Clinical anatomy of the pelvis, hip and femur

Question 1

Answer 1

Question 2

How do pelvic fractures occur in a) young people b) old people?

Answer 2

a) High energy collisions e.g. RTA
b) low energy secondary to osteoporosis

Question 3

If the pelvic ring is disrupted at one point, what is invariably the result?

Answer 3

Disruption at another point e.g. the sacroiliac joint (can’t break a polo mint in only one place)

Question 4

What blood vessels are at risk in a high-energy pelvic fracture?

Answer 4

Branches of the internal iliac, presacral venous plexus

Question 5

How are minimally displaced (usually low energy secondary to osteoporosis) pelvic fractures managed?

Answer 5

Generally stable and settle with conservative measures

Question 6

What kind of fracture does the image show? What is the main complication of this?

Answer 6

“Open book” anteroposterior compression fracture. Massive haemorrhage into the pelvis

Question 7

What are the names of the three ligaments which reinforce the femoral head?

Answer 7

Ileofemoral, pubofemoral, ischiofemoral

Question 8

What is the blood supply to the femoral head?

Answer 8

Medial and lateral branches of the femoral circumflex artery

Question 9

What are these muscles, what is their role and where do they insert?

Answer 9

Hip flexors

Insert onto lesser trochanter of femur

Question 10

What is the role of these muscles and what is their common origin?

Answer 10

Adductors of the hip; inferior pubic rami

Question 11

Name the muscles/groups of muscle responsible for

a) Hip abduction
b) Hip extension

Answer 11

a) gluteus minimus and medius, tensor fascia lata
b) gluteus maximus, hamstring muscles (biceps femoris, semimebranosus, semitendinosus)

Question 12

What is the pattern of hip pain and what explains this?

Answer 12

Pain in the groin which may radiate to the knee- common path of the obdurator nerve

Question 13

What two important clinical signs may be seen in hip pathology?

Answer 13

Loss of internal rotation

Weakness of abduction (Trendellenburg)

Question 14

What might avascular necrosis of the femoral head be secondary to?

Answer 14

Alcohol abuse, hyperlipidaemia, thrombophilia, steroids, trauma

Question 15

Where is the broad tendinous insertion of the hip abductors and what pathology is often seen here?

Answer 15

Greater trochanter of the femur

Trochanteric bursitis

Question 16

How would trochanteric bursitis appear on clinical examination?

Answer 16

Tenderness over the affected area, pain on resisted abduction

Question 17

How is trochanteric bursitis treated?

Answer 17

Analgesia, NSAIDs, steroids injections, physiotherapy

Question 18

How are hip (femoral head) fractures classified?

Answer 18

Intra or extra capsular

Question 19

What is the potential risk/complication of an intracapsular fracture of the femoral head?

Answer 19

Avascular necrosis and non-union due to disrupted blood supply.

Question 20

How are a) intracapsular and b) extracapular hip fractures managed?

Answer 20

a) usually hip replacement- either hemiarthroplasty or THR
b) Dynamic hip screw, retaining the patient’s native hip joint

Question 21

What is a developmental dysplasia of the hip?

Answer 21

Aberrant development of the hip due to abnormal relationship of the femoral head to the acetabulum

Question 22

What are the risk factors for DDH?

Answer 22

Being female, FH, breech birth, Down Syndrome, first-borns

Question 23

What signs may be seen in examination of a neonate with a DDH?

Answer 23

Shortening, asymmetric skin creases, “click or clunk”, positive Olotani/Barlow tests

Question 24

Why is X-ray not a useful investigation in newborns with a suspected DDH? What is the alternative investigation?

Answer 24

Femoral head epiphysis is unossified until around 4-6 months

Question 25

How are children with unstable/dislocated hips managed if diagnosed:

a) up to 4-6 months old
b) 6-18 months old
c) after 18 months

Answer 25

a) Pavlik harness
b) closed reduction under anaesthetic followed by spica cast
c) open reduction followed by spica cast

Question 26

What is Perthe’s disease?

Answer 26

Idiopathic avascular necrosis of the femoral head, usually seen in active young boys with short stature

Question 27

How does Perthe’s present?

Answer 27

Pain and a limp

Loss of internal rotation and abduction, positive Trendellenburg test

Question 28

How is Perthe’s managed?

Answer 28

Avoidance of physical activity, bracing

Question 29

What is a SUFE?

Answer 29

Slipped upper femoral epiphysis- the epiphysis slips inferiorly in relation to the femoral neck

Question 30

What “type” of patient does a SUFE occur in?

Answer 30

Usually obese boys

Question 31

How does SUFE present and what may be the pitfall?

Answer 31

Pain in groin. May present exclusively as pain in knee

Question 32

What is the predominant sign in SUFE?

Answer 32

Loss of internal rotation

Question 33

How is SUFE treated?

Answer 33

Urgent surgery to pin the femoral head and prevent further slippage

Question 34

How is AVN managed a) early and b) late, where the femoral head has collapsed?

Answer 34

a) drilling to decompress bone
b) THR

Question 35

When is hip replacement indicated for OA?

Answer 35

Pain and severe disability (usually with corresponding X-ray changes) where conservative management has failed

Question 36

What is Paget’s disease?

Answer 36

Deformed, thickened, brittle bone which is prone to fracture

Question 37

How is Paget’s treated?

Answer 37

Bisphosphonates

Question 38

What are the possible causes of a femoral shaft fracture?

Answer 38

High energy collision

Stress fractures due to osteoporosis, Paget’s disease, metastatic disease and paradoxically due to bisphosphate use

Question 39

What are the possible complications of displaced femoral fractures?

Answer 39

Loss of substantial blood volume

Fat emboli

Question 40

How is femoral fracture managed?

Answer 40

Usually closed reduction with an intramedullary nail