Skeleton of the free lower limb. Large femur. The structure of the femur Greater trochanter of the femur in Latin

The greater femur is the longest tubular bone in the human skeleton. It is able to take heavy loads, since the bulk of the body weight falls on it. The femur plays an important role in the structure of the body and the ability of a person to move. With injuries and damage to this bone, serious complications arise. To have an idea of the importance of the femur, you need to know its structure.

Bone Anatomy

Like any tubular bone, the femur has a body, as well as a distal and proximal epiphyses. The anterior side of the bone is distinguished by a smooth surface, while the posterior side has a rough line divided into medial and lateral parts. The lateral lip from below deviates to the side towards the lateral condyle, and from above it passes into tuberosity. The medial lip in its lower part also passes to the lateral condyle. Thus, both lips form a surface bounding the popliteal region.

Upper epiphysis

In the body of the bone there is a hole, which is the entrance to the nutrient canal. Many vessels pass through it. On the proximal epiphysis are the greater and lesser skewers. The outer surface of the greater trochanter is easy to feel through the skin. Its inner surface has a trochanteric fossa. Between the greater and lesser trochanters, an intertrochanteric line begins and goes down, turning into a pectinate strip.

The posterior part of the upper epiphysis gives rise to the intertrochanteric crest, which ends at the lesser trochanter. The remaining part of the upper epiphysis forms the head of the femur. On it is the fossa of the head, which is the place of attachment of the ligaments. The head is continued by the neck of the femur, which is most prone to fractures, especially in the elderly. In the case of such an injury, a complex operation is necessary, followed by a long rehabilitation period.

lower epiphysis

The distal epiphysis differs somewhat in its structure from the proximal one. It consists of two condyles (medial and lateral). The first has an epicondyle on its inner side, and the second, on the contrary, on the outer.

Slightly above the medial epicondyle is the adductor tubercle - the site of attachment of the adductor muscle.

As you can see, the structure of the large femur cannot be called simple, therefore, the diagnosis of diseases of this anatomical structure is problematic. Also, the femur has a complex anatomy for the reason that it is the link between the upper and lower half of the human body. The hip joint together with the femur are important structural components of the human body. Sometimes, for various reasons, pain appears in them.

Causes of pain

In total, there are four groups of reasons why the hip joint and femur can hurt.

The most common group is injuries and injuries of various kinds. In this case, very severe pain occurs at the site of injury, immediate hospitalization is required.
The second group includes various diseases of the joints and bones: arthrosis, tendinitis, osteoporosis.
The third group includes sometimes appearing pain, the cause of which is difficult to establish accurately. They do not indicate joint disease, but are symptoms of neurological diseases.
This group includes systematic pain, which can be caused by gout, common tuberculosis and many allergic diseases.

Fracture diagnosis

Really dangerous consequences are characterized by a fracture of the femur. Young people can get such an injury as a result of an accident, an accident or a fall from a height. And for older people, even a banal fall can cause a fracture. If you are concerned about hip pain that does not go away for a long time, you should seek medical help. Fracture is fairly easy to diagnose using x-rays, in more complex cases, computed tomography may be required.

The bones of the free lower limb include the femur, the bones of the lower leg, foot, sesamoid bones (patella, etc.). Despite the fact that the bones of the lower limb are homologous to the bones of the upper limb, there are significant anatomical differences between them.

Femur

The femur (femur) (Fig. 94) is paired, has two epiphyses and between them is the diaphysis - the body (corpus femoris). The proximal end ends with a head (caput femoris), which is 2/3 covered by the articular surface. In the center of the head there is a small hole (fovea capitis femoris). The head continues into the neck (collum femoris), in men, located in relation to the body at an angle of 127 °. In women, the angle is slightly less than -112°, which, together with a wider pelvis, creates a wider pelvic girdle than in men. In a newborn, the angle is about 150°. Above and below the neck of the femur are two tubercles, named for their large size skewers (trochanter major et minor); from them, the intertrochanteric crest (crista intertrochanterica) passes along the posterior surface of the body, and the intertrochanteric line (linea intertrochanterica) runs along the anterior surface. On the back surface of the body below the intertrochanteric crest is the gluteal tuberosity (tuberositas glutea), from which a rough line is directed down, consisting of the lateral and medial lips (linea aspera). These two lines in the lower parts of the bone diverge and limit the popliteal surface (facies poplitea), which has a triangular shape. The medial lip in the upper part of the femur continues into the comb line (linea pectinea).

94. Right femur.

A - front view:
1 - caput femoris;
2 - collum femoris;
3 - trochanter major;
4 - linea intertrochanterica: 5 - trochanter minor;
6 - corpus femoris;
7 - epicondylus medialis;
8 - epicondylus lateralis;

B - rear view:
1 - fossa trochanterica;
2 - crista intertrochanterica;
3 - tuberositas glutea;
4 - labium laterale linea asperae;
5 - labium mediale lineae asperae;
6 - facies poplitea;
7 - fossa intercondylaris.

The distal end of the femur is expanded by two condyles (condylus lateralis et medialis); they are separated by an intercondylar fossa (fossa intercondylaris), bounded from above by an intercondylar line (linea intercondylaris). Both condyles in the sagittal direction have different curvature. The medial condyle has a larger radius than the lateral one. This is due to the fact that the femoral heads are 12.5 cm apart, and the medial condyles are almost in contact and their lower surfaces are located along one horizontal line. A different radius of the condyles inhibits extension in the knee joint, providing smooth movements, creating conditions for wedging at full extension, which makes the joint stronger and more stable. Above the condyles are supracondylar elevations (epicondylus lateralis et medialis). Anteriorly, the surfaces of both condyles pass into one another, forming the patella surface (facies patellaris), where the thigh articulates with the patella.

When studying the anatomy of the thigh, it is first necessary to pay attention to the structure of the femur. It is she who is the thickest and longest bone of the human body, which bears a significant part of the load of the body and is responsible for its balance. In this regard, a huge proportion of pathologies in this area falls precisely on damage to the femoral bone.

What is the femur made of?

The normal anatomy of the femur suggests the presence of the following main parts of it:

body;
proximal epiphysis;
distal epiphysis.

These parts need to be considered separately. For a better understanding of the features of the structure, you can watch the video.

Body

This is a section of a cylindrical shape, which is distinguished by a slight bend in the front side. Its surface is smooth in front, and a rough line runs from the back. Its main function is to strengthen the muscles. She, in turn, is divided into lateral and medial lips. The first in the upper part passes into the gluteal tuberosity, and in the lower part it passes to the lateral condyle when tilted to the side. The second also deviates downward, but departs to the medial condyle. In the upper part, it merges with the comb line. Together, these lips and supracondylar lines define the popliteal surface at the lower zone of the femur bone.

For reference! In the middle of the body of the femur there is a so-called nutrient hole. It leads to a nutrient canal with numerous vessels. It is they who provide nutrition to the bone, so such a hole performs a very important function in the human body.

proximal epiphysis

In this zone, there is a femoral head, in the center of which there is a fossa. The attachment of the head to the acetabulum is provided by its articular surface. The area in which it is connected to the body of the bone is called the neck. The latter forms an angle of approximately 130 degrees with the body.

In the area where the neck passes into the body of the bone, there are large and small skewers. They are interconnected by an intertrochanteric line and a ridge - from the front and from the back, respectively.

The greater trochanter can be palpated from the outside of the thigh, while the lesser trochanter, arising from the femur, is visible from behind and from the inside. There is a trochanteric fossa near the femoral neck. Such protrusions help to strengthen the muscles.

Distal epiphysis

The distal end or end of the femur becomes wide downwards and diverges into two parts. At this point, the medial and lateral condyles are separated by the intercondylar fossa. It is clearly visible from the back. The surface of the condyles is covered with joints that provide connection with the patella and tibia.

On the sides of the femur bone are the lateral and medial epicondyles. Ligaments are attached to them. They can be felt from the inside and outside of the limb.

For reference! The right femur is presented in detail in the photo, which clearly shows that the structure of the femur bone behind and in front differs significantly.

thigh muscles

It is the muscles of the thigh, together with the bone, that play a special role in providing motor movements in this area. There are three main muscle groups:

front;
medial;
back.

Each group is represented by different types of muscles that perform separate functions.

Muscles of the anterior group

The quadriceps muscle has four heads, hence its name. Each of them is a separate muscle. They perform the function of hip flexion and lower leg extension.

The tailor is the longest human muscle. With its help, it is possible to bend the thigh and lower leg. With hip abduction and flexion, it is clearly visible under the skin.

Muscles of the medial group

This includes the following muscles:

Adductor long: similar to a triangle in its shape, provides hip adduction.
Adductor short: involved in the drive and partly in hip flexion.
Large adductor: connects with the medial epicondyle and the rough line. She plays the main role in the drive.
Comb: involved in flexion, drive and supination of the thigh.
Thin: leads the thigh and helps to flex the lower leg.

This group consists mainly of the muscles involved in the hip drive. They play a special role in its proper functioning.

Muscles of the back group

These include the following muscles:

Double-headed: it can be felt in the area of the fossa under the knee. It is involved in flexion and supination of the lower leg, and also extends the thigh.
Semitendinosus: performs the same functions and has a common origin with the biceps.
Semimembranous: helps to extend the thigh, takes part in flexion and pronation of the lower leg.

You can see the location of the femoral muscles in the photo.

Congenital anomalies

The main anomalies of the human femur include the following congenital pathologies:

underdevelopment;
hip dislocation and joint dysplasia;
valgus and varus deformities.

These conditions, left unattended in childhood, can lead to serious consequences in the future. Some of them can make a child disabled for life.

Bone underdevelopment

This deviation is more than 1% of the number of congenital skeletal deformities. Often this condition is combined with other pathologies, including the absence of the patella. The main symptom of underdevelopment is lameness.

Important! The dysfunction of the leg in this case is associated with the severity of the deviation and the degree of its shortening.

Incomplete development of the femoral large bone has the following features:

In cases of pathology of the diaphysis, the joints retain their function.
With violations of the distal pelvis falls in the direction of the lesion.
The femoral and gluteal muscles atrophy.
The gluteal fold is not observed or smoothed.
Pathology is easily detected by X-ray examination.

In this case, surgical treatment is necessary to restore the length of the leg, which depends on the age of the patient and the severity of the pathology. The following methods can be used:

Surgical intervention aimed at stimulating the growth zones. It is done at an early age.
Osteotomy with distraction apparatus. This method is used for patients aged 4-5 years.
Foot amputation. It is used if the shortening is too strong, and therefore the restoration of the length is impossible. In some cases, the operation is combined with arthrodesis of the knee joint.
Orthopedic means and footwear. They can help with a slight underdevelopment of the child's bones in the early stages.

The earlier such a pathology is detected, the easier it will be to eliminate it. The methods of treatment in each case are determined by the doctor.

Congenital dislocation and joint dysplasia

A dislocation of this type is diagnosed in very rare cases, while unilateral hip dysplasia is a fairly common occurrence. It is expressed by lameness and shortening of the leg. If the pathology is bilateral, the so-called duck gait is formed in the child.

For reference! X-ray examination in such a situation reveals flattening and reduction of the femoral head, as well as its displacement from the acetabulum.

If the disease is diagnosed at an early age, therapy is carried out with conservative means using special splints, pillows and other devices that correct the articular structure. When the dislocation has not been eliminated before 3 years, surgical treatment and a long rehabilitation period will be required.

Varus and valgus deformities

Such pathologies are the result of cervical ossification. Often the cause is also damage to the cartilage in the womb. In almost 30% of cases, the deformation is bilateral.

Valgus deformity is rarely diagnosed, as it occurs without symptoms. Whereas varus significantly limits the movement of the leg and leads to lameness. Its manifestations are similar to a hip dislocation.

X-ray examination shows thinning and shortening of the bone, as well as violations of the ossification of the femoral head. The treatment is carried out with the help of surgery and corrective osteotomy.

Injuries

sharp and severe pain;
limb dysfunction;
swelling;
leg deformity.

A more intense pain syndrome is characteristic of a trochanteric fracture. On palpation and during movement, it increases significantly.

For reference! For a fracture of the femoral neck, the so-called stuck heel symptom is primarily characteristic. It is a condition where the victim is unable to rotate the limb at an angle of 90 °.

There are extra- and intra-articular injuries of the femur.

Extra-articular fractures

This type of injury to the human femur includes fairly common intertrochanteric and pertrochanteric fractures, which are distinguished by the location of the injury line. These lesions occur predominantly in elderly patients. This is due to age-related changes in the structure of skewers: voids gradually form in their spongy substance, and the crust becomes fragile and thin.

Trochanteric injuries are characterized by good fusion both after surgical intervention and during conservative treatment. This fact is explained by the covering of this area by the periosteum and the presence of a large number of surrounding muscles. In addition, this area has a good blood supply, which also contributes to the rapid fusion of the bone.

Conservative therapy in such situations is based on skeletal traction. This procedure makes it possible to prevent the displacement of bone particles, eliminate them, or ensure the correct position until complete fusion. The traction period is usually one and a half to two months.

Important! In cases of elderly patients, such long-term conservative treatment may be unacceptable: many of them cannot withstand a long lying position. Therefore, in these cases, surgical intervention in the form of osteosynthesis of the fracture is more often performed. Half a month after it, the patient can walk on crutches.

Intra-articular fractures

The most common types of such injuries are fractures of the neck and head of the femur. In traumatology, this category is usually divided into fractures of the following types:

Transcervical: in this case, the fracture line runs in the neck area.
Capital: the line is located in the region of the femoral head.
Basiscervical: the fracture occurred at the junction of the neck with the body of the bone.
Subcapital: The fracture line passes directly under the femoral head.

In case of impacted fractures (when a piece of the thigh bone enters another bone), the patient is prescribed conservative therapy. At the same time, he should be in a lying position on a bed with a wooden shield. Often in such cases, the Beller tire is used. After that, skeletal traction is necessary.

If a displaced fracture is diagnosed, which is characterized by an incorrect position and deformation of the leg, the doctor, as a rule, prescribes surgery. With intra-articular fractures of the femur, in addition to X-ray examination, an MRI of the hip joint may be needed.

- the upper part of the lower limb, the area between the pelvis and the knee. The muscles passing in this area control the hip and knee joints, therefore they are called biarticular:

The volume of the front part and the strength of the thigh is given by the quadriceps muscle - the main extensor of the knee. For example, when walking or when playing football. She also performs hip flexion.
A group of flexors runs along the back, which has other functions in relation to the pelvic region - it promotes extension.

Therefore, the thigh bones form two large joints of the lower limb.

Where is it located and what does it consist of?

The photo shows that the thigh is limited to the inguinal ligament in front and the gluteal folds in the back. The area ends 5 cm above the knee.

It includes the longest bone that forms two joints - the knee and the hip. The contraction of the thigh muscles is provided by nerves from the lumbar plexus.

Next to them lie the arteries that supply blood to the bones, muscles, and skin. Veins take blood, providing outflow from the lower extremities. Trophic supply passes through the tendon canals. The thigh area contains lymph nodes and blood vessels.

Bones

The structure of the femur (femur) allows you to find out the places of muscle attachment. The tubular bone that forms the skeleton of the thigh occupies about a quarter of a person's height.

For example, the right femur deviates in shape to the left or inward relative to the pelvis to enter the knee, and is cylindrically expanded downwards. Most of the large muscles are attached to the proximal ends of the lower leg.

At the top, the head of the femur enters the acetabulum of the hip joint. The body and head are connected by the neck at an angle of 130 degrees to the axis of the bone itself. In the female pelvis, the angle is close to a straight one, which affects the width of the hips, while in men, the angle is wide. Below, at the transition to the body, the bones stand out into the greater and lesser trochanters:

large - this is a palpable protrusion on the lateral surface of the thigh directly under the pelvis;
small - located inside and backwards, therefore it is not palpable.

A trochanteric fossa is formed between them. The tubercles are connected by an intertrochanteric line in front and a crest behind. At the top of the head in a rough fossa, a ligament of the same name is attached.

The main anatomical landmark of the posterior surface is a rough line running through the center. On the sides it has ridges called lips:

the lateral (or external) expands and forms the gluteal tuberosity, where the gluteus maximus muscle is attached, and from below it connects to the condyle;
medial (or internal) - in the upper part it has a comb line for attaching the muscle of the same name, and in the lower part it passes into the condyle.

For the right femur, the medial condyle or protrusion is on the left and the lateral is on the right. From them come the supracondylar lines, forming the popliteal region.

The femur is equipped with a nutrient hole - a channel for the exit of nerves and blood vessels. The listed anatomical landmarks serve to attach the muscles.

muscles

Conventionally, the muscles of the thigh are divided into three groups. The muscles of the anterior part are responsible for knee extension and hip flexion:

Lumbar- the main flexor, the step starts from it. Attaches to all lumbar and last thoracic vertebrae, ends at the lesser trochanter of the thigh. The function depends on the nerves of the first three lumbar vertebrae. With her weakness, the pelvis moves forward, a stoop is formed - the pose of a teenager.
Rectus femoris It's a knee stabilizer. It comes from the lower edge of the iliac spine in front and the supraacetabular groove. At the patella, it connects to its ligament and reaches the tibial tuberosity. Included in the anterior superficial myofascial chain - involved in the forward tilt. Without diaphragmatic breathing - expansion of the ribs to the sides - muscle function is impaired. Nutrition - the lateral artery, enveloping the femur.
Intermediate wide lies from the intertrochanteric line to the tibia. Affects the joint capsule.
medial wide- descends from the same edge of the lip of the rough line to the lower leg. It is innervated by the muscular branches of the femoral nerve, which emerges from the roots of the 2nd, 3rd and 4th lumbar vertebrae.
Lateral wide- from the greater trochanter and intertrochanteric line stretches along the lateral lip of the rough line - stabilizes the joint from the outside. Same innervation.
Tailoring- descends from the upper part of the ilium and, bending around the thigh, reaches the upper medial edge of the tibia. With her hypotension, valgus of the knee will develop, the pelvic bone on the sides of hypotension falls and topples back.

Five adductors (adductor muscles) on the medial part stabilize the hip in the step, preventing it from deviating to the side:

Large adductor, the largest of the group, is functionally divided into two parts: adductor - goes from the pubic and ischial bones to the rough line; posterior - from the tuberosity of the ischium to the adductor tubercle and the internal supracondylar line. Brings legs together, participates in hip flexion. The posterior fibers are involved in its extension. Innervated by the obturator nerve and the tibial branch of the sciatic nerve. Turns the limb outward. Therefore, it is erroneous to assume that with valgus it is necessary to stretch it, on the contrary, it is weak.
long adductor covers the fibers of other adductor muscles - short and large, along the outer edge of the femoral triangle. From the pubic bone it expands like a fan to a rough line. Performs adduction and external rotation of the femur, innervated by the obturator nerve.
short adductor passes under the long one from the pubic bone and its lower branch to the rough line. It also adducts, rotates outward, and flexes the hip.
Comb- stretches from the pubic bone and its crest to the area between the lesser trochanter and the rough line. Therefore, when contracting, it bends the hip joint and turns the leg outward. The area often hurts while walking when the iliopsoas muscle is affected.
Thin- the most superficial muscles, crosses both joints. From the pubic bone and symphysis descends to the inner edge of the tibia, between the tailor and semitendinosus. Adducts limb and flexes knee.

The muscles of the posterior group form powerful tendons under the knee region. They extend the hip joint and flex the knee. They are innervated by the sciatic nerve, which emerges from the vertebrae L4-S3 - the last two lumbar and three sacral.

Each type of muscle has its own role:

two-headed- extends along the outer edge of the thigh. The long head comes from the ischial tuberosity, and the short head comes from the rough line. The tendon formed by them is fixed on the head of the fibula. Flexes the knee, extends the hip, and rotates the femur outward. With weakness, valgus deformity is formed. The long head is innervated by the tibial part of the sciatic nerve, and the short head by the common peroneal. With flat feet, the function of this flexor suffers.
Semitendon lies on the inside and intersects with the semimembranous. It starts on the ischial tuberosity and ends on the inside of the tibia, therefore it flexes the knee, extends the thigh. Its fibers turn the leg and knee inward. Nerve impulses come from the sciatic nerve.
Semimembranous- a thin and stretched in width muscle located under the semitendinosus. It starts on the ischial tuberosity and ends on the medial tibial condyle. Flexes the knee and extends the hip joint, rotates the limb inward. With the weakness of the last two muscles, varus deformity of the knee occurs.

All muscles enter the posterior myofascial chain along with the extensors of the spine, calves.

Vessels

The tissues are fed by the femoral artery, which emerges from the groin. Its branches supply blood to the muscles of the anterior and inner thighs, genitals, skin, lymph nodes, and bone.

The vessel lies between these two muscle groups, passes into the femoral triangle. Further, above the comb muscle, it descends into the gunter's canal. With prolonged sitting, it is often pinched by the flexor muscles and the inguinal ligament.

A branch departs from it - the deep artery of the thigh three centimeters below the inguinal ligament, above the iliopsoas and pectineus muscles. When sitting, squatting and anterior tilt of the pelvis, muscle fibers can compress the vessel.

From the deep artery of the thigh depart branches that envelop the femur:

medial blood supply to the medial broad muscle;
the lateral with its lower branch passes under the tailor, straight to the intermediate and lateral broad muscle of the thigh.

The perforating arteries, departing from the deep artery of the thigh, pass to the posterior surface below the pectineus muscle. They nourish the adductor muscles, knee flexors, and also the skin. Therefore, prolonged sitting, spasm of the iliopsoas muscle leads to starvation of the tissues of the lower limb as a whole.

The vessels and nerves of the thigh pass in the fascial canals along with the veins, forming neurovascular bundles.

Nerves

The performance of the hip depends on the health of the sacrum. From its roots, as well as the last two vertebrae of the lumbar plexus, two important nerves emerge:

Femoral- passes under the inguinal ligament, innervates the muscles of the anterior thigh group.
obturator- passes through the membrane of the same name in the opening of the pelvic bone to the adductor muscles.
Sciatic- comes out of the sacrum and lower back - to the flexors.

The femoral nerve may be pinched by spasmodic fibers of the lumbar and inguinal ligaments. When passing through the pelvis to the thigh, there is a division into the anterior and posterior sections.

The sciatic nerve exits the pelvic cavity through the greater sciatic foramen under the piriformis muscle and innervates the back of the thigh. With its weakness, the nerve is pinched, sciatica develops.

The obturator (obturator) nerve exits the obturator foramen through the canal of the same name. The condition of the adductor muscles, the capsule of the hip joint and the periosteum of the thigh depends on it.

It is often compressed by the psoas, sacroiliac joint, sigmoid colon, or inflamed appendix at the level of the membrane and with long hip flexion.

Conclusion

The thigh is made up of bone, several muscle groups that provide leverage to the hip and knee joints.

No muscle works in isolation in daily activities, as all muscles are connected by nerves, blood vessels and connective tissue - fascia. If one part of the thigh is damaged, the biomechanics of the movement of the pelvis, trunk, shoulders, and feet will change.

In contact with

Fracture of the femoral neck is one of the most complex and dangerous injuries, they account for approximately 6% of all fractures.

In most cases, this kind of fracture affects the elderly, this is due to a disease such as osteoporosis.

With this disease, bone density decreases, which significantly increases the risk of fracture, even with a slight traumatic force.

The hip joint is the largest joint in the human body.

It also performs the main supporting functions and carries a significant load when walking, running, lifting weights.

The shape of the hip joint is presented in the form of a ball placed in a rounded cavity.

The articular cavity is formed by the pelvic bone, it is called the acetabular or acetabular cavity. It contains the head of the femur, which is connected to the body of the femur through the neck.

In the common people, the neck of the femur is called the "neck of the femur." At the base of the neck are bone elevations - a large and small trochanter, to which muscles are attached.

Mechanism and causes

If you are examining an elderly person who, while walking down the street or around the apartment, fell on his side and was unable to stand up on his own, then the thought of a fracture of the femoral neck should first of all arise.

It is due to a fall on the side, on the site of the greater trochanter in the elderly that fractures of the femoral neck and acetabular area occur.

As you know, older and older people always have a pronounced progressive osteoporosis.

The degree of its manifestation depends not only on the age of the person, but also on concomitant diseases, physical activity. In addition to these general factors, the condition of the proximal end of the femur is affected by the quality of blood supply, especially to the head and neck.

With age, the blood supply to the head and neck becomes more complicated due to obliteration of the artery of the femoral head, which runs in the round ligament, and the state of the vessels in the sclerotic fibrous joint capsule.

All these factors lead to an intensive increase in osteoporosis in the proximal end of the femur, especially in the region of Ward's triangle, Adams' arch.

Due to the loss of spongy tissue, the strength of the bar architectonics of the proximal end of the femur is significantly reduced.

In addition, in older and elderly people, significant manifestations of degenerative-dystrophic changes in the spine (osteochondrosis, deforming spondylosis with secondary recurrent polyradiculitis) worsen muscle trophism against the background of involutive processes.

Muscles lose their elasticity, strength, endurance, especially in the case of limited range of motion in the hip joint, their defensive reaction and grouping ability decrease.

This leads to a decrease in the protective function, and therefore the impact of the fall falls directly on the greater trochanter, which protrudes.

In cases where the head more or less retains its structure and the acting traumatic force is directed along the axis of the neck, a fracture of the bottom of the acetabulum or a central hip dislocation occurs.

When the traumatic force acts somewhat at an angle from below outside the acetabulum with the hip adducted with external rotation, the neck under the head rests against the lower edge of the acetabular fossa, a subcapital fracture occurs.

Traumatic force and contraction of the gluteal muscles displace the distal fragment upwards, an adduction fracture (coxa vara traumatica) occurs.

Due to the action of a traumatic force outside and somewhat above the acetabular area, aimed at extension of the cervical-femoral angle, an abduction fracture (coxa valga traumatica) occurs.

Under the action of a traumatic force from above and from the outside on the trochanter site, isolated fractures of the greater trochanter occur.

In adolescents who have not yet experienced synostosis of the greater trochanter, a sudden sharp contraction of the gluteal muscles leads to the separation of the greater trochanter, and with the tangential action of a traumatic force, epiphyseolysis of the greater trochanter occurs.

Avulsion fractures of the lesser trochanter also occur due to sudden sudden contractions of the iliopsoas muscle.

Thus, in the occurrence of fractures of the proximal end of the femur, involutive changes, neurotrophic bone lesions, osteoporosis, loss of muscle elasticity, limitation of the range of motion in the joint, a decrease in the protective reaction of muscles in older and elderly people, the direction, area and strength of the traumatic force play a role.

Symptoms

For fractures of the femoral neck and trochanters

Complaints in the victims are similar: pain in the hip joint, lack of active movements and loss of function of the injured leg.

But with a detailed clinical examination, it is possible to make a differential diagnosis.

For abduction fractures

Significant external rotation of the limb is not typical for abduction fractures of the femoral neck. There is a slight inward displacement of the axis of the lower limb, the tip of the greater trochanter is on the Roser-Nelaton line, there is no relative shortening of the limb.

Pressure on the heel along the axis of the lower limb or tapping on it causes exacerbation of pain in the hip joint, Briand's triangle is isosceles, Shemaker's line passes above the navel.

For adduction fractures

The injured limb is externally rotated, has a significant relative and functional shortening, the tip of the greater trochanter is located above the Roser-Nelaton line.

Shemaker's line passes below the navel, the isosceles triangle of Briand is broken. Passive movements and loads along the axis of the limb exacerbate pain in the hip joint.

In people with not very developed subcutaneous fatty tissue, the pulsation of the femoral artery under the inguinal ligament is clearly visible.

Acetabular area

The injured limb is significantly externally rotated.

The outer surface of the acetabular area is flattened, the contour of the greater trochanter is smoothed, expanded, its apex is higher than the Roser-Nelaton line.

Briand's triangle is broken and Shemaker's line passes below the navel. On palpation, the intensity of pain increases with direct touch to the swivel itself.

In case of displacement of fragments, a protrusion is palpated at the site of the fracture of the greater trochanter. Active limb movements are impossible, passive ones are significantly limited due to exacerbation of pain in the acetabular region.

greater trochanter

Occur due to direct trauma in young and middle-aged people.

In young men, with the tangential action of a traumatic force and a sudden sharp, excessive contraction of the gluteal muscles, the greater trochanter comes off.

There is a sharp pain on the outer surface of the hip joint.

The victim can walk independently, but at the same time, the injured limb does not actively move forward, but pulls it up with a healthy step. Can actively bend the leg in the hip joint, feeling a moderate exacerbation of pain.

The victim is unable to actively abduct the hip at the hip joint. Rotational movements exacerbate pain in the greater trochanter.

In people with insufficiently developed subcutaneous tissue, with fractures of the greater trochanter with displacement of fragments or multi-comminuted fractures, deformation of the contours of the greater trochanter is clearly visible, its apex is located above the Roser-Nelaton line.

On palpation, the pain is aggravated by direct contact with the greater trochanter, and with significant displacement, there is diastasis between the fragments.

Isolated fractures of the lesser trochanter

Another of the injuries of the femur, is rare.

Fractures of the lesser trochanter are observed in adolescence, when synostosis with the femur has not yet occurred, and, in fact, a fracture of the lesser trochanter is an avulsion fracture of the apophysis.

Detachment of the lesser trochanter occurs mainly in boys during jumping, that is, due to a sharp, sudden, excessive contraction of the iliopsoas muscle, and there is a sharp pain in the depths of the base of the femoral triangle.

The victim loads the lower limb, walks independently, tilting his torso forward, dragging his leg. On palpation, the severity of pain is localized in the projection of the lesser trochanter.

The injured hip adducts, abducts, but cannot actively bend it, while passive flexion is possible in full (positive Ludloff's symptom).

So, when the lesser trochanter is torn off, only the function of the iliopsoas muscle is disturbed, and the function of the gluteal muscles, adductor and rotational, does not suffer.

The final diagnosis is established after an X-ray examination, which makes it possible to confirm the clinical diagnosis, to identify the structure of the proximal end of the femur, which is necessary to substantiate and select an effective tactics and method of treatment.

With fractures of the femoral head, the number of fragments, their position are detected, with fractures of the neck - the place of the fracture, features of the fracture plane, the nature of the angular displacement of the fragments.

Neck fractures

Most often they are subcapital, less often - transcervical or basal.

Due to the fact that fractures of the femoral neck are intra-articular, the joint capsule limits significant displacements in length and width, and the displacement occurs mainly at an angle, that is, there is a decrease or increase in the neck-diaphyseal angle.

Among the fractures of the femoral neck are:

fractures with a decrease in the cervical-diaphyseal angle - adduction (drive);
varus with a vertical or vertically oblique fracture plane.

From a biomechanical point of view, adduction fractures are unfavorable for the process of reparative regeneration due to the instability of fragments, which is due to the constant contraction of the gluteal muscles.

In addition, with a vertical or vertically oblique fracture plane, a shear force is constantly acting, which destroys the restoration of the vascular network and disrupts reparative regeneration.

This causes the formation of false joints and resorption of the femoral neck.

With abduction (valgus) fractures of the femoral neck, the cervical-diaphyseal angle increases, which in turn leads to an increase in the tone of the gluteal muscles and the fragmentation of fragments with the exclusion of any mobility between them.

This becomes a positive factor for the process of reparative regeneration.

So, abduction fractures in the absence of circulatory disorders and degenerative-dystrophic changes in the head, prognostically favorable for fusion.

For transcervical fractures, a vertically oblique fracture plane is typical, and basal fractures are mostly impacted with a decrease in the neck-diaphyseal angle (traumatic coxa vara).

Among the fractures of the acetabular area, the first place is occupied by pertrochanteric ones with a fracture or detachment of the lesser trochanter, the second place is occupied by multi-comminuted ones, and the intertrochanteric ones are third.

With acetabular fractures, fragments are displaced in length and width more than with neck fractures. This is explained by the fact that all fractures of the acetabular region are extra-articular and the displacement of fragments is not limited to the capsule.

Isolated fractures of the greater trochanter have a transverse-oblique fracture plane and are often multi-comminuted.

Most isolated fractures of the lesser trochanter have an oblique fracture plane. The proximal displacement of the lesser trochanter occurs under the action of the iliopsoas muscle.

Treatment

Fractures of the neck of the femur

Depends on the age of the victim, the type and nature of the fracture.

Considering that fractures of the femoral neck occur predominantly in the elderly, all conservative methods, as experience has shown, are not indicated.

After all, conservative methods of treating elderly victims for a long time chain them to the bed in a forced position, which leads to such life-threatening complications as decompensation of the cardiovascular system, hypostatic pneumonia, bedsores, and pulmonary embolism.

This gave grounds to G.I. Turner to declare that nothing pushes the arrow of life in the elderly so quickly as fractures of the femoral neck.

It is necessary to take into account the fact that in elderly victims, in addition to involutive changes in the structure of bones, muscles, vessels in the joints, there are, to a greater or lesser extent, pronounced degenerative-dystrophic processes, which also negatively affect the regeneration process.

At the site of a fracture, especially an adduction fracture, there are constant movements between the fragments that disrupt the process of reparative regeneration and lead to the development of such a severe complication as a false joint.

Therefore, until recently, the main method of treating adduction fractures of the femoral neck was surgical closed comparison of fragments with stable osteosynthesis with a three-bladed nail.

But it is possible to achieve stable osteosynthesis only in the presence of a normal bone structure of the proximal end of the femur, which occurs in people of middle and young age.

As for older or elderly people, the proximal end of the femur, especially the central fragment, has significant involutive changes and degenerative-dystrophic lesions of the head and vascular network.

Under such conditions, to obtain stable osteosynthesis in the vast majority of victims impossible.

This is evidenced by statistical data, according to which unsatisfactory consequences in osteosynthesis of adduction fractures of the femoral neck due to non-union are observed in 30-38% of the victims, due to aseptic necrosis of the head after fracture union - in 24-26% of cases.

In addition, the disadvantage of osteosynthesis is that the victims have to walk with the help of crutches, which is not so easy for an elderly person.

Therefore, in the last decades of the 20th century, all traumatological schools of the world switched to implantation of artificial joints for fractures of the femoral neck in elderly patients.

The accumulated experience of surgical treatment of femoral neck fractures in patients of older age groups gives grounds to assert that the introduction of artificial joints into clinical practice has made it possible to apply an active functional method of treatment, free the victims from prolonged use of crutches, significantly reduce the time spent in the hospital and prevent fatal complications, which cause high mortality.

Method of osteosynthesis of the femoral neck

Fractures of the femoral neck in young and middle-aged people who do not have neurotrophic and degenerative-dystrophic changes in the proximal end of the femur are treated with closed osteosynthesis of fragments with a Smith-Petersen three-blade nail or Klimov's T-nail, Bokicharov's fixator.

Many methods of closed osteosynthesis of femoral neck fractures have been proposed (Belera, Klimov, Ozerova, Grutsi, etc.).

But now, with the advent of new X-ray equipment, the control guide pin in the center of the neck is carried out under visual control. The operation became technically simple.

The operation of closed osteosynthesis of a fracture of the femoral neck is performed under anesthesia or local anesthesia. First, a closed reposition of fragments is performed.

The assistant fixes the pelvis to the operating table with his hands, and the surgeon flexes the thigh to 90°, makes thrust along the axis and, without reducing, without jerking, slowly unbends the leg to 180° and abducts it to 30°, rotating it inward.

The same position is given to the opposite lower limb. The feet are fixed with flannel bandages, keeping the tension of the lower extremities to the feet of the orthopedic table, preventing the pelvis from being distorted.

Make control x-rays in two projections, make sure that the fragments are compared, treat the surgical field with an antiseptic.

An incision 6-8 cm long is made along the outer surface of the hip joint, from the greater trochanter down the projection of the femur. Next, the subcutaneous tissue and fascia are cut, and hemostasis is performed.

Sharply and bluntly separate the lateral broad muscle under the trochanter to the bone. A hole is made along the outer surface of the femur under a large swivel for inserting a nail into the cortical layer of the bone with a chisel or drill.

Under the control of the X-ray machine in the center of the neck at an angle of 127-130°, a guide pin is passed through both fragments, which serves as a guide.

After that, the needle is removed, the surgical wound is sutured in layers. A derotational boot or a plaster splint is applied to the foot and lower leg up to the middle third.

Splicing occurs in 5-6 months. Efficiency in people of non-physical labor returns after 6 months, and physical - after 10-12 months.

Acetabular fractures

In young and middle-aged people, they are treated conservatively (skeletal traction or immobilization with a plaster cast).

Unlike femoral neck fractures, acetabular fractures heal well after 8 weeks.

As for older and elderly people, their method of choice for the treatment of acetabular fractures is surgical.

The victim is placed on an orthopedic table and, by traction along the axis with a tap, internal rotation of the limb, the fragments are compared. Both lower limbs are symmetrically fixed to the footrests of the orthopedic table.

A control X-ray is taken, the fragments are compared, the surgical field is treated with an antiseptic, and the soft tissues are cut to the bone along the outer surface of the upper third of the thigh.

The incision starts 1-1.5 cm above the top of the greater trochanter and is led down along the axis of the femur 8-10 cm long. After hemostasis, the outer surface of the greater trochanter and femur is isolated.

Under the base of the greater trochanter in the cortical layer of the femur, an electric drill makes a hole with a size corresponding to the width of the latch, after which the bent proximal part of the L-shaped latch is driven into the greater trochanter and neck, and the distal plate is applied throughout its entire length directly to the outer surface of the femur and fixed .

The surgical wound is sutured in layers. A derotational plaster boot is placed on the lower third of the lower leg and foot.

After 3-5 days, the victims are allowed to get up, and after removing the stitches - on the 12-14th day - to walk with the help of crutches, without loading the operated limb.

1 month after the operation, the victims are allowed to load the operated limb up to 50%, and after 2 months - full. Working capacity returns 3-4 months after the operation.

Isolated fractures of the greater trochanter with no or slight displacement

Isolated fractures of the greater trochanter without displacement or with slight displacement are treated conservatively.

Regardless of the method (a coxite plaster cast is indicated for young people, functional treatment in bed is for elderly victims), the injured limb should be abducted (to relax the gluteal muscles and restore the cervico-diaphyseal angle) and ensure that the fragments are real at the fracture site.

In fractures with displacement of the greater trochanter or with the presence of diastasis between fragments, surgical treatment is indicated - an open comparison of fragments with osteosynthesis with screws.

In case of fragmentation fractures with displacement, the latter are repositioned and fixed transosseously with lavsan threads with additional suturing of adjacent soft tissues.

In cases where the fragments cannot be compared or they are too small, the latter are removed, and the gluteal muscles are sutured transosseously to the central fragment of the greater trochanter.

Fractures of the lesser trochanter

Fracture of the lesser trochanter is treated conservatively. The victim is laid on the bed, the injured limb is placed on the Beller splint.

The femur should be flexed at the hip joint to an angle of 110-100° and rotated somewhat outward. Fracture union occurs in the fifth or sixth week.

Rehabilitation

With proper rehabilitation, the patient can avoid most of the possible complications.

Recovery requires comprehensive measures.

Need to remember: the sooner the patient gets on his feet and begins to move independently, the higher the chances of recovery.

Rehabilitation measures should be started as early as possible, within a few days after the injury (in the case of conservative treatment) or surgery (in the case of surgery).

One of the most important components of rehabilitation is exercise therapy. Lack of mobility can be extremely dangerous, but exercise should not be overdone.

Loads should be carried out under the supervision of a doctor, and increase gradually. At the initial stage, all exercises are performed lying down.

To maintain normal blood circulation in the tissues during bed rest, the patient needs to learn how to perform simple exercises - contractions of the muscles of the press, back, hips and legs.

Joint work is also important for recovery. The patient performs flexion and extension of the fingers, turns and inclinations of the neck, arms, work with expanders and small dumbbells.

After removing immobilization, it is necessary to develop joints that have been immobile for a long time. The next stage - the patient tries to walk with the help of special walkers.

After two weeks, they can be replaced with a cane, then the aids can be completely left. To speed up recovery, massage and physiotherapy are used.

Nutrition is also of great importance for a speedy recovery. During rehabilitation, the body needs calcium and collagen, which contribute to the healing of the fracture.

To maintain immunity and vitality, you need to take vitamins. Dairy products, vegetables, fruits are very useful.