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Ortho/Rheumatology > Hip Disorders > Flashcards

Hip Disorders Flashcards

1
Q

What are the MC X-ray findings of Osteoarthritis in the hip?

A
  • Joint space narrowing - loss of cartilage.
  • Osteophytes - new bone formation around the joint.
  • Sclerosis - thickened, white lines around joint.
  • Subchondral lucency - focal loss of bone density around joint space.
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2
Q

Advantages of a Total Hip Arthroplasty?

A
  • Provides immediate pain relief.

- Enhances mobility and restores function.

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3
Q

Complications/Disadvantages of Total Hip Arthroplasty?

A
  • Loosening of components = pain and loss of function.
  • Dislocations.
  • Infection….this is a disaster.
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4
Q

What is AVN?

A

**Avascular Necrosis that results from interruption (or decrease) of blood supply to the femoral head.

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5
Q

What happens in AVN at the hip?

A

The femoral head ischemia leads to collapse or “flattening of the ball.”

*Most cases are atraumatic in origin.

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6
Q

What are the Types of Hip Fractures?

A
  • Femoral head/Subcapital Neck Fx - Fx below femoral head.
  • Transcervical Neck Fx - neck of femoral bone.
  • Intertrochanteric Fx - b/t greater/lesser troch.
  • Subtrochanteric Fx - below troch.
  • Fx of the Greater Trochanter.
  • Fx of the Lesser Trochanter.
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7
Q

Know the anatomy of the hip…

A
  • A “ball and socket” joint.

- Femoral head, Acetabulum, Acetabular Labrum, Ligament of head of femur.

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8
Q

What is the Acetabular Labrum?

A

The ring of cartilage that surrounds the acetabulum of the hip.

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9
Q

What are 3 common areas of pain in the hip that patients complain about?

A
  • Anterior hip and groin.
  • Posterior hip and buttock.
  • Lateral hip.
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10
Q

Anterior hip and groin pain suggest…

A

Intra-articular pathology (OA, labral tear), subacute or stress Fx, septic arthritis, avn.

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11
Q

Posterior hip and buttock pain suggest…

A

Piriformis syndrome, SI dysfunction, lumbar radiculopathy, ischiofemoral impingement, vascular claudication.

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12
Q

Lateral hip pain suggests…

A

greater trochanteric pain (bursitis), gluteus medius/minimus insertion tears.

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13
Q

What is the standing “C-Sign” test?

A

When the pt places a cupped hand around anterolateral hip indicating where they have pain.

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14
Q

What is antalgic gait?

A

Limp, shortened stance; the pt is compensating for pain.

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15
Q

What is trendelenburg gait?

A

Pt standing, lift leg and look for drop in iliac crest on affected side.

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16
Q

What does FABER stand for? What does it suggest?

A

Flexion aBduction external rotation. It suggests intra-articular hip lesions, iliopsoas pain or SI dysfunction.

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17
Q

What does FADIR stand for? What does it suggest?

A

Flexion aDduction internal rotation. It suggests a labral tear or femoral acetabular impingement.

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18
Q

What does a straight leg raise suggest?

A

If painful, intra-articular pathology.

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19
Q

Key points to note on inspection of hip disorders?

A

Leg length, position/rotation, obvious deformity.

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20
Q

Key points to note on palpation of hip disorders?

A
  • pain over greater trochanter/bursa (bursitis, tendonitis, infection, Fx).
  • ASIS (sartorius avulsions/injuries).
  • Ischial tuberosity (hamstring avulsions/tendinopathy).
  • Iliac crest (oblique avulsions/hip pointers).
  • Iliotibial band/Tensor Fascia Latae (TFL).
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21
Q

Hip Pain Work-up?

A

*XR Pelvis and 2-view Hip XR (see affected hip in both planes, AP/Lat; compare to other side).

  • MRI/MRA - test of choice in chronic hip pain if XR normal.
  • evaluates soft tissues; not GT bursitis.
  • bone edema on MRI in stress Fx, MRA to identify intra-articular labral tears.
  • Labs
  • typically not indicated in isolated chronic hip pain.
  • ACUTE PAIN: CBC, ESR/CRP to r/o infection or inflammation.
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22
Q

DDx of Acute Hip Pain?

A

Fx, Dislocation, Femoral Acetabular Impingement (labral tear).

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23
Q

DDx of Chronic Hip Pain?

A

AVN, OA, RA.

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24
Q

DDx of Referred Hip pain?

A

Lumbosacral radiculopathy, Aortoiliac arterial insufficiency.

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25
Q

What is the most common type of joint disease? What is it?

A

Osteoarthritis; >30 million in US.
**Degenerative joint disease w/some inflammatory components.
AKA Wear and Tear Disorder.

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26
Q

What are the risk factors for OA?

A

Age, Obesity, Repetitive Use, Trauma, Infx.

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27
Q

AVN of the Femoral head in children ages 4-10 y/o?

A

Legg - Calve - Perthes

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28
Q

Who does Legg - Calve - Perthes affect the most?

A

Boys&raquo_space; Girls; 5:1.

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29
Q

Pathophysiology of Legg - Calves - Perthes?

A
  • -Direct cause is unknown; has an insidious onset, sometimes after injury.
  • *Rapid growth and ossification of the epiphysis can cause interruption in the blood supply – revascularization w/resorption – then collapse.
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30
Q

Presentation of Legg - Calves - Perthes?

A
  • Painless limp w/intermittent hip/knee pain; maybe down the thigh; typically unilateral.
  • Stiffness, loss of Internal Rotation and ABDuction.
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31
Q

Diagnosis of Legg - Calves - Perthes?

A

**XR – AP Pelvis + 2v Hip (medial joint space widening is early finding.

-Bone scan, MRI.

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32
Q

Treatment of Legg - Calves - Perthes?

A

**Conservative if <8 y/o = OTC pain med PRN, WB restrictions, ROM exercises.

–Surgery if >8 y/o and pain continues.

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33
Q

Presentation of OA?

A
  • *Deep achy joint pain, exacerbated by use – hurts later in the day.
  • *STIFFNESS during REST…morning stiffness < 1 hour.
  • Reduced ROM, Crepitus.
  • Progression leads to JOINT INSTABILITY and PROMINENT PAIN even at rest w/little response to medications.
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34
Q

Diagnosis of OA?

A
  • *XR – 80% show signs on XR
  • *Weigh-bearing XRs to assess joint space.
  • CT occasionally, MRI not typically necessary.
  • Lab work unrevealing in OA.
  • ARTHROCENTESIS:
  • –obtain fluid to r/o inflammatory arthritis, gout, infx, etc.
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35
Q

Treatment for OA?

A
  • *CONSERVATIVE:
  • education, heat and ice, weight loss, exercise/PT.
  • weight loss is the #1 modifiable RF.
  • Tylenol, NSAIDs, Tramadol, Steroid Injection.
  • *Total Hip Arthroplasty (THA) – failed conservative mgmt is indicative for surgery (Elective procedure).
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36
Q

The most common metabolic bone disease?

A

Osteoporosis.

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37
Q

What is Osteoporosis?

A

Abnormal bone remodeling that leads to a decrease in bone mass “2dry to uncoupling of osteoclast - osteoblast activity.”

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38
Q

Prevalence of Osteoporosis?

A
  • Affects 10 million americans.

* *FEMALES affected 4x more than men, ages 50-70.

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39
Q

Pathophysiology of Osteoporosis?

A

The creation of new bone does not keep up with the removal of old bone – bones become porous and brittle.

  • *Fragility Fx are the most common complication.
  • Wrist, Vertebrae, Hip, Sacrum.
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40
Q

What are the 2 different Primary types of Osteoporosis?

A

**Type 1 - primarily in Post-menopausal women (MC).

**Type 2 - age related; men and women.

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41
Q

What causes Secondary Osteoporosis?

A

**Bone loss caused by other diseases such as malignancy, steroid-use, hormonal imbalances, etc.

42
Q

Define Type 1 Primary Osteoporosis?

A

MC post-menopausal women:

  • loss of estrogen in women, testosterone def in men.
  • Trabecular bone primarily affected.
43
Q

Define Type 2 Primary Osteoporosis?

A

Age-related; men and women:

  • poor calcium absorption, >75 y/o.
  • Trabecular and cortical bone affected.
44
Q

Initial Presentation of Osteoporosis?

A
  • *Asymptomatic – under diagnosed and under treated.

- Initial presentation is often w/a fracture.

45
Q

Diagnosis of Osteoporosis?

A
  • LABS – typically normal.
  • -CBC = +/- anemia, BMP, Calcium.
  • -TSH may be low, 25-Hydroxyvitamin D level is low.
  • *XRs – don’t show features until 30% bone loss.
  • DEXA (Dual-energy XR Absorptiometry) is the best modality to measure bone density w/least radiation.
46
Q

Treatment of Osteoporosis?

A
  1. Start antiresorptive agents (Bisphosphonates) in known Osteoporosis.
  2. LIFESTYLE MODIFICATIONS - exercise, PT (water aerobics, WB exercises).
  3. Calcium and Vit D Supps, Estrogen therapy.
  4. Surgical stabilization of fractures.
47
Q

What is the MOA of Bisphosphonates?

A

Inhibits osteoclast activity and bone resorption; decreases fracture risk by 50%.

48
Q

Risk Factors for AVN?

A
  • Previous hip dislocation.
  • Femoral neck Fx.
  • Radiation.
  • SCFE (Slipped Capital Femoral Epiphysis).
  • Alcoholism.
  • Corticosteroid use.
  • Sickle cell disease.
49
Q

Presentation of AVN?

A
  • *Gradual onset of pain and decreased ROM.
  • Anterior hip pain common that radiates to the groin.
  • Exam similar to HIP OA.
50
Q

Diagnosis of AVN?

A
  • *XR – shows lucency and subchondral sclerosis.

* *MRI – study of choice if XR norma.

51
Q

Treatment of AVN?

A
  • Bisphosphonates if caught prior to collapse.
  • Surgery - type depends on age and comorbidities, oten THA.
  • Pain control.
52
Q

Painful inflammation of the greater trochanteric bursa?

A

Trochanteric Bursitis.

53
Q

Where is the greater trochanteric bursa located?

A

Superficial to the ABDuctors and DEEP to the IT band.

**Hip ABDuctors – gluteus medius and maximus, tensor fasciae latae.

54
Q

Causes of Trochanteric Bursitis?

A

Trauma, Tendon or Muscle tear, Hematoma, Arthritis, Infection.

55
Q

Presentation of Trochanteric Bursitis?

A
  • *Lateral hip pain; may radiate down the lateral thigh but NOT to the foot.
  • *Point tenderness over the greater trochanter, reproducible symptoms.
  • Exacerbated by hip movement.
56
Q

Diagnosis of Trochanteric Bursitis?

A

Dx typically on PE, Imaging done only to r/o other pathology.

57
Q

Treatment of Trochanteric Bursitis?

A
  1. Typically Self-Limiting.
  2. Rest, Ice, NSAIDs, topical anesthetic path (OTC Salonpas is 4% Lido vs Rx Lido at 5% - don’t Rx).
  3. CS and anesthetic injection, if does not respond to conservative measures.
58
Q

Disorder caused by muscles/tendons sliding over bony structures? Who is it common in?

A

Snapping Hip.

**Athletes and dancers, tweens and twenties.

59
Q

What is the most common cause of Snapping Hip?

A
  1. INTERNAL (most common) – iliopsoas tendon slides over femoral head, iliopectineal eminence, iliopsoas bursa or lesser trochanter.
  2. Intra-articular – acetabular labral tear and intra-articular loose body (rare).
  3. External – iliotibial band or gluteus maximus over greater trochanter.
60
Q

Presentation of Snapping Hip?

A
  1. Internal:
    - -audible snap or click around the hip.
    - -reproducible w/PASSIVE ROM (from flexed ER to extended IR).
  2. External:
    - -Visible snap or click around hip.
    - -during active flexion, palpate greater trochanter and pressure will stop snapping.

**Painful (may be painless…typically, don’t seek eval until pain progresses).

61
Q

Diagnosis of Snapping Hip?

A
  • XR usually normal.
  • U/S = “catch” it in action, aid in injection to r/o other pathology.
  • MRI/MRA = may show inflamed bursa.
62
Q

Treatment of Snapping Hip?

A
  1. Activity Modification.
  2. Tylenol, NSAIDs.
  3. Steroid injection.
  4. Rarely surgical:
    - -excision of greater troch bursa (external).
    - -release of iliopsoas tendon (internal).
63
Q

Disorder of instability of the proximal femoral growth plate that leads to slippage of the metaphysis?

A

Slipped Capital Femoral Epiphysis (SCFE) – displacement of the femoral head due to disruption of the growth plate.

**Not common but DO NOT miss.

64
Q

Cause of SCFE and who gets it?

A
  • *Caused by mechanical forces on susceptible physis.
  • Can be Bilateral (25%), LEFT hip more common.

Predominantly ADOLESCENT OVERWEIGHT MALES; associated w/rapid growth during puberty.

65
Q

Presentation of Slipped Capital Femoral Epiphysis?

A
  • Acute vs Chronic (Sx for < or > 3 weeks).
  • *Groin and medial thigh pain, Hip.
  • Knee pain.
  • Limp (painful).
  • Externally rotated foot.
  • Decreased ROM of hip (loss of IR, ABDuction, Flexion).
  • Thigh atrophy.
66
Q

Diagnosis of SCFE?

A
  • *XR – need AP pelvis and bilateral hip XRs (AP and frog leg lateral).
  • -will show posterior inferior displacement of femoral head.

+/-MRI (if not sure and not super obvious on XR, but highly suspected).

67
Q

Treatment of SCFE?

A
  1. Immediate Surgical Fixation – typically, percutaneous in situ (“where it’s at” – fixation b/c forceful reduction increases risk of AVN).

**Needs to be done by a Ped Ortho Surgeon.

68
Q

Complications of SCFE?

A
  • *AVN (up to 50% of unstable slips).

* OA

69
Q

Abnormal development of the hip creates a shallow acetabulum, femoral head cannot fit firmly in the socket? Cause?

A

Developmental Dysplasia of the Hip (DDH).

*Caused by Ligamentous Laxity and sometimes abnormal position in utero.

70
Q

What are the different degrees of DDH?

A
  1. Dysplasia – shallow/underdeveloped acetabulum (1:100).
  2. Subluxation – displacement of joint w/some contact remaining b/t articular surfaces.
  3. Dislocation – complete displacement of joint w/no contact b/t articular surfaces (1:1,000).
71
Q

Prevalence of Developmental Dysplasia of the Hip?

A

Typically, present at birth, but may develop in the 1st year.

More common in Girls (6:1); first born, breech, FH, Oligohydramnios.

72
Q

PE Presentation of DDH < 3 months?

A
  • Palpable “clunk” of subluxation/dislocation on exam.

* *Perform Barlow and Ortolani maneuvers on all newborns up to 3 months.

73
Q

What is the Barlow Maneuver?

A

Dislocates the hip by ADDuction and depression of a flexed femur.

**BADD – Barlow ADDuction.

74
Q

What is the Ortolani Maneuver?

A

Relocates the hip by elevation and ABDuction of the flexed femur.

**Dr. O is good - relocates the hip.

75
Q

PE Presentation of DDH >3 months?

A
  • Limited hip ABDuction.
  • Look for GALEAZZI SIGN:
  • Bilateral dislocations often lack the signs of unilateral and require a close index of suspicion.
  • Once walking, LOOK FOR LIMP, always abnormal.
76
Q

What is the GALEAZZI Sign?

A

Pt. lies supine, hips and knees flexed, ONE LEG (at knee) APPEARS SHORTER than the other.
–any limb length discrepancy = ++Galeazzi.

77
Q

Imaging for DDH?

A
  • *IMAGING if ++PE tests.
  • U/S primarily used from birth to 4 months (AAP recommends at 6 wks of age in high risk pt’s).
  • XR – AP Pelvis after 4-6 months.
78
Q

Treatment for Developmental Dysplasia of the Hip?

A

**< 6 months and reducible: ABDuction splint/brace = Pavlik Harness.

**6-18 months and failed Pavlik = closed reduction and spica cast.

*Surgery if >18 months and failed closed reduction.

79
Q

MOI in Hip Dislocations?

A
  1. Typically, high-energy trauma, young adults.
  2. MVC, fall, High-intensity athletes.
  3. Often associated w/other injuries.
    - -ex: sciatic nerve compression/irritation 2/2 to swelling.
80
Q

What to do if you pt has a Hx of THA and they are older, Hx of falls or previous dislocations?

A

Call their joint surgeon!

81
Q

Clinical Presentation of a Hip Dislocation?

A
  • Acute onset of pain.
  • Inability to bear weight.
  • Deformity – swelling at hip, flexed, shortened.
  • Numbness.
82
Q

What is important when evaluating a Hip Dislocation?

A

**Don’t get distracted!

Do a FULL head to toe exam, ATLS guidelines, don’t miss a subtle life-threatening injury.

83
Q

Presentation of a posterior hip dislocation?

A

ADDucted, shortened/flexed and internally rotated limp.

84
Q

Presentation of an anterior hip dislocation?

A

**RARE.

Superior = extension, external rotation.
Inferior = flexion, ABDuction, external rotation.
85
Q

What makes up the majority of traumatic diagnoses?

A

Posterior Hip Dislocations (90%).

**aka “Dashboard Injury” - axial load through flexed knee.

86
Q

What other injury is a posterior hip dislocation associated with?

A

Posterior wall acetabular Fx (MC), Femoral head Fx.

Sciatic nerve injury in 10-20% of cases.

87
Q

Diagnosis of Hip Dislocations?

A
  1. XR – AP Pelvis and AP/Lateral hip if able.
    - -Posterior = femoral head smaller and superior to acetabulum.
    - -Anterior = femoral head larger, medial or inferior to acetabulum.
  2. CT to eval for femoral neck Fx and acetabular Fx.
  3. Obtain post reduction complete Pelvis XRs (AP, Judets, Inlet/Outlet views).
88
Q

What is important in utilizing CT for a hip dislocation?

A

Don’t always wait to reduce the hip to get the CT; it may be more detrimental to the pt’s prognosis and compromise NV status.

89
Q

Treatment of hip dislocations?

A
  1. URGENT Closed Reduction should be attempted w/sedation in the ER.
  2. If unsuccessful, proceed to OR for full sedation and repeat attempt at closed reduction.
    - -occasionally, need to OPEN surgically and reduced on presentation.
  3. Staged surgical fixation of assoc. acetabular Fx.
90
Q

Post-reduction of Hip Dislocation?

A
  • If simple dislocation and no Fx, OK to WBAT!
  • Associated Fx or instability – limited weight bearing.

**POSTERIOR Hip Dislocations – NO flexion past 90 degrees or ABDuction; recreates injury and re-dislocate.

91
Q

How do you reduce a hip dislocation?

A

**Need adequate sedation and relaxation; conscious sedation in the ER.

Posterior Dislocation – “Allis Technique.”

92
Q

What is the Allis Technique?

A

*Reduction maneuver to reduce a posterior hip dislocation.

  • supine, need friend to stabilize the pelvis.
  • apply traction (pull) towards foot of the bed.
  • slowly flex hip and knee, apply gentle upward traction.
  • internally and externally rotate w/cont’d traction.
  • feel the clunk!
93
Q

Complications of Hip Dislocation?

A
  1. AVN – increases w/length of time to reduction.
  2. Post-traumatic arthritis.
  3. Sciatic Nerve Injury**
  4. Recurrent dislocation.
94
Q

What is the classic presentation of a hip fracture?

A
  • *Leg shortened and externally rotated.

- Hip/Groin pain w/inability to flex hip/knee.

95
Q

Etiology of Hip Fractures?

A
  • *Typically, ground level fall.
  • Older population, 60+.
  • -Can see in younger pt’s w/high-energy trauma.
96
Q

What is important when a pt presents w/a hip fracture?

A

Was the fall due to a mechanical or syncopal problem?
–need to differentiate.

**Did the pt hit their head? LOC? Against furniture? Did they try to catch themself?

97
Q

Stabilization of a hip fracture before OR?

A
  1. BUCK’s Traction (5-10lbs):
    - -PRN comfort, muscle spasms and pain relief.
  2. Skeletal Traction for hip dislocations, acetabular Fx, femoral shaft Fx – up to 25 lbs.
98
Q

Why is important to know where the hip fracture is located?

A

It will dictate how it is fixed.

99
Q

Do all hip fractures need to be fixed?

A

Surgical fixation is almost ALWAYS recommended regardless of age, co-morbidities and previous fxn.

  • The alternative is 6-8 wks of bedrest….quality of life is diminished.
  • -increased M/M from DVTs, PNA, pressure wounds.
  • -nonunion, malunion and cont’d pain; limp.
100
Q

Types of Hip implants?

A
  1. Intramedullary Nail (IMN) for IT, Subtroch, +/-basicervical Fx – small incisions, metal rod inside the bone.
  2. OPEN Reduction Internal Fixation (ORIF)
    - -often lgr incisions, reduce Fx and fix it on the inside w/plates and screws.
  3. Arthroplasty for displaced femoral neck fractures.
    - -joint replacement: Total (ball and socket) vs Hemi “half” (just the femoral head - “shiny new ball”).
  4. Percutaneous Pinning or Dynamic Hip Screw for non-displaced femoral neck fracture or basicervical.
101
Q

Goal of Rehab in hip fractures?

A

**GOAL – to reduce down time and morbidity/mortality.

  • Get them to PT/OT asap.
  • Almost always WBAT, unless acetabulum/pelvic Fx.
  • Occasionally, ROM restrictions based on surgical approach.

Ortho/Rheumatology (15 decks)

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