OA of hip tx
young pts
femoral head resurfacing
OA of hip tx
old pts
THA or bipolar arthroplasty
avoid narcotics
Hip impingement syndrome
abnormal wear and tear of ball and socket joint due to increased friction
2/2 abnormal formation of hip during childhood (athletes notice sooner but NOT caused by exercise)
Cam and Pincer lesions
associated with FAI
cam = lesion on femur pincer = lesion on hip
cross over sign
acetabular retroversion seen on XR
indicates a pincer lesion on femur
blood supply to hip
obturator (head of femur)
medial and lateral circumflex arteries
compromise of these = osteonecrosis
systemic diseases that may cause osteonecrosis
sickle cell SLE RA EtOH abuse steroid
radiographic finding osteonecrosis
crescent sign
indicates head of the femur is about to collapse
imaging in osteonecrosis
if radiograph normal but still suspect get MRI
tx of osteonecrosis prior to collapse
core decompression w/wo graft
avoid of steroids
tx of osteonecrosis after collapse
bipolar hemiarthroplasty or head resurfacing
avoid steroids
ITB snapping hip
over greater trochanter
occurs w/walking or rotation, reproducible
LATERAL hip pain
iliopsoas tendon snap
over pectineal eminence
rising from seated position
more annoying than painful
Not often palpable snap
labrum or femoral head tear
shocking, catch pt off guard - must brace to prevent fall
pain occurs RIGHT in groin
diagnostic work up of snapping hip
AP Pelvis and frog let
MR Arthrogram = labral tear
strained hip/thigh muscle recovery phases (1-5) long *
- RICE 48-72 hrs
- PROM exercise, heat 72hrs - 1 week
- isometrics 1-3 weeks
- increased strengthening 3-4 weeks
- sport specific training
strain imaging work up
XR to r/o avulsion fx to ASIS/AIIS
MRI if torn muscle/tendon (athlete)
hx of hamstring tear
sudden onset of pain
“pop” while running
hx of quads tear
direct blow to area (soccer or football)
trochanteric bursitis presentation
pain over lateral hip when standing from seated position or lying down
also pain with lying on that side
PE trochanteric bursitis
focal tenderness over greater trochanter
get XR to r//o boney pathology
tx trochanteric bursitis
don’t lay on side
NSAIDS –> steroid injection
hip dislocation presentation
following MVA
posterior dislocation MC
posterior hip dislocation on PE
hold thigh flexed, ADducted, INTERNALLY/MEDIALLY rotated
check NV status
anterior hip dislocation PE
ABducted, EXTERNALLY/LATERALLY rotated
less NV injury
Hip dislocation imaging
posterior = head of femur is smaller anterior = head of femur larger
CT done to check acetabulum
hip dislocation tx
ortho emergency
reduction W/IN 3 HRS
femur shaft fx
high energy trauma
PE look at entire extremity
tx of femoral shaft fx
if open fracture but pt has no pulses
traction splint
+ Ancef, TIG
pelvis fracture work up
worry about shock
XR AP pelvis, inlet, Judet and oblique –> CT
complications of pelvis fracture
shock, organ damage, injury to entire body
pelvic girdle for hemodynamic stability or bed sheets over GREATER TROCHANTER
osteoporosis and femur fx
MC in femoral neck
especially in older women
RF for femur neck fracture
smoking sedentary lifestyle alcohol abuse dementia psych medication
hx of a femoral neck fx
fall on affected side, land on hip
unable to stand or ambulate
femoral neck fx will appear
displaced and shortened in ER
what do we used to classify femoral neck fx
Garden classification
OA of hip XR
narrowing of articular space
OA of hip tx (Rx)
NSAIDS, steroids, avoid narcotics
Mobic is good option
OA of knee
progressive pain (activity –> constant)
aging, obesity, repetitive wear and tear, previous trauma
OA of knee XR
AP and lateral weight bearing
loss of joint space, sclerosis, subchondral cysts, osteophytes
bursa of knee
pre patellar
infrapatellar
pes anserine
prepatellar bursitis
located b/t skin and patella
swell to size of tennis ball
found in carpet layers or wrestlers
pes anserine bursitis
medial knee, under SGT
over use or obese patients (warning of medial joint DJD)
hx bursitis of knee
pain present with active or direct pressure
relieved after resting then worse when resuming activity
aspiration of bursa
is suspicion of infection (redness, swelling)
tx of bursitis
ice, decreased activity, preventative measures (I.e. knee pads)
NSAIDs, steroid injections
patellofemoral pain hx
insidious onset
aching knee, worse with prolonged sitting, climbing stairs, jumping or squatting
patellofemoral pain PE
increased Q angle (esp. women)
malt racking of patella
patellofemoral pain tx
NSAIDs, quad strengthening, referral
meniscus tear - which one MC? why?
medial meniscus
fixed to tibial plateau
cause of meniscus tear
Degenerative (OA cascade)
Trauma (twisting motion)
meniscus tear hx
worse with forced flexion (squatting)
buckling or catching sensation
bucket handle
meniscus tear flips over and blocks knee from full extension
meniscus tear PE
McMurray test positive
MRI (2-3 days after injury to help visibility)
tx of meniscus tear
PT then sx
PT improves post op outcomes by strengthening muscles around the knee
ACL tear test +
lachman’s test
MRI
MoI ACL tear
twisting on bent or hyperextended knee
testing MCL tear
valgus stress testing
testing LCL tear
varus stress testing
conservative tx of ACL tear
PT with ROM strengthening and bracing
sx following MRI
always check contralateral extremity
two spots that rupture patellar quad tendon tear (age)
< 55: distal
>55: proximal
hx patellar quad tendon tear
fall on partially flexed knee
PE patellar quad tendon tear
inability to fully extend against gravity
patellar quad tendon tear tx
EARLY sx repair
avoid NSAIDS
hx tibial plateau fx (medial)
MVC hit from side
tibial plateau fx (lateral)
direct blow to distal lateral thigh w/foot planted
tibial plateau fx diagnostic tests
CT recon (surgical planning)
MUST also asses for meniscal or ligamentous injury
tibial plateau fx tx
ORIF and referral
patella fx
direct blow (by fall or object)
inability to extend knee
patella fx dx studies
AP and lateral XR of knee
tx patella fx
complete/extensor mechanism not intact = SX
otherwise long leg cylinder cast or long leg hinged brace in full extension
osgood schlatter dz
receptive stress on quad groups pulls on apophysis of tibial tuberosity
boys 11-13
prominence of tibial tuberosity
management osgood schlatter dz
if pain is UNILATERAL = XR to r/o tumor
ice pack and stretching exercise
Sinding larsen Johansson
injury at the junction of PATELLAR tendon and distal pole of patella
pain is INFERIOR patella
S-L-J v. Osgood
OS= tibial pain SLJ= patellar pain
meniscus tear confirmed with
MRI (get XR first)