Chapter 37- the hip Flashcards
Where does buttock pain localize the pathology to?
Suggests spinal origin
Stiffness and deformity of the hip transfers movement to the spine, which with time will cause…..
Backache
What in the hip joint may cause a limp?
mostly due to pain
also be due to shortening
stiffness or weakness of the abductors
What childhood problems affect the hip and should be asked about on history?
Congenital dislocation of the hip
Perthes
Sufe- slipped upper femoral epiphyses
Infection
Describe the short limb gait
The shoulder on the affected side ‘dips’ relative to the unaffected side as if stepping into a hole
Describe the antalgic gait
Time spent on the painful side is shorter than the unaffected side
Describe the stiff hip gait
The affected side swings through by rotation of trunk over the unaffected hip
Describe the trendelenberg gait
Due to abductor weakness, the trunk veers laterally over the affected hip in an attempt to lift the pelvis or at least keep it level so that the opposite leg can swing through and to maintain balance during the single leg phase
How do you measure the true length of the legs
- Place legs in equal add or abduction so that the iliac crests of the pelvis is perpendicular to the long axis
- Measure the distance from ASIS to medial malleoli
How do you measure the apparent length of legs
Place both legs with ankles together so that they are in line with the trunk
Measure the distance from the xiphisternum to the medial malleoli
What may cause apparent shortening and lengthening of the legs?
- Flexion and adduction will give the impression of shortening
- Abduction of the hip will create lengthening
What is the pathology in hip dysplasia?
The acetabulum fails to develop properly during foetal development resulting in a shallow acetabulum which cannot contain the femoral head
How may hip dysplasia present
- Congenital dislocation of the hip as a neonate
- Developmental degeneration of the hip as a young adult
When does pain develop in hip dysplasia
Pain only develops when the articular surface breaks down, usually in late 20s or early 30s –> osteoarthritic hip
What is usually the prognosis of hip dysplasia
Frequently require joint replacement surgery at a young age
What is the natural history of septic arthritis of the hip
Once the infection has healed, there will be varying degrees of articular cartilage or subcondral bone damage
With load bearing activities the articular cartilage wears out resulting in secondary osteoarthrosis
What is the surgical management of septic arthritis/ infection of the hip?
- Replacement surgery is optimal
- arthrodesis in joints previously infected
- TB arthritis, joint replacement may be performed if the condition has healed
What age group does Perthes disease affect?
-5-10 year old age group
What age group does slipped upper femoral epiphyses affect?
-10-17 years old
What is the pathology in slipped upper femoral epiphses?
The displaced position of the femoral head on the neck and the shaft results in abnormal joint articulation, impingement of non-articular parts with the acetabulum and premature joint wear-out
What is avascular necrosis of the hip?
death or necrosis of a conical segment of the femoral head with subsequent collapse and deformation
What are causes of avascular necrosis of the hip?
- Binge drinking of cheap wine
- Systemic steroid therapy
- Post traumatic (Dislocation of femoral head, fractures of the femoral neck)
- Decompression sickness- Caisson’s disease
- Sickle cell disease
- Gaucher’s disease
What is the clinical presentation of avascular necrosis of the hip
- Knee pain that subsequently localises in the hip
- Same symptoms and signs for arthritis of the hip
- Hip pain severe initially and as the disease process progresses, it becomes less painful
- When the acetabulum becomes involved, it follows the same course as osteoarthritis
Describe the Xray changes seen in avascular necrosis of the hip
- Only femoral head is involved
- Wedge shaped portion of the head appears denser and its articular surface may be collapsed or depressed relative to the rest of the articular surface
- Head may not be spherical and the crescent sign ay be present especially on the lat view
- The acetabulum is unaffected but the deformed head will eventually damage it
Which is the most accurate method of identifying avascular necrosis of the hip and defining the degree of involvement
MRI
What are the options for treatment of avascular necrosis of the hip
- Treat as osteoarthritis for symptomatic relief
- Core decompression (pain relief)
- Osteotomy
- Arthroplasty (Hemiarthroplasty or total replacement arthroplasty)
- Arthrodesis- if opposite side uninvolved and spine is normal
What is the differential for pain over the greater trochanter
- Frictional bursitis
- tendinitis of the gluteal muscles
What is the typical pain associated with trochanteric bursitis?
Pain over the greater trochanter which is prominent at night, especially when lying on the affected side or if leg adducts
What are the examination findings associated with trochanteric bursitis
- tenderness to direct pressure over greater trochanter
- Pain on adduction of effected leg
What is the treatment of trochanteric bursitis?
Local anaesthetic and steroid injection to the affected area.
Repeat x 1 after 2-4 weeks if necessary (use a long spine needle)
What is snapping hip?
Usually found in teens and young adults. Caused by tight band in iliotibial band or tensor fascia femoris at trochanter level which snaps over the trochanter on flexion and extension of hip. Relieved by flexing and extending, in abduction
What is the treatment of iliotibial band
Benign condition and is seldom painful. If it interferes with activities the tight part of the band can be released surgically
Where does synovial chondromatosis or osteochondromatosis usually occur
Occurs often in large synovial joints like the knee, hip and the shoulder
How does synovial chondromatosis or osteochondromatosis present?
Presents with catching, locking or giving way accompanied by pain and recurrent swelling
What can be seen on radiology in synovial chondromatosis or osteochondromatosis
- multiple loose bodies
- often co-existing osteoarthritis
Treatment of synovial chondromatosis or osteochondromatosis
- remove loose bodies if the giving way or locking is troublesome
- management of the underlying arthritis
