quiz - hip Flashcards
(28 cards)
range of motion
-Abduction = 45 deg.
-Adduction = 20 deg.
-Flexion = 90-135 deg.
-Internal rotation = 20-25 deg.
-External rotation= 35-45 deg.
special tests
-Thomas Test for Flexion Contracture- hug one knee -> if the stright extended leg bends -> iliopsoas is tight; flexion contracture of the hip flexors
-if it abducts iliotibial band is tight (J sign/stroke sign)
-Trendelenburg Test
leg length discrepancy
-True Leg Length Discrepancy - ASIS to medial malleolus (Tibial vs Femoral)
-Apparent Leg Length Discrepancy - Umbilicus to medial malleolus (Pelvic Obliquity, adduction or flexion deformity)
A 66 y/o female presents to the orthopedic clinic complaining of right sided lateral hip x 5 months. She denies any injury. She complains of pain with lying on that side, with stairs and going from a seated to standing position. On occasion she has knee pain as well. Her medical history is positive for obesity (5’4”, 220lbs), DM and hypercholesterolemia. On P/E she has pain to palpation laterally on her hip and distally to her knee. She has a leg length discrepancy where she is short on the right side. She denies groin pain.
later hip pain
greater trochanteric pain syndrome
PAIN WITH GOING UP THE STAIRS OR FROM SEATED TO STANDING = greater trochanteric pain syndrome
greater trochanteric pain syndrome RF and S&S
-MCC of lateral hip pain in adults
-Gluteus medius and minimus tendinopathy -> Hip abduction & pelvic stability with stairs, squatting, running
-? Bursa involvement (goes hand and hand with tendonitis usually)
risk factors:
-F > M
-Age >50
-Obesity
-Knee, back and foot pain
-Hip osteoarthritis
-Leg length discrepancy
S&S:
-Lateral pain and tenderness
-can go down to mid thigh
-Decrease strength with hip abduction
-Positive FABER or PATRICK Test (flexion-abduction-external rotation)
-FABER (flexion-abduction-external rotation) test, or Patrick test:
-flexion of hip, with abduction and external rotation of the hip
-Force is applied down the bent knee and the opposite pelvis.
-pt with groin pain -> reproduction of this pain is suggestive of underlying hip joint disease
-pt with lateral hip pain -> lateral pain will suggest GTPS
-pt with buttock pain -> dx of sacroiliac joint disease will be supported
FABER test
what position
groin pain vs lateral pain vs buttock pain
- flexion of the hip, with abduction and external rotation of the hip.
- Force is applied down the bent knee and the opposite pelvis
- groin pain: suggestive of underlying hip joint disease
- lateral pain = GTPS
-buttock pain = sacroiliac joint disease
greater trochanteric pain syndrome dx and tx
DX:
-Clinical
-X-Ray to R/O calcium deposit other abnormality
-Ultrasound
-MRI
Treatment: conservative
-Activity and exercise modification
-NSAIDs (oral &/or topical)
-Tylenol
-Glute strengthening
-Physical therapy
-Corticosteroid injection (never first line)
-PRP injection
A 52 y.o. Male presents to the clinic complaining of left groin pain x years that is progressively worsening. He has pain with weightbearing activities and pain with putting his shoes & socks on. He states when he was a teenager he dislocated his hip in a waverunner accident. It was reduced at the time and he was pain free until 2-3 years ago. He has never been seen by anyone else because of this.
X-rays show increased density of the femoral head.
May show crescent sign (subchondral collapse)
Flattening or narrowing in advanced stage
-avascular necorsis
-loss of blood supply to femoral head years ago in the dislocation
AVascular Necrosis of femoral head
etiology and stages
Definition: Necrosis of weight bearing surface of femoral head
etiology:
-Post-traumatic: Subcapital or Femoral neck fx, Hip dislocation, SCFE
-Atraumatic: ETOH abuse, Coagulopathy, -Corticosteroid use, Gout, radiation
stages:
-Stage 1 = normal x-rays but MRI reveals the dead bone.
-Stage 2 = can be seen on regular x-ray but there is no collapse of the femoral head.
-Stage 3 = signs of collapse (called a crescent sign) on x-ray.
-Stage 4 = collapse on x-ray and signs of cartilage damage (osteoarthritis)
AVascular Necrosis dx , pe/presentation, and tx
Dx: MRI is most specific
-Able to detect early changes not seen on x-rays
P/E:
-30-50 y.o M> F
-Often B/L*
-Antalgic gait
-Pain worsens with weight bearing & activities/improves with REST
-Painful ROM initially / Limited ROM in advanced stages
Tx:
-Limit WB
-NSAID’s
-Physical Therapy
-Core decompression to relieve pressure in dead bone
-Limit ETOH use
-Quit smoking
-Arthroplasty
Hip dislocations
etiology, pe imaging, tx, complication
etiology:
-Trauma MCC (MVA, Fall) Ortho Emergency
-POSTERIOR MC (90%)
-Associated conditions = hip, pelvic, knee fx
P/E:
-Posterior: Hip pain with leg shortened, INTERNALLY rotated & adducted.
-Anterior: may be externally rotated & abducted.
Imaging:
-Posterior: femoral head appears smaller than contralateral side & femur appears adducted.
-Anterior: femoral head appears larger & femur appears abducted
Tx: Closed Reduction under sedation
-> Only if no hip fracture
Complications:
-AVN up to 13%. Decreased with reduction <6hrs.
-Sciatic nerve injury- foot drop
-DVT
-Femoral nerve injury (Anterior)- numbness, tingling
hip fractures etiology, PE, RF
etiology:
-elderly: Minor or indirect trauma
-young: High impact trauma
-Pathologic? Malignancy or bisphosphonate use
-MC = elderly osteoporotic women with decreased bone mass.
P/E:
-Hip, thigh or groin pain.
-Unable to straight leg raise (SLR)
-Unable to weight bare (WB)
-Leg is shortened, abducted, and EXTERNALLY rotated
Risk Factors:
-Older patients
-Falls
-Osteoporosis
-F > M
-Low body weight
-Low socioeconomic status
-Cardiovascular disease
-Endocrine disorders (DM, Hyperthyroidism)
-Medications (opioids, benzodiazepines, antidepressants)
-30-60% of community dwelling older adults fall each year
-PREVENTION IS KEY
3 types of hip fractures
staging name
1) Femoral neck fractures
-proximal to the trochanters
-higher incidence of AVN
-STAGE femoral neck WITH GARDEN GRADE- dont need to know it tho
2) Intertrochanteric hip fractures
-between the greater and lesser trochanters
-STAGE INTERTROCHANTERIC FX WITH EVANS CLASSIFICATION
3) Subtrochanteric hip fractures: distal to the trochanters
hip fractures dx and tx, complications
Dx:
-X-ray: AP/ Cross table lateral
-MRI: gold-standard
-CT: helpful in determining displacement and for pre-op planning
-Bone scan: helpful in ruling out occult fracture
-Duplex U/S to r/o DVT if delayed presentation
Tx:
-Operative (99%): ORIF (IM Nail!, Percutaneous pinning, THR, Hip hemiarthroplasty)
-Stable trochanteric fractures (Perc pinning, IM Nail, Dynamic hip screw- less common)
-Non-Operative: Generally reserved for HIGH-risk patients
Complications:
-Infection
-Thromboembolism
-Bleeding
-One year mortality rates 12-37%
pelvic insufficiency fracture: presentation, rf, tx
presentation: groin pain with no injury
- Low energy mechanism of injury or repetitive stress
-MC involve pubic rami and the sacral ala
RF:
-Older adults
-Osteoporotic bone
-Prior fracture
-Glucocorticoid use
-Smoking
-Low body weight
-Alcohol
-Sx- Hip, groin or low back pain with no trauma or minor fall
-Dx- MRI is gold standard - 96% specific
Tx:
= Important for education - get pt up and moving and don’t get them to decompensate (kinda same tx as low back pain)
-Pain control
-Early mobilization
-WB as tolerated vs Non-WB
-Physical therapy
-23% mortality rate at 1 year
insufficient? make it sufficient with exercise
pelvic fracture
Mechanism: High impact (MVA, Falls). Low Impact (elderly )
presentation: VISCERAL TRAUMA - bladder, bowel, neuro
-Intra-abdominal bleeding in 40% of cases.
-Soft tissue injuries: Perineum (rectum or vagina) lacerations. Perineal ecchymosis.
-Neurologic injuries: L5-S1 nerve roots. Sacral nerve root injuries may result in bowel or bladder incontinence
Dx:
-X-rays & CT scan
-Labs to monitor blood loss, Type & screen
Tx:
-Nonsurgical: WBAT, with PT & early mobilization
-Mechanical Stabilization
-External compression with pelvic binder to stabilize
-Skeletal traction or skeletal external fixation for vertical shear pelvic ring fracture
-stabilize -> then surgery
-Surgical: For severe fractures. Pelvic binder for increased bleeding
77 y.o. Female presents to the orthopedic clinic complaining of right sided groin pain x 1 year. She states she has no pain in the morning when she wakes, but states the pain is worsened throughout the day and the pain is worse at night. The pain radiates into her knee at times. She complains of difficulty putting her shoes and socks on. She takes Tylenol and Ibuprofen occasionally which decreases her symptoms somewhat. She saw a general surgeon who ruled out a hernia.
hip osteoarthritis
hip osteoarthritis
Progressive degenerative joint disease: characterized by:
-Loss of articular cartilage
-Remodeling of subchondral bone
-Formation of osteophytes
-The disease process usually involves all tissues that form the synovial (cartilage, bone, synovium, ligaments, muscles, capsule, etc)
-OA is MCC of disability in pts > 65 y/o, affecting all ethnicities and geographic locations
-OA is MC in Women
-Hip is common location for OA
Sx:
-Insidious onset of pain
- aggravated by motion relieved with rest
-Pain in groin and inner thigh
-Pain may refer to knee
- NIGHT pain and difficulty with: weight bearing, putting on shoes
-May have antalgic gait
-Assessment of ROM is critical
hip osteoarthritis dx and tx
-imaging: X Rays- AP Pelvis/Lateral hip
-Decreased joint space, subchondral space, sclerotic changes
tx:
-EXERCISE & Physical Therapy
-Analgesics,
-NSAIDs
-Intra-articular steroid injections
-Total hip replacement (definitive tx)
Complications of hip replacement:
-Dislocation
-Prosthetic joint infection
-Peri-prosthetic fractures
-Revision surgery
Parents bring a 6 y.o. Caucasian boy into the orthopedic office because he has been limping and complaining of intermittent left leg pain. He has a history of Factor V Leiden Thrombophilia. They know this because mom has been diagnosed with this in the past and felt the need to get their son tested. He has had no clotting events himself. His limp seems to be worse after soccer and at the end of the day.
Legg-calve perthese
- 5-8 yrs old male
painLESS
Legg-Calve-Perthes disease def
risk factor
sx
pe
Def: Idiopathic Avascular Necrosis of the capital femoral epiphysis of the femoral head in children due to ischemia.
Risk Factors:
-3-12 y.o (peak 5-8)
-Boys
-Low birth weight
-Caucasians and Asians
-Coagulopathies & thrombophilias
Signs & Symptoms:
-Acute or insidious hip pain
-PAINLESS limp
P/E:
-Decreased ROM
-Atrophy of muscles
-Antalgic gait (acute)
-Trendelenburg gait (chronic)- weak glut medius
Legg-Calve-Perthes Disease
imaging, tx
Radiographs:
-Early: Increased density & smaller appearance of femoral epiphysis
-Advanced: +CRESCENT sign, flattening of the femoral head, sclerosis
-Bone Scan: Decreased perfusion to femoral head
-MRI: marrow changes
Treatment: Self-limiting with re-vascularization in 2 years
-Non-Surgical: NWB, modification of activities, P.T., NSAIDs
-Surgical: Pelvic osteotomy in more advanced disease or older children (>8y.o)
14 year old African American male presents with his parents complaining of “achy” left groin pain that radiates into his knee. He denies any trauma or recent illness. His medical history is unremarkable aside from being overweight.
On his P/E he walks with a limp and ℅ pain with ambulation. He holds his leg in external rotation while lying flat. His ROM is limited with flexion, IR & abduction.
slipped capital femoral epiphysis
- 12 yr female
- 13.5 yr male during growth spurts
slipped capital femoral epiphysis def, risk factor, sx, pe
Def: Displacement of the femoral epiphysis from the femoral neck through the growth plate. Slips posterior & inferior.
Risk factors:
-8-16y.o. (females mean 12y.o, males mean 13.5y.o). If before puberty think hormonal or systemic disease
-Obese
-African-American
Signs & Symptoms / P/E:
-Dull & achy hip, thigh, knee pain.
-PAINFUL limp. Pain with activities.
-PE:
-EXTERNALLY ROTATED LEG (!!Obligatory External Rotation when you flex the hip!!)
-Limited ROM (IR, Flexion)
