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1857HyrtlJ


The author discusses the anatomy, structure, and role of the ligamentum capitis femoris (LCF). Based on his own research, Josef Hyrtl asserts that the vessels of the LCF do not participate in supplying blood to the femoral head. The author highlights the high strength of the LCF and changes in congenital dislocations. Apparently, this work was the first to suggest that the LCF serves as a conductor of inflammatory processes and a cause of coxalgia.


Hyrtl J. Handbuch der topagraphischen Anatomie und ihrer praktisch medicinisch-chirurgischen Anwendungen. Zweiter band. Wien: W. Braumüller, 1857. [fragment]

Quote p. 410-412

c. Rundes Band des Schenkelkopfes. Einfluss desselben auf die Stellung des Beins bei Coxalgie.

Ein verticaler, durch die Mitte der Pfanne und des Schenkelkopfes und bei richtiger Beckenneigung von aussen nach innen geführter Schnitt, trennt das runde Band in zwei gleiche Schenkel, einen vorderen und hinteren. Das Band muss somit in der Pfanne selbst eine verticale Lage haben. Es entspringt am tiefsten Punkte des Pfannenrandes (wo die Incisura acetabuli durch das über sie weglaufende Labrum cartilagineum in ein Loch verwandelt wird) und von der ganzen Fläche der knorpellosen Fovea acetabuli, und endigt in der Mitte der Schenkelkopffläche kann somit nur die Adduction des gestreckten Schenkels beschränken. Bei dieser Verwendung des Bandes ist jedoch nicht zu übersehen, dass die Beschränkung der Adduction des Schenkels vorzugsweise vom vorderen Verstärkungsbande der Hüftgelenkkapsel geleistet wird, und das runde Band nur geringen Antheil an dieser Hemmung nimmt. Schon sein Gefässreichthum lässt es vermuthen, dass es kaum je durch Zerrung und Spannung in Anspruch genommen werden darf. Erst wenn das eben erwähnte vordere Verstärkungsband der Kapsel durchschnitten wurde, tritt das runde Band als adductionshemmend auf, und Henle zeigte überdies, dass man durch Zerschneiden des runden Bandes nach gemachter Eröffnung der Pfanne von der Beckenhöhle aus, und bei Unversehrtheit der Kapsel, die Grösse der Adductionsbewegung (natürlich in gestreckter Lage des Gelenks) nicht vermehren kann) (1).

1) Bänderlehre, pag. 131.

Bei gebeugtem Hüftgelenk, wo das runde Band und das vordere Ver stärkungsband erschlaffen, kann die Adduction bis zum Uebereinanderschlagen der Beine getrieben werden, und man kann es an jedem Gaukler sehen, dass er z. B. seine rechte Ferse mit geringer Nachhilfe der Hand auf die linke Schulter legt. Das Band ist dreieckig, hiess deshalb bei Weitbrecht Ligamentum prismaticum. Seine Stärke ist nicht unbedeutend, wie die Beobachtung lehrt, dass häufig bei Luxationen nicht das Band, sondern seine Insertion am Schenkelkopfe ausreisst. Seine oberflächliche Schichte ist bedeutend fester, als seine innere Masse, welche zuweilen so locker und weich erscheint, dass das Band beim Querschnitt für einen hohlen Cylinder imponirt.

Dass das runde Band dem Schenkelkopfe Ernährungsgefässe zuführe, ist unrichtig. Ich habe mich durch die subtilsten Injectionen überzeugt, dass die Blutgefässe des runden Bandes nicht in die Substanz des Schenkelkopfes eindringen, sondern an der Einpflanzungsstelle schlingenförmig in rücklaufende Venen umbeugen. Es wäre auch nicht erklärbar, wie, wenn der Schenkelkopf auf diesem Wege allein seine Nahrungszufuhr empfinge, er sich nach Verrenkungen mit Zerreissung des runden Bandes so lange erhielte. Auch ist das Vorkommen des runden Bandes in der Säugethierwelt keine allgemeine Norm, und Paletta hat mehrere Fälle von Fehlen dieses Bandes im Menschen gesammelt (1). Flourens hat bei der Entstehung der Hüftgelenkverrenkungen dem runden Bande einen sonderbaren Antheil zugedacht. Da das Band eine der Convexität des Schenkelkopfes entsprechende Krümmung hat, so muss es, wenn es bei gewissen Bewegungen dieses Kopfes gespannt wird, und dadurch geradlinig zu werden strebt, auf den Schenkelkopf drücken, und ihn aus der Pfanne heraustreiben. Bei angeborenen Hüftgelenksverrenkungen fehlt das runde Band nur selten. Dupuytren, Robert Adams, und Hutton fanden es verlängert. Letzterer fand es 4 Zoll lang, und so dick wie die Achillessehne. Diese merkwürdige Dicke und Länge des Bandes lässt für den günstigen Erfolg der Reductionsversuche wenig Hoffnung übrig, da das Band wie eine vorgefallene Nabelschnur schlingenförmig über den Rand der Pfanne herabhängen, und wie ein fremder Zwischenkörper den Contact der Gelenkflächen hindern wird.

1) Meckel's Archiv. 6. Bd. Seite 341.

Da das Band blutgefässreich ist, und seine Arterien von einem Zweige der Arteria obturatoria erhält, so wird es gewissermassen die Heerstrasse zeichnen, auf welcher extracapsulare Entzündungen in den Binnenraum des Gelenks eindringen. Tritt die Entzündung im Gelenke selbst auf, wie bei Coxalgie, so wird das runde Band aus demselben Grunde wohl den Ausgangspunkt des Leidens bilden. Die durch die Entzündung bedingte Schwellung des Bandes, und seine gesteigerte Empfindlichkeit, werden eine solche Stellung des Beins bedingen, in welcher das Band am wenigsten gespannt ist, d. i. die Abductionsstellung, und da in dieser Stellung der Gebrauch des Beins zum Gehen ein sehr beschwerlicher ist, so werden die Kranken, so lange sie noch ausser Bett sind, durch Senkung des Beckens auf der leidenden Seite den abducirten Fuss, ohne Zerrung des runden Bandes, dem gesunden näher bringen, und da er durch diese Senkung der Hüfte länger wird, so muss eine Beugung im Knie die Ungleichheit corrigiren. Die Verlängerung des Beins ist somit in diesem Stadium der Krankheit keine wirkliche, sondern eine scheinbare, und durch den einseitigen tieferen Stand des Beckens bedingt. Eine wirkliche Verlängerung kann sich nur dann einstellen, wenn der Schenkelkopf durch Producte der Entzündung oder der Vereiterung von der Pfanne weg nach unten gedrängt wird, ohne jedoch ganz aus ihr herauszutreten, in welchem Falle Verkürzung des Beins eintreten muss, indem die am Trochanter befestigten Beckenmuskeln den Schenkel an der Hüfte in die Höhe ziehen.

c. Round ligament of the femoral head. Influence on the position of the leg during coxalgia.

A vertical incision made through the center of the acetabulum and femoral head, directed from outside to inside with the correct tilt of the pelvis, divides the round ligament into two equal legs, anterior and posterior. Therefore, the ligament must have a vertical position within the acetabulum itself. It originates at the lowest point of the acetabular rim (where the acetabular notch is transformed into a hole by the labrum cartilagineum passing over it) and from the entire surface of the cartilage-free acetabular fossa, ending in the middle of the femoral head surface, thus it can only restrict adduction of the extended thigh. However, in such use of the ligament, it cannot be overlooked that the restriction of thigh adduction is primarily provided by the anterior reinforcing ligament of the hip joint capsule, and the round ligament plays only a minor role in this inhibition. Its vascular richness alone suggests that it is unlikely to ever be subjected to stress and tension. Only when the aforementioned anterior reinforcing ligament of the capsule is cut does the round ligament, presumably acting as a shunt, and Henle also demonstrated this by cutting the round ligament after opening the acetabulum from the pelvic cavity side and with an intact capsule, there is no increase in adduction movement (of course, when the joint is in an extended position) (1).

1) Bänderlehre, page 131

With the hip joint flexed, where the round ligament and the anterior reinforcing ligament relax, adduction can be performed until the legs cross, and this can be seen in every juggler, for example, B. places his right heel on his left shoulder with a little help from his hand. The ligament is triangular in shape, which is why Weitbrecht called it the Ligamentum prismaticum. Its strength is significant, as observations show that in dislocations, it is often not the ligament itself that tears, but rather its attachment site on the femoral head breaks off. Its superficial layer is considerably stronger than its inner mass, which sometimes appears so loose and soft that in cross-section the ligament resembles a hollow cylinder.

It is incorrect to say that the round ligament provides blood supply to the femoral head. Through the finest injections, I have confirmed that the blood vessels of the round ligament do not penetrate the substance of the femoral head but bend in a loop at the site of insertion into the returning veins. It would also be inexplicable how, if the femoral head received nutrition only in this way, it could persist for so long after stretching and tearing of the round ligament. The presence of the round ligament in mammals is also not a common norm, and Paletta has collected several cases of its absence in humans (1). Flourens attributed a strange role to the round ligament in the development of hip joint dislocations. Since the ligament has a curvature corresponding to the convexity of the femoral head, when it is stretched during certain movements of this head and thus tends to straighten, it must press on the femoral head and push it out of the acetabulum. In congenital hip joint dislocations, the round ligament is rarely absent. Dupuytren, Robert Adams, and Hutton found it elongated. Hutton found it to be 4 inches long and as thick as the Achilles tendon. This remarkable thickness and length of the ligament offer little hope for successful reduction attempts, as the ligament will hang in a loop over the edge of the acetabulum like a foreign body, impeding contact of the joint surfaces.

1) Meckel's Archiv. Vol. 6. Page 341.

Since the ligament is rich in blood vessels and receives nourishment from a branch of the obturator artery, it essentially dictates the pathway through which extracapsular inflammatory processes penetrate into the joint. If inflammation occurs within the joint itself, as in coxalgia, then for the same reason, the starting point of the condition is likely to be the round ligament. The swelling of the ligament caused by inflammation and its increased sensitivity will force the leg to position itself so that the ligament is least tense, i.e., in the abduction position. Since using the leg for walking is very difficult in this position, patients, while still not in bed, can raise the abducted leg by lowering the pelvis on the affected side, without straining the round ligament, and bring its foot closer to the healthy one. And since due to this lowering of the pelvis, the leg becomes relatively longer, bending at the knee should correct the inequality. Thus, lengthening the leg at this stage of the disease is not real but rather apparent and is due to the one-sided tilt of the pelvis. Real lengthening can only occur if the femoral head is displaced downward from the acetabulum by inflammatory or purulent products, but does not completely exit it, and in such a case, shortening of the leg should occur, as the pelvic muscles attached to the greater trochanter lift the femur upward. 

 


External links 

Hyrtl J. Handbuch der topagraphischen Anatomie und ihrer praktisch medicinisch-chirurgischen Anwendungen. Zweiter band. Wien: W. Braumüller, 1857. [books.google] 

Authors & Affiliations

Josef Hyrtl (1810-1894) was an Austrian anatomist, a professor at the University of Vienna. wikipedia.org

Josef Hyrtl (1850)
Lithograph by Eduard Kaiser; original in the wikimedia.org collection
(CC0 – Public Domain, no changes)

Keywords

ligamentum capitis femoris, ligamentum teres, ligament of head of femur, anatomy, conductor of inflammation, role, pathology

                                                                     .

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MORPHOLOGY AND TOPOGRAPHY

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