20: Orthopaedic Hip Conditions Flashcards
Describe the blood supply to the femoral head.
- The profunda femoris artery is the largest branch of the femoral artery.
- Shortly after its origin, it gives off medial (MFCA) and lateral (LFCA) circumflex arteries.
- The MFCA is the major contributor to the femoral head. It gives off two branches.
what is the clinical significance of an intracapsular fracture on femur neck vs an extracapsular fracture?
- intracapsular fracture: blood supply disrupted
- extracapsular fracture: blood supply maintained
what is trochanteric brusitis?
- The trochanteric bursa is a fluid-filled sac sandwiched between hip abductors and IT (iliotibial) band.
- Bursitis is inflammation of this bursa causing swelling.
list causes of trochanteric bursitis
- trauma
- overuse: athletes- often runners, repetitive movements
abnormal movements:
- distant problem: e.g. scoliosis
- local problem: muscle wasting following surgery, total hip replacement, osteoarthritis
trochanteric bursitis clinical presentation and examination cues
- pain: point tenderness, lateral hip
- LOOK: may have scars from previous surgery, may have muscle wasting: gluteals.
- FEEL: tenderness at greater tuberosity
- MOVE: worst pain in active abduction
trochanteric bursitis investigations
- history and exam
- x-ray: may be normal, can show OA, THR, spine abnormalities
- MRI: shows soft tissues and fluid
- US: can be therapeutic as well as dagnostic . guided injection
trochanteric bursitis treatment
- NSAIDs
- relative rest/activity modification
- phsyio
- corticosteroid injection
- surgery: buresctomy, rarely required
what is avascular necrosis?
death of bone due to loss of blood supply
avascular necrosis risk factors
- trauma
- idiopathic
- hypercoaguable states
- steroids
- sickle cell disease
- lymphoma
- leukaemia
- Caisson’s disease
- alcoholism
what is the final common pathway in avascular necrosis?
intravascular coagulation
avascular necrosis symptoms and signs
symptoms:
- insidious onset of groin pain
- pain with stairs, walking uphill and impact activities
- limp
Examination signs:
- can be largely normal
- may replicate early arthritis: reduced ROM, stiff joint
avascular necrosis investigations
- history and exam
- x-ray
- MRI: 99% sensitive and specific, will identify earliest changes
avascular necrosis treatment
non-operative and operative
Non-operative:
- reduce weight-bearing (crutches)
- NSAIDs
- Bisphosphonates in early AVN (controversial)
- anticoagulants
- physio
Surgical:
- restore blood supply: core decompression +/- vascularised graft
- move the lesion away from the weight-bearing area > rotational osteotomy
- total hip replacement
Describe Femoroacetabular Impingement (FAI)
- results in impingement of femoral neck against anterior edge of acetabulum
- broadly divided into two categories: Cam lesion, Pincer
describe FAI - Cam lesion
- femoral based impingement
- excess bone leading to decreased head to neck ratio and aspherical head of femur.
- abutment of lesion on edge of acetabulum
- usually in young athletic males
Describe an FAI - Pincer
- acetabulum-based impingement
- usually in active females
- abnormal acetabulum leading to: anterosuperior acetabular rim overhange and acetabular protrusion.
- Abutment of lesion on edge of acetabulum
Femoroacetabular Impingement (FAI) associated injuries
- labral degeneration and tears
- cartilage damage and flap tears
- secondary hip osteoarthritis
Femoroacetabular Impingement (FAI) presentation
- groin pain: worse with flexion
- mechanical symptoms: block to movement, pain with certain manoeuvres e.g. getting out of chair, squatting, lunging
Femoroacetabular Impingement (FAI) exam clues
- reduced flexion and internal rotation
- positive FADIR test: flexion, adduction, internal rotation
Femoroacetabular Impingement (FAI) treatment
Non-operative:
- activity modification
- NSAIDs
- physio
Operative:
- Arthroscopy: shave down defect, deal with labral tears, resect artic cartilage flaps
- Open surgery: resection, periacetabular oesteotomy, hip arthroplasty: resurfacing or replacement.
list some causes of a labral tear
- FAI
- trauma
- OA
- dysplasia
- collagen diseases e.g. Ehlers-Danlos
labral tear presentation and exam clues
Presentation:
- groin or hip pain
- snapping sensation
- jamming or locking
Exam:
- can be normal
- positive FABER test: flexion, abduction, external rotation
labral tear investigations
- history and exam
- x-ray: OA, dysplasia
- MRI arthrogram: 92% sensitive
- diagnostic injection with local anaesthetic
labral tear treatment
non-operative:
- activity modification
- NSAIDs
- physio
- injection of steroids
Operative:
- arthroscopy: repair, resection
