
stiff (i.e., modulus mismatch) and cause stress shielding.

• Bearing surfaces: Acetabular liners and femoral head implants. Polyethylene (PE) liner and cobalt-chrome (Co-Cr)
femoral head currently most common. Ceramic and metal also used.
‫ ؠ‬UHMWPE (ultra high molecular weight PE): good surface, but high wear rates and debris lead to aseptic loosening.
Direct compression molding is preferred manufacturing technique. Sterilization with irradiation in nonoxygen environ-
ment promotes cross-linking. Highly cross-linked PE has much better wear rates.
‫ ؠ‬Co-Cr: “supermetal” alloy. Commonly used for femoral bearing surface with PE liner. Metal on metal implants avail-
able. Debris particles are much smaller, create less histocytic response. Carcinogenesis is a theoretic concern.
‫ ؠ‬Ceramic (alumina): Excellent wear rates, but brittle (could fracture). Can be used with PE liner or ceramic cup.

Techniques

• Two types of fixation: 1. Cement, 2. Uncemented/biologic
‫ ؠ‬Cement: Methylmethacrylate. Most often used in elderly patients. Provides immediate static fixation, no remodeling
potential. Cement resists compression better than tension. As such, femoral implants do better than acetabular cups
with this fixation. 3rd generation cementing techniques: pressurization, precoat stem, centralizer/restrictor, canal
preparation, 2mm mantle
‫ ؠ‬Uncemented/biologic: Used in younger patients (increasing popularity). Bone ongrowth or ingrowth—bone grows
onto/into implant. Has remodeling potential, gives dynamic fixation. Not good a good choice in post-irradiated hip.

• Fixation is NOT immediate, needs initial fixation for stability: 2 techniques.
‫ ؠ‬Press fit: Implant 1-2mm larger than bone. Bone hoop stresses provide initial fixation while bone on/ingrows.
‫ ؠ‬Line to line: Implant and bone are same size. Screws used to provide initial fixation while bone on/ingrows.

• Optimal porous ongrowth pore size: 50-150 micrometers. Ongrowth surface area varies.
• Current gold standard implant: Uncemented (ingrowth) acetabular cup and cemented femoral steel. Trends are chang-

ing, and more uncemented femoral components and alternative bearing surfaces are being used more frequently.
• Head size affects stability (larger is more stable) and wear (large head ϭ high volumetric wear). 28mm is optimal size.

Indications

• Arthritis of hip

‫ ؠ‬Common etiologies: osteoarthritis, rheumatoid arthritis, osteonecrosis, prior pediatric hip disease

‫ ؠ‬Clinical symptoms: groin/hip pain, worse with activity, gradually worsening over time, decreased functional capacity

‫ ؠ‬Radiographic findings: appropriate radiographic evidence of hip arthritis should be present

Osteoarthritis Rheumatoid arthritis

1. Joint space narrowing 1. Joint space narrowing

2. Sclerosis 2. Periarticular osteoporosis

3. Subchondral cysts 3. Joint erosions

4. Osteophyte formation 4. Ankylosis

‫ ؠ‬Failed conservative treatment: NSAIDs, activity modification, weight loss, PT, cane (contralateral hand), injections

‫ ؠ‬Other: Fractures (e.g., femoral neck with hip DJD), tumors, developmental disorders (e.g., DDH, etc)

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 277

8 Thigh/Hip • DISORDERS

Femoral preparation: Trial prosthesis inserted Reduction of hip with
Rasp in shape of stem of into femoral canal to ensure prosthesis in place.
trial prosthesis used to fit (its collar flush with cut
complete channel. surface of femoral neck)

TOTAL HIP ARTHROPLASTY—CONTINUED

Contraindications

• Absolute
‫ ؠ‬Neuropathic joint
‫ ؠ‬Infection
‫ ؠ‬Medically unstable patient (e.g., severe cardiopulmonary disease). Patient may not survive the procedure.

• Relative
‫ ؠ‬Young, active patients. These patients can wear out the prosthesis many times in their lives.

Alternatives

• Considerations: age, activity level, overall medical health
• Osteotomy: femoral or pelvic; usually performed in younger patients
• Arthrodesis/fusion: young laborers with isolated unilateral disease (i.e., normal spine, knee, ankle, contralateral hip)

Procedure

• Approaches
‫ ؠ‬Posterior, lateral, and anterolateral approaches
‫ ؠ‬Minimally invasive, one- and two-incision approaches are becoming more common.

• Steps
‫ ؠ‬Acetabulum: remove labrum & osteophytes, ream to a cortical rim, implant cup (35-45° coronal tilt, 15-30°
anteversion)
‫ ؠ‬Femur: dislocate head, cut neck, remove head, find and broach canal (lateralize as needed)—stem cannot be in
varus, implant stem, trial head, & neck. Implant the appropriate head/neck and acetabular liner.

Complications

• Infection: Diagnose with labs and aspiration. Prevention is mainstay: perioperative antibiotics, meticulous prep/drape
technique, etc. Acute/subacute: irrigation & debridement with PE exchange. Late: one- or two-stage revision.

• Loosening: Patient often complains of “start up” pain. Radiolucent lines seen on plain radiographs. Most often caused
by osteolysis. Osteolysis caused from macrophage response to submicron-sized wear particles (usually PE).

• Dislocation: Can be caused from component (either femur or acetabulum) malalignment or soft tissue injury/
dysfunction. Decreased in posterior approach when short external rotators are repaired during closure.

• Neurovascular injury
‫ ؠ‬Sciatic nerve: peroneal division (resulting in foot drop) at risk from vigorous retraction in posterior approach
‫ ؠ‬Femoral nerve: with vigorous retraction in anterolateral approach
‫ ؠ‬Obturator vessels: under the transverse acetabular lig., injured with retractors or anteroinferior quadrant cup screw
‫ ؠ‬External iliac vessels: at risk if cup screw placed in anterosuperior quadrant (posterosuperior quadrant is safe)
‫ ؠ‬Medial femoral circumflex artery: under quadratus femoris, at risk in posterior approach if muscle is taken down

• Heterotopic ossification: Usually in predisposed patients. Can cause decreased ROM. One dose of XRT can prevent it.
• Medical complications: Deep venous thrombosis (DVT) & pulmonary embolus (PE) known risk of THA. Prophylaxis

must be initiated.
• Periprosthetic fracture of femur

‫ ؠ‬Stable implant: ORIF (plates, cables, ϩ/Ϫ bone graft).
‫ ؠ‬Unstable implant: replace with longer stem that passes fx site.

278 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

PEDIATRIC DISORDERS • Thigh/Hip 8

Development dysplasia of hip

Normal Hip dislocation

Anterior inferior Perkins’ Triradiate cartilage False
iliac spine vertical acetabulum
line

Line of acetabular roof

Acetabular >30°
index <30°

Average Radiograph of 15 month old

in newborn 27.5° with DDH showing classic

Hilgenreiner’s horizontal line H N S H shortened; signs: increased acetabular
S femoral index, a broken Shenton’s line
H = Hilgenreiner’s line as a S neck may and a false acetabulum.
horizontal line thru the
tri-radiate cartilage be above

D = Perkin’s line is a vertical Hilgenreiner’s
line thru the lateral edge of
the acetabulum line

N = ossification center of D Femoral Anteversion
femoral head, should be in Internal Femoral Torsion
inner lower quadrant.
Testing
S = Shenton’s curved line (broken for
in hip dislocation)
femoral
Pavlik harness torsion

Harness adjusted to In standing With feet turned max- With feet turned max-
allow comfortable position, imally inward, knees imally outward, knees
abduction within safe knees and point directly medially so rotate only slightly
zone. Forced abduction feet point that they face each other beyond neutral position
beyond this limit may inward
lead to avascular
necrosis of femoral head.
Posterior strap serves as
checkrein to prevent
hip from adducting to
point of redislocation.

DESCRIPTION EVALUATION TREATMENT

DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)

• Abnormal hip development result- Hx: Usually unnoticed by parents. Obtain & maintain concentric
ing in dislocation, subluxation, or ϩ/Ϫ risk factors
laxity of hip PE: Barlow (dislocation), ϩ Ortolani reduction:
(relocation), ϩ/Ϫ Galeazzi test & de- ‫ ؠ‬0-6mo: Pavlik harness
• Most from capsular laxity & posi- creased abduction ‫ ؠ‬6-24mo: Closed reduction, spica
tioning; irreducible teratologic form XR: Useful after 6mo (femoral head
seen in congenital syndromes or begins to ossify). Look for position cast; open reduction if CR fails
neuromuscular diseases. in acetabulum. Multiple radiographic ‫ ؠ‬2-4yr: Open reduction with or
lines help evaluate hip.
• Risk factors: female, breech, first US: Useful in neonate. Alpha angle without femoral osteotomy
born, family hx, decreased uterine Ͼ60 is nl. ‫ ؠ‬Ͼ4yr: Acetabular osteotomy; ter-
space conditions
atologic hips need open treat-
• Early diagnosis and treatment
essential ment

COMPLICATIONS: Osteonecrosis of femoral head: can occur during reduction or from nonanatomic positioning postreduction.

FEMORAL ANTEVERSION

• Internal rotation of femur, femoral Hx: Usually presents 3-6yr 1. Most spontaneously resolve
anteversion does not decrease
properly PE: Femur IR (IRϾ65°), patella points 2. Derotational osteotomy if it persists

• #1 cause of intoeing medial, intoeing gait past age 10 (mostly cosmetic)

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 279

8 Thigh/Hip • PEDIATRIC DISORDERS

Slipped Capital Femoral Epiphysis Slipped Capital Femoral Legg-Calve-Perthes Disease
Epiphysis:
Best diagnostic sign is
physical examination. Operative Fixation
With patient supine, as
thigh is flexed it rolls
into external rotation
and abduction

Frog-leg radiograph, Threaded cannulated screw
which demonstrates introduced over guide wire
slipped epiphysis
more clearly, always Young girl walking in Atlanta Scottish Rite
indicated when Children’s Hospital brace. Advantages of
disorder is suspected brace: allows child to walk without support,
allows for further abduction by telescoping
bar, and permits free knee and ankle motion

DESCRIPTION EVALUATION TREATMENT

LEGG-CALVE-PERTHES DISEASE

• Idiopathic osteonecrosis of femoral Hx: Boys (4:1), usually 4-8y.o. Limp • Goals: 1. Relieve pain symptoms;
head with hip, thigh, or knee pain. No 2. Maintain/obtain full ROM;
trauma. 3. Contain femoral head
• Femoral head must revascularize, PE: Decr. ROM (esp. IR & abduction)
can take 2-5yr to complete XR: AP/lateral hip: sclerosis in early • Traction, reduced weight-bearing
stages. “Crescent sign” sign of sub- • ROM: rest, traction, ϩ/Ϫ therapy
• Prognosis good with onset Ͻ6yo chondral collapse/fx • Osteotomy: femoral or acetabular
& minimal lat. pillar involvement MR: Will show early necrosis when
plain x-rays are still normal. usually reserved for older patients
• Catterall & Herring classifications
• Poor healing results in hip OA as

adult

SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)

• Displacement (“slip”) of femoral Hx: 10-16y.o., obese, limp, hip or • Percutaneous in situ screw fixation
epiphysis through the proximal knee pain, ϩ/Ϫ weight bear (WB) • One cannulated screw is gold stan-
physis PE: Decr. ROM (esp. IR), hip ER with
flexion, antalgic gait (if able to WB) dard
• Classification: Stable: able to bear XR: AP/lateral: BOTH hips, will show • Progressive slip may still occur
weight (WB); Unstable: unable to WB slip; Klein’s line should intersect • Forceful reduction NOT recom-
epiphysis. Graded on percent of
• Associated with obesity, renal & epiphysis that slipped: Gr 1:Ͻ33%, mended
thyroid disease Gr 2: 33-50%, Gr 3: Ͼ50% • Prophylactic pinning of contralateral

• Epiphysis is usually posterior to side is common and supported
neck but remains in acetabulum.

COMPLICATIONS: Osteonecrosis (50% in unstable slips), chondrolysis, early osteoarthritis

TRANSIENT SYNOVITIS

• Aseptic hip effusion of unknown Hx: Ages 2-5y.o., MϾF, insidious on- • Aspirate hip under anesthesia with
cause set limp fluoroscopy if PE & labs indicate
PE: Decreased ROM (esp. abd), antal- infection
• May be caused by post viral syn- gic gait
drome or overuse XR: r/o other hip pathology • Septic hip requires I&D and antibi-
LABS: CBC, ESR, blood culture otics
• Common cause of hip pain & limp US: Evaluate for effusion (if suspect
• Diagnosis of exclusion, r/o septic septic hip) • Transient synovitis resolves: 2-10
days
hip
• Observation, rest, ϩ/Ϫ NSAIDs

280 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

SURGICAL APPROACHES • Thigh/Hip 8

Anterior Approach to Hip

Gluteus medius Sartorius
(retracted)

Rectus femoris

Ascending br.
lateral femoral
circumflex artery
and vein

Tensor fasciae
latae (retracted)

Sartorius Anterior capsule
(retracted)
Rectus femoris (cut)
Ascending br. lateral femoral
circumflex artery and vein

Rectus femoris (cut)

Tensor fasciae Femur
latae (retracted) Anterior capsule

Gluteus medius
(retracted)

USES INTERNERVOUS PLANE DANGERS COMMENT

Open reduction ANTERIOR (SMITH-PETERSON) APPROACH TO HIP • Retract LFCN anteriorly
‫ ؠ‬Pediatric congenital • Ascending branch of
hip dislocation Superficial • Lateral femoral
‫ ؠ‬Adult anterior dislo- • Sartorius (femoral nerve) cutaneous n. LFCA must be ligated in
cations • Tensor fasciae latae (SGN) approach
• Femoral nerve • Take down both heads of
Irrigation & debridement Deep • Ascending branch rectus femoris to expose
Fractures: anterior femo- • Rectus femoris (femoral n.) joint
ral head (ORIF) • Gluteus medius (SGN) of lateral femoral • Vigorous medial retrac-
Hemiarthroplasty circumflex artery tion can injure femoral
Tumor excision nerve
MEDIAL (LUDLOFF) APPROACH TO HIP
Pediatric hip dislocation • Used most in pediatric
Adductor or psoas re- Superficial: Intermuscular plane • Obturator nerve cases
lease • Adductor longus (obturator n.) (ant. division)
Irrigation & debridement • Gracilis (obturator n.) • Good access to trans-
• Medial femoral cir- verse acetabular liga-
Deep cumflex artery ment & psoas tendon,
• Adductor brevis (obturator n.) which can block closed
• Adductor magnus (obturator & • Obturator nerve hip reduction. Poor ac-
(post. division) cess to acetabulum.
sciatic n.)
• External pudendal
artery (proximally)

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 281

8 Thigh/Hip • SURGICAL APPROACHES

Anterolateral (Watson-Jones) Approach to Hip Joint

Anterior capsule
Rectus femoris

Tensor fasciae latae

Gluteus medius Vastus lateralis
Greater trochanter

Lateral (Transtrochanteric) Approach to Hip Joint

Incision Gluteus maximus Gluteus medius
site (retracted) (split and retracted)

Greater Femoral head
trochanter
Joint capsule
Fascia
lata

Gluteus Greater Gluteus medius
maximus
trochanter (split and retracted)

Joint Tensor fasciae
capsule latae

Femoral Vastus
head lateralis
Acetabulum

USES INTERNERVOUS PLANE DANGERS COMMENT

• Total hip arthro- ANTEROLATERAL (WATSON-JONES) APPROACH TO HIP
plasty
Intermuscular plane • Descending branch of • Must detach abductors (either oste-
• Hemiarthroplasty • Tensor fasciae latae LFCA (under rectus otomy or extensive release)
• ORIF of proximal femoris)
(SGN) • Vigorous medial retraction can injure
femur fxs • Gluteus medius (SGN) • Femoral nerve femoral nerve

• Total hip arthro- LATERAL (HARDINGE) APPROACH TO HIP
plasty (not used
for revisions) • Split gluteus medius • Superior gluteal artery • No osteotomy of greater trochanter
(superior gluteal n.) • Femoral nerve required; less dislocation risk
• Femoral artery & vein
• Split vastus lateral n. • Superior gluteal nerve • Split gluteus medius 1⁄3 anterior, 2⁄3
distally (femoral n.) posterior; release minimus

282 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

SURGICAL APPROACHES • Thigh/Hip 8

Posterior (Southern) Approach to Hip Joint

Incision Gluteus maximus
site muscle (retracted)

Short external Piriformis
rotators
Gluteus
Superior gemellus medius
Obturator (retracted)
internus
Inferior gemellus Joint
capsule
Gluteus
maximus
(retracted)

Gluteus Sciatic Sciatic Greater
maximus nerve nerve trochanter
(split and
retracted) Quadratus Medial femoral
femoris circumflex artery
and obturator
externus

Greater
trochanter

Posterior Short external
rotators

Femoral head
Anterior

USES INTERNERVOUS PLANE DANGERS COMMENT

• Total hip arthroplasty POSTERIOR (MOORE/SOUTHERN) APPROACH TO HIP • Reflecting piriformis pro-
• Hemiarthroplasty tects sciatic nerve
• Fractures/ORIF Split gluteus maximus • Sciatic nerve
• Posterior hip dislocation (inferior gluteal n.) • Inferior gluteal artery • IGA injured in proximal
• Medial femoral circum- extension

flex artery (under qua- • Repair short ERs to pre-
dratus femoris) vent dislocation

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 283

8 Thigh/Hip • SURGICAL APPROACHES

Lateral Approach to Thigh (Femur) Hip Arthroscopy Portals

Vastus lateralis Femur
(split and retracted)

Vastus lateralis Posterolateral Anterolateral
(split and portal portal
retracted)

Periosteum
(opened)

Femur

Incision may be
extended proximally
and distally to
expose entire femur

Incision site Fascia lata Anterior
portal

Vastus
lateralis

USES INTERNERVOUS PLANE DANGERS COMMENT

THIGH FASCIOTOMIES

See page 269.

LATERAL APPROACH TO THIGH

• Fractures Split vastus lateralis (femo- • Descending branch of lateral • Incision can be large or small;
• Tumors ral nerve) or elevate it off femoral circumflex artery made along line between greater
intermuscular septum trochanter and lateral condyle
• Perforates from profunda
femoris • Arteries (at left) encountered or
require ligation
• Superior lateral geniculate a.

HIP ARTHROSCOPY PORTALS

• Arthroscopy used for diagnosis, labral tears, loose body removal, synovectomy, irrigation, and debridement

Anterior Intersection of vertical line 1. Lateral femoral cutaneous n. Second portal. Angle 45° cephalad,
from ASIS and horizontal 2. Femoral nerve 30° to midline. Pierce sartorius &
line from tip of GT 3. Ascending branch of LFCA rectus before capsule

Anterolateral Anterior tip of greater 1. Superior gluteal nerve Safest portal, establish 1st. Pierce
trochanter (GT) gluteus medius & lateral capsule

Posterolateral Posterior tip of greater 1. Sciatic nerve Last portal. Pierce gluteus medius/
trochanter (GT) minimus

• Long cannulae, arthroscope, instruments, and traction are needed for hip arthroscopy.

284 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

Topographic Anatomy CHAPTER 9
Osteology
Radiology Leg/Knee
Trauma
Joints 286
Minor Procedures 287
History 290
Physical Exam 292
Origins and Insertions 296
Muscles 306
Nerves 307
Arteries 308
Disorders 314
Pediatric Disorders 315
Surgical Approaches 320
322
323
332
335

9 Leg/Knee • TOPOGRAPHIC ANATOMY

Quadriceps Vastus Gracilis Biceps femoris
vastus lateralis medialis tendon muscle
muscle muscle
Long head
Iliotibial Quadriceps Short head
tract tendon
Popliteal
Lateral Patella Great fossa
retinaculum saphenous
Medial vein Gastrocnemius
Lateral retinaculum muscle
joint line Semi-
Medial membranosus Medial head
Fibular joint line muscle Lateral head
head (superficial
Patellar posterior
Fibularis tendon compartment)
(peroneus)
longus Tibial Small
muscle tuberosity saphenous
vein
Gerdy’s Great saphenous Lateral
tubercle vein compartment

Tibialis Pes anserinus Fibularis
anterior muscle and bursa (peroneus) longus
Lateral and brevis tendons
compartment Anterior border
of tibia Lateral malleolus
Anterior
compartment Calcaneal
(Achilles)
Lateral tendon
malleolus
Medial
malleolus

Medial malleolus

STRUCTURE CLINICAL APPLICATION
Iliotibial tract (band) Tightness can cause lateral knee and/or thigh pain.
Quadriceps muscle Atrophy can indicate an injury and/or contribute to knee pain.
Quadriceps tendon Can rupture with eccentric loading. Defect is palpated here.
Patella Tenderness can indicate fracture; swelling can be prepatellar bursitis.
Patellar tendon Can rupture with eccentric loading. Defect is palpated here.
Patellar retinaculum Patellar femoral ligaments palpated here. They can be injured in patellar dislocation.

Joint line Plicae can also be palpated here.
Tibial tubercle Tenderness here can indicate meniscal pathology.
Pes anserinus & bursa Tender in Osgood-Schlatter disease.
Gerdy’s tubercle Insertion of medial hamstrings. Bursitis can develop. Site of hamstring tendon harvest.
Popliteal fossa Insertion of the iliotibial tract (band).
Muscle compartments Popliteal artery pulse can be palpated here.
Will be firm or tense in compartment syndrome. Anterior most common.

286 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

OSTEOLOGY • Leg/Knee 9

Lateral Adductor Lateral
epicondyle tubercle epicondyle

Lateral Medial Lateral
condyle epicondyle condyle

Medial
condyle

Trochlear groove Intercondylar fossa
Superior pole
Odd facet Lateral facet

Anterior

Medial facet Lateral facet

Medial facet Posterior

Inferior pole

Anterior view Posterior view Superior view

CHARACTERISTICS OSSIFY FUSE COMMENTS

• Distal femur—2 condyles DISTAL FEMUR
‫ ؠ‬Medial: larger, more posterior
‫ ؠ‬Lateral: more ant. & proximal Secondary • Condyles: rounded posteriorly (for flexion) and flat
Distal Birth 19yr anteriorly (for standing)
• Trochlear groove: a depression physis ‫ ؠ‬Epicondyle: origin of collateral ligaments
between the condyles anteriorly ‫ ؠ‬Epicondylar axis and/or post. condylar axis
for patella articulation used to determine femur rotation (e.g., in TKA)

• Intercondylar notch: between • Sulcus terminale: groove in lateral condyle. Infe-
condyles, site of cruciate origins rior to groove, it is weight-bearing portion of
condyle.
• Ovoid shaped, inf. & sup. poles
• Triangular in cross section • Adductor tubercle: insertion of adductor magnus
• 2 facets (larger lateral & medial) • Distal femoral physis: grows approx. 7mm/yr

separated by a central ridge PATELLA
‫ ؠ‬Each facet is subdivided into
Primary 3yr 11-13yr • Largest sesamoid bone in body
superior, middle, inferior facets (single center) • Bipartite patella: failure of superolateral portion
‫ ؠ‬Odd facet (7th sub-facet) is
to fuse. It is often confused with a fracture.
far medial on medial facet • Functions: 1. Enhances quadriceps pull (as

fulcrum); 2. Protects knee; 3. Enhances knee
lubrication
• Contact point on patella moves proximally
w/flexion
• Odd facet articulates in deep flexion
• Has thickest articular cartilage (up to 5mm)

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 287

9 Leg/Knee • OSTEOLOGY

Bones of Anterior view Posterior view
right leg
Intercondylar eminence
Intercondylar eminence

Lateral intercondylar Lateral intercondylar Medial intercondylar tubercle
tubercle tubercle
Anterior intercondylar Medial intercondylar
area (ACL insertion) tubercle Posterior Superior articular surfaces
Lateral condyle intercondylar (medial and lateral facets)
Apex, Medial area
Head, condyle (PCL fovea) Lateral condyle
Neck Gerdy’s tubercle
of fibula (insertion of Soleal line Apex,
iliotibial tract) Head,
Lateral surface Oblique line Interosseous Neck of fibula
border Groove for insertion of
Anterior border Tibial tuberosity Posterior semimembranosus
surface tendon
Interosseous border Lateral surface
Nutrient foramen
Medial surface Anterior border
Posterior surface
Interosseous
border Medial border Medial crest
Medial surface

Medial border

Tibia Lateral surface

Fibula Tibia Groove for tibialis
posterior and
Lateral malleolus Medial flexor digitorum Fibula
malleolus longus tendons
Posterior
Medial border
malleolus Fibular notch

Articular facet of Articular facet of Articular facet of Lateral malleolus
lateral malleolus medial malleolus medial malleolus
Malleolar fossa of
lateral malleolus

Inferior articular surface (plafond) Inferior articular surface (plafond)

CHARACTERISTICS OSSIFY FUSE COMMENTS
18 yr
• Long bone characteristics TIBIA 18-20yr • Lateral plateau fx more common
• Proximal end: plateau (canc.) • Osgood-Schlatter: traction apophysi-
Primary: Shaft 7wk 20yr
‫ ؠ‬Medial plateau: concave (fetal) 18-22yr tis at open tibial tubercle apophysis
‫ ؠ‬Lateral plateau: convex • Tubercle: patellar tendon insertion
‫ ؠ‬7-10° posterior slope Secondary 9mo • IM nail insertion point proximal to
• Tubercle: 3cm below joint line 1. Proximal epiphysis 1yr
• Eminence: medial & lateral 2. Distal epiphysis tibial tubercle
tubercles (spines) 3. Tibial tuberosity • Tibial spine avulsion fx of ACL (peds)
• Shaft: triangular cross section • Gerdy’s tubercle on proximal tibia:
• Distal end: pilon (cancellous) Primary: Shaft FIBULA
‫ ؠ‬Articular surface: plafond insertion site of iliotibial tract (band)
‫ ؠ‬Distal tip: medial malleolus 7wk • Fibularis incisura: lat. groove for fibula
(fetal) • Plafond is roof and medial malleolus
• Long bone characteristics
• Proximal end: head Secondary is medial wall of ankle mortise
1. Proximal epiphysis 1-3yr
‫ ؠ‬Neck 2. Distal epiphysis 4yr • LCL & biceps femoris insert on head
• Shaft: long, cylindrical • Neck has groove for peroneal nerve
• Distal end: lateral malleolus • Nerve can be injured in fibula fx
• Shaft used for vascularized BG
• Lat. mal. is lat. wall of ankle mortise

288 NETTER’S CONCISE ORTHOPAEDIC ANATOMY

OSTEOLOGY • Leg/Knee 9

Posterior ligament of fibular head

Apex Superior view Posterior intercondylar area (origin
Posterior of posterior cruciate ligament)
Head Intercondylar eminence

Fibula Tibia

Anterior ligament Medial condyle
of fibular head
Superior articular surface (medial facet)
Lateral condyle
Medial
Superior articular Lateral Intercondylar tubercles
surface (lateral facet) Tibial tuberosity

Anterior

Anterior intercondylar area (origin
of anterior cruciate ligament)

LOWER EXTREMITY ALIGNMENT 3˚

Definitions 6˚ Vertical
axis
Anatomic axis Line drawn along the axis of the Femoral
of femur femur anatomic Knee axis
Anatomic axis Line drawn along the axis of the axis 87˚
of tibia tibia
Mechanical axis Line drawn between center of fem- Femoral Tibial
of femur oral head and intercondylar notch mechanical mechanical and
Mechanical axis Line drawn between center of knee axis anatomic axis
of tibia and center of ankle mortise
Knee axis Line drawn along inferior aspect 81˚ 87˚
of both femoral condyles
Vertical axis Vertical line, perpendicular to the
ground
Lateral distal Angle formed between knee axis
femoral angle and femoral axis laterally
Medial tibial angle Angle formed between knee axis
and tibial axis

Relationships

Knee axis Parallel to the ground and perpen-
dicular to vertical axis
Mechanical axis Average of 6° from anatomic axis
of femur Approximately 3° from vertical axis
Mechanical axis Normally same as anatomic axis of
of tibia tibia unless tibia has a deformity
Lateral distal 81° from femoral anatomic axis
femoral angle 87° from femoral mechanical axis
Medial proximal 87° from tibial mechanical axis
tibial angle

NETTER’S CONCISE ORTHOPAEDIC ANATOMY 289