Hip Disorders Flashcards
What are the MC X-ray findings of Osteoarthritis in the hip?
- 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.
Advantages of a Total Hip Arthroplasty?
- Provides immediate pain relief.
- Enhances mobility and restores function.
Complications/Disadvantages of Total Hip Arthroplasty?
- Loosening of components = pain and loss of function.
- Dislocations.
- Infection….this is a disaster.
What is AVN?
**Avascular Necrosis that results from interruption (or decrease) of blood supply to the femoral head.
What happens in AVN at the hip?
The femoral head ischemia leads to collapse or “flattening of the ball.”
*Most cases are atraumatic in origin.
What are the Types of Hip Fractures?
- 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.
Know the anatomy of the hip…
- A “ball and socket” joint.
- Femoral head, Acetabulum, Acetabular Labrum, Ligament of head of femur.
What is the Acetabular Labrum?
The ring of cartilage that surrounds the acetabulum of the hip.
What are 3 common areas of pain in the hip that patients complain about?
- Anterior hip and groin.
- Posterior hip and buttock.
- Lateral hip.
Anterior hip and groin pain suggest…
Intra-articular pathology (OA, labral tear), subacute or stress Fx, septic arthritis, avn.
Posterior hip and buttock pain suggest…
Piriformis syndrome, SI dysfunction, lumbar radiculopathy, ischiofemoral impingement, vascular claudication.
Lateral hip pain suggests…
greater trochanteric pain (bursitis), gluteus medius/minimus insertion tears.
What is the standing “C-Sign” test?
When the pt places a cupped hand around anterolateral hip indicating where they have pain.
What is antalgic gait?
Limp, shortened stance; the pt is compensating for pain.
What is trendelenburg gait?
Pt standing, lift leg and look for drop in iliac crest on affected side.
What does FABER stand for? What does it suggest?
Flexion aBduction external rotation. It suggests intra-articular hip lesions, iliopsoas pain or SI dysfunction.
What does FADIR stand for? What does it suggest?
Flexion aDduction internal rotation. It suggests a labral tear or femoral acetabular impingement.
What does a straight leg raise suggest?
If painful, intra-articular pathology.
Key points to note on inspection of hip disorders?
Leg length, position/rotation, obvious deformity.
Key points to note on palpation of hip disorders?
- 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).
Hip Pain Work-up?
*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.
DDx of Acute Hip Pain?
Fx, Dislocation, Femoral Acetabular Impingement (labral tear).
DDx of Chronic Hip Pain?
AVN, OA, RA.
DDx of Referred Hip pain?
Lumbosacral radiculopathy, Aortoiliac arterial insufficiency.
What is the most common type of joint disease? What is it?
Osteoarthritis; >30 million in US.
**Degenerative joint disease w/some inflammatory components.
AKA Wear and Tear Disorder.
What are the risk factors for OA?
Age, Obesity, Repetitive Use, Trauma, Infx.
AVN of the Femoral head in children ages 4-10 y/o?
Legg - Calve - Perthes
Who does Legg - Calve - Perthes affect the most?
Boys»_space; Girls; 5:1.
Pathophysiology of Legg - Calves - Perthes?
- -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.
Presentation of Legg - Calves - Perthes?
- Painless limp w/intermittent hip/knee pain; maybe down the thigh; typically unilateral.
- Stiffness, loss of Internal Rotation and ABDuction.
Diagnosis of Legg - Calves - Perthes?
**XR – AP Pelvis + 2v Hip (medial joint space widening is early finding.
-Bone scan, MRI.
Treatment of Legg - Calves - Perthes?
**Conservative if <8 y/o = OTC pain med PRN, WB restrictions, ROM exercises.
–Surgery if >8 y/o and pain continues.
Presentation of OA?
- *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.
Diagnosis of OA?
- *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.
Treatment for OA?
- *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).
The most common metabolic bone disease?
Osteoporosis.
What is Osteoporosis?
Abnormal bone remodeling that leads to a decrease in bone mass “2dry to uncoupling of osteoclast - osteoblast activity.”
Prevalence of Osteoporosis?
- Affects 10 million americans.
* *FEMALES affected 4x more than men, ages 50-70.
Pathophysiology of Osteoporosis?
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.
What are the 2 different Primary types of Osteoporosis?
**Type 1 - primarily in Post-menopausal women (MC).
**Type 2 - age related; men and women.
What causes Secondary Osteoporosis?
**Bone loss caused by other diseases such as malignancy, steroid-use, hormonal imbalances, etc.
Define Type 1 Primary Osteoporosis?
MC post-menopausal women:
- loss of estrogen in women, testosterone def in men.
- Trabecular bone primarily affected.
Define Type 2 Primary Osteoporosis?
Age-related; men and women:
- poor calcium absorption, >75 y/o.
- Trabecular and cortical bone affected.
Initial Presentation of Osteoporosis?
- *Asymptomatic – under diagnosed and under treated.
- Initial presentation is often w/a fracture.
Diagnosis of Osteoporosis?
- 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.
Treatment of Osteoporosis?
- Start antiresorptive agents (Bisphosphonates) in known Osteoporosis.
- LIFESTYLE MODIFICATIONS - exercise, PT (water aerobics, WB exercises).
- Calcium and Vit D Supps, Estrogen therapy.
- Surgical stabilization of fractures.
What is the MOA of Bisphosphonates?
Inhibits osteoclast activity and bone resorption; decreases fracture risk by 50%.
Risk Factors for AVN?
- Previous hip dislocation.
- Femoral neck Fx.
- Radiation.
- SCFE (Slipped Capital Femoral Epiphysis).
- Alcoholism.
- Corticosteroid use.
- Sickle cell disease.
Presentation of AVN?
- *Gradual onset of pain and decreased ROM.
- Anterior hip pain common that radiates to the groin.
- Exam similar to HIP OA.
Diagnosis of AVN?
- *XR – shows lucency and subchondral sclerosis.
* *MRI – study of choice if XR norma.
Treatment of AVN?
- Bisphosphonates if caught prior to collapse.
- Surgery - type depends on age and comorbidities, oten THA.
- Pain control.
Painful inflammation of the greater trochanteric bursa?
Trochanteric Bursitis.
Where is the greater trochanteric bursa located?
Superficial to the ABDuctors and DEEP to the IT band.
**Hip ABDuctors – gluteus medius and maximus, tensor fasciae latae.
Causes of Trochanteric Bursitis?
Trauma, Tendon or Muscle tear, Hematoma, Arthritis, Infection.
Presentation of Trochanteric Bursitis?
- *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.
Diagnosis of Trochanteric Bursitis?
Dx typically on PE, Imaging done only to r/o other pathology.
Treatment of Trochanteric Bursitis?
- Typically Self-Limiting.
- Rest, Ice, NSAIDs, topical anesthetic path (OTC Salonpas is 4% Lido vs Rx Lido at 5% - don’t Rx).
- CS and anesthetic injection, if does not respond to conservative measures.
Disorder caused by muscles/tendons sliding over bony structures? Who is it common in?
Snapping Hip.
**Athletes and dancers, tweens and twenties.
What is the most common cause of Snapping Hip?
- INTERNAL (most common) – iliopsoas tendon slides over femoral head, iliopectineal eminence, iliopsoas bursa or lesser trochanter.
- Intra-articular – acetabular labral tear and intra-articular loose body (rare).
- External – iliotibial band or gluteus maximus over greater trochanter.
Presentation of Snapping Hip?
- Internal:
- -audible snap or click around the hip.
- -reproducible w/PASSIVE ROM (from flexed ER to extended IR). - 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).
Diagnosis of Snapping Hip?
- XR usually normal.
- U/S = “catch” it in action, aid in injection to r/o other pathology.
- MRI/MRA = may show inflamed bursa.
Treatment of Snapping Hip?
- Activity Modification.
- Tylenol, NSAIDs.
- Steroid injection.
- Rarely surgical:
- -excision of greater troch bursa (external).
- -release of iliopsoas tendon (internal).
Disorder of instability of the proximal femoral growth plate that leads to slippage of the metaphysis?
Slipped Capital Femoral Epiphysis (SCFE) – displacement of the femoral head due to disruption of the growth plate.
**Not common but DO NOT miss.
Cause of SCFE and who gets it?
- *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.
Presentation of Slipped Capital Femoral Epiphysis?
- 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.
Diagnosis of SCFE?
- *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).
Treatment of SCFE?
- 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.
Complications of SCFE?
- *AVN (up to 50% of unstable slips).
* OA
Abnormal development of the hip creates a shallow acetabulum, femoral head cannot fit firmly in the socket? Cause?
Developmental Dysplasia of the Hip (DDH).
*Caused by Ligamentous Laxity and sometimes abnormal position in utero.
What are the different degrees of DDH?
- Dysplasia – shallow/underdeveloped acetabulum (1:100).
- Subluxation – displacement of joint w/some contact remaining b/t articular surfaces.
- Dislocation – complete displacement of joint w/no contact b/t articular surfaces (1:1,000).
Prevalence of Developmental Dysplasia of the Hip?
Typically, present at birth, but may develop in the 1st year.
More common in Girls (6:1); first born, breech, FH, Oligohydramnios.
PE Presentation of DDH < 3 months?
- Palpable “clunk” of subluxation/dislocation on exam.
* *Perform Barlow and Ortolani maneuvers on all newborns up to 3 months.
What is the Barlow Maneuver?
Dislocates the hip by ADDuction and depression of a flexed femur.
**BADD – Barlow ADDuction.
What is the Ortolani Maneuver?
Relocates the hip by elevation and ABDuction of the flexed femur.
**Dr. O is good - relocates the hip.
PE Presentation of DDH >3 months?
- 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.
What is the GALEAZZI Sign?
Pt. lies supine, hips and knees flexed, ONE LEG (at knee) APPEARS SHORTER than the other.
–any limb length discrepancy = ++Galeazzi.
Imaging for DDH?
- *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.
Treatment for Developmental Dysplasia of the Hip?
**< 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.
MOI in Hip Dislocations?
- Typically, high-energy trauma, young adults.
- MVC, fall, High-intensity athletes.
- Often associated w/other injuries.
- -ex: sciatic nerve compression/irritation 2/2 to swelling.
What to do if you pt has a Hx of THA and they are older, Hx of falls or previous dislocations?
Call their joint surgeon!
Clinical Presentation of a Hip Dislocation?
- Acute onset of pain.
- Inability to bear weight.
- Deformity – swelling at hip, flexed, shortened.
- Numbness.
What is important when evaluating a Hip Dislocation?
**Don’t get distracted!
Do a FULL head to toe exam, ATLS guidelines, don’t miss a subtle life-threatening injury.
Presentation of a posterior hip dislocation?
ADDucted, shortened/flexed and internally rotated limp.
Presentation of an anterior hip dislocation?
**RARE.
Superior = extension, external rotation. Inferior = flexion, ABDuction, external rotation.
What makes up the majority of traumatic diagnoses?
Posterior Hip Dislocations (90%).
**aka “Dashboard Injury” - axial load through flexed knee.
What other injury is a posterior hip dislocation associated with?
Posterior wall acetabular Fx (MC), Femoral head Fx.
Sciatic nerve injury in 10-20% of cases.
Diagnosis of Hip Dislocations?
- 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. - CT to eval for femoral neck Fx and acetabular Fx.
- Obtain post reduction complete Pelvis XRs (AP, Judets, Inlet/Outlet views).
What is important in utilizing CT for a hip dislocation?
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.
Treatment of hip dislocations?
- URGENT Closed Reduction should be attempted w/sedation in the ER.
- If unsuccessful, proceed to OR for full sedation and repeat attempt at closed reduction.
- -occasionally, need to OPEN surgically and reduced on presentation. - Staged surgical fixation of assoc. acetabular Fx.
Post-reduction of Hip Dislocation?
- 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.
How do you reduce a hip dislocation?
**Need adequate sedation and relaxation; conscious sedation in the ER.
Posterior Dislocation – “Allis Technique.”
What is the Allis Technique?
*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!
Complications of Hip Dislocation?
- AVN – increases w/length of time to reduction.
- Post-traumatic arthritis.
- Sciatic Nerve Injury**
- Recurrent dislocation.
What is the classic presentation of a hip fracture?
- *Leg shortened and externally rotated.
- Hip/Groin pain w/inability to flex hip/knee.
Etiology of Hip Fractures?
- *Typically, ground level fall.
- Older population, 60+.
- -Can see in younger pt’s w/high-energy trauma.
What is important when a pt presents w/a hip fracture?
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?
Stabilization of a hip fracture before OR?
- BUCK’s Traction (5-10lbs):
- -PRN comfort, muscle spasms and pain relief. - Skeletal Traction for hip dislocations, acetabular Fx, femoral shaft Fx – up to 25 lbs.
Why is important to know where the hip fracture is located?
It will dictate how it is fixed.
Do all hip fractures need to be fixed?
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.
Types of Hip implants?
- Intramedullary Nail (IMN) for IT, Subtroch, +/-basicervical Fx – small incisions, metal rod inside the bone.
- OPEN Reduction Internal Fixation (ORIF)
- -often lgr incisions, reduce Fx and fix it on the inside w/plates and screws. - Arthroplasty for displaced femoral neck fractures.
- -joint replacement: Total (ball and socket) vs Hemi “half” (just the femoral head - “shiny new ball”). - Percutaneous Pinning or Dynamic Hip Screw for non-displaced femoral neck fracture or basicervical.
Goal of Rehab in hip fractures?
**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.
