pathologies related to pelvis & hip I - exam 2

Question 1

what is a pathological hip fracture?

Answer 1

proximal femur fx, particularly of the neck, due to disease

Question 2

causes of a pathological hip fx?

Answer 2

conditions with compromised bone
- osteoporosis and osteomalacia
- osteogenesis imperfecta (congenital and inherited brittle bone disease - peds)
- paget’s disease (chronic bone disorder w abnormal bone turnover that results in bigger but softer bones)
- tumors
may or may not involve a fall (break can cause fall or fall can cause break)

Question 3

prevalence of pathological hip fx

Answer 3

mostly older
european americans

Question 4

pathogenesis of pathological hip fx

Answer 4

gradual weakening of bone resulting in fx

Question 5

S&S of pathological hip fx

Answer 5

fx S&S
painful snap and possible giving way
groin and possible anteromedial thigh P! to knee and lateral hip
– increased: WB
– decreased: non WB

Question 6

what would you observe in someone with a pathological hip fx

Answer 6

shortened and excessively externally rotated LE due to displacement and pull of ERs
antalgic (painful) and asymmetrical gait

Question 7

pathological hip fx:
- ROM:
- Special tests:

Answer 7

• several but particularly IR limitations
• (+) patellar-pubic percussion

possible sign of the buttock

Question 8

what is the sign of the buttock? causes?

Answer 8

collection of signs indicating a serious pathology

fx
tumor
infection
hematoma

Question 9

what would you find in your interview & scan for sign of the buttock?
- Hx
- Observation
- ROM
- Resisted

Answer 9

• possible cancer, infection or fx S&S
• gluteal swelling - one larger than the other
• hip flx limitation the same no matter knee position with empty ends feels. same degree of trunk flexion limitation in relation to femur and trunk position
• weak and painful glutes

Question 10

what is the referral for someone with the sign of the buttock?

Answer 10

urgent referral to MD but emergent if fx due to possible displacement and/or vascular compromise

Question 11

what can result from a sedentary situation in someone with a pathological hip fx?

Answer 11

significant morbidity, mortality and health issues

Question 12

what referral for pathological hip fx?

Answer 12

immobilize w emergent referral due to possible displacement and potential vascular compromise

Question 13

what is osteonecrosis and where is it located?

Answer 13

avascular necrosis (AVN) of the femoral head

Question 14

true or false. osteonecrosis may be bilateral in 60% of the cases

Answer 14

true

Question 15

who is more likely to get osteonecrosis?

Answer 15

older individuals

Question 16

what is the cause of osteonecrosis?

Answer 16

insufficient arterial supply to femoral head associated with trauma
- fx/dislocation
- slipped femoral epiphysis/growth plate

Question 17

where does the blood supply for the femoral head come from?

Answer 17

medial epiphyseal a. to supply head of femur
medial and lateral circumflex artery

Question 18

what intracapsular ligament contains the blood supply of the femur head?

Answer 18

ligamentum teres
- attachments: acetabulum –> fovea of femoral head

Question 19

what are secondary associations that could exist with osteonecrosis?

Answer 19

vascular abnormalities
toxicity (radiation, smoking, alcoholism)
sickle cell disease with a shortage of healthy oxygen carrying RBCs
chronic corticosteroid and oral contraceptive use
bone marrow pathology
metabolic syndrome (obesity, diabetes)

Question 20

pathogenesis of osteonecrosis?

Answer 20

ischemia leading to death of bony tissue
rapid progression to age related joint changes
may involve labral tears

Question 21

S&S of osteonecrosis
Hx -
observation -

Answer 21

groin and possibly anteromedial thigh P! and to the knee
– suddenly w trauma (possible sign of buttock)
– intermittent but worsening with gradually and unknown onset and occurring at rest due to ischemia
age related joint change – corticosteroid use

antalgic and asymmetrical gait

Question 22

what referral for osteonecrosis?

Answer 22

urgent referral to MD

Question 23

if a patient with osteonecrosis gets referred to PT, how do you proceed?

Answer 23

with caution!
gait training with an assistive device to protect the femur
PT directed primarily at protection motion, improving circulation, and for bone and cartilage integrity (similar to age related joint change Rx)

Question 24

if PT doesn’t work well, what may a patient with osteonecrosis end up having to do?

Answer 24

hemi arthroplasty or possible THA

Question 25

what is legg-calve perthes?

Answer 25

coxa plana or flat hip AVN of femoral head in children

Question 26

causes of legg-calve perthes?

Answer 26

trauma exposure to 2nd hand smoke prenatal factors (genetics, endocrine, nutritional, socioeconomic conditions) developmental dysfunction of bone or vasculature

Question 27

who is more likely to get legg-calve perthes?

Answer 27

most common in 5-8 year old caucasian boys

Question 28

how does legg-calve-perthes happen?

Answer 28

impaired vascular supply to epiphyses that changes shape of the femoral head and acetabulum

Question 29

S&S of legg-calve-perthes

Answer 29

vary in magnitude gradual and unknown onset antalgic and asymmetrical gait if painful, groin and possibly anteromedial thigh P! and to the knee -- increased with activity -- decreased with rest possible hip muscle atrophy limited IR and ABD

Question 30

true or false. legg-calve perthes is a short term problem

Answer 30

false long term

Question 31

what referral for legg-calve perthes

Answer 31

urgent

Question 32

if a patient with legg-calve perthes is referred to PT, how do you proceed?

Answer 32

with caution! - gait training with an assistive device to protect the femur - PT directed primarily at protection motion, improving circulation, and for bone and cartilage integrity - periodically, splinted, braced, or casted in an abducted position --> better femoral head contact --> maintain and help better form femoral head in acetabulum as healing can occur --> prone to contractures

Question 33

describe the relationship between legg-calve perthes and age related joint changes

Answer 33

these people will experience age related joint change in early adulthood and 50% will develop age related joint disease by 50 years old

Question 34

most individuals with legg-calve perthes will need ____ and experience ____

Answer 34

corrective surgery and/or early total hip arthroplasty earlier LB and knee P! development in life due to gait dysfunction

Question 35

what is slipped capital epiphysis?

Answer 35

anterior displacement of femoral neck on femoral head adolescent coxa vara MOST significant epiphyseal plate disorder of the LE

Question 36

what is the cause of slipped capital epiphysis?

Answer 36

mostly idiopathic (unknown) association with endocrine and renal disorders and Down syndrome

Question 37

what is the most common cause of slipped capital epiphysis?

Answer 37

hypothyroidism

Question 38

what do risk factors of slipped capital epiphysis create?

Answer 38

increased shear forces across epiphyseal plate

Question 39

what is the most significant risk factor of slipped capital epiphysis? what are the 4 other risk factors?

Answer 39

obesity male rapid growth radiation therapy femoral torsion

Question 40

who is more likely to get slipped capital epiphysis?

Answer 40

most common in early adolescence African American boys higher BMI bilateral (1/3 of patients)

Question 41

how does slipped capital epiphysis happen?

Answer 41

progressive displacement of femoral neck relative to the head through the growth plate due to shear forces and/or weakened epiphyseal plate

Question 42

symptoms of slipped capital epiphysis

Answer 42

more likely gradual and unknown onset than trauma, but trauma may seem benign like rolling in bed groin and possibly anteromedial thigh P! and to the knee

Question 43

what would you observe in someone with slipped capital epiphysis? ROM?

Answer 43

antalgic and asymmetrical ER hip muscle atrophy if long standing ROM: - limited IR, abd, flex - obligatory ER during flexion possible sign of the buttock

Question 44

if a peri-adolescent patient shows up to your clinic with atraumatic hip pain, particularly if associated with antalgic gait, what do you need to always consider?

Answer 44

slipped capital epiphysis

Question 45

slipped capital epiphysis referral

Answer 45

urgent

Question 46

what do you do for your patient with slipped capital epiphysis if the slip is < 1 cm

Answer 46

splinted in an abducted position with non-WBing post splinting: gait training with an assistive device is often necessary to protect the femoral neck PT directed primarily at protected motion, improving circulation and for bone and cartilage integrity * avoid AVN or chondrolysis (rapid loss of articular cartilage)

Question 47

what is needed for a patient with slipped capital epiphysis if the slip is > 1 cm

Answer 47

surgery

Question 48

what are vascular insufficiency S&S?

Answer 48

coldness blueish or pale discoloration diminished pulses impaired capillary refill with nail bed recovery shiny skin hair loss

Question 49

referral for vascular insufficiency

Answer 49

emergency