Download the structure and function of the proximal end of the femur

THE
STRUCTURE
PROXIMAL
R. S.
From
The familiar
outline
slightly
flattened
head,
ridge
(Fig.
1
Frontal
).
and fragile
medulla
reversed,
and a thin
forms
the
internal
the
AND
FUNCTION
OF
END
OF THE
FEMUR
GARDEN,
Orthopaedic
Departmnemit,
ofthe
proximal
neck and two
end ofthe
trochanters
section
uppermost
of the
cortical
of the
shaft
(Fig.
2).
shell clothes
weight-bearing
system
INTERNAL
The
a
calcar
vertical
femorale,
plate
ofbone
PRESTON,
lying
deep
third
of the
neck
(1900)
to the lesser
margin
group,
of the head.
The lateral
arrangement
arises
from the lateral
femoral
cortex
area
Royal
and
Infirmary
femur
head
WEIGHT-BEARING
medial
as the
trabeculae
Preston
the
of trabeculae
group,
which
junction
of
of lessened
density
This interpretation
neck
and
it
trochanter.
in the
streams
three-dimensional
features
descriptions
of the calcar
of the
femorale
powerful
cortex
3).
the
“
The
true
calcar
neck
forms
of the
femur,”
the distal
is
anchorage
internal
weight-bearing
system,
sometimes
upwards
to end fan-wise
at the articular
of trabeculae,
sometimes
and curves
upwards
and
shaft.
appearance
However,
the
SYSTEM
described
Enclosed
these
system
known
medially
of trabeculae
to decussate
within
known
as Ward’s
triangle.
of the internal
weight-bearing
and from the radiographic
so well foresaw
(Fig.
4).
shows
(Fig.
group
in the femoral
head.
A third
group
of the cortex
at the level of the lesser
trochanter
at
by its almost
spherical
intertrochanteric
Above
the lesser
trochanter
this arrangement
is
the dense
arrangement
of cancellous
bone
which
of the
known
the compression
medial
aspect
arrangement
compression
ENGLAND
femur
is characterised
with their communicating
in the
or as Bigelow
THE
springs
with
trabecular
derives
from
the
the lateral
systems
largely
from
of the femora!
neck and head which
both
diagram
and radiograph
fail to
proximal
end of the femur,
and internal
weight-bearing
as the tension
to merge
with
is the
Ward
(1838)
Ward’s
diagram
demonstrate
the
and for this reason
the
system
are inadequate.
above
The femoral
neck
inclines
upon
the shaft
at an angle
of about
127 degrees,
ranging
normally
between
I 13 and 136 degrees
(Humphry
1888).
The neck is also set upon
the shaft
at an angle varying
from 38 degrees
anteversion
to 20 degrees
retroversion,
but which is usually
in the region
of 10 degrees
anteversion
(Kingsley
and Olmsted
1948).
In the opposite
direction
the neck itself shows
a slight curvature
with its convexity
directed
forwards
(Walmsley
19 1 5).
This
twisting
the
upright
to
a vertical
is striving
and
turning
position
direction.
towards
presumably
which
demands
It also
suggests
that,
It is hoped
a spiral/ornz.
a better
understanding
By stereo-radiography
represents
conversion
of the internal
the calcar
system
are seen to be an upward
shaft,
and the lateral
trabeculae
lateral
cortex.
The
medial
conformation
576
of
the
group
the
response
stresses
in basic
to show
weight-bearing
femorale
and
bearing
of the
group
an antero-superior
the following
experiment
former
to represent
the
which
the radiological
developmental
of the weight-bearing
and spiral
an expanded
of trabeculae
outline,
that
the
this
proximal
observation
occupies
end
of the
femur
of
the
the
internal
and
femur
key
to
weight-
of the postero-medial
continuation
of the
a postero-inferior
to
an oblique
provides
system.
media!
trabeculae
continuation
and rotated
of the
from
the
cortex
anterolateral
position
in the femoral
neck.
This description
may be clarified
by
in which
a tube
of multiple
parallel
wires
is mounted
on a wax
radio-opaque
Haversian
systems
with their
concentric
lamellae
on
appearance
of the femoral
shaft
depends
(Fig.
5).
The
spiral
proximal
end
of
the
femur
suggests
THE
that
JOURNAL
its
peculiar
OF
BONE
angulation
AND
JOINT
has
SURGERY
TIlE
AND
FUNCTION
OF
THE
PROXIMAL
FIG. 1
posterior aspect of the proximal end of the femur.
Figure 1-The
of the femur
STRUCTURE
to show
preponderance
FIG.
3
of cortical bone
END
OF
FIG.
Figure
2-Frontal
in the shaft and of cancellous
THE
FEMUR
2
section of the upper
bone in the neck and
FIG.
577
third
head.
4
weight-bearing system in the femoral neck. M-medial
system of lamellae; L-lateral
system of lamellac; W-Ward’s
triangle;
and 1-intertrochanteric
arch.
Figure 4-Diagram
from Outlines
of Human
Osteology,
F. 0. Ward,
1838, for comparison
with radiographic
appearances.
(Reproduced
by
permission
of the Editor,
Journal
of Bone
and Joint
Surgert’,
American
volume.)
Figure 3-Internal
VOL.
43 B,
NO.
3,
AUGUST
1961
578
P. S. GARDEN
FIG.
S
FIG.
6
Figure
5-Radiograph
of tube of parallel
wires.
Note
appearance
of “cortex”
where
wires
are superimposed.
Figure
6-Disposition
of wires after twisting
tube to show
their similarity
to the pattern of the medial and lateral lamellae
in the internal
weight-bearing
system.
FIG.7
FIG.8
Wire model bisected in the line of its spiral.
Figure 7-Horizontally
arching
disposition
of the wires in the antero-lateral
half.
Figure
Vertical disposition of the wires in the postero-rnedial
half.
THE
JOURNAL
OF
8-
BONE
AND
JOINT
SURGERY
THE
been
STRUCTURE
achieved
and
then
produce
weight-bearing
FUNCTION
developmentally
backward
antero-lateral
and
Similar
(Fig.
shadow
6).
-,
THE
PROXIMAL
twisting
twisting
closely
Bisection
postero-medial
-
OF
by simple
direction.
a radiographic
system
to
AND
ofthe
END
of the
original
tube
ofparalle!
OF THE
shaft
FEMUR
579
in an inward,
wires
forward
is found,
in practice,
resembling
the trabecular
pattern
of the internal
of the wire mode!
in the line of its spiral
into
halves
is then
found
to
present
a horizontally
arching
..
44
A
FIG.
Removal of anterior
to show antero-medial
outwards
as expanded
trochanteric
line.
tubercle
of the neck
9
wall of upper end of femur
group oflamellaeextending
continuation
of interArrow
indicates
inferior
and direction
of intertro-
chanteric
disposition
medial
in the
half
their
(Figs.
(Benninghoff
American
line.
antero-lateral
7 and
use is strictly
half
8).
are
and
Parallel
incorrect,
1925)
FIG.
10
Appearance
of the calcar
femorale
on posterior
dissection.
Removal
of the posterior
cortical
shell
results
in partial
removal
of the calcar
itself, and
creates
the illusion
of a spur projecting
into the
femoral
metaphysis.
F-calcar
femorale;
L.T.lesser trochanter.
(From
M. Harty (1957):
The
Calcar
Femorale
and the Femoral
Neck.
Reproduced by courtesy
of Dr Harty, and by permission
of the Editor,
Journal
of Bone and Joint Surgery,
since
diagonally
a near-vertical
wires
the
have
Haversian
disposed
disposition
been
chosen
systems
to the
long
volume.)
ofthe
for
the
orientated
axis
of the
wires
in the postero-
sake
ofclarity
along
the
femur
(Harris
although
lines
of stress
and
Cohen
1957).
Further
examination
shows
that the third
lateral
group
in the intertrochanteric
region
thickened
ridge
in the femoral
cortex
known
A small
area
in the
anterior
wall
of the
trochanters
with their
communicating
Ward’s
triangle
therefore
represents
in the
medulla
The
upper
femoral
then appears
of the
VOL.
and
calcar
NO.
tissue
3,
AUGUST
and
1961
posterior
displayed
This dissection
plate or spur
in the
neck,
the
posterior
wall
ridge
are seen to be devoid
a central
area where
trabecular
anterior
is usually
metaphysis.
as an isolated
cancellous
43 B,
in both
femorale
group
of trabecu!ae
which
decussates
is centred
upon
a lamellar
expansion
as the anterior
intertrochanteric
line
femoral
walls
of the
by removal
results
projecting
neck
after
of the
neck
of specialised
reinforcement
with
of
(Fig.
and
the
the
the
9).
two
trabeculae.
is absent
neck.
of the
posterior
cortical
shell
of the
in partial
removal
of the calcar
itself which
into the metaphysis
(Fig.
10).
Removal
bisection
of the
femur
through
the
lesser
580
R. S. GARDEN
II
Bisection
femorale
of the femur through
as the uninterrupted
FIG.
Serial
radiographs
of
level of lesser trochanter
to illustrate
continuation
of the postero-medial
lesser trochanter
is based.
12
the
FIG.
calcar
femorale
Figure
showing
13-Oblique
its
view.
laminar
Figure
true nature
of calcar
cortex
on which
the
13
structure.
14-Lateral
THE
FIG.
Figure
12-Antero-posterior
14
view.
view.
JOURNAL
OF
BONE
AND
JOINT
SURGERY
THE
trochanter,
however,
hardness
lying
AND
reveals
in
FUNCTION
the
continuity
calcar
with
OF THE
as an
the
in different
14),
displaced
and
to
by every
subcapital
radiograph
fracture
(Fig.
15).
The weight-bearing
therefore
the
required
in the
obviously
amount
femoral
be
no
ofthe
and
of
the
closely
Brodetti
combined
ill
packed
(Figs.
shaft
in
(1956)
cortical
both
the
for
lamellae
16 and
have
and
superior
femoral
50 per
17).
and
neck
cent
inferior
calcar
sheet
and
of almost
overlain
is demonstrated
58!
FEMUR
by
by serial
cortical
the
lesser
radiography
the
of
Hirsch
shown
cancellous
laminar
cortex
THE
need
than
diaphysis.
Expansion
of the upper
end
of the
femur
has thus
been
achieved
simply
by a splitting-off
or lamination
of
OF
I
bone
metaphysis
greater
uninterrupted
END
of a
the
of
capacity
total
PROXIMAL
postero-media!
(Fig.
I I). The laminar
structure
degrees
of rotation
(Figs.
12
trochanter
femur
STRUCTURE
I
the
and
that
the
layers
aspects
of
are each responsible
of its weight-bearing
capacity,
and Tobin
(1955)
pointed
out
that, weight
for weight,
cancellous
bone
is as strong
as cortical
bone.
Above
the
level
of the
lesser
trochanter,
therefore,
compact
and
cancellous
made
a compromise-each
share
of
time,
preserving
long
the
bones
load
the
neck
(1 900)
character
is partly
suggested,
Removal
of the
little the
attachment
radiological
ofthese
and
whilst,
at the same
tubular
nature
of
tubular
skinned
where
of
the
the
concealed,
as
by the developmental
trochanteric
system
is seen
greater
both
the
medial
and
fuse
and
with
arching
lamellae
VOL.
each
other
for
evenly
from
43 B,
NO.
the
the
description
does little
the
internal
first
time
opposite
3, Au(;usT
of the
to clarify
dissection,
separated
from
cortex
1961
the
superior
in a series
zone
in a series
Furthermore,
Bigelow’s
the calcar
aspect
of the
other
affects
the
views.
neck
(Fig.
but
mode
of
A double-
femorale
shows
it to be the
(Fig.
18)
2).
of Gothic
intertrochanteric
of the diaphysis
arches
arch,
also
meeting
which
(Fig.
system
to represent
by trabecular
of lamellar
domes
place
here
19).
the cross-section
of
approach
A similar
and the circumferential
terminate
in this
metaphysial
lamellae
refers
only to their
the true nature
of their arching
disposition.
however,
each
epiphyses.
certainly
meets
weight-bearing
ofthe
aspect
traction
specimen
ZONE
sub-epiphysial
is found
at the apex
the entire
internal
by microscopic
plates,
of
with
trochanter
SUB-EPIPHYSIAL
of the
elements
The above
section,
and
be shown
fellows
lateral
arrangement
throughout
(Fig. 20).
in frontal
bony
examination
lesser
merges
TIlE
Microscopic
of the trochanteric
the anatomical
weight-bearing
trabeculae.
is much in accordance
with
where
trochanter
addition
from
en bloc
pattern
of the
bulbous
trochanters
appearance
the
15
Displaced subcapital
fracture
of the femur to demonstrate
laminar
nature
of the calcar femorale.
With lateral rotation
of the distal
fragment
the calcar
“disappears”
and is
replaced
by a series of longitudinal
trabeculations
which are,
in effect,
the laminae
of the calcar
itself presented
in 90
degrees
rotation.
FIG.
elsewhere.
This
femoral
Bigelow
r
bone
have
accepting
a
way
appearance
This may
of widely
curved
tie-beams
and
merging
with
(Triepel
1922).
This
observation
their
582
R.
at once provides
be explained
and
a geometric
understood
The cancellous
bony
plates
wide
structures.
The
then
patterns
or
term
interpretation
(Fig. 21).
of the
which,
patterns
lamellae
of these
internal
on
“trabecula”
becomes
S. GARDEN
end
which
misleading
since
by which
weight-bearing
section,
create
has
this
lamellae
been
term
their
system
are
the illusion
freely
used
denotes
therefore
of narrow
in describing
a small
beam.
FIG.
16
FIG.
Figure
16-Microphotograph
of the medial
lamellae
in the internal
weight-bearing
mode of origin from the postero-inferior
cervical cortex.
The expansion
of the bone
the extremity
of all long bones-has
been achieved
by a splitting-off
or lamination
layers of the cortex.
Figure
17-The
appearance
of the lamellae
shown in Figure
with that of the ruffled leaves of a book.
applied,
however,
to the
the femoral
head
and
has likewise
been
used
innumerable
neck
(Fig.
freely,
of cancellous
bone peculiar
way to describe
the twisted
are
visualised
radiologically
tie-beams
22).
ought
The
not to be held
to the femoral
and expanded
of the
the
years
weight-bearing
of growth
lamellae
epiphysial
that the
plate
is demarcated
specialised
lamellae
through
this
that
this
media!
defined
and
larnellae
breach
the
scar
is not
lateral
the
to reach
so.
Neither
are certainly
in continuity
group
connect
to imply
support
formed
by
beam-like
these
cancel!ous
justly
of
the
the
lamellae
system,”
ofisolated
arrangements
be regarded
rather
as a convenient
proximal
end of the femur
as they
SCAR
plate
forms
femoral
neck.
In
medial
confined
of the
margin
nor
projected
into
may be discerned
is likewise
in
which
section.
EPIPHYSIAL
articular
be
to show their
region-as
at
the compact
be compared
a barrier
a young
to the
adult
upward
femur
extension
the
site
by a clearly
defined
epiphysial
scar.
It is generally
the internal
weight-bearing
system
are then continued
the
may
It may
17
system
in this
of
16 can
weight-bearing
the existence
should
in the
epiphysial
in the
and
internal
“
neck, but
lamellae
or on coronal
THE
During
which
expression
behaviour
lateral
head,
lamel!ae
but
careful
cross
the
the epiphysial
segment
in each lamella
at the
to the
sub-epiphysial
THE
of the
shows
scar.
The
of the head,
but a well
level of the scar (Fig. 23),
zone.
JOURNAL
examination
line
of the
believed
upwards
The
OF
BONE
epiphysia!
AND
JOINT
scar
SURGERY
of
THE
early
STRUCTURE
maturity
but
does
becomes
years
seldom
to
arteries
run
bone
in
tunnels
until,
be seen.
may
THE
(Fig.
The
manner
the
subject
(1838)
likened
lamp
bracket,
be
the
femoral
Culmann
that
of
appearance
femur
in frontal
section,
ation
compressive
weight-bearing
movement
unyielding
the trunk
is
base,
upon
for
the
of the
to
(1866)
a
These
the
tensile
system.
stresses
They
theories,
of the
existence
in the
ignore
in wall-
static forces
strains
joint
pattern
posture.
securely
and its function
the lower limb
street-
neck
presume
hip
femur
compared
of the
dynamic
or
not
neck
structure
has been
many
years.
Ward
a crane.
the
unlike
the
through
the
changing
crane,
femur
of
must
with
r
weight
form
every
a
alter-
Furthermore,
anchored
to
as a member
is far
.
in
The junction
of the calcar femorale
with the inferior
cortical
buttress
of the neck to show double-skinned
appearance
where the calcar,
or” true neck of the
femur,”
has been overlain
by the developmental
addition
of the lesser trochanter.
an
the movable
linkage
from that of a crane.
of
removed
FIG.
supporting
and
19
Microphotograph
of the decussation
of the medial
and lateral
lamellae
of the
internal
weight-bearing
system
in the proximal
end of the femur
to show the
manner
of their meeting
in a series of Gothic
arches in the subepiphysial
zone of
the head.
43 B,
VOL.
L
NO.
3,
583
FEMUR
OF
neck
and
that,
in
the
the
and
the
bearing
OF THE
NECK
in which
to
perpetually
mistaken
FEMORAL
upon
or
END
of laminar
and these
ASPECTS
based
the fact
bracket
with
PROXIMAL
24).
its function
of both
internal
life
distinct
tunnels
region,
as a weight-bearing
of conjecture
for
functions
THE
in the aged, its remnants
The lateral
epiphysial
MECHANICAL
THE
OF
throughout
less
sometimes
scar
FUNCTION
persist
within
protective
juxta-epiphysial
the
epiphysial
not
progressively
advancing
are
AND
AUGUST
1961
balancing
584
R.
The
the
presence
of compression
co-existence
(1948)
arise
point
in
could
valga
of tension
the
out
hardly
Some
(Fig.
exceeding
that
upper
if tensile
fernoral
withstand
confusion
25), and
that
of the
forces
stresses
such
stresses
an
compression
neck
of the
universally
enormous
to two
group
normally
displacing
force.
(Fig.
is easy
This
Wilson
hundred
occur
of the
they may
26).
to understand,
Farkas,
or three
would
by the disappearance
in coxa vara when
“
femur
accepted.
amounting
slipping
has been caused
by their
increase
“
in the
is not
epiphysis
S. GARDEN
“
Hayner
pounds
since
were
the epiphysial
tensile
assume
variation,
but
and
“
to
line
!ame!lae
in coxa
an intensity
even
however,
is not
the
result
of an actual
increase
or decrease
in the number
of these
lamellae,
but depends
upon
whether
they are seen in full-face
or profile.
In coxa valga they remain
in their original
position
as the circumferential
lamel!ae
of the antero-lateral
cortex
where
they are poorly
visualised.
In coxa vara they expand
and rotate to present
in profile as clearly defined
individual
structures.
The
numerical
depends
provided
or Spy
variation
of these
lamellae
is therefore
The tensile
action
of the muscles
which
fix the head
must be resisted
by an equal
and opposite
compressive
It is difficult,
therefore,
to accept
the presence
of two
other,
tensile
and
illusory,
and
upon
the degree
of rotation
in the femoral
neck.
Further
by the fact that these so-called
tensile
lamel!ae
are poorly
men, and are completely
absent
in primates
or quadrupeds
and if the lateral
lamel!ae
in nature
they would
surely
argument
have
been
expended
of the internal
buckle
as soon
by
many
radiological
evidence
developed
(Walkhoff
intensity
for this belief
in Neanderthal
1904).
is
of the femur
firmly
in the acetabulum
force in the femoral
neck as a whole.
tensile
systems
in opposition
to each
weight-bearing
as weight
bearing
writers
their
in attempting
THE
JOURNAL
system
were indeed
to be
was begun.
Much
thought
to clarify
OF
BONE
this
AND
provoking
JOINT
SURGERY
THE
STRUCTURE
Microphotograph
separate
and
AND
to show
support
OF
FUNCTION
the
the trabecular
lamellae
in
FIG.
VOL.
43 B, NO.
3, AUGUST
1961
PROXIMAL
tie-beams
the
femoral
Microphotograph
of
A breach
in continuity
weight-bearing
system
THE
internal
neck.
END
or “distance
weight-bearing
OF
THE
pieces”
system
FEMUR
which
of
the
23
the epiphysial
scar in the proximal
end of the femur.
may be seen between
the medial
lamellae
of the internal
and their fellows in the epiphysial
segment
of the head.
585
586
R. S. GARDEN
FIG.
24
Microphotograph
of laminar
tunnel which protects
and contains
the lateral epiphysial
blood
vessels at the junction
of the epiphysial
segment
of the femoral
head with its underlying
subepiphysial
zone, and which may be mistaken
for the epiphysial
scar.
26
lamellae
of the”
FIG.
Figure 25-Antero-posterior
Figure 26-Antero-posterior
radiograph showing
the absence
of “tensile”
radiograph
showing
the relative
increase
in intensity
in coxa vara.
THE
JOURNAL
OF
BONE
in coxa
valga.
tensile”
Iamellae
AND
JOINT
SURGERY
THE
problem,
and
an attractive
stresses
that
compression
is reversed.
stresses
the
FUNCTION
when
applied
and tension
whether
the
to
OF
THE
of Scott (1957),
although
Scott
believes
that
artificial
compression
according
tension
AND
the work
compromise.
is somewhat
the
and
STRUCTURE
PROXIMAL
END
OF
THE
in a different
context,
the subdivision
into
comes
at first sight as
tension
and pressure
“
to an elastic
lamellae
are
bone
is under
substance
such
both
subjected
compression
as bone.”
of evidence
indicates
that
this
is mainly
He suggests
to alternating
pressure
or
or not, and states
that when
is removed
a process
ofrecoil
takes place and the compression-tension
This, of course,
is true of steel or any other
elastic
body subjected
within
the limits
of its elasticity.
The point
at issue concerns
the
weight
587
FEMUR
compressive
in both
relationship
to strains
and
initiating
force,
medial
and
lateral
patterns
of the system
under
discussion.
However
this may be, the undistorted
head and neck
of the femur
can certainly
continue
to function
as a weight-bearing
unit when decalcification
has removed
a!! but the medial
system
of !amellae.
The principal
thrust
of weight
bearing
is
undoubtedly
directed
through
this almost
vertical
system
which
retains
its integrity
long after
the lateral
lamellae
have been sacrificed
to age or to disease.
Although
it would be presumptuous
to oversimplify
this intricate
mechanical
problem
by denying
the presence
of all tensile
forces
in the neck of the femur,
the predominance
of compressive
forces
can safely be assumed.
THE
The
simple
mechanics
lever,
clinical
but
involve
every
major
hip
fails
utterly
has
a most
with
led
joint
function
fallacious
the
knee,
on the
tibia
as the
knee
screws
JOINT
diagrammatically
complexity
of hip
conclusions.
not
only
the
ankle
function
and
home
The
of the
foot.
the muscles
which
bind pelvis,
femur
and tibia together
purpose
of supporting
and balancing
the trunk
upon
It is well established
that in the final stage
of
medially
HIP
depicted
the
In particular,
of
THE
usually
co-ordination
in the body.
the
are
OF
to indicate
to many
delicate
muscle
concerned
of the
this
application
must
MECHANICS
in full
in the
joint
act
of balancing
muscles
of the
Any
function,
around
hip joint
of a
and
in its
on
the
must
interpretation
form
one
hip,
leg
but
of
be intimately
of the
action
of
should
thus be related
to their primary
the movable
linkage
of the lower
limb.
knee joint
extension
the femur
rotates
extension.
This
movement
will
also
be
reflected
at the hip, and simple
observation
shows
that in weight
bearing
the hip joint
also
screws
home
in medial
rotation.
Just as the neck of the femur
has come to acquire
a spiral
conformity
in the upright
position,
so also have the soft tissues
which
surround
the hip joint
acquired
application
with the
plane
a
spiral
disposition,
and
contraction
It
is well
ischio-femoral
and stability
effort.
congruity
1928).
known
the
hip
must
will therefore
femoral
neck.
joint actually
movement
locks
in these
the
hip
joint
is locked
are tightened
is in this way
by
the
ilio-femoral,
or wound
up by media!
achieved
with the utmost
head
as
43 B, NO. 3,
fresh anatomical
specimen,
from which
confirms
Walms!ey’s
(1928)
observation
in extension
directions
a rotational
AUGUST
and
only
ellipsoid,
1961
the
axis with its condyles
lying in a horizontal
articular
surface
of the head,
the bone will
pubo-femora!
rotation
economy
at
media!
rotation,
and can
the expense
of subluxation.
but
it may
more
accurately
all muscles
that this
be made
Aeby
and
of the femur,
of muscular
It is less well known
that the head of the femur
is not perfectly
spherical,
with the acetabulum
only in the functional
position
of weight
bearing
The hip joint
is generally
supposed
to resemble
the artificial
ball and
of the
clearly
imply
be combined
suggests
that the shape
of the femur
has been so perfectly
of ligamentous
or muscular
control
its inherent
response
to
in medial
rotation,
the rise and fall of its spiral compensating
ligaments
as they
of the extended
hip
but examination
been removed,
femoral
that
about
An element
oftorsion
to bear upon
the
If a femur
he freely
mounted
on a vertical
and downward
pressure
be applied
to the
rotate
medially
(Fig.
27).
This
evolved
that even in the absence
weight
bearing
is to screw home
for the tilting
axis of the knee.
VOL.
muscular
of a rotatory
thrust
to the femur.
compressive
forces
which
are brought
and lies in
(Walmsley
socket
joint,
and ligaments
have
allegedly
universal
to unlock
by further
(1863)
described
the
be visualised
as a hemisphere
R. S. GARDEN
588
twisted
it
is
slightly
congruous
stated,
It
out of truth
articulating
only in the position
the hip is a screw joint.
thus
appears
that
the
spirally
regarded
disposed
as
ligamentous
turn
and lock
a
with a similarly
of extension
and
femur
serves
as
an
twisted
medial
independently
and muscular
sleeve,
and
mechanism
which
depends
Experiment
to illustrate the response
of the femur,
in the
“screw
home”
in medial rotation
when downward
pressure
femur
to
vertical
conformity
about
the
pelvis,
loading
by rotating
of the articular
hip, and 4) the
femur
and
medially,
acetabular
rotation.
runway
with
As Walmsley
acting
weight
upon
member
bearing
at
1) the natural
2) the locking
of media!
rotation
rotation
muscular
within
the hip
response
shape of a vertically
mounted
is applied
on the medial aspect
surfaces,
3) the restriction
of medial
overall
control
of this rotation
by the
which
(1928)
its
may be
of the
spiral,
to
of its axis.
by the peculiar
by the
interplay
ligaments
between
tibia.
SUMMARY
Many
analyses
femur
have
accepted
Meyer
(1867),
and
embodies
mechanical
departure
from
and
an attempt
but
little
from
the
has
the
of the
geometric
arrangement
and
perpetuated
have
contributed
principles
which
normal
been
norma!
pattern
made
of skeletal
to show
anatomy
of trabecu!ae
the theories
of
to the belief
that
are foreign
to bony
that
of the
behaviour
the structure
long
in the
proximal
Ward
(1838),
Culmann
the structure
of the
formations
elsewhere.
is considered
to be
of the femoral
end
of the
(1866)
and
femoral
neck
This isolated
most
unlikely,
head
and
neck
departs
BONE
AND
JOiNT
SURGERY
bone.
THE
JOURNAL
OF
THE
STRUCTURE
a developmental
interpretation,
From
in its simplest
has undergone
bearing
system
neck
AND
FUNCTION
OF THE
PROXIMAL
END
rotation
and
are likewise
in nature,
The
rejected.
spiral
expansion.
believed
and
both
The cancellous
to represent
the
crane
conformity
I wish
to thank
Dr A. A. Miller
Laboratory
M.S.R.,
and
investigations
and
at Preston
and
of the
spiral
disposition
of the soft-tissue
ofhipjoint
mechanics
the principle
Pathological
589
FEMUR
point
of view, the proximal
end of the human
femur
to represent
an upward
continuation
of the original
arrangements
expanded
and
as they are presented
radiologically
or on coronal
section.
The forces
acting
upon
the proximal
end of the femur
compressive
OF THE
street-lamp
proximal
are
bracket
end
of
the
his technical
staff
Infirmary
her team of radiographers
which this study has entailed.
who
for their
at my
have
many
femur
I am
so willingly
has
weightof the
to
mainly
be
have
therefore
been
related
been
to
the
hip, and in the interpretation
to the principle
ofthe
lever.
courtesies
disposal.
internal
lamellae
considered
theories
structures
that surround
the
ofthe
screw has been preferred
Royal
of the
rotated
is believed,
shaft which
in placing
also
undertaken
indebted
the resources
to
Miss
M.
the innumerable
of the
G.
Work,
radiographic
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Zeitschrift
f#{252}r
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Medicin,
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BENNINGHOFF,
A. (1925):
Spaltlinien
am Knochen,
eine Methode
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der Architektur
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der Anatomischen
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Anatomischer
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Erganzungsheft
zum
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BIGELOw,
H. J. (1900):
The Mechanism
of Dislocation
and Fracture
ofthe
Hip.
Boston : Little,
Brown
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CULMANN,
C. (1866):
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FARKAS,
A., WILSON,
M. J., and HAYNER, J. C. (1948): An Anatomical
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Healing
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of the Femoral
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W. H., and COHEN,
J. (1957):
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