11d. Hip Flashcards
what is the acetabulum
the socket of the hip bone, into which the head of the femur fits.
what should you consider as ddx for hip pain?
general:
- septic arthritis
- osteoarthritis
- fracture could be fragility/pathological w/o trauma
adult:
Trochanteric bursitis
Acetabular labral tears
Paediatrics:
Developmental dysplasia
SUFE
Perthes
Transient synovitis
what is greater trochanteric pain syndrome/troachentric bursitis
GTPS used to be referred to as trochanteric bursitis- however current research suggests that pain is more commonly caused by injury to the soft tissues (muscles and tendons) in these regions, rather than by inflammation of the trochanteric bursa.
cause trochanteric bursitis/GTPS
minor injury or inflammation
Excessive weight-bearing exercise- e.g. walking or running.
Prolonged standing on one leg, and/or sitting with crossed legs.
Inactivity- leading to weakness and reduced flexibility of the gluteal muscles.
Obesity
presentation greater trochaenteric bursitis/GTPS
Chronic, intermittent, lateral hip/thigh/buttock pain exacerbated by:
Weight bearing activity
Lying on affected side
Some patients report radiation of pain to the knee.
o/e trochanteric bursitis
look:
- positive trendelenberg gait
- Pain within 30 seconds of standing of one leg
feel:
- Pain on palpation of the greater trochanter
move:
- Pain on movement of hip in directions that cause increased tension of the gluteus medius and minimus tendons- i.e. FABER test (flexion, abduction, and external rotation)
invetsigation ?trochanteric bursitis/GTPS
GTPS is generally a clinical diagnosis; made on the basis of history, and examination findings.
Ultrasound and MRI can be used to confirm the diagnosis.
Positive findings on ultrasound/MRI imaging include:
Inflammation of the trochanteric bursa
Tendinopathic echogenic findings
Tears of the gluteus medius or minimus muscles and/or tendons.
Patients in whom the diagnosis is unclear will often undergo a hip X-ray. This is to exclude the common differentials of GTPS e.g. hip osteoarthritis.
management trochanteric bursitis/GTPS
self-limiting
Reduce compressive forces across greater trochanter and gluteal tendons
Weight loss
Avoidance of positions of excessive hip adduction (i.e. Crossing legs, ITB stretching exercises).
Strengthen gluteal muscles (i.e. The hip abductors)
Physiotherapy
Peri-trochanteric corticosteroid injection
Generally reserved for cases where other conservative treatment modalities have failed, or in the short-term to enable physiotherapy (which has been shown to improve the long-term outlook).
Surgical intervention is reserved for the small portion of cases in which conservative management is unsuccessful
triad of symptoms for acetabular labral tear
hip pain, locking and instability.
invetsigations for acetabular labral tear
MR-arthrogram
Diagnostic laparoscopy is the gold standard definitive investigation.
management of acetabular labral tears
- physio and NSAIDS/intra-articualr steroid injections
+ if >4w and positive on imaging –> hip arthroscopy
when should you refer a paeds pt with hip pain for same day assessment? when can children be monitored just with primary care with ?transient synovitis
FEVER
If a child with a limp/hip pain has a fever they should be referred for same-day assessment, even if a diagnosis of transient synovitis is suspected
children may be monitored in primary care (with a presumptive diagnosis of transient synovitis) ‘If the child is aged 3–9 years, well, afebrile, mobile but limping, and has had the symptoms for less than 72 hours
what is the main thing you need to rule out in a child with hip pain/limp?
septic arthritis
what is perthes disease
Perthes disease involves disruption of blood flow to the femoral head, causing avascular necrosis of the bone. This affects the epiphysis of the femur, which is the bone distal to the growth plate (physis).
Over time there is revascularisation or neovascularisation and healing of the femoral head. There is remodelling of the bone as it heals
Presentation transient synovitis
limp/refusal to weight bear
groin or hip pain
a low-grade fever is present in a minority of patients
after respiratory illness
