Flashcards in MSK Hip/Pelvis Deck (94):
4 joints of the pelvic girdle
1. femoroacetabular (hip)
2. pubic symphysis
3 & 4. bilateral SI joints
The hip is a ball-and-socket joint called ____
pathology of hip may be due to ___, ___, and ___.
weight bearing, ambulation, or motion.
Angle between the femoral neck and shaft of the femur is different in males:_____ than in females ______
males 125 degrees
females 115-120 degrees
Difference is due to female pelvis being wider to accommodate the birth canal and gravid uterus
2. affected limb is ___ and ____ is limited
femoral neck and shaft angle is decreased
affected leg is shortened and hip abduction is limited. Knee assumes a valgus deformity
2. affected limb is ___.
angle between femoral neck and shaft are increased.
affected limb is lengthened and the knees assume a varus deformity.
Name the hip flexors with myotomes: 9
1. Iliopsoas (nerve to iliopsoas or femoral nerve L-3) - prime hip flexor
2. Sartorius (femoral nerve L2-4)
3. Rectus femoris (Femoral N L2-4)
4. Pectineus (Femoral N L2-4)
5. TFL (Superior gluteal nerve L4-S1)
6. Adductor brevis (obterator N L2-4)
7. Adductor longus (obturator N L2-4)
8. Adductor magnus (obturator and sciatic - tibial div. L2-S1)
9. Gracilis (obturator L2-4)
Name the hip adductors (anterior placed) with myotomes
1. gracilis (obturator nerve L2-4)
2. Pectineus (femoral nerve L2-4)
3. Adductor brevis (Obturator nerve L2-4)
4. Adductor longus (Obturator nerve L2-4)
5. Adductor magnus (obturator and sciatic tib div L2-S1)
Name the hip adductors (posteriorly placed) with myotomes
1. Gluteus maximus (inferior gluteal n L5-S2)
2. Obturator externus (obturator nerve L3-4)
3. Gracilis (obturator nerve L2-4)
4. Long head of biceps femoris (Sciatic N (tib div) L5-S2
5. Semitendinosus (sciatic nerve Tib div) L4-S2
6. Semimembranosus (sciatic nerve tib div L5-S2)
Name the 2 hip abductors with myotomes
What about abductors with IR component? 4
1. Gluteus medius (superior gluteal nerve L4-S1)
2. Gluteus minimus (same)
1. TFL (sup glut n. L4-S1)
2. Sartorius (femoral nerve: L2-4)
3. Piriformis (nerve to piriformis L5-S2)
4. Glut maximus, superior fibers (inferior gluteal n L5-S2)
Hip extensors with myotomes 6
1. Glut maximus (inferior gluteal nerve L5-S2) - PRIME MOVER
2. Glut medius (posterior fibers - superior gluteal nerve L4-S1
3. Glut Minimus, posterior fibers - superior gluteal nerve L4-S1
4. Piriformis - nerve to piriformis S1,2
5. Adductor magnus - sciatic innervated part (tib div) L2-4
6. Hamstring muscles [tib div of sciatic]
- long head of biceps femoris (L5-S2)
- Semimembranosus (L5-S2)
- Semitendinosus (L5-S2)
Name the prime hip flexor
iliopsoas - nerve to iliopsoas or femoral nerve L1-3)
Name the prime hip extensor
glut maximus (inferior gluteal nerve L5 -S2
name the external rotators of the hip with myotomes 6
1. Piriformis (N to piriformis - S1/2)
2. Obturator internus (N to the obturator internus: L5/S1)
3. Superior gamellus (nerve to superior gamellus L5-S2)
3. Inferior gamellus ( nerve to inferior gamellus L5-S2)
4. Obturator exturnus (L5, S1, S2)
5. Quadratus femoris (N to quadatus femoris - L4, L5, S1)
6. Gluteus maximus (inferior gluteal nerve L5, S1, S2)
Internal rotators of the hip with myotomes
1. TFL (superior gluteal nerve L4-S1)
2. Adductor magnus, longus and brevis
- magnus (obturator nerve and sciatic tib div L2-S1)
- Adductor longus and adductor brevis (obturator nerve: L2-4)
3. Gluteus medius (sup glut n L4-S1)
4. Glut minimus (sup glut n L4-S1)
5. Gracilis (obt n L2-4)
6. Semitendinosus (Sciatic nerve tib div L5-S2)
7. Semimembranosus (Sciatic nerve tib div L5-S2)
_____ serves to deepen the acetabulum. Its function is to hold the femoral head in place.
_____ extends from the acetabular rim to the intertrochanteric crest forming a cylindrical sleeve that encloses the hip joint and most of the femoral neck. Circular fibers around the femoral neck constrict the capsule and help to hold the femoral head into the acetabulum
articular fibrous capsule
_____ is the strongest ligament in the body. Extends from the AIIS to intertrochanteric line.
limits extension, abduction, and external rotation of the hip
Y-ligament of Bigelow
____ ligament extends from the ischium behind the acetabulum to blend with the capsule
Function: limit internal rotation of the hip
____ ligament extends from the superior pubic ramus and joints the iliofemoral ligament.
Function to limit hip abduction.
____ extends from the acetabular notch to the femur. this ligament is fairly weak and does little to strengthen the hip.
in 80% of cases, it carries _____.
Ligamentum capitis femoris
a small arter to the femoral head.
Normal Hip ROM in an adult:
OA will limit ____ of the hip first.
Hip flexion: 120
Hip extension: 30
Hip abduction: 45-50
Hip adduction: 0-30
External rotation: 35
Internal rotation 45
internal rotation of the hip first.
FABERE (patrick's test) is a provocative maneuver to assess for:
How is it performed?
SI joint dysfunction
Patient supine, passively flex, abduct the hip and externally rotate. Extension of the leg is achieved with downward force by the examiner.
Posterior hip pain indicative of SI joint disorder
Anterior hip/groin pain is indicative of pathology in the hip joint and surrounding tissues.
_____ is a test used to assess hip flexion contractures.
How to perform?
Thomas test: patient is supine, flex one hip fully reducing the lumbar spine lordosis stabilizing the lumbar spine and pelvis, extend the opposite hip. If that hip does not fully extend, a flexion contracture is present.
degree of flexion contracture is done by estimating the angle between the table and the patient's leg.
_____ tests for contraction of the tensor fascia lata/IT band tightness.
How to perform?
With the patient side lying with the uninvolved leg on the table, flex the knee to 90 degrees. extend the hip to 0 degrees, and abduct the involved leg as far as possible. The leg is then lowered from full abduction.
If thigh remains abducted, there may be contracture of the TFL or IT band.
____ tests for glut medius weakness.
With the patient standing, ask him/her to raise one foot off of the ground. strength of the gluteus medius on the standing leg is assessed.
a positive test occurs when the pelvis on the unsupported side descends or remains level (ex - pelvic drop on the left side in a patient standing on his right leg is indicative of right gluteus medius weakness.)
a negative test occurs when the pelvis on the unsupported side stays the same height or elevates slightly.
What are 7 conditions associated with gluteus medius weakness.
4. fractures of the greater trochanter
5. slipped capital femoral epiphysis (SCFE)
6. Congenital hip dislocation
_____ tests for femoral nerve irritation
Femoral nerve stretch test (Elys test)
with patient lying prone, flex the knee >90 degrees and extend the hip.
pain in anterior thigh is positive for femoral nerve irritation
To assess true leg length, measure from ____ to ____
ASIS to medial malleolus. - fixed bony landmarks
With regard to leg length discrepancy, how do you determine if discrepancy is in the femur or the tibia?
With patient supine, flex knee to 90 degrees and place feet on the table. If one knee is higher than the other, that tibia is longer. If one knee projects further anteriorly, then that femur is longer.
true leg length discrepency has many causes, which include fractures crossing the epiphyseal plate in childhood or poliomyelitis
If no discrepency - called "apparent leg length discrepency"
_____ discrepency may be caused by pelvic obliquities or flexion or adduction deformity of the hip.
Apparent leg length discrepency
With patient supine, measure from umbilicus to medial mall (from non fixed to fixed landmark)
Pelvic obliquity may be assessed by observing the levelness of the ASIS or the PSIS.
TRUE LEG LENGTH MEASUREMENTS ARE EQUAL DESPITE APPARENT DISCREPENCY
normal strength ratio of hamstrings to quads:
Predisposing factors for hamstring strain 5
rehab program addresses these things
Hamstring injuries occur during ____ phase of conraction
Injuries range from ____ (strain) to _____ (complete tear)
Grade I, Grade III
Hamstring strains most commonly seen in ___ and ____
track and gymnastics
Hamstring strain presents as pain where?
May occur with loss of _____
Tenderness over ____
pain in hamstring region after a forceful hamstring contraction or knee extension
May occur with loss of function
Tenderness over muscle belly or origin
provocative test - pain elicited in ischial region with knee flexion
Treatment of hamstring strain
RIC. weight bearing reduction if necessary, NSAIDs, gentle stretch
advance to strengthening and risk factor modification when inflammation is reduced.
Rehab of piriformis syndrome seeks to reduce ___ and ___ and recover full hip ____
Piriformis syndrome pain can be exacerbated by_____
walking up stairs.
over muscle belly that stretches from sacrum to the greater trochanter.
what is the provocative test for piriformis syndrome
flexion, adduction, and internal rotation.
Treatment of piriformis syndrome:
1. stretching of external rotator hip muscles, NSAIDs, ultrasound are initial therapies
2. CSI can be used if more conservative treatment fails.
______ is inflammation of the muscle tendon unit and bursa which occurs with overuse or trauma, causing muscle tightness and imbalance.
iliopsoas bursitis and tendonitis
Ice, NSAIDs, stretching and strengthening.
CSI if conservative management fails
With iliopsoas bursitis and tendonitis
____ may occur with flexion and may cause pain
Tenderness over _____
pain on hip flexion
What are the potential causes for external and internal snapping hip syndrome?
Name locations of pain
External: due to tight IT band or glut maximus snapping over the greater troch
- Pain over TFL,ITB or glut max
Internal: may be due to tight iliopsoas tendon/iliopsoas tendonitis snapping over the iliopectineal prominence of the pelvis.
- pain in anterior groin or inferior abdomen
- less commonly, the patient may have an acetabular labral tear or loose body in the hip joint.
Provocative tests for
external snapping syndrome:
internal snapping hip syndrome:
external - internally and externally rotate the hip passively while the patient is in the lateral decubitus position.
Internal - extend, abduct and externally rotate the affected hip.
_____ occurs during resisted forceful abduction of the hip. Adductor groups are injured during:_____.
hip adductor strain (groin strain)
RF: relative weakness and tightness of the adductor muscle groups
must get Xrays of the hip including the adductor tubercle to rule out avulsion.
Provocative test for groin strain
pain with resisted adduction and occasionally with hip flexion. on palpation there is tenderness of the adductor muscle.
The greater trochanteric bursa is located where?
over the greater troch, which is deep to glut medius and glut minimus and TFL.
What is the clinical feature of greater troch bursitis?
night pain and patient is unable to lay on affected side .
Provocative test for greater troch bursitis?
tenderness over the greater troch on palpation or during movement from full extension to flexion.
Rehab program for Greater troch bursitis
IT band stretching
if severe, cane may be needed for support and stability
Strengthening hip abductor muscles
Local CSI injection for resistant cases.
Most common type of hip dislocation
posterior hip dislocation - 90%
How does posterior hip dislocation occur
possibly in MVC
Hip flexed, adducted, and medially rotated. Knee strikes the dashboard with the fumur in this position driving it posteriorly. Head of femur is covered by capsule but not by bone.
Due to close proximity of _____, it is jeopardized in posterior hip dislocation
___ might be compromised in anterior hip dislocation
____ can occur in 10-20% of patients
sciatic nerve. - may be stretched or compressed in posterior hip dislocation.
Femoral nerve compromise
avascular necrosis (in 80% of patients, artery to femoral head lies in ligamentum capitis femoris
Clinical presentation of a posteriorly dislocated hip?
hip will be flexed, adducted, and internally rotated. affected leg appears shorter because the dislocated femoral head is higher than the normal side.
Will not be able to abduct the hip. - must get XRs.
THIS IS AN ORTHO EMERGENCY due to potential vascular compromise and sciatic nerve injury
In children aged 2-12, AVN is known as:
Most common cause of AVN in adults?
steroid use and alcohol abuse.
with AVN there is loss of ____ and ___
on hip flexion there will be ____
___ and ___ may be observed with the patients gait.
external and internal rotation of the hip
hip will externally rotate
short swing and stance phase on affected side is observed.
____ is test of choice to catch AVN early. What will be seen?
MRI of both hips. Most sensitive to early changes. Low signal intensity on T1 imaging.
Main objective when trying to treat AVN?
maintain femoral head within the acetabulum while healing and remodeling occurs.
- bracing and casting may help in peds population to retain femoral head in the acetabulum.
Osteotomy of the femoral head and pelvis may be used to treat patients symptomatically and patients are monitored if the disease is not signficantly advanced.
Fixed risk factors for OA of the hip:
Modifiable risk factors:
1 age, sex, race
- 60% of hip fx occur in patients >75 yoa
- females have higher incidence of fx than males
- among females there is a 2-3:1 higher rate of fracture in European Americans than in African Americans.
2. Alcohol and caffeine consumption, smoking, medications (steroids, antipsychotics, benzodiazepines), malnutrition, body weight below 90% of ideal.
VTE occurs in > ___% of unprotected patients undergoing hip surgery
50% - highest during 2nd and 3rd week.
_____ is the most common complication after hip replacement. Incidence?
heterotopic ossification, >50%
Mortality rate of those who survive a hip fracture:
____ after 1 year
_____ after 2 years
____ return to premorbid level of functioning
20-30% after 1 year
40% after 2 years
50% return to baseline
Name the three types of hip fractures
1. intracapsular - neck fractures
Fractures of the femoral neck are classified by ______.
Stage I - incomplete, nondisplaced and occasional valgus angulation
Stage II - Complete, nondisplaced, occasionally unstable.
Stage III - displaced with the hip joint capsule partially intact
Stage IV - displaced with the hip joint capsule completely disrupted
Morbidity associated with the fractures that disrupts blood vessels to the femoral head.
Treatment of femoral neck fractures per garden stage
Garden stage I and II - surgical: pins across the fracture site or a cannulated hip screw. Rehab early with partial or full weight bearing if fixed
Garden stage III and IV - surgical: replacement of femoral head with HA, total hip or bipolar arthroplasty (have a femoral component that articulates by snap-fit into a cup that moves freely within the acetabulum.
rehab by cemented cases - full weight bearing
uncemented -- partial or full
what are total hip precautions
avoid hip flexion greater than 90 degrees
hip adduction past midline
extreme hip internal rotation
____ is the most common type of hip fracture
_____ type of hip fractures are in an area subjected to very high mechanical stresses and is the most difficult stabilize surgically
may be simple, fragmented, or comminuted.
surgical management of subtrochanteric hip fractures:
1. ORIF with blade plate and screws
2. IMN to make an extremely strongfixation throughthe prox femur
What are the two types of femoral neck stress fractures? Treatment?
compression-type fx - more common and generally occur along the inferior neck of the femur (more stable)
- may be treated with bedrest. If no pain at rest, weight bearing to limitation by pain is allowed. If compression type fracture progresses, they may require IR.
transverse - fracture along the superior aspect of the femur neck. These are more unstable and are also termed tension side fractures
- Generally treated with Internal fixation due to high risk of displacement.
Endurance athletes, such as runners and military recruits, are susceptible to _____ fractures
proximal femur stress fractures
Clinical presentation of femoral neck stress fracture
groin pain made worse with activities of daily living. There will be pain at extremes IR and ER.
If XR negative in femoral neck stress fracture ____ should be ordered. May be positive _____ after onset of symptoms
bonescan; 2-8 days
______ is an injury to the epiphyseal growth plate at the head of the femur causing displacement of the plate.
Slipped capital femoral epiphysis (SCFE)
Most common age of incidence of SCFE is ___
Injury may be associated with direct ____
direct hip trauma
SCFE is classified base on:
percentages of degree of slippage
Grade I 50%
SCFE clinical features:
associated with ____ gait
____ is limited
____ occurs on hip flexion
____ and ____ occur in the acute phase
spasms and synovitis
Treatment of SCFE
immediate cessation of weight bearing
surgical stabilization is required
in patients with SCFE should also test for: 5
1. growth hormone deficiency
5. multiple endocrine neoplasia (MEN syndromes)
____ generally occur with a forceful hamstring contracture with the knee in extension and hip in flexion.
ischial tuberostiy avulsion fracture
the origin of the hamstring is pulled away from the ischial tuberosity. must be differentiated from ischial bursitis
Ischial bursitis (also known as weaver's bottom) is of insidious onset and is more progressive in presentation
Ischial tuberosity avulsion fractures will present as. Will be reproduction of pain at:
TTP over the ischial tuberosity of sudden onset
reproduction or increased pain on straight leg raise
_____ is caused by forceful contraction with the hip extended and knee flexed. Muscle?
If ____ nerve involved, parasthesias may also be present
ASIS avulsion fracture - sartorius
lateral femoral cutaneous nerve - at anterolateral thigh
______ may be caused by forceful kicking and contraction of the quadriceps. Muscle?
Pain reproduced how?
AIIS avulsion fracture.
rectus femoris muscle
acute onset pain at AIIS or groin pain. Pain will be produced with quadriceps contraction, hip flexion, or hip extension
_____ is an inflammatory condition of the joint of the pubic rami. Is often caused by:
overuse of the adductors.
Clinical features of osteitis pubis:
Presents as pain where?
Normal ambulation may produce:
Pain will be produced on _____
Pain can be elicited in ____ with one leg hopping
- pubic symphysis or groin pain which may radiate into the thigh
- popping in the pubic region
- resisted adduction
- the groin or pubic area with one-legged hopping.
treatment of osteitis pubis:
2 CSI injection may be required in resistant cases
3. stretching and strengthening may proceed after reduction in pain
4. surgery for arthrodesis may be required in severe cases.
____ is the formation of heterotopic ossification within the muscle . How?
Ossification occurs within an area of muscle formed from an encapsulated blood secondary to a hematoma. It usually is the result of repeated trauma to that area of muscle or can be due to a direct blow to the hip.
What exacerbates the process of myositis ossificans?
ultrasound, heat, massage, or repeated trauma at the onset of myositis ossificans can exacerbate the process
In myositis ossificans, initially radiographs will show ____. within ____ calcific flocculations can develop. Ossification can be seen between ______.
soft tissue mass