hip clinical conditions part 1 (bursitis to SCFE) Flashcards
between iliopsoas and iliopectineal eminence
communicates with joint cavity
Iliopectineal or Iliopsoas bursitis
Clinical features of Iliopectineal or Iliopsoas bursitis
tenderness over anterior hip at the middle of inguinal ligament
Hip held in flexed, abducted and ER (action of iliopsoas)
Extending, adducting and IR the hip elicits pain
Differential diagnosis of Iliopectineal or Iliopsoas bursitis
Femoral hernia, psoas abscess (pain in psoas in posterior), synovitis and septic arthritis
Bed rest in traction, hot compress
Cellulitis or frank infection necessitates antibiotic treatment
Subsides within several weeks
Treatment of Iliopectineal or Iliopsoas bursitis
Behind greater trochanter and in front of tendinous portion of gluteus maximus
Deep trochanteric bursitis
Clinical features of Deep Trochanteric Bursitis
Tenderness behind greater trochanter
LE held in abducted and ER position to relax the tension from gluteus maximus and bursa
Pain may radiate to back of thigh
Differential diagnosis of Deep Trochanteric Bursitis
septic arthritis hip, osteomyelitis proximal femur
rest and heat
- Hot Packs, ultrasound, NSAIDS
If bursa is infected - antibiotic therapy and possible drainage
Treatment of Deep Trochanteric Bursitis
Between GT and skin and subcutaneous tissue
Superficial trochanteric bursitis
Clinical features of Superficial trochanteric bursitis
Tenderness and swelling over the area of the bursa
Pain on extreme adduction of the hip
same with deep trochanteric bursitis
Treatment of Superficial trochanteric bursitis
Located superficial to the ischial tuberosity
AKA weaver’s bottom (develops in tailors, boatmen - occupation necessitates prolonged sitting on hard surfaces)
Ischiogluteal bursa
Clinical features of Ischiogluteal bursa
Tenderness over the ischial tuberosity
Pain radiates down the posterior thigh mimicking a herniated disc
rest and heat
Use of pillow or cushioned seat to prevent recurrence
Steroid + anesthetic injection (to lessen inflammation)
Excision of bursa if persistent
Treatment of Ischiogluteal bursa
results from impairment of the blood supply to the femoral head
Osteonecrosis
It may involve entire head (Total) or incomplete (spotty distribution or limited to one segment of the femoral head)
Pathology of Osteonecrosis
Etiology of Osteonecrosis
Trauma to the major blood vessels supplying the femoral head
Impairment of circulation occurring in small vessels and sinusoids of the femoral head
Idiopathic
Stages of Osteonecrosis
Degeneration and disappearance of osteocytes from their lacunae is seen in the bone trabeculae
Marked hyperemia of tissues adjacent to the infarct
Revascularization
Osteoclastic resorption of dead trabeculae and osteoblastic repair with new bone occurs
invasion of the infarcted area by new blood vessels and young connective tissue
Revascularization
process of removal of dead bone and replacement of new bone
Creeping substitution
results from a subchondral fracture due to osteoclastic activity
collapse of the entire head causes flattening of the femoral head
Crescent sign
Signs and symptoms vary
Children
limp and slight spasm of the hip are the first manifestations
Pain referred to thigh or knee on weight bearing
Pain worse on standing and walking, relieved by rest
Atrophy (hip or thigh muscles)
Limited Abduction and internal rotation
Clinical features of Osteonecrosis
protect the hip joint in abduction until reconstitution (healing) of the head is complete
Treatment of Osteonecrosis for CHILDREN
surgery often needed (give cane or crutch to lessen weight)
core decompression
derotation osteotomy
arthrodesis (joint fusion)
arthroplasty (joint replacement) - treatment of choice in older less active patients
Treatment of Osteonecrosis for ADULT
idiopathic form (unknown cause) of osteonecrosis in children
AKA Coxa Plana as osteonecrosis often results in flattening of the head
Previously thought to be tuberculosis of the hip
Legg-Calve Perthes Disease (LCPD)
Characteristics of LCPD
Age: 3-12 years old (majority < 7 yo)
Boys, young thin and short (80%) > Girls
Unilateral (85%) > Bilateral
Short stature
No evidence of being hereditary but occasionally more than 1 family member is affected
Etiology of LCPD
Not clearly established
injury or disease of the blood supply to the head
increased intra-articular pressure occluding retinacular vessels
extensive metaphyseal changes affecting metaphyseal- epiphyseal vessels
Theories of LCPD
Pathology of LCPD
Self limited over a period of 2-3 years
Necrosis of the bone and marrow of the epiphysis
Severe involvement may involve physis causing growth disturbance
- leads to a broad and short femoral neck
- If it affect epiphyseal plate, poorer chance of recovery
Clinical features of LCP
Limp
Pain
Limited hip abduction and IR
Atrophy of hip, thigh and leg muscles
Thickening of joint capsule which becomes palpable posteriorly as having a boggy feel
OA is a late complication
most common sign of LCPD
associated with muscle spasm
with or without
pain worsens as disease progresses
Limp
Pain of LCPD is often referred to the
knee
Radiographic Stages of LCP
Initial stage
Fragmentation stage
Reossification or reparative stage
Remodeling stage
sclerotic, smaller proximal femoral ossific nucleus
Initial stage
segmental collapse (resorption) of the capital femoral epiphysis follows, with increased density of the epiphysis
Fragmentation stage
necrotic bone is resorbed with subsequent reossification of the capital femoral epiphysis
Reossification or reparative stage
remodeling begins when the
capital femoral epiphysis is completely re-ossified
Remodeling stage
Self limited with tendency towards spontaneous recovery
Prognis of LCPD
best prognosis
Catterall Group I
better chance to recover
Younger children
Good prognosis of LCPD
Catterall Group I (best prognosis)
Younger children (better chance to recover)
Slender than heavier children (move heavy, can be easily broken)
Boys > Girls
radiographic changes that indicate poorer prognosis
“Head at risk”
Defect or lytic area at the lateral border of the epiphysis with underlying metaphyseal resorption
Gage’s sign
only anterior part of the head is involved, best prognosis
Group I
1/2 head involved & collapse of central portion
Group II
Most of head involved, metaphyseal resorption maybe present
Group III
total head involvement
Group IV
most important factor in preventing hip deformity
Containment of the femoral head within the acetabulum
Non-surgical treatment for children under 4 yo with partial involvement
periodic observation
relief from deforming forces of weight bearing, muscular tension and subluxation must be done
Traction
Abduction Brace
Non-surgical Treatment for older px of LCPD
in early stages, for 1-2 weeks when spasm subsides
Traction
maintains hip in abduction and slight internal rotation to keep the femoral physis completely within the acetabulum, for 1-2 years
Abduction brace
reserved for hips with poor prognosis (i.e older than 6 yo, total or near total head involvement)
Varus osteotomy at the subtrochanteric level
Tilting acetabulum laterally (Salter innominate osteotomy)
Surgical intervention of LCPD
AKA Developmental or Infantile Coxa Vara
Usually not detected at birth and becomes
evident as the child begins to walk
Congenital Coxa Vara
Etiology of Congenital Coxa Vara
Congenital or growth defect of the femoral neck
Painless waddling gait if bilateral affectation, if unilateral patient lurches to affected side
Trendelenburg test (+) due to inefficient gluteus medius action
Abduction and internal rotation limited, while adduction and external rotation is increased
Prominent greater trochanter on palpation
Leg length shortening of 2-4cm (shortening
depends on the extent of depression of the head and neck relative to the shaft)
Clinical features of Congenital Coxa Vara
Radiograph Congenital Coxa Vara
Decreased neck shaft angle
triangular area of bone in the lower side of the neck close to the head
inverted Y ossification defect
upward prominence of the GT and proximal shaft
Diagnosis of Congenital Coxa Vara
Clinical features + Radiographs showing decreased neck shaft angle
protected weight bearing is adequate but must be followed up regularly to detect progression
Treatment for MILD DEFORMITIES of Congenital Coxa Vara
to correct fixed adduction deformity
Abduction osteotomy thru the GT or subtroch for Congenital Coxa Vara
equalize the leg length in children with unilateral involvement and residual leg length discrepancy even after osteotomy
Leg Lengthening procedure for Congenital Coxa Vara
Obese children 10-16 yo less common in tall and thin children
Boys > Girls
average age of onset is about 2 years earlier in girls than boys coinciding with the earlier bone maturation in girls
Bilateral in 25% of cases
History of trivial trauma or strain
Slipped Capital Femoral Epiphysis
Types of Slips
Acute
Acute Superimposed on Chronic
Chronic
least common, symptoms are severe
usually follows severe trauma (fall from a height)
not preceded by significant symptoms
Acute Slip
mild hip and knee discomfort followed by sudden onset of severe pain and disability
acute symptoms associated with mild trauma (stumbling or tripping)
Acute Superimposed on Chronic Slip
gradual onset slowly increasing symptoms for weeks to months
no history of trauma symptoms often mild, aching, fatigue and feeling of stiffness after standing or walking
limp (with a gait pattern/leg length discrepancy)
early diagnosis often missed as pain is frequently referred to the knee
Chronic Slip
Etiology and Pathology of SCFE
Unknown
Combination of rapid growth, obliquity of physis and minor trauma
Endocrinopathies
Head slips at the epiphyseal plate due to disruption in the hypertrophic zone
Direction of slip of the head: downward and backward on the neck
important stabilizer of the physis
thins out during adolescence and yields to shear forces associated with increased body weight and a vertical slope of the physis
periosteum
Direction of slip of the head SCFE
downward and backward on the neck
difficult to spot on AP xray because direction of initial displacement to posterior
Lateral view is essential
Early slippage
determines prognosis
determines prognosis
widening only of the physis, barely detectable displacement
AKA Pre-slipping
Minimal slip
displacement between minimal and one third of femoral neck diameter
Mild slip
1/3 to 1/2 diameter of the neck
Moderate slip
> 1/2 displacement
Severe slip
Diagnosis should be suspected in any adolescent with limp accompanied by hip or knee discomfort with restriction of internal rotation
Affected limb gradually becomes shorter and smaller
ROM especially IR and abduction is restricted
“Obligatory external rotation”
Other clinical features of SCFE
flexion of the hip accompanied by adduction and ER
“Obligatory external rotation
Signs of SCFE
Widening of epiphyseal line
Displacement of the neck upward and forward on the head Remodeling causes neck to be bowed or curved → results in a form of coxa vara
Nearly half of pain referred to knee or medial side of thigh - thus often misdiagnosed
Xrays confirm the diagnosis
lateral view is essential
Diagnosis of SCFE
Differential Dx of SCFE
LCPD, Congenital coxa vara, RA, fractures and tuberculous infection
Complications of SCFE
Osteonecrosis
Chondrolysis
Osteoarthritis
cartilage necrosis
Chondrolysis
directly related to severity of the slip
Osteoarthritis
slipping itself
after attempts of reduction of a chronic slip
after surgical correction at the proximal neck
Osteonecrosis
related to early detection and treatment and the degree of slipping
Prognosis
Good prognosis of SCFE if
slip is treated early, slip is minimal or mild
Treatment for ACUTE SCFE
Reduction by gradual traction
Manipulation under anesthesia + pinning (using 3 threaded pins) to fix the reduction
Treat for > 3 wks duration
manipulation should not be attempted, may disrupt retinacular vessels leads to osteonecrosis
pinning in situ
osteotomy at the subtrochanteric region
Treatment for mild to moderate slip
pinning in situ (pinning is temporary, can be removed eventually)
Treatment for mild to severe slip
osteotomy at the subtrochanteric region corrects the ER, adduction and extension deformities
Prophylactic pinning indicated for
high risk patients (younger age, very obese male)
treatment for obese patients
Weight reduction
Monitoring of opposite hip since bilaterality is common
