Hip + pelvis

Question 1

Gradual onset of unilateral or bilateral groin or anterior thigh pain
Buttock, lateral thigh, knee
Initial = activity → increased frequency + intensity to pain at rest and at night
Stiffness at rest that subsides w/ activity
Difficulty putting shoes/socks on, getting into car

Answer 1

hip osteoarthritis

Question 2

RF for hip osteoarthritis

Answer 2

Trauma, obesity, childhood hip diseases, family history, AVN
Correlated w/ age

Question 3

hip osteoarthritis is caused by –

Answer 3

loss of articular cartilage in the hip joint

Question 4

Less ROM as disease progresses
→ internal rotation is usually first to occur
→ pain at end point
→ flexion contractures (compensation)

Gait that becomes a limp

XR: AP + frog lateral
Joint space narrowing
Osteophyte formation
Subchondral cyst
Subchondral sclerosis

Answer 4

hip osteoarthritis

Question 5

How do you treat hip osteoarthritis?

Answer 5

Conservative treatment: acetaminophen, NSAIDs, activity modification, cane/walker, ice/heat, gentle ROM, non-weight bearing exercise, correct obesity

Intra-articular steroid injections

If conservative treatment fails, → refer
Require total hip arthroplasty, metal on metal hip resurfacing

Question 6

Motion extremely painful, often unable to move extremity
Commonly other injuries to knee, abdomen, head, chest

Answer 6

hip dislocation

Question 7

Femoral head displaced from acetabulum from severe/high energy trauma (MVA), commonly resulting from direct trauma to knee while hip + knee are flexed
Ass w/ posterior acetabular wall fracture
Anterior dislocations are less common - force to knee w/ thigh abducted + externally rotated

Answer 7

hip dislocation

Question 8

Assess neurovascular status → sciatic nerve/ femoral nerve palsy can occur (foot drop)
Posterior: leg is shortened w/ hip flexed, adducted, internally rotated
Anterior: leg held in mild flexion, abducted and externally rotated

Evaluate knee! Rule out other fractures

XR: AP view of pelvis, AP + lateral of femur with knee
Posterior, head looks smaller, with anterior, appears larger
Acetabular fracture → CT to further evaluate extent of fracture

Answer 8

hip dislocation

Question 9

type of hip dislocation: leg is shortened w/ hip flexed, adducted, internally rotated

Answer 9

posterior

Question 10

type of hip dislocation: leg held in mild flexion, abducted and externally rotated

Answer 10

anterior

Question 11

How do you treat a hip dislocation?

Answer 11

Closed reduction attempted ASAP: Allis maneuver
Rule out fracture/loose bodies before reduction is performed
Post reduction and CT are necessary
Document neurovascular function before + after reduction

Closed reduction fails → open reduction (or if there are bony fragments)

Abduction pillow + dislocation precautions
Weight bearing status depends on acetabular fracture

Crutch assistance w/ WBAT 2-4 weeks, progression to exercises → cane

Question 12

the —- —– is used for a closed reduction in hip dislocation

Answer 12

allis maneuver

Question 13

Gradual onset of progressive pain to groin, lateral hip/buttock, limp + loss of motion
– severe pain in initial phases with bone death

Answer 13

avascular necrosis

Question 14

avascular necrosis is common in

Answer 14

30s-50s
Trauma, chronic alcoholism, sickle cell, rheumatoid arthritis, SLE, steroids

Question 15

Death of bone in femoral head, from traumatic disruption of vascular supply or progressive arthritis
Often bilateral
is caused by

Answer 15

avascular necrosis

Question 16

Pain with straight leg raise (+) and ROM → decreased especially internal rotation
Antalgic or trendelenburg gait

XR: AP pelvis and AP, frog leg lateral of affected hip – may be normal to patchy areas
Crescent sign appears

Eventual collapse + change in shape
IF XR is normal, get MRI

Flattened top of femoral head

Answer 16

avascular necrosis

Question 17

How do you treat avascular necrosis?

Answer 17

Refer!

Non weight bearing w/ use of crutches may allow regeneration of involved segment
Pulse magnetic electrical fields
Surgical treatment - core decompression

Collapse → surgery

Question 18

Fall → groin pain + inability to bear weight or ambulate, referred pain to the knee

External rotation, abduction, shortening of affected leg

May have no deformity with nondisplaced/stress fracture

Answer 18

hip fracture

Question 19

RFs for hip fractures include

Answer 19

Elderly
Osteoporosis
Age
Decreased proprioception, increased fall, dizziness, stroke, syncope, meds, white women, sedentary, smoking, alcoholism, dementa, urban

Question 20

— and — determines risk of compromise of a hip fracture

Answer 20

location and displacement

Question 21

dx for hip fracture

Answer 21

Unable to perform straight leg raise

XR: AP + cross table lateral reveal fracture

MRI to rule out occult fracture

Question 22

tx for hip fracture

Answer 22

Refer to ortho + internist → needs surgery within 48 hours:
Displaced: hemiarthroplasty or total hip arthroplasty
Nondisplaced/impacted: pinning
Intertrochanteric: ORIF or IM nail

Question 23

Severe thigh pain w/ deformity, inability to move or bear weight, often multi-system bc of high impact

Answer 23

femoral shaft fracture

Question 24

consider risk of —- —– with a femoral shaft fracture

Answer 24

fat embolism

Question 25

PE: deformity, swelling, open fracture Check vascular + neuro status, joints XR: AP and lateral of affected extremity, pelvis and knee

Answer 25

femoral shaft fracture

Question 26

tx of femoral shaft fracture

Answer 26

Splint + immediate referral Surgery to perform external fixation, traction, IM nailing

Question 27

Point tenderness over greater trochanter radiating down lateral aspect of leg w/ inability to lie on that side Worsened with rising from seated position, improvement w/ a few steps before worsening after 30 min of walking Pain worse with active hip abduction, adduction of him or adduction + internal rotation

Answer 27

greater trochanter bursitis

Question 28

On XR for greater trochanter bursitis you may see

Answer 28

XR: AP + frog lateral - may see calcific deposits

Question 29

greater trochanter bursitis tx

Answer 29

NSAIDs, activity modification, IT band stretching, ice, short term cane, hip abduction strengthening, steroid Referral to orthopedist when treatment fails Rarely surgery

Question 30

IT band (external) = snapping or popping w/ walking or rotation of the hip → patients will point to trochanteric area Iliopsoas (internal) = popping felt in groin when rising from a chair (no pain)

Answer 30

snapping hip

Question 31

Snapping or popping sensation occurring with tendons moving over bony prominences: MC = band snapping over greater trochanter Or iliopsoas tendon, intra-articular tears

Answer 31

snapping hip

Question 32

PE: IT band felt over greater trochanter when patient stands + rotates hip while adducted Iliopsoas palpated as hip is extended XR: AP pelvis + lateral hip CT, MRI to rule things out

Answer 32

snapping hip

Question 33

How do you treat snapping hip?

Answer 33

Avoid provocative maneuvers, stretching, strengthening NSAIDs, steroid

Question 34

Pain over injured muscle that is exacerbated when area continues to be used - location specific to muscle, often from overuse or vigorous muscle contraction

Answer 34

hip strain

Question 35

PE: pain w/ palpitation, stretch, movement against resistance XR of pelvis and frog-lateral to rule out others, avulsion injury common

Answer 35

hip strain

Question 36

How do you treat a hip strain?

Answer 36

RICE + protected weight bearing Rehab - PROM, heat, e-stim, US, activity modification, home exercise, strength, flexibility

Question 37

Hamstring → sudden onset of posterior thigh pain while running or other rapid movements, may feel a “pop” Localized tenderness at muscle sit, possible ecchymosis Often from direct blow

Answer 37

thigh strain

Question 38

Hamstring - pain w/ combined flex of hip + extension of knee Quads - pain with flexion of knee

Answer 38

thigh strain

Question 39

tx of thigh strain

Answer 39

RICE - rehab, NSAIDs, prevent long-term complications

Question 40

groin pain, lateral hip pain or buttock pain worsened with weight bearing or inability to bear weight Pain with hip ROM + straight leg raising, antalgic gait

Answer 40

low energy pelvic fracture

Question 41

ABCs, pelvis for swelling, ecchymosis, deformity, lacerations, neurovascular status, GI injury

Answer 41

high energy pelvic fracture

Question 42

3 types of pelvic fracture:

Answer 42

Stable pelvic ring → one side, unilateral Unstable pelvic ring → disruption of pelvic ring at two sites Acetabular fracture → intra-articular injuries

Question 43

How does diagnosis process differ between low + high energy pelvic fractures?

Answer 43

Low impact = AP of pelvis High impact = XR – trauma - AP, lateral of C-spine and AP of pelvis, CT

Question 44

treatment of pelvic fractures

Answer 44

Based on degree of instability + associated injuries Low impact → analgesics, rest, gait training w walker ~6 weeks for fracture healing + improved pain, evaluation for osteoporosis High impact → hemodynamic resuscitation + injury treatment Pelvic binding w/ sheet, skeletal traction, surgery once stable