Hip Flashcards
1
Q
Closed packed position of hip
A
- combined extension, IR, and ABD
2
Q
Open packed position of hip
A
- 30 degrees hip flexion, 30 degrees of abduction, slight ER
3
Q
Capsular pattern of hip
A
- limitation of flexion, IR, and some ABD
4
Q
3 primary ligaments supporting hip joint
A
- iliofemoral: limites hyperextension
- pubofemoral: limits extension and ABD
- ischiofemoral: spirals around neck of femur and prevents hyperextension
5
Q
Ligamentum teres
A
- does not help with tension but helps to guide/protect branch of obturator artery to femoral head. If damaged can lead to avascular necrosis.
6
Q
anterior muscular support
A
- pectineus, iliopsoas, rectus femoris
7
Q
posterior muscular support
A
- ischiofemoral ligament, obturator internus/externus, piriformis
8
Q
superior support of the hip
A
- ischiofemoral ligament, rectus femoris, gluteus minimus
9
Q
inferior support of the hip
A
- obturator externus, pectineus
10
Q
posterior muscles of the hip
A
- glute max, med, min, and hamstrings
11
Q
Normal acetabular anteversion
A
- about 20 degrees, normally greater in women and less than men
12
Q
Angle of inclination
A
- angle between neck and shaft of the femur
- begins at 150 degrees in infants and with weight bearing lessens to about 125
13
Q
Smaller than normal angle of inclination
A
- coxa vara: can lead to genu valgum
14
Q
Larger than normal angle of inclination
A
- coxa valga: can lead to genu varum
15
Q
Angle of torsion
A
- angle of femoral head and neck relative to femoral condyles. Normal is 13-15 degrees
16
Q
Retroversion of hip
A
- decrease in the angle of torsion (patient will lack IR and seems to have increased ER)
17
Q
Anteversion of hip
A
- increase in the angle of torsion (patient will have increased femoral IR)
18
Q
Femoral neck fractures
A
- sudden hip pain with increase in activity
- pain referred to anteromedial thigh, knee, groin
- fatigue stress fractures
- ->d/t repetitive and abnormally high forces
- ->relatively uncommon but should be addressed quickly to prevent serious complications
- ->5% of these fx’s involve femoral neck and 5% involve femoral head
19
Q
Insufficiency fractures
A
- d/t compromised bone density
- post menopausal women
- radiation treatments, RA, corticosteroid treatment
20
Q
Avascular necrosis
A
- blood supply to femoral head is compromised for a prolonged period of time
- male more than female
- patients demonstrate and antalgic gait and present with a capsular pattern of restriction
- patients complain of sharp intermittent pain and extreme ROMs
- it is a common complication following hip dislocations, fractures, and chronic synovitis
- patients may also report dull or aching pain in groin and occasionally lateral hip/buttock pan.
21
Q
Femoral acetabular impingement
A
- CAM impingement: non-spherical femoral head, more common in younger males
- Pincer impingement: increased acetabular coverage around the femoral head. Labrum pinched between acetabulum and anterior femoral head-neck. Middle aged females.
22
Q
Mixed impingement
A
- concommitant CAM and Pincer impingement
- potential for labral compromise
- most common symptom is pain and catching
23
Q
Acetabular labral tears
A
- degenerative, traumatic, or idiopathic
- represents 20% of groin pain in athletes
24
Q
Type I acetabular lesion
A
- usually due to a twisting movement
- detached labrum from articular cartilage surface
- perpendicular to surface
- can extend to subchondral bone
25
Type II acetabular lesion
- history of acetabular dysplasia repeated twisting/pivoting
- one or more tears within the labrum
- buckling, pain with forced ADD and IR
26
Physical exam for acetabular lesion
- pain at extremes of ROM, especially with flexion, ADD, and IR
- normal radiographs
- pain with ASLR
27
Ruptured ligamentum teres
- traumatic injury (repetitive microtrauma, particularly with laxity)
- iatrogenic injury
- micro-instability: CAM lesions, ehlers-danlos syndrome, those with increased flexibility
- reduced and painful movement in extension or combined flexion/IR
28
Snapping hip syndrome internal, external, and intra-articular
- internal: iliopsoas snapping over lesser trochanter produces snapping in groin. Stenosing synovitis of the iliopsoas
- external: generally seen in women with wider pelvises who run on banked surfaces. ITB or gluteus maximus snapping over the greater trochanter
- intra-articular: synovial chondromatosis, loose bodies, labral tears
29
Snapping hip syndrome symptoms
- c/o snapping and popping with ambulation with complaints of pain with laying on involved side, especially if ITB is involved.
- if iliopsoas is involved pain is usually felt in the groin when the hip is moving from flexion to extension
- palpate ITB subluxation
- (+) ober/thomas test, patient usually responds well to conservative management
30
Trochanteric bursitis
- 2nd leading cause of lateral hip pain
- lateral thigh, groin, and gluteal pain
- pain with palpation, active or resisted ABD
- often associated with length deficits in abductors, potential leg length discrepancies
31
Iliopsoas/iliopectineal
- anterior hip or groin pain increased with extension
- pain with end range passive hip flexion/ADD
- palpable tenderness of involved bursa
32
Ischial bursitis
- results from chronic compression or direct trauma
- pain with sitting in a firm chair
- females>males
33
Gluteal bursitis
- located above and behind greater trochanter
- individuals aged 40-50
- pain in gluteal, trochanteric area and may spread to posterior thigh
- pain increases with walking and going upstairs
- pain with passive IR and ABD, resisted ER
34
Screening for colon cancer
- >50 y/o
- bowel disturbances
- unexplained weight loss (10% of total weight in 1 month)
- colon CA in first degree relative
- pain unchanged by positions or movement
35
Screening for pathological fracture
- >70 y/o females
- fall history
- pain worse with movement
- shortened and externally rotated LE
36
ROM required for walking
flexion: 40-60
extension: 15-20
ABD: 7
ADD: 5
ER: 9
IR: 4
37
Accessory movements/direction of femoral head for...
- flexion: dorsal glide
- extension: ventral glide
- ABDuction: caudal glide
- ADDuction: lateral glide
- IR: dorsal and lateral glide
- ER: ventral glide
38
Skeletal modeling in children occurs through adaptation
- wolf's law
- gravity
- genetics
- alignment
- weight distribution
- muscle recruitment
- motor control
39
Normal acetabular anteversion
- 18.5 males
| - 21.5 females
40
Yellow flags for hip
- avoidance of activity
- poor social interaction
- emotional lability
- poor engagement in treatment
- unrealistic parental expectations
41
Osteomyelitis
- birth-5 y/o
- 1 in 5,000 children
- recent infection, trauma, or spontaneous occurence
- sudden onset, localized bone tenderness, swelling, and pain
42
Septic arthritis
- birth-5 y/o
- 75% of cases occur before age 3
- rapid inflammatory response
- permanent joint destruction
- irritability, fever, anorexia, painful WB, (+) FABER
43
Transient synovitis
- Children <10 y/o
- males>females
- may be preceded by upper respiratory infection or illness
44
Juvenile idiopathic arthritis
- autoimmune disorder which is activated by an external trigger in a genetically predisposed individual
- age and gender vary by disease and sub-type
- acute or chronic iridocyclitis, most common in oligoarticular
45
Legg-Calve-Perthes disease
- ischemic necrosis of the femoral head
- occasionally follows episodic transient synovitis
- males>females, ages 4-8 y/o
46
Growing pains
- occurs during periods of rapid growth and joint hypermobility
- most common cause of musculoskeletal pain
- >30% of children 4-6 years
- pain is non articular and always bilateral
- self limiting, no signs of inflammation
- more serious conditions must be ruled out
47
Slipped capital femoral epiphysis (SCFE)
- acute, acute on chronic, or chronic
- 2-10 per 100,000
- 3.94 times higher in African-American children
- 2.53 times higher in hispanic children
- males>females, 60% bilateral
- ->males: 9-15 y/o
- ->females: 10-16 y/o
- obesity may be a factor
- patient will demo an antalgic gait, growing pain, anteromedial thigh pain, and/or knee pain. May only present with knee pain
48
Legg Calve Perthes disease
- children may be small for their age
- antalgic gait (shortened stance phase on affected side, hip ABD, weakness leading to trendelenburg or ABDuctor lurch)
- limited hip ABD and IR
- pain complaints related to activity
- pain referred to anteromedial thigh/knee
49
Initial stage of legg-calve-perthes disease (1 of 4)
- lateralization of femoral head, widening of medical joint space.
- later signs include subchondral fracture and physeal irregularity
50
Second stage of legg-calve-perthes disease (2 of 4)
- Fragmentation stage: epiphysis is fragmented and acetabulum contour is more irregular
51
Third stage of legg-calve-perthes disease (3 of 4)
- re-ossification (healing) stage, new bone formation on femoral head
52
Fourth stage of legg-calve-perthes disease (4 of 4)
- residual stage, femoral head fully re-ossified
53
Treatment of oegg-calve-perthes disease
- prevent deformation and maintain ROM
- ABDuction orthosis
- conservative management vs surgical containment
54
Slipped capital femoral epiphysis symptoms
- pain in groin with referred pain to thigh or knee
- antalgic gait, limitation in IR
- affected limb positioned in ER and shortened position
- with flexion, thigh rotates into ER and flexion is limited
- acute: sudden onset, severe pain following a minor fall or twisting
55
Imaging for slipped capital epiphysis symptoms
- plain film radiography with AP, lateral views: AP shows widening of growth plate, lateral any slipping will disrupt the alignment
- CT: confirm closure of physis
- MRI: aide early diagnosis
- severity graded on amount of displacement
56
Treatment for slipped capital epiphysis
- keep displacement to a minimum, maintain ROM
- delay or prevent degenerative changes
- acute patients may be stable or unstable
- if suspected, limit weight bearing until further evaluation can be performed
- post-op rehab can lead to increased strength and progressive weight bearing
57
Osteonecrosis
- vascular injury associated with displacement
- frequently associated with acute/unstable joint
- antalgic gait, capsular pattern
- intermittent sharp pain in extreme ends of range
- can be a complication of SCFE
- treatment: maintain ROM, prevent collapse with decreased weightbearing until healing occurs
58
Chondrolysis
- disolution of articular cartilage
- often found after surgical fixations, specifically if the pain penetrates the femoral head or if there is manipulation or reduction
- rapid, progressive joint stiffness and pain
- ABDuction contracture
- treatment: activity modification, protective WB with crutches, gentle ROM and anti-inflammatories
59
Transient synovitis and septic arthritis
- atraumatic, acutely irritable hip
- antalgic gait or difficulty with weight bearing
- limited motion, joint effusion
- abnormalities in blood and joint fluid
- treatment: transient synovitis will resolve with conservative management. Activity modification, protected WB. Septic arthritis=>antibiotic therapy
60
Juvenile idiopathic arthritis
- not a single disease but encompasses all arthritis that occur prior to the age of 16, persists >6 weeks and are of unknown origin
- joint pain, swelling, and limited mobility
- morning stiffness
- gait deviations
- hip affected in 30-50% of children
- early signs: leg length discrepancy, pain in groin, buttock, medial thigh, or knee
61
Acute juvenile idiopathic arthritis
- joint inflammation, effusion, ligamentous laxity
- muscular spasm and hypertonicity
- management: maintain and preserve joint function
62
Sub-acute-chronic juvenile idiopathic arthritis
- synovial hypertrophy
- loss of joint integrity
- muscle atrophy and weakness
- disease onset early in life may negatively affect muscle development
- management: restoration and compensation of function. Education and support to child and family
63
Long term effects of atypical musculoskeletal development
- idiopathic conditions characterized by disorder of endochondral ossification (limp during walking)
- critical ROM values for stability (at least 30 degrees of ABDuction, avoid hip flexion contracture of 20-25 degrees or more)
64
Developmental dysplasia
- 1 per 100 for dysplasia
- 1 per 1000 fore dislocation in newborns
- origin is multifactorial
- clinical exam must include hip flexion/ABD ROM
- most infants have 75-90 degrees of ABD
- limitation or asymmetry of 5-10 degrees
- asymmetrical thigh folds
- apparent femoral shortening with uneven knee heights
- barlow or otolani signs
65
Barlow maneuver
- dislocation of the femoral head over the posterior acetabular rim
- hip is flexed, abducted, and gradually adducted with pressure posteriorly. A positive otolani sign indicates a more unstable hip than a positive barlow sign
66
ortolani test
- the hip is dislocated in a position of flexion, abduction, and slight traction to reduce
67
Developmental dysplasia intervention
- panlikk harness used birth-9 months: position child in flexion and ABDuction and restricts hip extension and ADDuction
- 9+ months: ABDuction orthosis(>9 months), closed reduction (6-18 months), open reduction (>2 years)
68
Apophysitis and avulsion fractures
- hip and pelvis ossification patterns
- fuse later in childhood
- muscular contraction or excessive stretching
69
Iliac apophysitis
- affects adolescents in T and F or XC or dancers
- D/t repeated contraction of the TFL, rectus femoris, sartorius, gluteus medius, and oblique abdominal muscles
- treatment: rest, normalize 2-joint muscle flexibility, increase strength
70
Avulsion injuries
- occurs in ASIS (sartorius), ischium (hamstring), lesser trochanter (iliopsoas), AIIS (rectus femoris), iliac crest (abdominals)
- treatment: rest. gradual increase in ROM, PRE, reintegration to play
71
Stress fractures
- due to repetitive microtrauma
- junction of the ischium and pubic ramus, femoral neck and shaft are often affected
- persistant pain and groin tenderness
- limited mobility and activity related increases in pain.
- treatment: relative rest, protected WB'ing, restriction from percussive activities)
72
Sutlive CPG for hip OA
- squat is aggravating activity
- hip flexion causes pain laterally
- active hip extension causes pain
- passive hip IR <25 degrees
- (+) scour test
73
6 minutes walk test
- walk 30 m laps as many times as possible in 6 minutes
- relative contraindications: HR >120, BP >180/100
- absolute contraindications: unstable angina, MI in previous month are absolute contraindications
74
TUG
- >12 seconds=increased fall risk
| - in those with hip OA >10 seconds correlated with up to 3x higher risk of being a near faller
