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HIPS Flashcards

1
Q

Articulating surfaces of the hip?

A

Head of femur
Acetabulum of the pelvis - has an acetabular labrum

Both covered in articualr cartilage

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2
Q

Intracapsular ligaments of the hip?

A

Ligament of head of femur

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3
Q

Extracapsular ligaments of the hip?

A

Anterior:
Iliofemoral ligament
Pubofemoral ligament

Posterior:
Ischiofemoral ligament

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4
Q

What is the ligament of head of femur? What does it contain?

A

It runs from the acetabular fossa to the fovea of the femur
It encloses a branch of the obturator artery

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5
Q

Where is the iliofemoral ligament found?

A

Arises from the anterior, inferior iliac spine and then bifurcates before inserting into the intertrochanteric line of the femur

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6
Q

Where is the pubofemoral ligament found?

A

Runs between the superior pubic rami and the intertrochanteric line of the femur anteriorly

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7
Q

Where is the ischiofemoral ligament found?

A

Runs between the body of the ischium and the greater trochanter of the femur posteriorly

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8
Q

Function of the iliofemoral ligament?

A

Prevents hyper extension of the hip joint

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9
Q

Function of the pubofemoral ligament?

A

Prevents excessive abduction and extension of the hip joint

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10
Q

Function of the ischiofemoral ligament?

A

Prevents hyper extension and holds the femoral head in the acetabulum

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11
Q

Arterial supply to the hip joint?

A

Medial and lateral circumflex femoral arteries that anatstamose at the base of the femoral neck to form a ring
The medial circumflex artery is repsonsible for the majority of the arterial supply
The artery to the head of femur and superior/infeiror gluteal arteries also provide some additional supply

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12
Q

Which nerves innervate the hip?

A

Sciatic, femoral and obturator nerves

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13
Q

Why can pain in the hip be referred to the knee?

A

As the sciatic femoral and obturator nerves supply both the hip and the knee

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14
Q

Stabilising factors for the hip?

A

Acetbulum is deep and encompasses nearly all of the head of femur
Acetabular labrum increases the depth and provides a larger articular surface
Iliofemoral, pubofemoral and ischiofemoral ligaments - have a unique spiral orientation which causes them to become tighter when the joint is extended

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15
Q

What movements can the hip do?

A

Flx/ext
Abd/add
Lateral and material rotation

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16
Q

Which muscles help carry out hip flexion?

A

Iliopsoas, rectus femoris, sartorius and pectineus

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17
Q

Which muscles help carry out hip extension?

A

Gluteus maximus
Hamstrings (Semimembranous, Semitendinous, Biceps femoris)

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18
Q

Which muscles help carry out hip abduction?

A

Gluteus medius and minimus
Piriformis
Tensor fascia latae

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19
Q

Which muscles help carry out hip adduction?

A

Adductor longus, brevis and Magnus
Pectineus
Gracilis

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20
Q

What does the degree to which flexion at the hip can occur depend on?

A

Whether the knee is flexed or not
When the knee is flexed, the hamstrings muscles are relaxed and the range of flexion is increased

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21
Q

What causes hip dislocations?

A

Trauma mostly - RTAs and significant falls from height

Can be a complication of total hip replacements
Congenital hip dislocations can be a cause - spectrum of DDH

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22
Q

What % of all hip dislocations do posterior dislocations account for?

A

90%

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23
Q

Position of leg following a posterior hip dislocation?

A

Affected leg is shortened, adducted and internally rotated

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24
Q

Position of leg following a anterior hip dislocation?

A

Leg is abducted and externally rotated

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25
Types of hip dislocation?
Posterior Anterior Central
26
Clinical presentation of any hip dislocation?
Significant clunk/popping followed instantly by severe pain Physical deformity Inability to walk from pain May be possible neurovascular injury
27
What is an important complication of posterior hip dislocations?
Sciatic nerve injury - in 10-20% This is because the sciatic nerve runs posteriorly in the hip joint
28
Management of hip dislocations?
ABCDE approach Analgesia Reduction under GA within 4 hours XR of hip following reduction PT long term to strengthen surrounding g muscles
29
Why must reduction of a hip dislocation be done within 4 hours?
To reduce the risk of a vascular necrosis
30
Complications of hip dislocations?
Sciatic or femoral nerve injury Avascular necrosis Osteoarthritis: more common in older patients. Recurrent dislocation: due to damage of supporting ligaments
31
Prognosis of hip dislocations?
2-3 months for hip to heal Prognosis is best when the hip is reduced <12 hours post-injury and when there is less damage to the joint
32
What is avascular necrosis of the hip?
A type of osteonecrosis Death of bone tissue secondary to loss of the blood supply which leads to bone destruction and loss of joint function
33
Possible causes of avascular necrosis of the femoral head?
Trauma - hip dislocations or fractures Alcohol excess - can decrease blood supply to the bone Chemotherapy Long-term steroid use
34
Presentation of avascular necrosis of the hip?
initially asymptomatic pain in the hip that may radiate to the groin or thigh. Aggravated by walking/climbing stairs and alleviated by rest.
35
Investigation for avascular necrosis of the hip?
MRI is investigation of choice XR can be done but may be normal initially.
36
Possible findings on plain XR of the hip following avascular necrosis?
Osteopenia and micro fractures may be seen early on and then collapse of the articular surface may result in the crescent sign
37
Management of avascular necrosis of the hip?
Conservative management e.g. alcohol cessation, discontinuing steroids, analgesia Core decompression - surgical drilling into ares of dead bone to reduce pressure and allow for increased blood flow Joint replacement may be necessary
38
Epidemiology of hip fractures?
>65,000 hip fractures each year in the UK Becoming increasingly frequent due to an aging population Mortality following a femoral neck fracture is up to 30% at 1 year 50% of pts become less independant following a hip fracture
39
What causes neck of femur fractures?
Low energy injuries are the most common type e.g. fall in frail older pt
40
Risk factors for neck of femur fracture?
Female Increasing age Osteoporosis
41
Where does a fracture occur for it to be considered a “neck of femur” fracture?
From subcapital region of the femoral head to 5cm distal to the less trochanter
42
What are the 2 distinct areas of the neck of femur?
Intracapsular and extra-capsular
43
What is the intra-capsular region of the neck of femur?
From the subcapital region of the femoral head to the basocervical region of the femoral neck, immediately proximal to the trochanters
44
What are the 2 regions of the extra-capsular region of the neck of femur?
Inter-trochanteric - between greater and lesser trochanter Sub-trochanteric - from the lesser trochanter to 5cm distal to this point
45
Describe the blood supply to the neck of femur?
It is retrograde, passing from distal to proximal along the femoral neck to the femoral head… The medial and lateral circumflex femoral arteries join the femoral neck just proximal to the intertrochanteric line. Branches of this artery run along the surface of the femoral neck within the capsule towards the femoral head
46
Which hip fractures are at greatest risk of avascular necrosis of the femoral head?
Displaced intra-capsular fractures - this is because they disrupt this blood supply to the femoral head
47
What is considered an intra-capsular hip fracture?
One which affects the femoral neck proximal to the intertrochanteric line
48
What classification is used for intra-capsular fractures?
Garden classification: Grade 1 - incomplete fracture and non-displaced Grade 2 - complete fracture and non-displaced Grade 3 - partial displacement (trabeculae at an angle) Grade 4 - full displacement (trabeculae are parallel)
49
Consider the garden system… which types of intracrapsular neck of femur fractures are most at risk of disrupting the blood supply?
Types 3 and 4 (any displaced fractures)
50
Management of a non-displaced intra-capsular neck of femur fracture?
Internal fixation with cannulated hip screws Or hemiarthroplasty if unfit
51
Management of displaced intra-capsular neck of femur fractures?
Hemiarthroplasty Total hip replacement
52
Which patients with displaced intracapsular hip fractures should be managed with a total hip replacement rather than a hemoartroplasty?
If they were able to walk independently out of doors with no more than the use of a stick and are not cognitively impaired and are medically fit for anaesthesia and the procedure.
53
What is a hemiarthroplasty?
It’s a partial hip replacement Replacing the head of the femur but leaving the acetabulum in place Cement is used to hold the stem of the prosthesis in the shaft of the femur
54
Management of intertrochanteric fractures?
Dynamic hip screw
55
What are dynamic hip screws?
A screw is inserted into the neck of the femur, a side plate and several cortical screws that are fisted into the proximal femoral shaft
56
Management of subtrochanteric neck of femur fractures?
Intramedullary device (a metal rod in the medullary cavity of the bone)
57
How do hip fractures present?
Often trauma followed by… Pain in groin or hip, that may radiate to the knee Not able to weight bear Shortened, abducted and externally rotated leg
58
Investigations for suspected hip fracture?
Assess neurovascular status of leg XR hip and pelvis (MRI or CT if XR is negative but fracture still suspected) Bloods - FBC, U&Es, coagulation screen, group and save (CK if long lie) Other investigations to discover reason for fall
59
What is a key sign on an XR that there is a hip fracture?
Disruption of Shenton’s line
60
Genera management of fractured neck of femur?
A-E assessment Analgesia Surgical management - within 48 hours of admission Rehabilitation with PT and OT following surgery
61
Complications following a neck of femur fracture?
Joint dislocation Avascular necrosis of femoral head Aseptic loosening Peri-prosthetic fracture Infection Development of leg length differences -> changes in gait or chronic pain Mortality - 30% at 1 year
62
What usually causes an acetabular fracture?
High-energy injury e.g. RTA or fall from height
63
What are Morel-Lavellee lesions?
An internal devolving injury The skin a nd subcutaneous tissues are abruptly separated from the underlying fascia due to trauma. A potential space is produced superficial to the fascia and can fill with fluid Often associated with pelvic, acetabular and proximal femur fractures
64
What is greater trochanteric pain sundrome?
A regional pain syndrome in which chronic, intermittent pain is felt around the greater trochanter Used to be known as trochanteric bursitis but now its shown that pain us due to micro injuries to the gluteal muscles and tendons
65
What causes greater trochanteric pain syndrome?
Inflammation or physical trauma in muscles/tendons/fascia/bursae in the hip: Most commonly tendinopathy or a muscle tear of gluteus medius, minimus or a trochanteric bursitis There is often co-existence of bursitis and tendinopathy Less commonly it can be caused by ITB thickening or septic trochanteric bursitis Main causative factors: repetitive activity, mechanical overload, training errors, sedentary lifestyle etc
66
Pathophysiology of greater trochanteric pain syndrome?
Repetitive friction between the greater trochanter and iliotibial band causes microtrauma in the greater trochanter at the level of infection with the gluteal tendons = inflammation, degeneralisation of tendons and increased tension on the ITB
67
Presentation of greater trochanteric pain syndrome?
Chronic lateral hip/thigh/buttock pain that can be intermittent or persistent Onset is usually gradual and progressively worsens over time Pain may radiate down the lateral aspect of the thigh, but not below the knee Pain is aggravated by physical activity and pressure on that side of the body Pain on palpation of greater trochanter
68
What tests can be done for greater trochanteric pain syndrome?
FABER test FADER test Resisted active abduction causes pain Resisted internal and external rotation causes pain
69
What is the FABER test?
Hip Flexion ABduction and External Rotation test The lateral malleolus of the test leg is placed above the patella of the contralateral leg, the pelvis stabilized via the opposite anterior superior iliac spine and the knee passively lowered so the hip moves into abduction and external rotation. If there is lateral hip pain, the test is positive for greater trochanteric pain syndrome
70
What is the FADER test?
Hip Flexion, ADuction and External Rotation test With the person lying supine, the hip is passively flexed to 90°, adducted, and externally rotated to end of range. If there is lateral hip pain, the test is positive for greater trochanteric pain syndrome
71
Who is greater trochaneric pain syndrome most common in?
Women aged 50-70
72
Management of greater trochanteric pain syndrome?
Conservative - rest, ice, analgesia Walking aids and devices If conservative measures fail - consider peri-trochanteric corticosteroid injection and refer to PT
73
What is an iliopsoas abscess?
A collection of pus in the iliopsoas compartment
74
Primary causes of iliopsoas abscess?
Haematogenous spread of bacteria - most commonly staph aureus
75
Secondary causes of iliopsoas abscess?
Crohn’s - most common Diverticulitis or colorectal cancer UTI GU cancers Vertebral osteomyelitis Femoral catheter Lithotripsy Endocarditis IVDU
76
Mortality rate of iliopsoas abscess?
20% in secondary iliopsoas abscess 2.4% in primary
77
Features of iliopsoas abscess?
Fever Back/flank pain Limp Weight loss
78
Specific test for iliopsoas inflammation?
Place hand proximal to the patient's ipsilateral knee and ask patient to lift thigh against your hand. This will cause pain due to contraction of the psoas muscle. Lie the patient on the normal side and hyperextend the affected hip. This should elicit pain as the psoas muscle is stretched.
79
Investigations for iliopsoas abscess?
Bloods - FBC, CRP, U&Es, septic screen CT abdo is most commonly done (MRI is gold standard)
80
Management of iliopsoas abscess?
Antibiotics Percutaneous drainage - works in 90% of cases If this fails then surgery can be indicated
81
Clinical features of OA of the hip?
Pain in the grain, lateral hip or deep in buttock - aggravated by weight-bearing and improved with rest. Worse towards the end of the day Stiffness Grinding/crunching sensation Antalgic gait ROM is reduced and passive movement painful
82
What is an acetabular lateral tear? What causes them?
A tear in the acetabular labrum Most commonly caused by direct traumas, sporting activities requiring frequent external rotations or hyperextension e.g. ballet
83
Presentation of acetabular labral tears?
Constant dull pain with periods of sharp pain that worsens during activity. Aggravated by walking, pivoting, prolonged sitting and impact activities Clickly, locking, catching, giving way may occur FADIR test positive
84
Presentation of hip RA?
Pain and stiffness that is worse after not moving e.g. when you wake up
85
Hip pain in children
Look at paeds

MUSCULOSKELETAL (13 decks)

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