Quote p. 94
The head (i, figs. 49 and 50)
is the most regularly spheroidal of all the eminences in the skeleton, and
forms nearly two thirds of a sphere. In the middle of it we observe a rough
depression (k) of variable dimensions, which gives attachment to the round ligament.
Quote pp. 159-162
COXO-FEMORAL ARTICULATION (fig. 76).
Preparation. Remove with care all the muscles that surround the joint,
preserving the reflected tendon of the rectus femoris. The psoas and iliacus
muscles, the synovial capsule of which so often communicates with the articular
synovial membrane, must be removed with particular care. After the fibrous
capsule has been studied upon its external surface, a circular division should
be made round its middle portion, for the purpose of uncovering the deep-situated
parts. This articulation is the type of the order enarthrosis, being a true
ball and socket joint.
The articular surfaces are the globular head of the femur, and the
cotyloid cavity of the os innominatum. There is a striking difference between
this joint and that of the shoulder, as far as regards the size of the
articular head and the depth of the articular cavity. While the head of the
humerus and the glenoid cavity are simply in juxtaposition without any
reception of the former into the latter, so that the scapulo-humeral
articulation has for a long time been, and is now considered as an arthrodia,
there is a deep and complete fitting of the head of the femur into the cotyloid
cavity, which we have pronounced to be the deepest articular cavity of the body.
Both of the surfaces above named are covered with cartilage, with the exception
of two depressions, one of which is situated on the head of the femur, the
other at the bottom of the cotyloid cavity: the latter is filled with a reddish
adipose tissue, improperly called the cotyloid gland. It is analogous to the
adipose tissue found in the neighbourhood of all the joints; its use is not
well known. I have often asked myself the question. Why should there be this
posterior cotyloid cavity? On submitting the joint to an antero-posterior
vertical section, slightly encroaching on the margin of the posterior cotyloid
cavity, it will be seen that the object of this cavity is to protect the round
ligament in all the possible positions of the head of the femur; and that,
without this cavity, the round ligament could not have existed without its
being compressed between the articular surfaces. Now, as the intraarticular
vessels enter this cavity, and go to the head of the femur along the round
ligament, it is not impossible but that the exclusive use of this posterior
cotyloid cavity should be to protect the vessels destined to the head of the
femur, and that the round ligament itself should have no other use than to
support these vessels, and to transmit them to the head of the femur. The
cotyloid adipose tissue does not seem to have any other object, except to fill
the empty space of this posterior cavity.
It appears to me that the round ligament of the coxo-femoral
articulation of the posterior cotyloid cavity serves the same purpose as the
space between the condyles of the lower end of the femur and the crucial
ligaments of the knee-joint.
Means of Union. The cotyloid ligament (n, fig. 76). This band,
improperly called cotyloid ligament, is attached to the margin of the
acetabulum, which it, as it were, completes; it augments the depth of the
cavity, and renders smooth its sinuous and notched circumference. It is of
greater size at the notches than in any other part: by its means the
irregularities of the edge of the acetabulum are effaced, and the deep notch in
front and below is converted into a foramen for the passage of vessels to the
fatty tissue, the inter-articular ligament, and the head of the femur.
The cotyloid band is much thicker above and behind than below and in front, and it is precisely against the first two points that the head of the femur constantly presses. It is also remarkable, in this respect, that the diameter of its free borders is smaller than that by which it is attached; and this circumstance assists, in some degree, in retaining the head of the femur in the cotyloid cavity.* It consists of fibres which arise successively from all points of the circumference of the acetabulum, and interlace at very acute angles. This interlacement is especially visible in the situation of the great anterior notch, where the fibres may be seen arising from each side of the notch, and passing across each other.
*I have never seen this disposition better exhibited than in a subject in which the cotyloid band was ossified in its whole extent, except at the place on a level with the anterior and inferior notch. The head of the femur was mechanically and solidly retained in the acetabulum, whose bottom, being partly worn out and pressed inward, formed a prominence in the interior face of the pelvis.
The orbicular ligament, or fibrous capsule (p, fig. 76). This represents
a fibrous sac, having two openings, by one of which it embraces the acetabulum,
outside the cotyloid ligament, while the other surrounds the neck of the femur.
The femoral insertion of the capsular ligament requires to be carefully
studied, for the purpose of explaining the difference between fractures within,
and fractures beyond, the capsule. This insertion is so arranged, that at the
upper part and in front of the joint it corresponds with the base of the neck of
the femur, while beneath and behind it is situated at the junction of the
external with the two internal thirds of the neck. The insertion of the capsule
in front takes place not only at the base of the neck of the femur, but also
internally to this base, to the extent of several lines, as may be ascertained
by an incision being made along this insertion in the direction of the axis of
the neck. The length of the orbicular ligament is exactly equal to the distance
between its insertions, excepting at the inner part, where it is much more
loose. Hence the extent of the motion of abduction, which is so remarkable in
some jugglers, that they are able to separate their legs until they form right
angles with the body, without producing dislocation.
The thickness of this ligament is not equal throughout: it is greatest
above and on the outside, where the reflected tendon of the rectus muscle is
situated; it is yet very considerable in front and above; it is less thick
behind, and still thinner on the inside. In some subjects the thickness of the
superior part of the capsule is to that of the inferior as five to one. In
front, the capsule is strengthened by a bundle of fibres stretched obliquely,
like a sling, from the anterior inferior spinous process of the ilium to the
inside of the base of the neck of the femur. It is called by Bertin the
anterior and superior ligament (r, fig. 76). This band, which serves as a
re-enforcement to the capsule, lies under that portion of the iliacus muscle
which arises from the anterior spinous process of the ilium, and follows the
direction of this muscle; it is composed of parallel fibres, and closely
adheres to the capsule, without adhering in the least to the muscle. Within
this bundle the capsule is often imperfect, and permits a communication between
the synovial membrane of the joint and the bursa of the psoas and iliacus
muscles. This last synovial membrane may be considered as a prolongation of the
articular synovial membrane; this prolongation is analogous to the one which we
have described at the scapulo-humeral articulation for the subscapularis
muscle. In one subject that I dissected, the communicating orifice was so
large, that the common tendon of these muscles was in immediate contact with a
considerable portion of the head of the femur; the tendon itself being split
into several bands, some of which had been lacerated, and, as it were, worn
away by friction.
The external surface of the capsular ligament is in relation with the
psoas and iliacus muscles in front, being separated from them by a bursa at the
upper part, in those cases where the fibrous capsule is not interrupted, and
giving insertion to many of their fibres below. On the inside, it is in
relation with the obturator externus and the pectineus; on the outside, with
the gluteus minimus; behind, with the quadratus femoris, the gemelli, the
pyriformis, and the obturator internus. Several of these muscles send
fortifying bundles of fibres to the capsule. I may point out an aponeurotic
expansion coming from the gluteus minimus, which establishes a close connexion
between this muscle and the capsule; a second expansion, furnished by the
pyriformis and the gemelli; and a third, which is furnished to the capsule by
the tendon of the vastus externus. The internal surface is lined by the
synovial membrane.
The orbicular ligament of the hip-joint differs from the generality of
such structures in being of a dull white instead of a pearly white colour, and
in being composed of irregularly interlaced fibres, except the superficial
fibres, which are disposed in parallel lines. I have also observed a very
remarkable fact, apparently overlooked by anatomists, viz., that it is
extremely thin at its inferior orifice, but especially behind; and that near
this insertion it is strengthened by some circular fibres which embrace the
neck of the bone like a collar, but without adhering to it; and that in its
different movements this sort of collar rolls round the neck, but is retained
in its place by small bundles of fibres, reflected from the capsule upon the
neck of the bone, which raise the synovial membrane from the surface.
The inter-articular, which is improperly called round ligament (t, fig.
76). This ligament arises, under the form of a fibrous band, folded backward
upon itself, from the depression on the head of the femur, which depression is
not entirely filled by it. It is twisted around this head, and is divided into
three bands, one of which, after having again been subdivided, traverses the
adipose tissue and is fixed into the bottom of the cotyloid cavity, while the
two others are attached to the two edges of the cotyloid notch, below the
cotyloid band, by which this insertion, with which it is often continuous, is
concealed.
In one case a prolongation of this ligament traversed the cotyloid notch, and was attached to the part nearest the capsule. The thickness and the strength of this inter-articular ligament are extremely variable: sometimes it is extremely strong, sometimes very weak; sometimes it adheres to one edge only of the notch; sometimes it consists merely of a few ligamentous fibres, contained within the substance of the reflected synovial membrane; sometimes in its place is found a fold of that membrane, which may be torn by the slightest force; and, lastly, it is not uncommon to find that it is altogether wanting. The synovial membrane lines the whole internal surface of the capsular ligament, the two non-adhering surfaces of the cotyloid ligament, and that part of the neck of the femur contained within the joint; it embraces the round ligament, and sends off a prolongation from it to a quantity of fatty matter at the bottom of the acetabulum;* an arrangement which led the older anatomists to believe that the round ligament was inserted into the bottom of the cotyloid cavity.
*The synovial membrane is often seen, being interposed and descending between the adipose substance and the posterior cotyloid cavity. I may also point out semilunar folds, which are often formed by the synovial membrane round the neck of the femur. These folds are supported by some detached fibres of the capsule, so that the neck, on a level with those fibres, is lined with synovial membrane only in the neighbourhood of the head of the femur. The synovial folds appear to me destined to conduct vessels to the margin of the head of the femur. Round the head of the femur, at its point of union with the neck, are constantly found very small adipose bundles.
Mechanism of the Coxo-femoral Articulation.
Like all enarthroses, the coxo-femoral articulation can execute
movements of flexion, extension, abduction, adduction, circumduction, and
rotation.
1. In flexion, the head of the femur rolls in the cotyloid cavity around
an imaginary axis corresponding with that of the neck of the bone, while the
lower end of the femur is carried from behind forward, and describes the
segment of a circle, whose radius is represented by the shaft of the bone. In
the mechanism of this movement, the neck of the femur has the effect of
substituting a rotatory motion of the head of that bone upon a fixed point,
without changing the relation of the head with the acetabulum, and,
consequently, without any tendency to displacement, for a very extensive
movement backward and forward, which would otherwise have been necessary, and
in which the surfaces would have been liable to separation from each other. We
can, indeed, scarcely believe that luxation would be possible during this
motion, although it can be carried so far that the front of the thigh and the
fore part of the abdomen may be brought in contact. 2. Extension is effected by
the same mechanism, the head and the neck of the femur rolling upon themselves
from behind forward, while large arcs of a circle, from before backward, are
described by the body of the bone; but such is the obliquity of the acetabulum,
which looks both forward, outward, and downward, that when the femur is in the
vertical direction, the head projects and carries forward the fibrous capsule.
The anterior re-enforcing bundle is stretched. The psoas and iliacus muscles
perform the office of an active ligament. Luxations of the femur forward are
not common, for the movement of extension is limited by the meeting of the edge
of the acetabulum and the back part of the neck of the femur; and the ligament
and muscles above named also tend to counteract it. 3 and 4. The mechanism of
adduction and abduction is altogether different from that of the preceding
movements, where the articulation forms the centre of a circle described by the
femur, the radius of which is measured by a line stretched from the head of the
bone to the space between the condyles. In abduction, the head of the femur
presses against the inner part of the capsular ligament; and, on account of the
looseness of this ligament, the obliquity of the acetabulum, and the
arrangement of the inter-articular ligament, this movement may be carried very
far without displacement, and is only limited by the meeting of the upper edge
of the neck of the femur with the rim of the cotyloid cavity. But this very
meeting may itself become the cause of luxation, and then the edge of the
cotyloid cavity may be regarded as the fulcrum of a lever of the first order
with unequal arms, the whole length of the femur being the arm, to which the
power is applied, and the neck of the bone, that by which the resistance acts.
In adduction, the femur moves in precisely the opposite direction: this
motion is limited by the mutual contact of the two thighs, but, by means of
slight flexion, it may be carried so far as to throw one over the other. The
great depth of the upper and external part of the cotyloid cavity, and the
strength of the capsular ligament in the same directions, would seem to oppose
all displacement. But it should be observed, that falls upon the knees almost
always happen during adduction of the thighs, for this is an instinctive
movement of preservation. However slight the adduction may be, the
interarticular ligament is of necessity stretched; and from this it follows, as
my colleague, M. Gerdy, has ingeniously remarked, that the head of the femur is
detached from the bottom of the cavity by a kind of rolling of the round
ligament upon it, and comes to press against the fibrous capsule. The rupture
of the inter-articular ligament is not always necessary in luxation. I have
seen several instances of a so-called incomplete luxation inward, without this
ligament being torn.
5. Circumduction consists in the transition from one of these motions to
another. The femur circumscribes a cone, of which the apex is in the joint,
while the base is described by the lower end of that bone. The axis of the cone
is represented by a line drawn from the head of the femur to the interval
between the condyles; and the length of the femur accounts for movements which
are scarcely felt at the coxo-femoral articulation, being so considerable at
the lower end of the bone.
6. Independently of the movements above described, the coxo-femoral articulation performs motions of rotation, arising by no means from its enarthrodial shape, but from the presence of the neck of the femur. Generally no movement appears to require a greater expenditure of power on the part of nature than the rotatory movements, and these movements are not always regulated by the same mechanism. We have already seen an example of this movement in the atlo-axoidian articulation, where a cylinder formed by the odontoid process rolls in the partly osseous and partly fibrous ring of the atlas, as an axletree in a wheel. Here the arrangement is quite different; the rotatory movement is obtained simply by the lever being bent like an elbow in such a manner as to make the rotatory movements of the femur upon its axis result from the movements forward or backward of the bent portion. This movement should be studied both at the upper and at the lower part of the femur. At the upper part it is a motion of horizontal displacement, the radius being represented by the head and neck of the bone; at the lower part it is a rotatory motion of the femur, not precisely upon itself, but upon an imaginary axis placed on the inside of, and parallel to, the shaft. It follows that there can be no rotation in cases of fracture of the neck of the bone, and this is one of the diagnostic signs of that accident. Lastly, it may be observed that rotation is performed from without inward, or from within outward the latter is the more extensive and more natural movement; it is produced by a great number of muscles, and, therefore, during repose, the point of the foot is slightly inclined outward.
External links
Cruveilhier J. The Anatomy of
the Human Body. New York: Harper & Brothers, 1844. [books.google , archive.org]
Authors & Affiliations
Jean Cruveilhier (1791-1874) was a French anatomist and pathologist, was a professor of anatomy in Paris, and the first chair of pathology in the Paris Faculty. [wikipedia.org]
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| Jean Cruveilhier (1837) Author: François-Séraphin Delpech; original in the wikimedia.org collection (CC0 – Public Domain, no changes). |
Keywords
ligamentum capitis femoris, ligamentum teres, ligament of head of femur, anatomy, role,
.
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