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Semester 2 - MSK > 10. Disorders of the hip > Flashcards

10. Disorders of the hip Flashcards

1
Q

What is the most common disease affecting synovial joints?

A

Osteoarthritis.

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2
Q

What is osteoarthritis?

A

a degenerative disorder arising from the breakdown of articular hyaline cartilage. It is also defined clinically as
a clinical syndrome comprising joint pain accompanied by functional limitation and reduced Quality of Life. OA is a chronic disease of the musculoskeletal system without systemic involvement (i.e. no involvement of eyes, skin, etc) and is non-inflammatory

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3
Q

What are the most common joints affected by osteoarthritis?

A

hips, knees, cervical spine, lumbar spine and small joints of the hands.

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4
Q

What is ankylosis and is it seen in OA?

A

Bony fusion across a joint, rarely seen in OA.

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5
Q

What is primary and secondary osteoarthritis?

A

Primary: unknown cause
Secondary: known precipitating cause

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6
Q

What are the risk factors for primary OA?

A
  • Age
  • Female sex
  • Ethnicity (e.g. increased risk in African-American, American Indian or Hispanic women compared with Caucasian Americans)
  • Genetics (OA runs in families)
  • Nutrition e.g. consumption of a diet rich in Vitamins C and E (antioxidants) may provide some protection against OA
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7
Q

Give examples of causes of secondary osteoarthritis.

A
  • Obesity
  • Trauma (including sports and occupational risk factors)
  • Malalignment e.g. Developmental dysplasia of the hip
  • Infection e.g. septic arthritis, tuberculosis
  • Inflammatory arthritis e.g. rheumatoid arthritis, ankylosing spondylitis
  • Metabolic disorders affecting the joints e.g. gout
  • Haematological disorder e.g. haemophilia with haemarthrosis (bleeding into joints)
  • Endocrine abnormalities e.g. diabetes with neurovascular impairment, which can lead to chronic malalignment of the articular surfaces (Charcot joint) and secondary osteoarthritis
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8
Q

What are the 3 main symptoms of OA in any joint?

A
  • A deep aching joint pain, exacerbated by use
  • Reduced range of motion and crepitus (grinding)
  • Stiffness during rest (morning stiffness, usually lasting < 1 hour)
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9
Q

What is the general effect of precipitating risk factors on joints?

A

Lead to excessive or uneven loading of the joint. This leads to damage to the hyaline cartilage covering the articular surface

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10
Q

Why does hyaline cartilage swell initially in OA?

A
  • increased numbers of chondrocytes differentiating from chondroprogenitor cells
  • increased proteoglycan synthesis by chondrocytes

Attempt to repair cartilage damage, can last several years

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11
Q

Why is there a loss of joint space over time in OA?

A
  • proteoglycan content falls, causing the cartilage to soften and lose elasticity
  • Microscopically, flaking and fibrillation (vertical clefts) develop along the normally smooth articular surface
  • cartilage becomes eroded down to the subchondral bone, resulting in loss of joint space.
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12
Q

What is the effect of changes in cartilage in OA?

A

surface changes in the cartilage alter the distribution of biomechanical forces and trigger further active changes in the tissues.

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13
Q

How do subchondral bones respond to changes in cartilage surface in OA? How does it manifest in x-rays?

A

The subchondral bone responds with vascular invasion and increased cellularity, becoming thickened and denser at areas of pressure. This process, known as eburnation, manifests as subchondral sclerosis on X-rays

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14
Q

Why might sunchondral bone form bone cysts in OA?

A

The traumatised subchondral bone may also undergo cystic degeneration to form subchondral bone cysts. These are attributable to either osseous necrosis secondary to chronic impaction (pressure), or to the intrusion of synovial fluid

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15
Q

How do osteophytes form in OA?

A

At areas along the articular margin, osseous metaplasia of connective tissue occurs, leading to irregular outgrowth of new bone (osteophytes).

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16
Q

What are the 4 cardinal signs of OA on an X-ray?

A

OA on an X-ray?

  • reduced joint space
  • subchondral sclerosis
  • bone cysts
  • osteophytes
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17
Q

Who are OA of the hip most common in?

A

Males over 40.

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18
Q

What symptoms might be experienced in OA of the hip.

A
  • Joint stiffness (typically occurs getting out of bed and when standing up after sitting down for a long time)
  • Pain in the hip, gluteal and groin regions radiating to the knee (via the obturator nerve)
  • Mechanical pain (pain accentuated by mobilisation or weight-bearing)
  • Crepitus (a grating sound or crunching/crackling sensation on movement of the joint)
  • Reduced mobility e.g. difficulty walking
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19
Q

Which nerve causes radiation of pain in OA of the hip to the knee?

A

Obturator nerve

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20
Q

How is OA of the hip diagnosed?

A

Diagnosed on clinical presentation (symptoms and signs) supported by X-ray changes

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21
Q

What is the only ‘cure’ of OA of the hip?

A

Total hip replacement.

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22
Q

What are some non-pharmacological treatments for OA?

A
  • weight loss (reduce load through joint)
  • walking stick/frame (reduce load through joint)
  • muscle strengthening exercises
  • orthotic footwear (rebalance a misaligned load)
  • activity modification (avoiding activities that precipitate symptoms)
23
Q

What are some pharmacological treatments for OA?

A
  • analgesics (e.g. paracetamol)
  • anti inflammatory (e.g. NSAIDs, COX2 inhibitors)
  • nutritional supplements (e.g. glucosamine and chondroitin sulfate)
  • steroid injections into joint (reduce swelling and stiffness)
  • hyaluronic acid injections (viscosupplementation) (may increase lubrication and possibly promote repair)
24
Q

How is Fractured neck of femur defined?

A

defined as a fracture of the proximal femur, up to 5cm below the lesser trochanter.

25
Q

What are the classification of fractures of the neck of the femur?

A
  • intracapsular

- extracapsular (further divided into intertrochanteric and subtrochanteric)

26
Q

Why is classification of fractures of the neck of femur important?

A

Site of the fracture has implications for the blood supply, and therefore the viability, of the femoral head

27
Q

Which arteries are intracapsular fractures likely to disrupt, what is the implication of this and when is this risk increased?

A

Intracapsular fractures are likely to disrupt the ascending cervical (retinacular) branches of the medial femoral circumflex artery (MFCA). Due to the inability of the Artery of the Ligamentum Teres to sustain the metabolic demand of the femoral head, there is a high risk of avascular necrosis of the bone. This risk is increased if the fracture is displaced.

28
Q

Who are intracapsular fractures more common in and what type of injury usually causes them?

A

More common in the elderly, especially postmenopausal women with osteoporotic bone. They often occur after a minor fall.

29
Q

Who are extracapsular fractures more common in and what type of injury usually causes them?

A

Tend to affect the young and middle-aged population and are usually the result of significant traumatic force e.g. a road traffic collision.

30
Q

Which arteries are extracapsular fractures likely to disrupt?

A

none, With extracapsular fractures, the retinacular arterial supply to the femoral head is likely to remain intact.

31
Q

How is a displaced intracapsular fracture treated and why?

A

Due to the high risk of avascular necrosis, a displaced intracapsular fracture in an older person is usually treated by surgical replacement of the femoral head (either hemiarthroplasty or total hip replacement)

32
Q

What is the difference between hemiarthroplasty and total hip replacement?

A

Hemiarthroplasty: replacement of femoral head only

total hip replacement/arthroplasty: femoral head and acetabular cup

33
Q

What are the prognosis for #NOF?

A

10% one-month mortality, rising to 20% at one year
- mostly due to old age and comorbidities

One year post #NOF:

  • 30% will have a permanent disability
  • 40% will be unable to walk independently
  • 80% will be unable to carry out at least one independent activity of daily living
34
Q

What are the symptoms of NOF?

A
  • Reduced mobility / sudden inability to bear weight on the limb
  • Pain which may be felt in the hip, groin and/or knee
35
Q

If a #NOF is displaced how will the affected leg look on examination, why does this occur and what causes exacerbation of pain?

A

Affected leg is usually shortened, abducted, and externally rotated - The #NOF allows the shaft of the femur to move independently of the hip joint.

Exacerbation of pain on palpation of the greater trochanter and by rotation of the hip

36
Q

Why is the hip shortened in a displaced #NOF?

A

Strong muscles of the thigh pull the distal fragment of the femur upwards. These include rectus femoris, adductor magnus and the hamstring muscles

37
Q

Why is the hip abducted in a displaced #NOF?

A

Strong abductors that attach to the greater trochanter (gluteus medius and minimus) abduct the femur distal to the fracture site.

They also rotate the greater trochanter laterally about the new longitudinal axis of rotation, adding to the external rotation caused by iliopsoas and the short lateral rotators.

38
Q

Why is the hip laterally rotated in a displaced #NOF?

A

Axis of rotation of the femur that normally passes obliquely through the head and down the neck of the femur, shifts to pass through the greater trochanter and vertically down the long axis of the femoral shaft.

The short lateral rotators of the hip contract and laterally (externally) rotate the femoral shaft. The iliopsoas also now acts as a lateral rotator of the femur as it pulls the lesser trochanter anteriorly about the new axis of rotation, so the femoral shaft rotates externally

39
Q

How is dislocation of the hip defined?

A

head of the femur being fully displaced out of the cup-shaped acetabulum of the pelvis

40
Q

What are the 2 causes of hip dislocations?

A

Congenital and traumatic

41
Q

What is subluxation?

A

less than complete displacement

42
Q

Give one example of a condition that causes congenital dislocation of the hip.

A

Developmental dysplasia of the hip (DDH)

43
Q

Who are mostly likely to preset with traumatic hip dislocation?

A

An acute traumatic hip dislocation is a severe injury, most commonly seen in 16 to 40-year-olds involved in high-speed road traffic collisions. It takes a massive amount of force to dislocate a normal hip

44
Q

What are the different types of dislocation and which is most common?

A

Anterior, posterior (90%) and central (life threatening)

45
Q

How might a person dislocate their hip posteriorly?

A

The most common cause is the knee impacting the dashboard during a road traffic collision.

46
Q

How will the affect leg be positioned in a posterior dislocation and what other complication may occur?

A

Affected limb will be shortened and held in a position of flexion, adduction and internal (medial)
rotation.

A sciatic nerve palsy is present in 8-20% of cases.

47
Q

Why do shortening and internal rotation of the limb occur after posterior dislocation of the hip?

A

Femoral head is pushed backwards over the posterior margin of the acetabulum and comes to lie on the lateral surface of the ilium. The head of the femur is then pulled upwards by the strong extensors (gluteus maximus and hamstrings) and adductors of the hip, causing limb shortening.
The anterior fibres of the gluteus medius and minimus pull on the posteriorly displaced greater trochanter and cause the femur to rotate internally

48
Q

How will the affect leg be positioned in an anterior dislocation and what complication may occur?

A

Limb is held in a position of external rotation and abduction with slight flexion.

Femoral nerve palsies can be present but are uncommon.

49
Q

What causes a central dislocation of the femur and this leads to a high risk of what?

A

Head of the femur is driven into the pelvis through the acetabulum. It is always a fracture-dislocation.

High risk of intrapelvic haemorrhage due to disruption of the pelvic venous plexuses

50
Q

Where is the femoral head palpable from in a central dislocation?

A

Palpable on rectal examination

51
Q

How can you remember the actions of the hip rotators?

A

The muscles of the Gluteal Region are all external (lateral) rotators of the hip:

(Gluteus maximus, Piriformis, Obturator internus, Obturator externus, Quadratus femoris, Superior and Inferior Gemelli)

Except Gluteus medius and Gluteus minimus which are internal (medial) rotators of the hip.

52
Q

How do you remember the position of the hamstrings?

A

SemiMembranosus is on the Medial Side of the thigh

SemiTendinosus is on Top of it

53
Q

How do you remember Major branches of the lumbar plexus and their nerve root values?

A

“I get leftovers on Fridays”

I                   Ilioinguinal (L1)
G                 Genitofemoral (L1, L2)
L                  Lateral femoral cutaneous (L2, L3)
O                 Obturator (L2, L3, L4)
F                  Femoral (L2, L3, L4)
54
Q

How do you remember Major branches of the sacral plexus and their root values?

A

“Salmon is so perfectly pink”

S        Superior gluteal (L4, L5, S1)
I         Inferior gluteal (L5, S1, S2)
S        Sciatic (L4, L5, S1, S2, S3)
P        Posterior femoral (S1, S2, S3)
P        Pudendal (S2, S3, S4)

Semester 2 - MSK (35 decks)

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