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314
ab
E. Fakhre and C. M. Henn
Fig. 12.17 (a and b) Photograph of a patient who sus-
tained a puncture wound to the dorsal webspace seen in b.
The patient lost the ability to ex the thumb IP joint due to
not managed urgently by a hand surgeon
(Fig.12.17). Therefore, it is important to contact
the hand surgeon who will eventually and denitively treat the patient so that appropriate care
and follow-up can be arranged. Nerve and exor
tendon injuries ideally are addressed within a
week or two to avoid permanent loss of
function.
a complete FPL laceration through this wound. Note the
resting posture of the extended IP joint, due to the complete FPL laceration
picion of a fracture, MRI or interval radiographs
may be required to conrm or rule out fractures.
Initial evaluation of hand fracture should assess
for associated soft tissue injuries, including open
fracture and/or nerve, tendon, or vessel injury.
Fractures of the phalanges range from simple
distal phalangeal tuft fractures to extensive
intraarticular fractures with signicant comminution and associated joint instability (Fig.12.18).
The fractures must be assessed for stability, angu-
Fractures andDislocations
lar deformity, rotational malalignment, and shortening. If these factors are all found to be
Fractures and dislocations of the hand and wrist
can occur through a variety of mechanisms
including falls on an outstretched wrist or hand,
crush injuries, or direct blows. They range from
minor, inconsequential nondisplaced fracture, to
highly comminuted, unreconstructable fractures
from high-energy injuries. Most fractures in the
hand and wrist are diagnosed with appropriate
radiographs, including orthogonal views of the
affected bone and often an oblique view. In the
case of normal radiographs and high clinical sus-
acceptable, the fracture can be treated conservatively with 3–4weeks of immobilization or protected early range of motion until healing occurs.
If these factors are not acceptable, surgical management should be considered to restore alignment and/or stability and facilitate healing of the
fracture and optimal function. Fracture healing is
often weighed against stiffness caused by fracture
treatment. Reduction of phalangeal fractures can
often be accomplished with manipulation under
anesthesia and then percutaneous wires or screws
cd
12 The Hand
a b
315
Fig. 12.18 (a) Comminuted middle phalangeal base
fracture with articular impaction and displacement. (b)
Rotational deformity from a middle phalangeal fracture.
(c) Bennett’s fracture dislocation of the rst metacarpal
base. The arrow points to the volar ulnar fragment of the
metacarpal. Note that the volar ulnar fragment remains
reduced to the trapezium while the rest of the metacarpal
has dislocated. (d) Scaphoid waist fracture designated by
the arrow
316
E. Fakhre and C. M. Henn
can be used to maintain the reduction until fracture healing. Occasionally an incision must be
made to restore phalangeal alignment because
manipulation was unsuccessful, and xation with
a plate-and-screw construct may be chosen to
facilitate earlier return to function or may be
required to stabilize a complex fractures. Goals of
surgery include restoring joint congruency, articular reduction, and overall alignment of the digit.
The vast majority of metacarpal fractures can
be treated nonoperatively with casting, bracing,
or buddy taping. Exceptions to this include fractures with rotational malalignment, excessive
angular deformity, or intraarticular displacement—especially of the rst metacarpal base.
Fractures of the rst metacarpal base often occur
in a pattern in which the ulnar segment of the
base stays attached to the trapezium and index
metacarpal through their ligamentous connections. The remainder of the metacarpal base and
shaft then subluxates or dislocates dorsally
(Fig.12.18c). This pattern is called a Bennett’s
fracture and routinely requires xation to restore
the metacarpal base articular surface and CMC
joint stability. Boxer’s fractures are fth metacarpal neck fractures that are extremely common. As
the eponym implies, the mechanism is from
punching a hard object. Rotational deformity,
and subsequent surgical intervention, is rare, and
up to even 70° of apex dorsal angulation can be
treated nonoperatively in most cases. Angular
deformity in the second and third metacarpal
neck fractures is less well tolerated due to the
relative lack of compensatory motion at the second and third CMC compared to the fourth and
fth CMC joints.
The most commonly injured carpal bone is the
scaphoid (Fig.12.18d). When patients are tender
over the anatomical snuff box or the scaphoid
tubercle, one should maintain a high index of suspicion for this fracture, because initial radiographs are often normal. If initial X-rays are
negative, and suspicion of a scaphoid fracture is
high, treatment should be initiated with a brace or
cast. Conrmation of the fracture can be obtained
immediately with an MRI, or follow-up radiographs can be obtained at weekly intervals to
identify a healing scaphoid fracture, which
becomes more obvious radiographically. Due to
its tenuous blood supply, scaphoid fractures have
high rates of nonunion and avascular necrosis,
and treatment delay increases the risk of both of
these complications. Scaphoid nonunion and
avascular necrosis can then lead to a well-dened
progression of carpal collapse and arthritis,
resulting in permanent wrist disfunction.
Nondisplaced fractures that are treated early heal
reliably with prolonged immobilization.
Displaced fractures or fractures that have been
missed are treated surgically to improve the rates
of union and decrease the chance of avascular
necrosis. Another common carpal fracture is the
dorsal triquetral avulsion fracture, which often
occurs after a fall on an outstretched wrist. This is
best seen on lateral radiographic view where a
small eck of bone is noted dorsal to the triquetral
region. Patients with these fractures reliably heal
with immobilization in a cast or brace for
4–6weeks and return to normal function with no
residual effects.
Dislocations of the interphalangeal joints are
quite common and can usually be reduced by
manipulation with or without anesthesia.
Radiographs should be obtained following reduction to ensure concentric joint reduction and to
evaluate for commonly associated volar plate
avulsion fractures. In the case of isolated dislocations or if the fracture fragment is small and the
joint is concentric, the treatment is immediate
range of motion to prevent signicant stiffness,
which sets in rapidly with any immobilization.
Irreducible dislocations or larger fracture fragments require urgent surgical intervention. DIP
and MP joint dislocations are rarer and more
commonly are irreducible due to interposition of
soft tissue. MP dislocations require special attention because attempted reduction by traction
alone can cause interposition of the volar plate
and turn a reducible dislocation into an irreducible dislocation. Therefore, emergent hand surgical consultation is recommended to avoid this
complication. Irreducible dislocations in the DIP
and MP joints also require surgical intervention.
Early range of motion following these injuries is
also required to combat inevitable stiffness that
results from the dislocation and surgery.
12 The Hand
317
Injuries to the collateral ligaments of the PIP
and MP joints are common. MP collateral ligament injuries, except for the index radial collateral
ligament and the thumb MP joint, are treated successfully with buddy taping the digit to the adjacent digit. PIP collateral ligament injuries are
treated similarly without surgery, but these injuries
can result in prolonged and often permanent swelling and stiffness of the joint. Index RCL and
thumb MP collateral ligament injuries are often
treated surgically. An injury to the thumb MP joint
ulnar collateral ligament is called a skier’s thumb
and is a frequent athletic injury. Patients who have
tenderness over the ligament, but good stability,
should be immobilized for 3–4 weeks and then
range of motion should be initiated. If the examination demonstrates obvious instability, signicantly increased deviation on stress radiographs,
or has a palpable Stener’s lesion (a completely
ruptured ulnar collateral ligament that is displaced
dorsal to the adductor pollicis apponeurosis), surgical repair of the ligament is indicated.
Severe andComplex Upper Extremity
Injuries
Amputations of portions of the upper limb, especially the ngers, are very common, especially in
industrial and agricultural environments. Modern
microvascular surgical techniques allow reimplantation of the amputated parts in many situations. The severed part should be wrapped in a
gauze dressing soaked in sterile saline and placed
in a container or sealed plastic bag that can be
immersed in ice and transported to a treating
facility. The part should never be placed directly
on ice, and dry ice should never be used. An
experienced hand surgeon should be consulted
emergently to assess whether the part is a good
candidate for reattachment. Relative indications
for replantation include any amputated part in a
child, the thumb at any level, multiple digits, or
an amputation through the mid palm or proximally. Relative contraindications to replantation
include severe contamination, crush injury, avulsion mechanism, segmental injury, broad area of
vascular damage. Replantation also requires a
lengthy surgery, prolonged hospitalization, and
specialized hand therapy to restore function.
Older patients, laborers, and medically complicated patients may elect to undergo revision
amputation rather than replantation. Extensive
mangling injuries must be treated by an experienced hand surgeon emergently. The extent of the
injury and what structures are salvageable and
what structures are primarily amputated are often
determined once the patient is under anesthesia.
Therefore, it is important to discuss with the
patient and/or the patient’s family the possibility
of amputation following such an injury.
Compartment syndrome in the hand or forearm occurs when signicant swelling causes
increased pressure in the muscle compartments,
preventing ow through the venules and
capillaries leading to ischemia of soft tissues of
the compartment. If the pressure is not emergently alleviated, permanent and profound disability ensues. Acute carpal tunnel syndrome is,
in effect, a compartment syndrome in the carpal
tunnel. Profound swelling leads to direct pressure
on the median nerve in the carpal tunnel and will
lead to permanent median nerve dysfunction if
not emergently surgically decompressed. The
mechanism of injury should raise suspicion for
these problems, including crush injuries and
high-energy trauma, such as a fall from signicant height or a car accident. Conscious patients
with these injuries should be closely monitored
for the signs of compartment syndrome, which
include the ve P’s: pain out of proportion to the
injury, severe pain with passive stretch, later paresthesias, pallor, and pulselessness. One should
not wait for the development of the last three P’s,
as these develop following muscle and nerve
necrosis and it is too late. If the index of suspicion is high due to increasing pain and the mechanism of injury, the compartment pressure can be
directly measured to conrm the diagnosis. When
the diagnosis is conrmed or when the suspicion
is high, the compartment should be emergently
and fully decompressed. In the case of an
obtunded or intubated patient, the clinical threshold may be lower to proceed with fasciotomy.
Thermal, chemical, or electrical injuries cause
widely variable degrees of soft tissue issue. The
318
E. Fakhre and C. M. Henn
degree of injury depends on many factors, including the mechanism, magnitude, and duration of the
exposure. The skin is the initial point of contact
and may show rst-degree (redness), seconddegree (blistering), or third-degree (full-thickness
or charring) injuries, particularly with thermal
burns. Early care of the second-degree injury can
minimize the chance of infection, which would
exacerbate tissue loss. Early referral to a hand
therapist for exercise and splinting may minimize
contractures. Third-degree burns should be treated
by early surgical excision of the eschar and skin
grafting. Chemical injuries should be treated in a
facility that has experience in managing these conditions as specic antidotes can be used to neutralize many chemicals and minimize damage.
Cold injury varies from minor frostbite to
extensive freezing of tissues and peripheral parts.
The initial treatment should involve rapid
rewarming of the area of frostbite followed by
observation. Blisters should be debrided to limit
soft tissue damage from the inammatory mediators found within the blisters. Early amputation is
not necessary in the absence of infection, and
observation until the injury and necrosis has fully
demarcated is the treatment of choice. Electrical
burns can be quite deceptive as to the extent in
damage and require repeated evaluation.
Other Common Injuries
Mallet nger is rupture of the terminal extensor
tendon’s attachment to the distal phalanx, often
following trivial injury. Fracture of the dorsal lip
of the distal phalanx may be seen on X-ray in
some cases. Full passive extension is present, but
active extension is not, leading to the classic mallet deformity. Treatment usually involves full
time splinting of the DIP joint in full extension
for 6–8weeks.
Boutonnière deformities occur from disruption
of the central slip of the extensor tendon over the
PIP joint by blunt trauma or laceration. Patients
may often exhibit full range of motion immediately after the injury due to intact pull of the terminal extensor through the lateral bands. However, if
the injury is untreated, the lateral bands subluxate
volar to the axis of rotation of the PIP joint. Once
this happens, the patient can no longer actively
extend the PIP joint and develops a exion deformity at the PIP joint and compensatory hyperextension at the DIP joint. When diagnosed early,
this can be treated by splinting the PIP joint in full
extension for 6weeks. It is important to allow DIP
exion and extension in the splint to prevent DIP
stiffness and prevent volar subluxation of the lateral bands. If initial treatment is delayed or fails,
surgical treatment can be considered.
Metabolic Disease
Many metabolic illnesses such as diabetes,
hyperthyroidism, hyperparathyroidism, and renal
failure can predispose patients to the development of many of the hand problems discussed in
this chapter, such as carpal tunnel syndrome.
Several metabolic diseases can directly affect the
hand, though. Perhaps the most common is crystalline arthropathy. Gout is a common metabolic
illness in which uric acid forms crystals of monosodium urate, which can then accumulate in
joints or soft tissues and cause impressive inammation. Although it is most common in the rst
MTP joint of the foot, it can occur in the joints
and soft tissues of the hand. Often, it presents as
a warm, tender, swollen, erythematous region
and can mimic infection. In fact, when gout ares
within one or two joints in the hand or wrist, it
can cause profound swelling throughout the
entire hand. Aspiration of an involved joint and
visualization of negatively birefringent crystals
under polarized light microscopy conrms the
diagnosis. Treatment options include rest, immobilization, anti-inammatory medications, corticosteroids (injections or oral steroids), and other
antigout medications. Rarely gout can progress to
severe tophaceous gout in one or more locations
in the hands, which can cause extensive destruction of tendons or joints. Surgery in the form of
debulking, joint fusion, and amputation can
sometimes be indicated for severe erosive gout.
Calcium pyrophosphate dihydrate deposition
disease (or pseudogout) is another crystalline
arthropathy in which calcium pyrophosphate
crystals accumulate in joints and around tendons,
leading to signicant inammation. This, too,
12 The Hand
causes signicant redness, swelling, and warmth
over a joint and, again, aspiration and visualization of crystals in the uid can be diagnostic for
the problem. Treatment includes corticosteroid
injections, nonsteroidal anti-inammatories, oral
steroids for acute areups, and surgery in severe,
chronic cases.
Vascular
Arterial occlusion and small vessel disease in the
hand can cause severe pain and occasionally
necrosis of the ngers. These can result from
scleroderma, peripheral vascular disease, embolic
phenomena, and Buerger’s disease. Ulnar artery
occlusion, which usually occurs at the level of the
hook of the hamate, can cause signicant ulnar
nerve symptoms in addition to ischemia in the
ulnar digits. When this occurs after a repetitive
trauma, it is called hypothenar hammer syndrome, and it is most often seen in manual laborers. A vascular ultrasound or angiogram may
conrm the diagnosis. The treatment depends on
the degree of ischemia in the digits and symptoms. Surgical treatment involves decompression
of the nerve and artery, and reconstruction of the
thrombosed segment of the artery.
Vascular deciencies secondary to other
underlying diseases can be a signicant problem
in the hand, particularly in diabetes and scleroderma. In earlier stages of scleroderma, a digital
sympathectomy or removal of the vascular
adventitia can decrease the amount of vascular
spasm that occurs, improve pain, and limit the
damage done to the digits. As the disease progresses, though, digital ulcers can progress into
gangrene, leading to autoamputation or surgical
amputation of the digit.
Patients who have severe loss of ow to the
hands due to shock can also develop gangrene of
the digits. This is particularly common in patients
who are inshock and require vasopressors, which
redirect blood ow from the extremities to the vital
organs, further decreasing the blood ow to the
digits. Treatment in these instances involves
warming the digits and occasionally applying nitro
paste to the digits. The primary treatment, though,
is treating the underlying cause of shock and then
319
Fig. 12.19 Clinical photograph demonstrating a gangrenous long nger developed after a prolonged exposure to
vasopressors. The extent of the necrosis demarcates the
extent of amputation necessary
reducing the vasopressors. Often, though, the digits have developed irreversible ischemia that progresses to gangrene. Treatment then involves
observation until the area of gangrene is clearly
demarcated, and then surgical amputation or
autoamputation follows (Fig.12.19).
True aneurysms of the wrist and hand are relatively uncommon, but they occasionally occur in
the ulnar artery at Guyon’s canal. These aneurysms cause symptoms very similar to hypothenar hammer syndrome and can be treated the
same way. Pseudoaneurysms are more common
and can occur anywhere in the hand. They result
of from direct trauma to an artery, typically from
an arterial line placement, blood gas draw or ganglion cyst aspiration attempt. Symptomatic aneurysms are usually treated by ligating or
reconstructing the artery involved, depending on
the collateral circulation.
Neoplasms
Skin Cancer
Skin cancers (squamous cell carcinoma, basal
cell carcinomas, and melanoma) are relatively
common, especially in the elderly or those with
predisposing factors (Fig. 12.20). These factors
320
Fig. 12.20 Clinical photograph of melanoma on the
volar aspect of the index nger of a 37-year-old patient.
This was treated with wide excision and full-thickness
skin grafting to the site
include prolonged exposure to the sun in farmers
and other outdoor workers, and excessive exposure to X-rays, arsenicals, or other chemicals.
Squamous and basal cell carcinomas can usually
be cured by wide excision if they have not already
metastasized. Melanomas and Merkel cell carcinomas are much more likely to recur and/or
metastasize. As such, a multidisciplinary
approach to these patients is vital to optimizing
survival. Treatment typically involves surgical
excision, reconstruction of the soft tissue, lymph
node biopsies, staging studies, chemotherapy,
and occasionally radiation.
Other Soft Tissue Masses
Benign soft tissue masses are very common in
the hand and wrist and can arise from nerves,
vessels, fat, or fascia. The most common “tumors”
of the hand include ganglion cysts and giant cell
tumors of the tendon sheath. Ganglion cysts are
uid lled sacks that arise from synovial lined
structures, such as joints and tendon sheaths.
Ganglion cysts occur in four common locations
in the hand and wrist: on the dorsum of the wrist
from the scapholunate ligament, on the volar
radial aspect of the wrist adjacent to the radial
artery from the radioscaphoid or scaphotrapezial- trapezoid (STT) joint, from the exor
tendon sheath at the base of the nger, and over
E. Fakhre and C. M. Henn
the dorsum of the DIP joint (mucous cyst).
Treatment options for ganglion cysts include
observation, aspiration or surgical excision. Cysts
on the dorsum of the wrist or over the exor
tendon sheath are easily amenable to aspiration,
although rates of recurrence are fairly high.
Aspiration of a volar wrist ganglion should be
approached cautiously, if at all, due to the proximity of the radial artery and risk of causing a
pseudoaneurym. Surgical resection is a more
denitive option, but recurrence following surgical excision is still 5–10%.
Giant cell tumors of the tendon sheath are
solid tumors that present as slowly growing,
painless, rm masses. Malignant etiologies are
often in the differential, so an MRI with and
without contrast can help point toward giant cell
tumor of the tendon sheath. These tumors can
extend into the joint, into the tendon sheath, and
even circumferentially around the tendon. They
also create mass effect and erosion into the adjacent phalanx. Treatment involves simple marginal excision which is typically curative. Local
recurrence is possible, though, and the rate of
recurrence increases for tumors that have invaded
into adjacent joints.
Other common benign soft tissue masses
include foreign body granulomas, epidermal
inclusion cysts, arteriovenous malformations and
hemangiomas, neurilemmoma, and glomus
tumors. Surgical excision is diagnostic and typically curative for these benign lesions.
Malignant soft tissue tumors in the hand are
very rare outside of skin cancers. The most common are epithelioid sarcoma, synovial cell sarcoma, and malignant brous histiocytoma.
Delay in diagnosis is a common problem due to
the extreme rarity of the diagnoses and relatively
common benign lesions. Preoperatively, if there
is any question that the lesion may be a soft tissue sarcoma, the patient should be referred
immediately to a tertiary medical center for
treatment. Similar to the treatment of melanoma
and Merkel cell carcinoma, treatment of malignant soft tissue tumors of the hand requires a
multidisciplinary team experienced the care of
these complex patients to optimize outcomes
and survival.
12 The Hand
321
Tumors ofBone
Benign bone tumors of the hand are often diagnosed incidentally on radiographic examination
for trauma. The most common is the enchondroma, which is a benign cartilage tumor of the
bone. Treatment of incidentally found enchondromas is controversial and often involves radiographic and clinical follow-up. There is a small
risk of malignant transformation into chondrosarcoma, and there is also a risk of pathologic fracture, which may lead the patient and/or surgeon
to choose surgical resection over observation. If a
pathologic fracture has occurred through the
lesion or is impending, surgical treatment is typically the treatment of choice. Simple curettage,
with or without bone grafting, often sufces. This
may be done concurrently with fracture xation
or following complete healing of the fracture.
Osteochondromas, brous dysplasia, and
giant cell tumor of bone can also present in the
small hand bones and may require surgery for
diagnosis or treatment. Malignant tumors of the
hand skeleton are very rare. Partial or total hand
amputation may be required along with adjuvant
radiation therapy or chemotherapy. Metastatic
tumors of the hand seldom occur as isolated
metastases, but are not uncommon during widespread metastatic disease, especially from lung or
breast cancers.
Management Protocols
A wide variety of problems can affect the hand
and wrist, which range from self-limiting and
inconsequential to devastating functional problems, to potentially life-threatening problems. It
is, therefore, important to have in mind a standardized approach to patients with these problems to help arrive at the correct diagnosis and
management options. The physician should begin
with a thorough problem-focused history. With a
differential diagnosis in mind, the physician
should then perform a directed, but thorough
physical examination. Plain radiographs are usually, but not always, useful adjuncts to conrm
the diagnosis.
Nearly all patients with a history of an injury
should obtain radiographs. If the initial radiographs show a fracture, dislocation, or carpal
instability pattern, appropriate operative or nonoperative treatment should be initiated. When
X-rays are negative, a soft tissue injury may
have occurred, or an occult fracture may be
present. When a specic soft tissue injury is
noted, appropriate treatment should be initiated.
If none is found and the patient’s symptoms
cannot be explained, either further imaging
should be performed or splinting or casting for a
period of time followed by reevaluation should
be considered.
In patients who have had no specic history of
trauma or injury, radiographs are often unnecessary, especially if the patient has a classic history
and physical examination for a soft tissue process, such as trigger nger or de Quervain’s tenosynovitis. If the diagnosis is unclear after the
history and physical, radiographs should be
obtained. If radiographs demonstrate arthritis,
tumor, or occult bony injury, appropriate operative or nonoperative management should be
undertaken. If they are negative, further evaluation and/or indicated treatment should be
initiated.
Due to the signicant variability in hand and
wrist conditions and associated variability in
urgency of treatment, early referral or consultation with a hand surgeon is often the best course
of action when dealing with hand and wrist complaints. However, it is equally important that all
physicians who manage patients with hand complaints have a basic understanding of the hand
pathology and treatment options described in this
chapter.
Further Reading
Weiss APC, editor. The American Society for Surgery of
the hand textbook of hand & upper extremity surgery.
2nd ed. Chicago, IL: American Society for Surgery of
the Hand; 2019.
Wolfe SW, Pederson WC, Kozin SH, Cohen MS, editors.
Green’s operative hand surgery. 8th ed. Amsterdam:
Elsevier; 2021.
Hip Osteoarthritis
andArthroplasty
GregoryPerraut, BrianG.Evans, andKevinW.Park
13
Anatomy
Development
The hip joint is a ball and socket joint with the
round femoral head articulating within the matching acetabular socket. The acetabulum is formed
from the conuence of three bones: the ischium,
ilium, and pubis. In skeletally immature patients,
these three bones are joined in the medial acetabulum by the triradiate cartilage, which is a growth
plate for the acetabulum. There is also appositional growth from the edges of the acetabulum
and pelvis resulting in increased depth of the
acetabulum and size of the pelvis. Normal development of the acetabulum requires the femoral
head to articulate with the acetabular cartilage.
The acetabular socket will not develop normally
if the femoral head is chronically dislocated or
subluxated out of the acetabular fossa. This often
results in a shallow and malformed acetabulum
and is termed developmental dysplasia of the hip
(DDH). The severity of this condition is determined by the degree of subluxation of the femo-
G. Perraut (*) · B. G. Evans · K. W. Park
MedStar Georgetown Orthopedic Institute,
Georgetown University School of Medicine,
Washington, DC, USA
Department of Orthopedics, MedStar Georgetown
University Hospital, Washington, DC, USA
e-mail: Gregory.T.Perraut@medstar.net;
Kevin.W.Park@medstar.net
ral head. If DDH is identied at birth or soon
thereafter, the hip can be reduced with either
casting or surgery. This treatment can allow the
hip to grow and develop almost normally. If the
hip is left subluxated or dislocated, the acetabulum will be shallow and predispose the patient to
develop osteoarthritis as an adult. This is reviewed
in greater detail in the chapter on pediatric orthopedic conditions.
Osteology andMusculature
The innominate bone consists of the ilium,
ischium, and pubis, which are joined in the area
of the acetabulum (Fig.13.1). The ilium is a large
at bone providing broad surfaces for muscular
attachment. The ischium extends posteriorly and
forms the posterior aspect of the acetabulum. The
ischium joins the ilium superiorly and the pubis
inferiorly through the inferior pubic ramus. The
ischium also serves as the origin of the hamstring
and short external rotator muscles of the hip. The
pubis consists of the superior pubic ramus, inferior pubic ramus, and the pubic symphysis.
The superior pubic ramus joins the pubic
symphysis with the ilium and the inferior pubic
ramus connects the pubic symphysis with the
ischium. The pubis serves as the site of insertion
of the musculature of the abdominal wall as well
as the site of origin for the adductor muscles of
the thigh.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
W. F. Postma et al. (eds.), Essentials of Orthopedic Surgery,
https://doi.org/10.1007/978-3-031-66215-7_13
323
324
Iliac crest
a
e
foramen
Internal view
a
G. Perraut et al.
b
Posterior superior
iliac spine
Posterior inferior
iliac spine
Ischial
tuberosity
spine
Obturator
foramen
Ischial
c
Ischiopubic
ramus
External view
a
Acetabulum
Anterior superior
Pubic
symphysis,
iliac spine
Anterior inferior
iliac spine
Iliopubic
eminence
Pubic crest
Pubic
tubercle
b
Iliac crest
Posterior superior
iliac spine
Sacroiliac joint,
articular surfac
Posterior inferior
iliac spine
Greater sciatic
notch
Arcuate line
Ischial
spine
Lesser sciatic
notch
Ischial
tuberosity
Obturator
Iliofemoral ligament
(cut)
Anterior inferior iliac
spine
Lunate surface
of acetabulum
Zona orbicularis
Iliofemoral
ligament (cut)
Ischiofemoral
ligament (cut)
Ligament of head
Acetabular labrum
Fat in acetabular fossa
Transverse acetabular
ligament
Pubofemoral ligament
(cut)
Obturator membrane
of femur (cut)
b
Greater trochanter
Iliofemoral ligament
Lesser trochanter
Fig. 13.1
(a) Lateral aspect of left hip bone. (b) Ligamentous attachments are shown. (From Mayer, S.W.,
Spahn, K.M., Grifth, R. (2020). Hip Joint. In: Khodaee,
M., Waterbrook, A., Gammons, M. (eds) Sports-related
Fractures, Dislocations and Trauma. Springer, Cham.
https://doi.org/10.1007/978- 3- 030- 36790- 9_22. From
Rectus femoris tendon
Pubofemoral ligament
Obturator canal
Obturator membrane
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