Hip and Knee disorders Flashcards
two classifications of OA of the hip
primary hip OA
-idiopathic
-associated with strong FHx
Secondary hip OA
-after prior injury to joint:
-truma
-infection
-AVN
-DDH
-SUFE (slipped upper femoral epiphysis fracture)
main clinical features of hip OA 3
pain
stiffness
loss of function
how can pain in hip OA present
in buttock
referred to groin and thigh
-can even present at knee
*-enquire about when pain occurs:
-only during certain activities
-when weight bearing
-at rest
-limiting sleep at night
examaintion findings in OA hip 4
antalgiic or tendeleberg gait
may have:
-deformities
-asymmetry
-swelling
-muscle wasting
-previous scars
may be tender on deep palpation over groin or around greater trochanter
ROM will be generally reduced
-noticably internal rotation
radiographic features of hip OA 4
reduced joint space
subchondral bone cysts
subchondral sclerosis
osteophyte formation
non-operative hip OA mangemnt 5
patient education
weight loss
walking stick in opposite hand to pain
analgesia- NSAIDs, watch GI risk in elderly
physio
operative management of hip OA
total hip replacement
overview of total hip replacement 5
replaced acetabular w high denisty polyethylene
femoral head replaced with metal
components cemented into bone
major operation - makes sure ptx aware of risks
need prophlyaxtic ABx and thromboprophylaxis
-reduce risk of infection, DVT and PE
classifications for knee OA
primary
-idiopathic and assoc w strong FHx
secondary
-develops after prior insult to joint:
-trauma
-infection
-ligament
-menicus injury
which part of knee joint is more commonly affected in OA
medial side more frequently affected
main clinical features of knee OA 3
pain
stiffness
loss of function
pain in knee OA
originates from knee
-may be able to pinpoint particularly painful area
pain can occur walking, at rest and at night
-climbing stairs and discomfort is a common complaint
examination findings in knee OA 7
varus malalignment due medial compartment OA
swollen
advanced cases- felxion contracture can develop
osteophytes may be felt esp tibial plateau/joint line
effusions in supra-patellar pouch
globally reduced ROM and stiffness
crepitus
non-operative managment of knee OA 6
patient education
weighht loss
walking stick opposite hand
analgesia
physio
alteration of activites/ lifestyle modification
operative options for knee OA 3
early OA in young patinet can hvae tibial osteotomy
if confined to single compartment of knee joint
-unicompartmental joint replacement can be performed
total knee replacement can also be done
describe tibial oesteomy
wedge of bone is removed from lateral side of tibia
-helps redistribute load travelling across knee joint
-diverts force away from damaged medial compartment
define avascular necrosis
also called osteonecrosis
occurs when blood supply to bone is disrupted
hip is common site
traumatic risk factors for AVN 3
so disrupting vascular supply:
-femoral head/neck fractue
-hip dislocation
-SUFE
non-traumatic risk factors for AVN 9
alcohol abuse- accounts for almost 90%
steroids
irradiation
Haematological disease- leukaemia, lymphoma, sickle cell
dysbaric disorders
-decompression sickness form deep sea diving
hyper-coaguable states
-pregnancy
CT disorders
-SLE
-vasculitis
virtual
-hepatitis
-HIV
idiopathic
pathological process of AVN assoc w trauma
direct injury to vasculature supplying femoral head resulting in ischaemia
basic pathophys of non-traumatic AVN 4
coagulation of intraossseous microcirculation occurs
-causes venoous thrombosis
then retrograde arterial occlusion
this decreases blood flow to osteocyte in femoral head and causes ischaemia and AVN
clinical features of hip AVN 6
risk factors present in history
-may be an idiopathic presentation
insidious onset of buttock, groint/anterior hip or thigh pain
-sudden increase in pain may indicate femoral head collapse
-can be asymptomatic until late stage disease
examination:
-hip joint stiff
-patient may walk with limp
imaging for AVN of hip 2
plain radiograph will detect advanced disease
MRI will detect earlier changes
non-operative mangemet of AVN of hip 2
observe w syx control
-bisphosphonates may be beneficial in early stage disease
operative manageent of AVN of hip
core decompression with or without bone grafting (in an attempt to re-vascularise bone)
options:
-rotational osteotomy (offlad small areas of AVN when weight bearing)
-total hip resurfacing/replacement- once OA changes have appeared
define SUFE
slipped upper femoral epiphysis
fracture through the capital femoral physis
-causing the epiphysis to ‘slip’ posteriorly and inferiorly
who gets SUFE 3
10-16yo (during rapid growth)
male gender
obseity =single biggest risk factor
-increased forces travelling through physis (growth plate)
clinical features of SUFE 6
can be acute aftery injury
-or subacute (<3wks)
-or chronic and more insidious (>3wks)
may have limp
groin pain- often referred to thigh or knee
leg externally rotated and appears shortened
localised tenderness around hip joint
pain on hip rotation
-decreased ROM -esp internal rotation
radiograph features of sUFE 5
disruption to shentons line
always need AP and frog-leg lateral to diagnose
shadow behind superior femoral neck- Steel sign
apparent widening of physics and reciprocal decrease in height of epiphysis
prominent lesser trochanter due to external rotation of hip joint
define developmental dysplasia of the hip
-three possible findings 3
abnormal development of hip joint due to resulting in dysplasia
-shallow underdeveloped acetabulum
possible subluxation of joint
-partial displacement
potential hip dislocation
-complete displacement
risk factors for developmental dysplasia of the hip 6
females
first born
left hip
-60% due to common intrauterine position
breech position in utero or delivery
FHx in parent or first degree relative
other MSK anomalies (foot deformity)
clinical features of developmental dysplasia of the hip for the following age:
neonates to <3mnth 3
asymmetry
-extra or deeper thigh creases
positive ortolani and barlow tests (palpable hip subluxation on exam)
reduced abduction
USS of hip joint to aid diagnosis
clinical features of developmental dysplasia of the hip for the following age:
>3mnths -18mnths 3
asymetry
-leg length discrepancy
limitation in hip abduction
after 6 months femoral head begins to ossify meaning plain radiographs can help to diagnose
clinical features of developmental dysplasia of the hip for the following age:
>1yr to walking child 4
lumbar lordosis
trendelenberg gait (abducotr weakness)
toe-walking
feel-pelvic obliquity
clinical features of developmental dysplasia of the hip for the following age:
delayed presentation into lateral childhood and adolescent 3
leg length discrepancy
unexpecteldy large range of motion
radiographs may show early onset OA |
management of developmental dysplasia of the hip for the following ages:
-neonates to <3mnths 1
splintage of joints in abduction and flexion with hips in reduced positon
-can cause remodelling of acetabluum
management of developmental dysplasia of the hip for the following ages:
>3mtnsh to 18mtnhs 1
closed or open reduction of hip joint under anaethesia w immobilisation in hip spica cast for minimum 3mnths
management of developmental dysplasia of the hip for the following ages:
>1yr to walking child 2
closed or open reduction of hip joint under anaethesia w immobilisation in hip spica cast for minimum 3mnths
+/-
femoral or acetabular osteotomy if significant dysplasia
management of developmental dysplasia of the hip for the following ages:
delayed presentation into lateral childhood and adolsecene 2
femoral or acetabular osteotomy
if OA has already begun will likely require early total hip replacement
what is the extensor mechanism made up of in the leg 3
-function
quadriceps tendon (inserts into superior pole of the pattela)
the patella
patella tendon (originates from interior pole of patella to insert into the tibial tuberosity)
-enables extension of the leg at the knee joint
define extensor mechanisms injury
injury to any part of the extendsor mechanism (patella, quad tendons, patella tendon) disrupts this mechanism and results in an inability to maintain knee extension
who gets quadriceps tendon rupture 2
elderly men with pre-exisiting tendonpathy resulting from fall or eccentric loading of tendon
in younger patients - usually direct trauma
where is the most common site of quadriceps tendon rupture
typically at insertion of tendon into the patella
-can be complete or partial
clinical features of quadriceps tendon rupture 4
pain in area before rupure indicating tendonopathy
significant bruising and swelling around the quadriceps tendon
tenderness at site of rupture
-palpable defect may be present
unable to extend knee against resistance
-iif complete tendon rupture is present patient may be unable to perform straight leg raise
imaging in quadriceps tendon rupture
ap and lateral radiographs of knee may show effusion and possibly patella baja (abnormally low lying patella)
management of quadriceps tendon rupture 2
requires open repair followed by protection in extension cast or splint
who gets patella tendon rupture 2
affects younger age group than quad rupture
usually male 20-40
rupture can be partial or complete
-occurs within tendon substance or avulse part of tibial tuberosity
clinical features of patella tendon rupture 5
infra-patellar pain after sudden quadriceps contraction with knee in flexed position
-may note popping sensation
elevated patella with large haemarthorsis
tenderness at site of rupture
-palpable defect may be present
if complete tear will be unable to straight leg raise or maintain extension of knee
reduced ROM at knee joint w difficulty weight bearing
imaging in patella tendon rupture
AP and lateral
show proximal migration of patella, known as patella alta
managment of patella tendon rupture 2
non-oeprative (for partial tears w intact extensor mechanism)
-immonilisation in full extension with progressive exercise programme)
operative- for complete rupture
-open repair of tenodn
-multiple techniques
risk factors for extensor mechanism injury (quadriceps and patella tendon rupture) 6
previous tendon injury
exisitng tendonopathy
previous corticosteoird injection
steroid use
co-morbidities- SLE,RA, chronic renal disease, DM
increasing age (for quadriceps rupture)
common meniscal tears 2
medial collateral ligament
anterior cruciate ligament
presenation of meniscal tears 6
pain -can localise to area
report instability when knee flexed
-often related to sporting injury
swelling and effusion around knee which develops gradually following initial injury
localised joint tnederness
ROM limited due to swelling and effusion
compression and twisting the knee joint may reproduce pain (McMurrays test)
imagign for meniscus tears 1
MRI scan
-show torn meniscus as well as soft tissue injuries
diagnostic arthroscopy can be used to directly visualise pathology
main ligaments of the knee 4
ACL
PCL
medial collateral
lateral collateral
typically sx and syx of meniscal tear 2
locked knee
giving way
typical sx and syx of ligament injury 3
sudden swelling
pain
feeling a ‘pop’ in knee
inability to finish match
examination findgins of ACL 2
positive anterior drawer test
positive lachmans test
examination findings of PCL 1
positive posteiror drawer test
examinaitno findings of medial collateral
brusing over medial aspect of knee
laxity on MCL testing
-apply valgus stress
examination findings on lateral collateral
brusing over lateral aspect of knee
laxity on LCL testing
-apply a varus stress
mechanism of ACL tear
forced felxion or hyperfelxion of knee
-twisting injruy or direct blow behind upper tibia
*-ptx may describe snapping sound or sensation
