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MSK > Hip Complex > Flashcards

Hip Complex Flashcards

1
Q

Angle of Inclination (Frontal Plane)

(3)

A

Coxa Valga: 170 degrees
- Tilt down = varus knee

Normal: 120-135 degrees

Coxa Vara: 100 degree (< 120)
Tilt up = valgus knee

Disburses FORCES differently through knee

Congenital Deformities - sometimes develop depending on the forces put through it

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2
Q

Angle of Torison (Transverse Plane)

(3)

A

Anteverison (Medial Femoral Torsion)
- Toeing-in
- Femur internal - associated w/ W-sitting > widen base of support, especially in children w/ hypotonia

Normal = 8-15 degrees

Retroversion (Lateral Femoral Torsion)
- Toeing-out

Does not mean pt will experience pain
May put them at a greater risk of developing a pathology

** May need different variations of how they squat / walk / run

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3
Q

Osteoarthritis (HIP)

Defintion

A

Degeneration of the articular & subcondral bone

Leads to joint space narrowing, rubbing of bone on done due to degeneration & break down of overlying articular cartilage, which may lead to osteophyte formation

NOCIEBO affect - expectations of something bad/negative is going to cause symptoms - imagine that they should have pain as a result of blank

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4
Q

Hip OA: Etiology

Risk Factors: Non-Modifiable & Modifiable

A

Non-Modifiable
- Age
- Gender (F>M)
- Heredity
- Congential Malformations - coxa valga/vara, ante/retroversion

Modifiable:
- Obesity: lead bearing = more load w/ INC wt
- Abnormal repetitive stress
- Trauma: previous injury = INC risk
- Joint mechanics (may or may not be able to modify)
May be natural - depends on the context of the activity (wt lifting vs running)

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5
Q

Hip OA: S/S

(6)

A
  1. Pain in groin, hip (greater trochanter), buttock, thigh, back, or knee
    Any hip pathology of the HIP JOINT - deep & around groin
  2. Pain w/ weight bearing activities
  3. DEC paini in loose packed position: 30 flexion, 30 abduction, slight ER
  4. Stiffness
    Limits motiono with a firm capsular end-feel
    Capsular pattern of restriction: IR > flexion > abduction
    Initally, limitations ONLY in IR. Advance stages hip is fiexed in adduction (limitation abduction), no IR or extension past neutral & limitations in hip flexion to 90 degrees
  5. DEC mm strength
  6. Limited functional abilities (LATER STAGES)
    - Difficulty w/ sit<-> stand (squating)
    - Difficulty walking on uneven surface
    - Difficult w/ ADLs
    - DEC walking distance (d/t pain)
    - DEC time in standing
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6
Q

Special Test: Scour

A

Not specific for hip OA rather a hip pathology

PT: flexion + add/abduction - moving femur on different surfaces of acetabulum

(+) = pain, spasm - “catch” feel resistance & moving over it

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7
Q

Special Test: Patrick’s (FABER) Test

A

Not specific for hip OA rather a hip pathology

“Figure 4” position

(+) = if ROM is limited & knee is not dropping down to parallel or lower
*Also part of cluster test for SI pain

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8
Q

Special Test: Flexion-Adduction (Hip Quadrant) Test

A

Not specific for hip OA rather a hip pathology

Looking for pain or discomfort
NOT scouing - just going into both mvmt

(+) = pain or discomfort

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9
Q

Hip OA: Interventions

4

A

Education:
- Safe ambulation patterns
- Minimizing aggravating activities stressing joints - ex. high impact

Decrease Pain:
- Grade I or II oscillation techniques w/ the joint in resting positon (30F, 30AB, ER)
- Provide assistive device during ambulation - cane on contralateral side
- If LLD is causing joint stress, gradually elevate short leg with shoe lifts
- Modiify chairs & commodes to make sitting & standing up easier = higher surface (limit in/out of deep squats)
- Modalities (TENS, heat, etc)

INC ROM = more functional ability
- ROM exercises w/in tolerable limitis
- Grade III or IV oscillation techniques using glides that stretch restricting capsular tissue
- Stretching (NO vigorous stretching until the chronic stage of healing)
ACUTE = INC irritability = DEC activity/exercise = INC deconditioning = DEC mvmt = INC stiffness/mm guarding

Strengthening:
- Hip strengthening as tolerated
- Begin with OKC (maybe more tolerable) & progress to functional exercsise using CKC as tolerated
CKC = WB which could INC pain/ discomfort
More functional activities = general WB <- progress to this

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10
Q

Total Hip Athroplasty

Description & indications

A

Surgical procedure performed where the femoral head & acetabulum are replaced w/ artificial components

Indication for THA:
- Severe hip pain, loss of function, DEC QoL as a result of joint deterioration associated with OA, RA, AS, avascular necrosis w/ failure of conservative management
- Nonunion fracture, instability, or deformity of the hip
- Bone tumors
- Failure of previous reconstrcution procedures

HEMI - replace only one component (ball or socket)

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11
Q

THA - Preoperative Management

(6)

A
  1. Preoperative examination of patient’s status
    Ie. pain, ROM, mm strength, balance, gait, function, etc
  2. Education regarding operative procedure - how its done, equipment
  3. Education regarding post-operative precautions & rationale
  4. Functional training for early post-operative days
    Ie. bed mobility, transfers, ambulation device training
  5. Early post-operative exercises
  6. Criteria for discharge for the hospital
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12
Q

TKA: Surgical Approaches

(3)

A
  1. Posterior / Posterolateral
  2. Lateral
  3. Anterior
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13
Q

Surgical Approach:
Posterior / Posterolateral

Involvement of Soft Tissues & Impact on Postoperative Function

A

Posterior or Posterolateral

Involvement of Soft Tissues:
1. Gluteus maximus divided in line with its fibers with a posterior approach
2. Interval b/t gluteus maximus & medius divided in posterolateral approach
3. Short ERs & piriformis released & repaired
4. Gluteus maximus tendon possibly released from femur; repaired at conclusion
5. Posterior capsule is incised & repaired
6. Gluteus medius & TFL left intact

Impact on Postoperative Function
- Possible earlier recovery of normal gait pattern d/t intact gluteus medius & TFL
Lurch or Trendelenberg
- Highest risk of dislocation or subluxation of prosthetic hip

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14
Q

Surgicial Approach:
Direct Lateral

Involvement of Soft Tissues & Impact on Postoperative Function

A

Direct Lateral

Involvement of Soft Tissues
1. Longitudinal division od the TFL
2. Release of up to one-half of proximal insertion of the gluteus medius & minimus; reaatched prior to closure
3. Longitudinal splitting of the vastus lateralis
4. Capsulotomy & repair

Impact on Postoperative Function:
- Weakness of the hip abductors
- Possible pelvic obliquity
Pelvic Obliquity is the misalignment of the pelvis, typically where one hip is higher than the other
- Delayed recovery of symmetrical gait

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15
Q

Surgical Approach:
Direct Anterior

Involvement of Soft Tissues & Impact on Postoperative Function

A

Involvement of Soft Tissues
1. Incision made anterior & distal to the ASIS, slightly anterior to the greater trochanter & medial to TFL
2. No muscles incised or detached but rectus femoris & sartorius retacted medially to access the joint
3. Anterior capulotomy & repair

Impact on Postoperative Function
- WBAT immediately after Sx
- More rapid recovery of hip mm strength & normal gait pattern comparde with anterolateral approach

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16
Q

TKA: Complications

(3)

A

Intra-operative:
- Malpositioning of the prosthetic component (takes load in ackward way)
- Femoral fracture
- Nerve injury
Anterior - femoral, superior gluteal, obturator
Peroneal division of the sciatic is the most common - exspecially w/ posterior & posteolateral approach
- Leg-length discrepancy (appliance is not fitted properly)

Early post-operative complications:
- DVT - d/t immobility - venous stasis (dislodge = life-treatening)
- Infection - invasive procedure - entry port for bacteria
- Wound healing problems - delayed = ?infection
- Dislcation of prosthetic joint

Later post-operative complications:
- Mechanical losening of components
- Atraumatic wearing out of components (lifespan ~10 years before need to be replaced)

17
Q

TKA: Post-operative Precautions

A

Posterior / Posterolateral Approaches:
- No hip flexion > 90 degrees
NO low seats - “nose over toes” = hip > 90
Need to be aware of functional activities
Use arms to stand up straight
- No hip internal rotation beyond neutral
No pivoting on leg = functional IR
- No hip ADDuction beyond neutral
No side-lying - lying w/o pillow between legs
ABD affected leg & ASS non-affected leg

Cognitive issues - lots of natural mvmt - could be at risk for post-operative complications as a result

Anterior / Anterolateral & Direct Lateral Approaches
- No hip flexion > 90
- No hip extension - very natural w/ reciporcal gait - Need to do STEP-TO gait
- No ER beyond neutral
- No hipp ADDuction beyond neutral
- No combined motion of hip flexion, ABDuction, & ER (FABER)
- If gluteus medius was incised, no resisted or antigravity hip ABDuction for > 6-8 weeks (at least)

Faster healing & lower risk of dislocation
- Especially for pt w/ cognitive / memory issues = less natural movements occuring that could lead to complications (compared to other approaches)

18
Q

TKA: Interventions
Maximum, Moderate & Minimal Protection Phase

A

Maximum Portection Phase:
Goals:
1. Prevent complications:
- Education to reduce risk of complications (precautions, safe bed mobility & transfers = reduce risk of falls, & S/S to look out for infection)
Infection = fever, INC/excessive pain, heat/warmth in area, feels inflammed, etc
- Ankle Pumps - reduce DVT risk
- Deep breathing exercises & secretion clearance - want them to cough & not retain mucus (= INC risk of infection)

  1. Prevent mm atrophy:
    - Submaximal mm setting (isometrics) of quadriceps, hip extensors (glute max & hamstrings), & hip abductors (Do NOT want to contract mm if they were cut - ie direct lateral approach)
  2. Regain active mobility & control
    - AROM or AAROM of hip w/in protected ranges
    - Bilateral closed-chain weight shifting, balance activities, heel raises, and mini-squats (repecting WB resistrictions)
  3. Achieve independent functional mobility
    - Bed mobility
    - Sit <-> stand
    - Transfer training
    - Ambulation w/ asistive device (older = walker / younger = crutches if adequate balance/stretch)
    - Stairs training

Moderate Protection Phase
Goals:
1. Regain strength & mm endurance
2. Improve cardiopulmonary endurance
3. Restore ROM (while adhering to precautions)
4. Improve postural stability, balance & gait

Minimal Protection Phase
Goals:
1. Continue previous goals if not met
2. Resume or modify functional activities
3. Return to sport activities (depending on surgeons’ approval of sport actvities)

19
Q

Guidelines for Sport, Recreational, & Fitness Activity Participation following TKA

(3 levels)

A

Allowed:
- Golf
- Swimming
- Walking
- Stationary cycling
- Elliptical trainer
- Cross country ski unit
- Bowling
- Low-impact aerobics
- Speed walking
- Hiking
- Stair-climbing unit
- Rowing unit
- Doubles tennis
- Use of weight machines

Allowed with Caution & Prior Experience
- Pilates
- Cross-country skiing
- Rollerblading
- Ice skating
- Downhill skiiing

Not Allowed
- Jogging / running
- Baseball / softball
- Raquetball / squash
- Snow boarding
- High-impact aerobics
- Contact sports (ie football, basketball, soccer)

AVOID high-impact activites
AVOID slippery surfaces where it is possible for pt to fall PR causes leg to go in ackward position (compromise the prosthetic components)

20
Q

Hip Fractures

Description & Epi

A

A fracture of the proximal hip
DISTAL = Extracapsular
PROXIMAL = Intracapsular
- Intra = potential to compromise the vascular strcture
Avascular necrosis = no longer congruent w/ hip - poor hip structure & wearing out of acetabulum > TKA
Delayed healing if vascular supplu is affected = nonunion

Epi:
- Majority of hip # occur in elderly populations (> 75 years old)
- F>M (osteoporotic factors)

21
Q

Hip Fractures: Etiology

(3)

A

Falls
- Age-related DEC in mm strength & flexibility
- DEC balance & gait deficits
- Poor vision
- Cognitive decline
- Medications - drowsy

Osteoporosis - less impact needed for a fracture to occur

Sudden twisting motion of LE

Walking speed decreases w/ age - when older ppl lose balance & fall -> typically fall to side = positionn likely to break femure
Faster gait speed = ppl are more likley to stick their hand out = more likely to fracture wrist

22
Q

Hip Fracture: S/S

(5)

A
  1. Pain in groin (INTRA) or hip region (EXTRA)
  2. Pain w/ AROM or PROM of the hip
  3. Pain w/ LE weight bearing - # caused femur to shift superiorly
  4. LLD (shorter leg)
  5. **LE assumed an ER / ABDucted position
23
Q

Hip Fracture: Interventions

(2)

A

Surgery
- ORIF - nails/pins to fixate it
- Hemiarthroplasty - just replace the FEMUR component - BALL not socket
Displaced intracapsular # gets a hemi instead of an ORIF > less risk for non-union
- TKA - may replace both acetabulum & femur depending on their state

Post-operative rehabilitation
- Goals

24
Q

Hip Fracture:
Post-operative Rehabiliation

A

Goal: Minimize adverse effects of bed rest (while protecting the surgicial site)
- Bed mobility training
- Transfer training
- Ambulation w/ assistive device - based on WB precautions
- Deep breathing & coughing exercise - limit infection from secretion retention
- LE edema control (compressive stockings)

Exercise program
- ROM - as much as we can - as soon as we can
- Strengthening
- Balance training

25
Q

S/S of Possible Failure of Internal Fixation Mechanism

(4)

A
  1. Severe, persistent groin, thigh, or knee pain that increases with weight bearing or hip mvmt
  2. Shortening of the involved limb that was not present immediately after surgery
  3. Persistent external rotation of operated leg (same position as a #)
  4. Positive Trendelenburg sign during weight bearing on the involved limb that does not resolve with strengthening
    - Could mean there is damage to the SUPERIOR GLUTEAL nerve
    - (+) Trendelenburg = hip hike on affected side during STANCE phase
    - May compensate with LURCH gait = move CoG directly over stance leg ~ no pevlic drop noted BUT they are leaning over

Trendelenburh named after WEAK side
- IPSI - hip hike
- CONTRA - hip drop

26
Q

Neuropathy

(3)

A

Major nerves subjected to injury or entrapment:

Sciatic nerve:
- May be due to entrapment of the sciatic nerve as it passes under the piriformis mm
- For most ppl - occassionaly passes through or over

Obturator nerve:
- May be due to uterine pressure & damage during labor OR post-partum

Femoral nerve:
- May be due to fractures of the upper femur or pelvis, reduction of congenital dislocation of the hip, or pressure during a forceps labor & delivery

27
Q

Hip Muscle Imbalances: Tests

(5)

A
  1. Modified Thomas Test
  2. Ely’s Test
  3. Ober’s Test
  4. Piriformis Test
  5. 90/90 Straight Leg Raising Test
28
Q

Developmental Dysplasia of the Hip (DDH)

Description & Epi

A

A condition of general instability of the hip joint, resulting in an increased risk for hip dislocations - does NOT mean they had a dislocation rather INC risk
- INSTABILITY is the key word

Also known as congenital dislocation of the hip (CDH) or congenital hip dysplasia (CHD)
- Congenital suggests it exist @ birth whereas developmental implies it can still develop in infancy

Epi:
- Infants
- F > M

29
Q

Hip Pathologies from youngest to oldest

Only children conditions (3)

A
  1. DDH
  2. LCPD
  3. SCFE
30
Q

Developmental Dysplasia of the Hip:
Etiology

(6)

A
  1. Family history
  2. First born
  3. Gender (F>M)
  4. Breech birth - legs first instead of head first
  5. Narrow uterus - positions that make them vulnerable to dislocation
  6. Certain swaddling positions - acquired - certain postions INC risk
31
Q

Developmental Dysplasia of the Hip:
S/S

(3)

A
  1. Asymmetry (if unilateral)
    Gluteal folds
    LLD - dislocated leg drops down
  2. Hip abduction limitations
  3. Hip clicks - dislocating & relocating

GOLD STANDARD for Dx is ULTRASOUND
- X-ray will NOT show this b/c babies hips are mostly cartilage - so x-ray just shows black space

32
Q

Screening for infants under 1 month

(2)

A

Barlow manuever
Procedure: The infant’s hip is adducted while applying a mild posterior directed force through knee
(+) = There is a palpable subluxation or dislocation of the hip

Ortolani manuever
Procedure: The infant’s hip & knees are flexed to 90 degrees & is gently abducted while applying an anterior directed force on the proximal femur
(+) = There is a palpable & audible clunnk as the hip reduces

Tip: B = comes first in the alphabet
- Need to dislocate in order to relocate

33
Q

Developmental Dysplasia of the Hip:
Interventions

(4)

A

Pavlik Harness - most relevant
- Maintains hip in flexion & abduction to promote acetabular development & prevent dislocation positions
- Putting the femur in the deepest end of the acetabulum = INC stability & development of femoral head = more congruency
- More preferred b/c there is room for spontaneous mvmt
- Worn 24/7

Hip spica
- Will holf the position w/ very little room for mvmt > lots of stability

Closed Reduction
- Manipulation back into place & then use spica - if Tx is early enough

Open Reduction
- Sx repair if suspect tissue is keeping the femur from going back into acetabulum - LAST resort

34
Q

Legg-Calves-Perthes Disease

Description & Epi & Etiology

A

A childhood hip disorder resulting from avascular necrosis of the femoral head

The most common cause of childhood hip pain

Epi:
- Children between 2-15 years of age (most common between 4-8)
- M>F

Etiology:
- Interruption of blood supply to head & neck of femur
- True cause is unknown

35
Q

Legg-Calves-Perthes Disease:
S/S

(5)

A
  1. Limp of insidious onset - gradual increasing worse limp
  2. +ve Trendelenburg sign
  3. Pain aggravated by activity & relieved by rest
  4. Pain in hip which may refer to anteromedial thigh or knee
  5. DEC hip ROM (especially in abduction & IR)

Usually unilateral but can occur bilaterally

36
Q

Legg-Calves-Perthes Disease:
Interventions

(6)

A
  1. Petrie cast - 1st line of Tx
    Holds pt on ABduction bilaterally
  2. Low impact exercises - AVOID loading - ie swimming
  3. Strengthening exercises: OKC > CKC (as it can be painful)
  4. ROM exercises
  5. Reduction of weight bearing if pain is severe (ie crutches or W/C)
    Temporary period until it becomes less irritable
  6. Hemiarthroplasty (LAST resort) - femoral head (ball)

Young children can sometimes heal w/o Tx in a couple of years - can regenerate blood supply to head of the femur

37
Q

Slipped Capital Femoral Epiphysis

Description & Epi & Etiology (RF)

A

A fracture through the growth plate (physis) causing slipping of the end of the femur (metaphysis)
- Mosnomer - femoral head is not slipping - still attached via **ligamentum teres ** > neck of femur & rest of femur (metaphysis) that falls DOWN

Head of femur is POSTERIOR relative to rest of femur (shaft is ANTERIOR)
Ball is still in the socket

Epidemiology:
- Most commonly seen in adolescents
- M>F

Etiology:
1. Obesity - most significant
2. Family history
3. Endocrine disorders

“Heavy set males” - clinical picture

38
Q

Slipped Capital Femoral Epiphysis:
S/S

(4)

A
  1. Pain in hip or anterior thigh
  2. Pain with activity - WB
  3. ROM limitations in Flexion, Adduction, IR - limitations in all mvmts of FADDIR
  4. Limp may be present
39
Q

Slipped Capital Femoral Epiphysis:
Intervention

(1)

A

Surgery

NOTE: Not going to relocate head of femur to line the bones up
Reason = high incidence / INC risk of avascular necrosis
So to avoid this (even if it is not lined up) - surgeon will just fixate it so it does not slip further

Same Tx post-op simillar to a FRACTURE

MSK (13 decks)

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