LE: Hip Flashcards

(40 cards)

1
Q

Hip Dislocation etiology

A
  • The femoroacetabular joint is one tough joint
    – Rarely dislocates
  • Requires huge forces or malformed joint
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2
Q

Hip Dislocation presentation

A

– Lots of pain
– Immobility of the lower extremity
– Due to the high impact forces involved in a hip dislocation, pt’s
may have other traumatic complaints and associated injuries

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3
Q

Hip Dislocation: posterior vs. anterior

A

Hip Dislocation

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4
Q

Hip Dislocation PE - posterior dislocations

A
  • Affected limb is shorter
  • Hip is fixed in position
    – flexion, adduction, & internal rotation
  • Assess distal pulses
  • Assess sciatic and femoral nerves
  • Check for sciatic nerve palsies
    (8-20% of patients)
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5
Q

Hip Dislocation PE - anterior dislocations

A
  • Affected limb is in some flexion, abduction, & external rotation
  • Nerve injuries are less frequent than posterior - still check though
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6
Q

Hip Dislocation PE - both dislocations

A
  • Check pulses
  • Check for abrasions and contusions of the skin
  • Knee examination
  • Check for an associated femur fracture
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7
Q

Hip Dislocation
Diagnostics

A

X-rays
* AP of the pelvis
* AP and lateral of affected hip
* Also get knee and femur if suspected injury

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8
Q

Hip Dislocation
Treatment

A
  • Reduce ASAP to decrease risk of osteonecrosis
  • Check for associated fractures before reduction
    – physical exam and x-rays
  • Perform the reduction in a nontraumatic way
  • Post reduction x-rays
  • CT is used when available for evaluation of reduction and soft tissue
    or bony damage
  • Document neural function before and after the reduction.
    – Crutch and assisted ambulation post reduction (WBAT)
  • until pt is pain free (2-4 weeks post injury)
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9
Q

Hip Dislocation
Adverse Outcomes

A

– Osteonecrosis (10% of pts)
– Capsular or labral tears
– Acetabular edge fractures
– Nerve damage
– Vascular damage
– Post traumatic arthritis

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10
Q

Hip Fracture

A
  • Surgical emergency in someone <60yo
  • Often seen in osteoporotic pts
  • Usually occur in the femoral neck or intertrochanteric region
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11
Q

Hip fracture risk factors

A

– Advanced age (risk doubles q decade >50 yo)
– Dizziness, stroke, syncope, peripheral neuropathies, meds,
sedentary lifestyle, alcohol use, smoking
– Caucasian women 2-3 times more likely than other races

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12
Q

Femoral neck fractures are also
_____ fxs

A

intracapsular

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13
Q

Three areas of hip fractures

A

– Subcapital
– Transcervical
– Basicervica

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14
Q

Intertrochanteric fractures are
_____

A

extracapsular

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15
Q

What does it mean that Intertrochanteric fractures are extracapsular?

A

– Between the greater trochanter
and the lesser trochanter
– Subtrochanteric
* distal aspect of lesser trochanter
* distal to the greater trochanter

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16
Q

Hip Fracture
Clinical Presentation

A

– Hx of a fall followed by pain in the affected side
– Inability to bear weight on affected side or ambulate
– Groin or buttock pain - worse with ambulation
– Elderly with pain in hip after a fall are treated as if they have a
fracture until proven otherwise

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17
Q

Hip Fracture physical exam

A

– Affected limb tends to be externally
rotated and can be abducted
– If fx is displaced the limb will be
shortened
– Nondisplaced fractures rarely have any
deformity
– Inability to perform straight leg raise
– Extension at knee and rotation of limb
causes pain

18
Q

Hip Fracture diagnostics

A

– AP Pelvis
– AP of affected hip
– Lateral of hip
– AVOID Frog leg film for suspected fracture - Lots of pain
– MRI or CT if x-ray doesn’t show fx, but H&P suggests a fx

19
Q

Hip Fracture Treatment

A

– Surgical treatment for most
* Frail and nonsurgical candidates - immobility (slew of issues)
– Timely referral to orthopaedics
* Surgical delay should not be longer than 48 hours (inc. mortality)
– Surgical repair is determined by the fracture location
* Screw and slide plate
* Intramedullary nail
* Cannulated screws
* Total hip arthroplasty (THA)

20
Q

Greater Trochanteric Bursitis

A

Inflammation and hypertrophy of the Greater Troch Bursa

21
Q

Greater Trochanteric Bursitis etiology

A
  • Lumbar spine disease
  • Intra-articular hip pathology
  • Leg length discrepancy
  • Inflammatory arthritis
  • Previous surgeries
  • Overuse
  • Idiopathic origin
22
Q

Greater Trochanteric Bursitis presentation

A

– Pain and tenderness over the greater trochanter
– Pain with almost any pressure over the lateral hip
– Sleeping is difficult
– Worse when first standing from sitting position

23
Q

Greater Trochanteric Bursitis PE

A

– Essential finding:
* Palpation of the greater trochanter with pt in the decubitus position, affected hip up.
* Pain increases with active abduction
– Pain above the trochanter suggests
tendinitis of the gluteus medius muscle
* Increased pain with adduction with internal
rotation
– Pain posterior to the Greater Troch
* Think piriformis and/or Obturator internus

24
Q

Greater Trochanteric Bursitis diagnostics

A

– X-ray - pelvis and lateral view of affected hip
* Necessary to rule out bony abnormalities and internal hip pathology
* May see calcium deposit above the trochanter
– MRI to evaluate soft tissue pathology and uncommon
conditions such as tumors, osteonecrosis of the femoral
head, or occult fractures

25
Greater Trochanteric Bursitis treatment
– NSAIDs – Activity modification – IT band stretching – Short-term use of cane – Hip stretching and home strengthening – Hip abduction strengthening (PT) – Corticosteroid injection – Surgery is rarely needed (bursectomy)
26
Greater Trochanteric Bursitis adverse outcomes
– NSAID reaction – Infection from injection (rare) – Persistent pain – Limp – Sleep disturbances – Bursectomy - can have a fluid accumulation and adhesions
27
AVN of the hip epidemiology
* Between 30-50 yo * Males > Females (3:1) * 10K-20K new cases per year in the US * Risk ↑ pts receiving high-dose steroids * Accounts for 5-18% of THAs
28
AVN of the hip risk factors
* Corticosteroid use * Alcohol abuse * Smoking * Hip trauma * Heavy workload * Associated conditions – Chronic pancreatitis, chronic liver disease, crohn disease, systemic lupus erythematosus, sickle cell disease, metabolic lipid disorders, coagulation disorders, HIV, Cushing’s disease, radiation and/or chemotherapy, pregnancy
29
AVN of the hip Etiology
– > 90% of nontraumatic osteonecrosis is secondary to: * corticosteroid use * alcohol abuse – Traumatic AVN may be secondary to: * Hip fx * Slipped capital femoral epiphysis * Hip dislocation * Prior hip surgery
30
AVN of the hip pathogenesis
– Osteocyte cell death due to disruption of vascular supply to femoral head * I.e., fat emboli – Continued stress causing fx * progressive collapse – Degenerative changes * articulation malalignment
31
AVN of the hip presentation
– Early stage may be asymptomatic – Painful hip with limited ROM * Pain can radiate to the buttocks, knees, or anterolateral thigh * worse with wt bearing, relieved by rest – Symptoms usually insidious – Hx of being on corticosteroids – Hx of hip trauma, SCFE, dislocation, or surgery – Hx of associated conditions – Social hx of alcohol use, smoking, deep sea diving, heavy workload
32
AVN of the hip PE
– Pain and limited active ROM of the hip(s) – Pain with: * hip abduction * Internal rotation * Logrolling (passive internal and external rotation)
33
AVN of the hip diagnostics
– Suspect in pts <50 yo with: * Groin pain * Hip pain * Thigh pain * Limited AROM – X-ray * AP, Lateral, frog leg * Compare both sides * Crescent sign – MRI * May confirm if early disease
34
AVN of the hip Treatment
– PT best for early disease – Medications * alendronate - improve pain and function * enoxaparin - prevent progression – Surgical * Core decompression * THA
35
AVN of the hip adverse outcomes
– subchondral sclerosis (scarring of articular cartilage) – focal osteoporosis – femoral head collapse – DJD (osteoarthritis)
36
Snapping hip etiology
* Tendons move over bony prominences – Most common is the iliotibial band sliding over greater trochanter – Iliopsoas sliding over the iliopectineal eminence of the pelvis – Intra-articular tears of the acetabulum
37
Snapping hip clinical presentation
– Iliotibial (IT) band subluxation * Subluxation of IT band due to walking or rotation of the hip * Pain in the greater trochanteric area * Some pts snap as they lay on unaffected side and rotate affected leg internally or externally – Iliopsoas tendon subluxation * Felt in the groin when flexed hip is extended (i.e. standing from chair) * more annoying than painful – Intra-articular acetabular tears * more disabling, pts reach for support to ambulate or stand
38
Snapping hip PE
– Re-create the snap * Pt stands, rotates hip while adducted * Can palpate and feel the snap over the greater trochanter * Stand from sitting position may recreate iliopsoas snap * A limp or restricted internal rotation suggest internal joint issue – Ober test * IT band tension – Not just for snapping hip
39
Snapping hip Diagnostics
– X-ray - AP and lateral of hip * Rule out bony pathology – CT arthrogram or MRA * Intra-articular pathologies
40
Snapping hip treatment
– Often painless, requiring no specific treatment – Educate patient on the etiology – Avoid provocative activities – PT - exercise and stretching – NSAIDs if needed – Cortisone injections sparingly for rare cases – Surgery in very rare cases to release the IT band – Internal derangement (labral issues) may be assisted by arthroscopy