Hip Pathologies

Question 1

Hip bones (3)

Answer 1

Ilium - superior and largest part of the hip bone
Ischium - forms the postero-inferior part of the hip bone and acetabulum
Pubis - forms the antero-medial part of the hip bone

Question 2

Acetabulum

Answer 2

Socket of the hip bone.
The head of the femur fits into here
Helps to give the hip more stability

Question 3

Which type of joint is the hip?

Answer 3

Ball and socket joint

Synovial joint

Question 4

The hip/shoulder joint is more stable?

Answer 4

Hip joint

Question 5

Movements of the hip

Answer 5

Flexion-extension
Abduction-adduction
Medial-lateral rotation
Circumduction

Question 6

Extracapsular ligaments

Answer 6

Anterior: iliofemoral, pubofemoral
Posterior: ishiofemoral

Function - the extracapsular joints strengthen the joint capsule

Question 7

Intracapsular ligaments

Answer 7

Ligamentum Teres

Function: this contains the arterial supply to the head of femur (branch of obturator artery)

Question 8

Arterial supply

Answer 8

Medial and lateral circumflex arteries
- arise from deep femoral artery (profundus femoris artery) and anastomose at the base of the neck of femur to form a ring

Branch of obturator artery supplies the head of femur

Question 9

Nerve supply

Answer 9

Femoral nerve
Obturator nerve
Nerve to quadratis femoris
Superior gluteal nerve

Question 10

Trochanteric bursitis - definition

Answer 10

Similar to rotator cuff problems of the shoulder

Inflammation of the bursa which lies over the greater trochanter

Question 11

Trochanteric bursitis - cause

Answer 11

Stresses at muscle insertions on the greater trochanter
Friction between trochanter and ilio-tibial band cause painful bursa
OA of hip
Lower back or knees

Question 12

Trochanteric bursitis - clinical features

Answer 12

Pain and tenderness at the greater trochanter region

Pain more intense when lying on the affected side

Question 13

Trochanteric bursitis - examination

Answer 13

Tenderness when palpating the greater trochanter

Pain during resisted abduction and external rotation

Question 14

Trochanteric bursitis - management

Answer 14

Rest
Analgesia
NSAIDs
Steroid injection if severe

Question 15

Avascular necrosis - definition

Answer 15

Interruption of the blood supply to the bone causing the bone to die

Question 16

Avascular necrosis - causes

Answer 16

Dislocation or fracture of the femur

Chronic steroid use

Question 17

Avascular necrosis - clinical features

Answer 17

Initial pain when weight is placed on hip

Pain in groin, buttocks and down the front of the thigh

Question 18

Avascular necrosis - investigations

Answer 18

X Ray

• only shows abnormalities in late stage disease
• patchy sclerosis
• hanging rope sign

MRI

Question 19

Avascular necrosis - management

Answer 19

Early detection: drill holes in the femoral neck to relieve pressure

Late detection: total hip replacement

Question 20

Avascular necrosis - associated conditions

Answer 20

Perthes

Question 21

Total hip replacement - when to consider it

Answer 21

When conservative measures fail to control symptoms

Older patients

Question 22

Total hip replacement - when is it not recommended

Answer 22

Younger patients

- they tend to put more demand on hip so try to delay surgery

Question 23

Total hip replacement - components

Answer 23

Cemented metal or polyethylene

Question 24

Total hip replacement - complications

Answer 24

Post op infection
- take hip replacement out for 3 months then re-fit

Metal-on-metal
- can get local reaction to metal debris which results in a inflammatory pseudotumour which causes necrosis

Blood loss
DVT/PE
sciatic nerve damage

Question 25

Hip fractures - types

Answer 25

Intracapsular Extracapsular Depends upon the position of the fracture in relation to the hip capsule

Question 26

Intracapsular fracture - definition

Answer 26

Fracture is within the capsule so the arterial supply to the femoral head could be disrupted (in a displaced fracture)

Question 27

Intracapsular fracture - location

Answer 27

Subcapital - below the femoral head | Basicervical - across the base of the femoral neck

Question 28

Intracapsular fracture - complications

Answer 28

Avascular necrosis | Non-union of the fracture

Question 29

Intracapsular fracture - management

Answer 29

Total hip replacement OR Hemi-arthroplasty (replacing the femoral head alone)

Question 30

Extracapsular fracture - definition

Answer 30

Fracture is outside of the capsule so the blood supply to the femoral head is still in tact

Question 31

Extracapsular fracture - location

Answer 31

Intertrochanteric - below the femoral neck, trochanter region Subtrochanteric - below the trochanter region

Question 32

Extracapsular fracture - management

Answer 32

All will heal so do not need a hip replacement Internal fixation - dynamic hip screw - intra-medullary nail Fracture tends to heal in a shortened position Subtrochanteric fractures are more difficult to treat and may require use of a thomas’ splint before internal fixation

Question 33

Shentons line

Answer 33

X-ray finding Formed from the medial edge of the femur to the inferior edge of the superior pubic ramps Disruption in shentons line indicates there has been a fractured neck of femur (intracapsular fracture)

Question 34

Neck of femur fracture - cause

Answer 34

Osteoporosis Falls in elderly Fragility fracture

Question 35

Neck of femur fracture - risk factors

Answer 35

Smoking Excess alcohol Malnutrition Steroids

Question 36

Neck of femur fracture - clinical features

Answer 36

Can’t weight bear Trochanteric bruising Pain in hip, groin, knee Reduced mobility

Question 37

Neck of femur fractures - examination

Answer 37

``` Affected leg is classically: -shortened -abducted -externally rotated Unable to straight leg raise Exacerbation of pain on palpating of the greater trochanter ```

Question 38

Neck of femur fracture - investigations

Answer 38

X Ray - shentons line distruption - lesser trochanter more prominent - sclerosis in fracture plane MRI -if no abnormality on X-ray

Question 39

Neck of femur fracture - management

Answer 39

Immediate: IV access, analgesia Undisplaced: stabilise with screws to prevent displacement Displacement: hip replacement

Question 40

Neck of femur fracture - complications

Answer 40

Avascular necrosis of femoral head | Risk of DVT/PE

Question 41

Femoral shaft fracture - cause

Answer 41

Young patient: high energy injury | Old patient: osteoporosis, fragility fracture, long term bisphosphonate use

Question 42

Femoral shaft fracture - clinical features

Answer 42

Immediate severe pain | Unable to weight bear

Question 43

Femoral shaft fracture - examination

Answer 43

Affected leg is classically: - shortened - abducted - externally rotated

Question 44

Femoral shaft fracture - investigations

Answer 44

X-Ray

Question 45

Femoral shaft fracture - management

Answer 45

Immediate management: analgesia, long leg splint | Open fracture - urgent cleanse, external fixation, internal fixation

Question 46

Distal femoral fracture - cause

Answer 46

Fall onto a flexed knee young person: high energy injury old person: osteoporosis

Question 47

Distal femoral fracture - type

Answer 47

Transverse - straight across Comminuted - breaks into many pieces Intra-articula - extends into the cartilage of the knee joint

Question 48

Distal femoral fracture - clinical features

Answer 48

Pain with weight bearing Swelling Tenderness Deformity

Question 49

Distal femoral fracture - investigations

Answer 49

X-ray | CT scan

Question 50

Distal femoral fracture - management

Answer 50

Internal fixation (plate and screws) as fracture position is difficult to maintain in a cast

Question 51

Pelvic fracture - cause

Answer 51

Young patients: high energy injury | Old patients: osteoporosis

Question 52

Pelvic fracture - investigations

Answer 52

PR exam - assess sacral nerve root function X-ray - if the pelvic ring is disrupted in one place it is highly likely that there will be another disruption elsewhere in the pelvic ring

Question 53

Pelvic fracture - management

Answer 53

stable - walking aids to avoid weight bearing | unstable - external fixation, open reduction internal fixation

Question 54

Pelvic fracture - open book

Answer 54

Pelvic fracture that results from an antero-posterior compression injury to the pelvis. Pelvis opens like a book

Question 55

Pelvic fracture - open book - management

Answer 55

reduction pelvic binder external fixation

Question 56

acetabulum fracture - management

Answer 56

undisplaced - pain relief, walking aids displaced young person - anatomic reduction and rigid fixation displaced old person - total hip replacement