Chapter 37- the hip

Question 1

Where does buttock pain localize the pathology to?

Answer 1

Suggests spinal origin

Question 2

Stiffness and deformity of the hip transfers movement to the spine, which with time will cause…..

Answer 2

Backache

Question 3

What in the hip joint may cause a limp?

Answer 3

mostly due to pain
also be due to shortening
stiffness or weakness of the abductors

Question 4

What childhood problems affect the hip and should be asked about on history?

Answer 4

Congenital dislocation of the hip
Perthes
Sufe- slipped upper femoral epiphyses
Infection

Question 5

Describe the short limb gait

Answer 5

The shoulder on the affected side ‘dips’ relative to the unaffected side as if stepping into a hole

Question 6

Describe the antalgic gait

Answer 6

Time spent on the painful side is shorter than the unaffected side

Question 7

Describe the stiff hip gait

Answer 7

The affected side swings through by rotation of trunk over the unaffected hip

Question 8

Describe the trendelenberg gait

Answer 8

Due to abductor weakness, the trunk veers laterally over the affected hip in an attempt to lift the pelvis or at least keep it level so that the opposite leg can swing through and to maintain balance during the single leg phase

Question 9

How do you measure the true length of the legs

Answer 9

• Place legs in equal add or abduction so that the iliac crests of the pelvis is perpendicular to the long axis
• Measure the distance from ASIS to medial malleoli

Question 10

How do you measure the apparent length of legs

Answer 10

Place both legs with ankles together so that they are in line with the trunk
Measure the distance from the xiphisternum to the medial malleoli

Question 11

What may cause apparent shortening and lengthening of the legs?

Answer 11

• Flexion and adduction will give the impression of shortening
• Abduction of the hip will create lengthening

Question 12

What is the pathology in hip dysplasia?

Answer 12

The acetabulum fails to develop properly during foetal development resulting in a shallow acetabulum which cannot contain the femoral head

Question 13

How may hip dysplasia present

Answer 13

• Congenital dislocation of the hip as a neonate

- Developmental degeneration of the hip as a young adult

Question 14

When does pain develop in hip dysplasia

Answer 14

Pain only develops when the articular surface breaks down, usually in late 20s or early 30s –> osteoarthritic hip

Question 15

What is usually the prognosis of hip dysplasia

Answer 15

Frequently require joint replacement surgery at a young age

Question 16

What is the natural history of septic arthritis of the hip

Answer 16

Once the infection has healed, there will be varying degrees of articular cartilage or subcondral bone damage
With load bearing activities the articular cartilage wears out resulting in secondary osteoarthrosis

Question 17

What is the surgical management of septic arthritis/ infection of the hip?

Answer 17

• Replacement surgery is optimal
• arthrodesis in joints previously infected
• TB arthritis, joint replacement may be performed if the condition has healed

Question 18

What age group does Perthes disease affect?

Answer 18

-5-10 year old age group

Question 19

What age group does slipped upper femoral epiphyses affect?

Answer 19

-10-17 years old

Question 20

What is the pathology in slipped upper femoral epiphses?

Answer 20

The displaced position of the femoral head on the neck and the shaft results in abnormal joint articulation, impingement of non-articular parts with the acetabulum and premature joint wear-out

Question 21

What is avascular necrosis of the hip?

Answer 21

death or necrosis of a conical segment of the femoral head with subsequent collapse and deformation

Question 22

What are causes of avascular necrosis of the hip?

Answer 22

• Binge drinking of cheap wine
• Systemic steroid therapy
• Post traumatic (Dislocation of femoral head, fractures of the femoral neck)
• Decompression sickness- Caisson’s disease
• Sickle cell disease
• Gaucher’s disease

Question 23

What is the clinical presentation of avascular necrosis of the hip

Answer 23

• Knee pain that subsequently localises in the hip
• Same symptoms and signs for arthritis of the hip
• Hip pain severe initially and as the disease process progresses, it becomes less painful
• When the acetabulum becomes involved, it follows the same course as osteoarthritis

Question 24

Describe the Xray changes seen in avascular necrosis of the hip

Answer 24

• Only femoral head is involved
• Wedge shaped portion of the head appears denser and its articular surface may be collapsed or depressed relative to the rest of the articular surface
• Head may not be spherical and the crescent sign ay be present especially on the lat view
• The acetabulum is unaffected but the deformed head will eventually damage it

Question 25

Which is the most accurate method of identifying avascular necrosis of the hip and defining the degree of involvement

Answer 25

MRI

Question 26

What are the options for treatment of avascular necrosis of the hip

Answer 26

• Treat as osteoarthritis for symptomatic relief
• Core decompression (pain relief)
• Osteotomy
• Arthroplasty (Hemiarthroplasty or total replacement arthroplasty)
• Arthrodesis- if opposite side uninvolved and spine is normal

Question 27

What is the differential for pain over the greater trochanter

Answer 27

• Frictional bursitis

- tendinitis of the gluteal muscles

Question 28

What is the typical pain associated with trochanteric bursitis?

Answer 28

Pain over the greater trochanter which is prominent at night, especially when lying on the affected side or if leg adducts

Question 29

What are the examination findings associated with trochanteric bursitis

Answer 29

• tenderness to direct pressure over greater trochanter

- Pain on adduction of effected leg

Question 30

What is the treatment of trochanteric bursitis?

Answer 30

Local anaesthetic and steroid injection to the affected area.
Repeat x 1 after 2-4 weeks if necessary (use a long spine needle)

Question 31

What is snapping hip?

Answer 31

Usually found in teens and young adults. Caused by tight band in iliotibial band or tensor fascia femoris at trochanter level which snaps over the trochanter on flexion and extension of hip. Relieved by flexing and extending, in abduction

Question 32

What is the treatment of iliotibial band

Answer 32

Benign condition and is seldom painful. If it interferes with activities the tight part of the band can be released surgically

Question 33

Where does synovial chondromatosis or osteochondromatosis usually occur

Answer 33

Occurs often in large synovial joints like the knee, hip and the shoulder

Question 34

How does synovial chondromatosis or osteochondromatosis present?

Answer 34

Presents with catching, locking or giving way accompanied by pain and recurrent swelling

Question 35

What can be seen on radiology in synovial chondromatosis or osteochondromatosis

Answer 35

• multiple loose bodies

- often co-existing osteoarthritis

Question 36

Treatment of synovial chondromatosis or osteochondromatosis

Answer 36

• remove loose bodies if the giving way or locking is troublesome
• management of the underlying arthritis