Hip Flashcards
What are some common childhood hip disorders?
- congenital hip dysplasia (CHD)
- leg-calve-perthes disease
- slipped capital femoral 4. epiphysis
septic arthritis
Which gender and age prevalence congenital hip dysplasia?
females
birth-3 months
What causes congenital hip dysplasia?
abnormally lax hip capsule
familial
breech delivery
What are the clinical features of CHD?
- asymmetrical skin folds at buttocks, adductors
- dec hip abduction due to adduction contracture
- shortening of dislocated side
What are two special tests for CDH?
Barlow test
Ortolani click test
What kind of harness is used for CHD and what does it do?
pavlik harness
holds hip in flexion and abduction to allow hip joint to form
How long is pavlik harness used and what is the outcome?
6-12 wks 23-24 hrs/day (aka take it off when changing diapers/bathing only)
good outcome when started early
After 3 months, how is CHD treated?
may need adductor tenotomy (release adductor tendon origin)
After 5 years, how is CHD treated?
ORIF and brace in ABD/flexion
Male to female ratio for legg-calve-perthes disease?
5:1
What percent of legg-calve-perthes disease is bilateral?
15%
What is legg-calve-perthes disease?
self limiting idiopathic osteonecrosis of the femoral head
What is the bone age associated with legg-calve-perthes disease?
1-3 years behind true age
What age children tend to have legg-calve-perhes disease?
average is 7 yo
4-13 years
Describe the disease process of legg-calve-perthes disease.
- initial loss of blood supply to capital femoral epiphysis
- revascularization and resumption of ossification
- subchondral fx and second ischemic episode
How does the femoral head appear with LCPD on X-ray?
smaller femoral head initially
later femoral head destruction (may see crescent sign of subchondral collapse)
What are early signs of LCPD?
antalgic gait
hip/groin/knee pain
hip adductor spasm
What are later signs of LCPD?
trendelenburg or compensated gait pattern
Describe the stages of LCPD:
necrosis
fragmentation
re-ossification
remodeling
What orthoses is used for LCPD?
scottish rite orthosis or toronto orthosis
Holds hip in IR and ABD
18-24 months
What are 2 surgical treatments for LCPD?
Varus Derotation Osteotomy (immobilize 6 weeks)
Adductor tenotomy
outcomes
side 20
What is SCFE?
slipped capital femoral epiphysis
Salter-Harris 1 epiphyseal slip
How does SCFE sublux?
post/inferior due to flattened femoral head
incidence
slide 22
intervention
slide 25
What age for septic hip arthritis?
usually < 2 years
What are the clinical features of septic hip arthritis?
Temperature
Irritability
LE held in LPP (flex/ABD/ER)
Pain with movement and with palpation in hip area
What is septic hip arthritis?
rapidly progressing hip joint infection with considerable joint effusion
How is septic arthritis treated?
aspirate joint quickly
antibiotics
may need spica cast
What are the common sites for hip area avulsion fx in youth?
AIIS - rectus femoris
ASIS - sartorius
Greater trochanter - abductors insertion
Lesser trochanter - iliopsoas
What is hip area avulsion fx in youth secondary to?
trauma and overuse
What are clinical features of avulsion fx?
pain at bony landmark
muscle weakness
How is avulsion fx managed?
ORIF with wires
What are common adult hip joint dysfunctions?
- arthritis
- avascular necrosis
- trauma (fx and disclocations)
- soft tissue injuries (bursitis, strains)
What percent of THR are done for RA?
2%
What is common hip RA usually treatment?
mostly medication
Which surfaces of the hip are usually destructed with OA?
WB surfaces:
- femoral head (posterior and superior surfaces)
- acetabulum
What are the clinical features of OA at the hip?
antalgic gait
limited ROM in capsular pattern
pain with WB
Hip OA early intervention?
NSAIDS, acetaminophen
assistive devices
AROM
Light resistance training as tolerated
Hip OA surgical options?
- arthroplasty (most common)
- osteotomy
- arthrodesis (fusion - salvage procedure)
Describe the osteotomy procedure for hip OA:
usually VARUS; take wedge from medial femoral shaft to change WB surface (usually performed on younger patients)
Pros and cons of cemented THR?
PRO: immediate WBAT
CON: cement may loosen
Pros and cons of non-cemented THR?
PRO: lower failure rate, little loosening
CON: restricts early WB status to PWB for 6-12 wks
What are the 3 most common surgical approaches to THR?
posterior (most common)
anterolateral
trans-trochanteric
Describe posterior precautions:
AVOID the following to prevent dislocation
- Hip flexion past 90*
- ADDuction past midline
- IR past neutral
Describe anterolateral precautions:
RESTRICTIONS
- Extension
- ADD
- ER
With ______ THR approach, dissect through gluteus medius.
anterolateral
Describe trans-trochanteric precautions:
RESTRICTIONS
- Extension
- ADD
- IR
LIMIT early active abduction until trochanter heals
With trans-trochanteric THR approach, osteotomize the _____.
greater trochanter
What types of patients have higher failure rates with THA?
men
its who weigh > 165 lbs
The chance of hip replacement lasting 20 years is approx. __%.
80
What is the role of PT in THR?
bed mobility transfer training gait training with device ROM muscle performance
What are the pros to minimally invasive arthroplasty?
1-2 small incisions
shorter hospital say
less post-op pain
What are common THR complications?
infection DVT dislocation loosening of cement fracture of femoral shaft near stem
What is the position of hip arthrodesis?
neutral abduction
0-30* ER
20-25* flexion
What are the precautions for hip arthrodesis?
AVOID
abduction
IR
The position of hip arthrodesis is designed to minimize _________ which helps minimize pain.
excessive lumbar spine motion and opposite knee motion
Age/gender prevalance for osteonecrosis of hip in adults?
30-70 yo
male > female
Subchondral bone death occurs secondary to:
ischemia
What are sources of AVN?
blood supply interruption secondary to hip fx long term corticosteroid use ETOH abuse decompression injuries from scuba diving sickle cell disease SLE (Systemic lupus erythamtosis)
Early radiological evidence of AVN of femoral head:
more lucent as bone dies
Common sites for AVN?
femoral head
scaphoid (prox fx)
talus
What are clinical signs of AVN at the hip?
inner thigh pain
antalgic gait
Later radiological evidence of AVN of femoral head:
crescent sign
indicative of subchondral bone death and collapse
Hip AVN surgical treatment options?
drill core into bone and graft
varus osteotomy
hip arthroplasty
Acetabular fx is most associated with:
posterior hip dislocation
AKA dashboard dislocation
What is the likely position of the femur on impact with acetabular fx?
Femur is ADD/IR on impact
What is the treatment for acetabular fx?
skeletal traction then PWB
Intracapsular capital femoral fx is usually due to:
osteoporosis
Intracapsular femoral neck fx is usually due to:
trauma
Intracapsular femoral neck fx surgical treatment for impacted vs displaced:
impacted: ORIF with pin
displaced: ORIF with dynamic screw
What % incidence of AVN with intracapsular femoral neck fx?
25%
Intertrochanteric (extracapsular) fx treatment:
ORIC with dynamic screw (most are comminuted and heal without complication)
Acetabular labral tear management:
NSAIDS
cortisone
arthroscopic repair if limited fxn
How to acetabular labral tears present?
twisting injury with immediate pain
pain with hip flexion
catching, clinciking, locking
Gluteal bursitis pain with:
location: buttocks
pain with resisted hip extension
Iliopectineal bursitis location and pain provocation:
location: between psoas and anterior hip joint
pain with resisted hip flexion
Trochanteric bursitis pain provocation:
pain posterolaterally with resistance into ABD
Hamstring muscle strain often secondary to:
eccentric loading
