Page 242 - Clinical Anatomy

ECA4 7/18/06 6:47 PM Page 227

The bones and joints of the lower limb 227

The synovium of the hip covers the non-articular surfaces of the joint and
occasionally bulges out anteriorly to form a bursa beneath the psoas tendon
where this crosses the front of the joint.

Movements
The hip is capable of a wide range of movements—flexion, extension,
abduction, adduction, medial and lateral rotation and circumduction.
The principal muscles acting on the joint are:
•◊◊flexors — iliacus and psoas major assisted by rectus femoris, sartorius,
pectineus;
•◊◊extensors—gluteus maximus, the hamstrings;
•◊◊adductors — adductor longus, brevis and magnus assisted by gracilis
and pectineus;
•◊◊abductors—gluteus medius and minimus, tensor fasciae latae;
•◊◊lateral rotators — principally gluteus maximus assisted by the obtura-
tors, gemelli and quadratus femoris;
•◊◊medial rotators — tensor fasciae latae and anterior fibres of gluteus
medius and minimus.

Relations (Fig. 166)
The hip joint is surrounded by muscles:
•◊◊anteriorly — iliacus, psoas and pectineus, together with the femoral
artery and vein;
•◊◊laterally—tensor fasciae latae, gluteus medius and minimus;
•◊◊posteriorly—the tendon of obturator internus with the gemelli, quadra-
tus femoris, the sciatic nerve and, more superficially, gluteus maximus;
•◊◊superiorly — the reflected head of rectus femoris lying in contact with
the joint capsule;
•◊◊inferiorly—the obturator externus, passing back to be inserted into the
trochanteric fossa.
Surgical exposure of the hip joint therefore inevitably involves consid-
erable and deep dissection.
The lateral approach comprises splitting down through the fibres of
tensor fasciae latae, gluteus medius and minimus on to the femoral neck.
Further access may be obtained by detaching the greater trochanter with
the gluteal insertions.
The anterior approach passes between gluteus medius and minimus lat-
erally and sartorius medially, then dividing the reflected head of rectus
femoris to expose the anterior aspect of the hip joint. More room may be
obtained by detaching these glutei from the external aspect of the ilium.
The posterior approach is through an angled incision commencing at the
posterior superior iliac spine, passing to the greater trochanter and then
dropping vertically downwards from this point.
Gluteus maximus is split in the line of its fibres and then incised along
its tendinous insertion. Gluteus medius and minimus are detached from
their insertions into the greater trochanter (or the trochanter is detached