Conditions Of The Hip And Surgery Flashcards
(68 cards)
1
Q
X ray changes in osteoarthritis
A
LOSS
- Loss of joint space
- Osteophytes
- Subarticular sclerosis
- Subchondral cysts (fluid filled holes in the bone) darker circles on x ray
2
Q
Presentation of OA in the hip
A
- joint pain
- stiffness
- morning stiffness <30 mins
- worsen with activity and towards the end of the day
- restricted ROM
- crepitus on movement
- effusions around the joint
- enlargement of joints
3
Q
Management of OA of the hip
A
- weight loss
- analgesia
- physio therapy
- intra-articular steroid injections
- joint replacement: hemiarthroplasty or THR
4
Q
Pathophysiology of osteoarthritis
A
- imbalance between degradation of cartilage and remodelling of bone
- due to active response of chondrocytes in the articular cartilage + inflammatory cells in surrounding tissues
- remodelling causes osteophytes + subchondral cysts
5
Q
Indications of elective hip replacement
A
- Osteoarthritis (most common)
- fractures
- septic arthritis
- osteonecrosis
- bone tumours
- rheumatoid arthritis
6
Q
What are the options for elective hip replacement?
A
- total hip replacement: replacing both articular surfaces of the joint
- hemiarthroplasty: replacing half of the joint
- partial joint resurfacing: replacing part of the joint surfaces
7
Q
Outline a total hip replacement
A
- lateral incision over the outer aspect of the hip made
- hip joint is dislocated
- head of the femur is removed + replaced by metal or ceramic
- stem is inserted into the femur
- this is either cemented or uncemented
- the acetabulum is hollowed out + replaced by a metal socket
- this is screwed or cemented into place
- a space is used between the new head and socket to complete the artificial joint
8
Q
Chemical VTE prophylaxis after elective hip replacement
A
- LMWH e.g. enoxaparin for 10 days then aspirin for 28 days
Or - LMWH for 28 days with anti-embolism stocking until discharge
- alternatives : aspirin, DOACs
9
Q
Mechanical VTE prophylaxis after elective hip replacement
A
- anti-embolism stockings
- intermittent pneumatic compression
- venous foot pumps
10
Q
Risks of elective hip replacement
A
- infection
- damage to nearby structures e.g. superior gluteal nerve > Trendelenburg gait
- VTE
- compartment syndrome
- haemorrhage
- haematoma
- pain
- fractures
- loosening or dislocation
11
Q
What is the most common organism to infect prosthetic joints?
A
Staphylococcus aureus
12
Q
Risk factors of prosthetic joint infection
A
- prolonged operative time
- obesity
- diabetes
13
Q
Management of prosthetic joint infection
A
- repeat surgery > joint irrigation, complete replacement or debridement
- prolonged abx
14
Q
Categories of hip fractures
A
Intracapsular fractures: NOF
Extracapsular fractures: intertrochanteric + subtrochanteric
15
Q
Blood supply to the head of the femur
A
Retrograde blood supply from the medial circumflex femoral arteries (via the retinacular arteries)
16
Q
Classification of intra-capsular hip fractures
A
_Garden classification_
- grade 1: incomplete fracture + non-displaced
- grade 2: complete fracture + non-displaced
- grade 3: partial displacement (trabeculae are at an angle)
- grade 4: full displacement (trabeculae are parallel)
17
Q
Success rate of hip replacement surgery and how long do they last?
A
- 95% of patients experience pain relief after surgery
- THR last 20-30 years
- hemiarthroplasty last 10-20 years
18
Q
Management of NOF fracture
A
- if undisplaced: cannulated hip screws
- if displaced (grade 3/4): hemiarthroplasty or THR
19
Q
When do you do a hemiarthroplasty compared to a THR?
A
- hemiarthroplasty: older, less mobile, more frail patients
- THR: younger, more mobile patients
20
Q
Types of extra-capsular hip/femur fractures
A
- intertrochanetric fractures
- subtrochanetric fractures
21
Q
Intertrochanetric vs subtrochanteric location
A
- intertrochanteric: between greater and lesser trochanter
- subtrochanteric: distal to the lesser trochanter (but within 5cm)
22
Q
Treatment of intertrochanetric fractures
A
Dynamic/sliding hip screw
- screw into the neck and head of femur
- plate is screwed into outside of femroal shaft
- this holds the femur in position + provides controlled compression
23
Q
Surgical management of subtrochanteric fractures
A
Intramedullary nail
- a metal pole inserted through greater trochanter into central cavity of the femoral shaft
24
Q
Presentation of hip fractures
A
Typically older pt who has fallen
- shortened, ABducted , externally rotated
- pain in groin or hip
- pain can radiate to knee
- unable to bear weight
25
Imaging of suspected hip fractures
- **X-ray** in two views (AP and lateral)
- MRI or CT if x-ray negative but still suspect fracture
26
What is a key sign of fractured NOF on an AP X-ray of the hip?
Disruption of Shenton’s line
27
What is Shenton’s line?
One continuous line formed by the medial border of the femoral neck + continues to inferior border of the superior pubic ramus
28
Management of hip fracture
- **analgesia**
- **VTE prophylaxis**
- **pre-op assessment** (incl. bloods + ECG to ensure they are fit for surgery)
- **hemiarthroplasty or THR** within 48 hours
- **Physiotherapy + post-op analgesia** after surgery
29
Types of femoral shaft fractures
Proximal
Mid shaft
Supracondylar
30
What is the major risk after a femoral shaft fracture
Hypovolaemic shock
31
Mechanism of femoral shaft fracture
high energy truama *e.g. fall from height, RTC*
32
Treatment of femoral shaft fracture
- analgesia
- open or closed reduction
- **Intramedullary nailing**
- plaster cast
33
Mechanism of distal femoral fracture
Younger person - high energy sport
Older - fall from standing
34
What is the most common type of hip dislocation?
Why?
**Posterior**
Only ischiofemoral ligament on posterior surface (weakest)
35
Where is the femoral head palpable in central hip dislocation?
Per rectum
36
Leg position in posterior hip dislocation
Shortened
ADducted
Internally rotated
37
Leg position in anterior hip dislocation
Externally rotated
ABducted
38
Leg position in NOF fracture
Shortened
Externally rotated
ABducted
39
Mechanism of action of hip dislocations
- **posterior**: high energy trauma, RTC, dashboard injury
- **anterior**: due to forced ABduction and external rotation
- **central**: side impact car accidents, fall onto the sides > fracture dislocation
40
Complications of hip dislocation
- a vascular necrosis
- sciatic nerve injury
- superior gluteal nerve injury
- recurrent dislocation
- post traumatic OA
- infection
41
Management of hip dislocation
- urgent reduction
- analgesia
- address associated injuries such as fractures
42
Why do intracapsular NOF fractures have a high risk of avascular necrosis?
Damage to medial femoral circumflex artery
43
Causes of avascular necrosis
- mechanical disruption in blood supply *e.g. fracture*
- thrombosis
- post trauma
- excess alcohol
- hypertension
- excessive steroid use
44
Causes of superior gluteal nerve injury
- complication of hip surgery
- buttock injection
- greater trochanter fracture
- hip dislocation
45
What muscles are impacted by superior gluteal nerve injury?
What does this cause?
Gluteus medius + minimus
.
Trendelenburg’s sign due to the muscles not contracting to prevent tilting
46
Mechanism of pulled hamstring
Sudden muscular exertion - stretching of posterior thigh muscles
47
Causes of hamstring injuries
Muscle sprain
Partial or complete tear of hamstring from ischial tuberosity
48
What can a complete tear of hamstring muscles from the ischial tuberosity cause?
An avulsion fracture
49
What is an avulsion fracture?
A small piece of bone breaks off due to excessive pulling from a tendon or ligament
50
What is trochanteric bursitis?
Inflammation of the bursa over the greater trochanter of the outer hip
51
Presentation of trochanteric bursitis
- Gradual onset of lateral aching/burning hip pain that radiates down the outer thigh
- worsens with activity, standing after sitting for a prolonged period and trying to sit cross legged
52
What worsens trochanteric bursitis?
Activity
Standing after sitting for a prolonged period and
Trying to sit cross legged
53
Examination findings of trochanteric bursitis
ask patient to resist the movements of **Abduction, internal rotation + external rotation** > pain will be felt in bursa region
54
Management of trochanteric bursitis
- rest
- ICE
- analgesia
- Physiotherapy
- steroid injection
55
What is pseudoarthrosis?
- ‘false joint’
- occurs when a fracture fails to he normally
56
what is meralgia paraesthetica?
- localised sensory symptoms of the outer thigh caused by compression of the **lateral femoral cutaneous nerve**
- mononeuropathy
57
why are there no motor symptoms with meralgia paraesthetica?
the lateral femoral cutaneous nerve only carries sensory signals
58
presentation of meralgia paraesthetica
- abnormal sensation (dysaesthesia) + anaesthesia to upper outer thigh
- burning
- numbness
- pins + needles
- cold sensation
- localised hair loss
- worsened on prolonged walking or standing + extension of hip
- eases on sitting down
59
management of meralgia paraesthetica
- rest
- loose clothing
- physiotherapy
- basic analgesia, neuropathic analgesia
- local steroid injections
- surgical decompression, transection or resection
60
Leg position in NOF fracture + why
Shortened, externally rotated + ABducted
Due to unopposed pull of Iliopsoas muscle
61
A patient is unable to doriflex the foot (food drop). What nerve is injured?
Sciatic nerve
62
What is an Iliopsoas abscess?
Collection of pus in Iliopsoas compartment
63
Primary causes of Iliopsoas abscess
- staph auerus (most common)
- Haematogenous spread
64
Secondary causes of Iliopsoas abscess -
- crohn’s (most common)
- colorectal cancer
- diverticulitis
- vertebral osteomyelitis
- endocarditis
- IVDU
65
Presentation of Iliopsoas abscess
- fever
- back/flank pain
- limp
- weight loss
- patient supine position with knee flexed + hip externally rotated
- hyperextension of affected hip > pain
66
What position does a person with a Iliopsoas abscess typically lie?
Knee flexed
Hip externally rotated
67
Investigation for Iliopsoas abscess
CT abdomen
68
Management of Iliopsoas abscess
- abx
- percutaneous drainage
- surgery if drainage failure or presence of another intra-abdominal pathology needing surgery
