Hip pain Flashcards
What (4) nerves supply the hip joint?
- femoral & obturator nerves (L2-4)
- superior gluteal nerve & nerve to the quadratus femoris (L4-S1)
Association between glomerulonephritis/any autoimmune conditions & hip pain
Acute glomerulonephritis may have been treated with prednisolone -> this may affect later on with avascular necrosis & osteoporosis.
Total dose is the one that matters. There is a latency for many years before Px.
How do you assess the severity of hip pain?
- is it relieved by painkillers?
- impaired functions? (PADL, DADL, CADL limitations)
- pain at rest?
- does the pain wake the pt up?
- stiffness, clicking/grating, limping, leg weaknes, numbness, paraesthesia
- WOMAC, Oxford hip scores
What are the possible etiologies of local & referred pain to the hip?
Local: bone, joint, soft tissue
Referred: spine, SI joint
Fracture, arthritis, bursitis, tendinopathy, infection, tumour
Risk factors for secondary OA
- Hx of trauma
- other pre-existing joint disease. e.g. gout, inflammatory arthritis, childhood developmental disorders (congenital hip dysplasia, Perthes, slipped femoral epiphysis)
- Prednisolone use
Describe GALS exam
Screening rheumatological examination (Gait, arms, legs, spine)
- Look while standing.
- wasting of quadriceps, hamstrings
- alignment; pelvic tilt, lumbar hyperlordosis, flexed hip posture - observe gait
- antalgic (limp; short leg or pain) - Lying
- feel greater trochanter/gluteal region for tenderness - Move
- Flexion & extension (Thomas test - sensitive for OA)
- IR, ER, abduction & adduction - Special test
- leg length
- Trendelenburg test
- Spine examination
How do you measure apparent & true leg lengths?
- Apparent: from umbilicus to medial malleolus
- True: from ASIS to medial malleolus
What is the Trendelenburg test?
Special test for hip
It tests the gluteal muscles of the stance leg.
If the gluteal abductor muscles are weak, when the other leg is lifted off the floor, there is a tilt of the pelvis due to no compensation (i.e. no contraction of gluteal abductors) from the other (stance) side.
How do you diagnose OA? (Hx, O/E, XR)
Hx: stiffness
O/E: limited ROM esp IR, ER. Lose extension
XR: loss of joint space, osteophytes, subchondral sclerosis, subchondral cyst
Rx goals & details of Rx in OA
Relieve pain & improve mobility
- minimise muscle deconditioning/weakness
- exercise (non-weight bearing; e.g. swimming, cycling)
- 10% weight reduction very effective
- application of local heat before & cold packs after exercise to reduce inflammation & pain
- physio (support devices; e.g. cances, walkers, braces)
Pharm:
- analgesics: paracetamol, tramadol, codeine etc
- NSAIDs. SE: nausea, abdo pain, diarrhoea, gastritis & ulcers +/- GI bleeding (esp if on antiplatelets or anticoag)
- Glucosamine & chondroitin: low evidence
- intra-articular corticosteroid injections: effective in early phase (when inflammatory component exists).
Indications of total hip replacement
Disabling pain with failed non-op treatment
- severe degenerative changes & failure of non-op treatment for 3-6 months
- severe disabling pain; painful hip joint at rest & at night
- severely deformed hip, decreased ROM & function, impaired ADLs
Goal: to relieve pain, correct deformity, restore ROM & ADLs
Discuss medical optimisation pre-op
Preadmission assessment
- FBE, UEC
- Coag screen, blood group & hold
- MSU, MRSA screen (nose, perineum)
- ECG indicated for known IHD
R/v of medical problems:
- ?recent angina
- adequacy of BP control
- symptoms of cardiac failure
Surgeons would NOT accept pts on dual antiplatelets (but most accept only aspirin).
Cx of orthopaedic surgery
- intra op
- early post op
- late post op
- Intra op: injury to neovascular structures, fractures
- Early post op: haematoma, infection, wound dehiscence
- Late post op: dislocation, leg length discrepancy, fracture, loosening (aseptic vs. septic), heterotopic ossification
Indications for inpatient rehabilitation post orthopaedic surgery
- medical Cx, multiple comorbidities, pre-existing functional impairment
- post op weight bearing restrictions
- persistent pain, decreased ROM
- poor social support, poor home environment setup (stairs, difficult access)
Issues post operatively (after orthopaedic surgery)
- post op hospital stay (4days)
- wound Mx
- pain Mx
- rehab
- hip precautions
- anti coagulation
- Cx
- follow up
Post op pain Mx
- regional
- systemic: simple (paracetamol) + opiate (initially parenteral via PCA -> oral slow release to avoid peaks & troughs)
Mx of post orthopaedic operation day 1
- Abx: caphezolin 1g 8hrly (3 doses): prophylaxis
- XR of pelvis AP & hip lateral view
- blood test: FBE, U&E
- PCA analgesia
Discuss options of anticoagulation in post orthopaedic pts
- keep mobile
- chemoprophylaxis: LMW heparin, aspirin, warfarin
- mechanical: foot pump, compression stocking
Hip precautions post-hip operation
- keep the bend at hip less than 90 degrees; no bending forward when sitting, no lifting knees when sitting, no sitting in low chairs e.g. cars
- no crossing of legs
DDx “hip pain” by sites
- buttock
- groin
- anterior thigh
- lateral pelvis
Buttock: lumbosacral spine, hip joint Groin: hip joint, lumbosacral spine, SI joint Anterior thigh: hip joint Lateral pelvis (common): gluteal muscles, trochanteric bursa
Mx of rapidly progressive GN
- underlying cause for post-infectious
- corticosteroids + cyclophosphamide (high dose steroids usually for several months +/- cyclophosphamide)
OR - other cytotoxic agent + plasmaphoresis in select cases
prognosis: 50% recovery with early treatment, depends on underlying cause
A 83yo female px with left ‘hip pain’ for 4/52. PMHx of HT, ‘mild stroke 3 years ago, no residual deficits. Walks with SPS & no falls. Home alone
Pain is lateral pelvis, worse on walking, also present at night in bed when she lies on the Left. No pain when sitting at rest, no red flag symptoms.
O/E: antalgic gait, no axial asymmetry, no leg length discrepancy or muscle wasting. Hip joint movements unrestricted & painless. Locally tender posterior to the greater trochanter
Pain on resisted abduction & resisted internal rotation of the thigh.
Dx?
Gluteus medius tendinopathy (GMT)
- Part of the spectrum of greater trochanteric pain syndrome (GTPS)
- Trochanteric bursitis (alone) is less likely but can co-exist with GMT.
- Tendon tears and calcification may be associated
- These conditions are analogous to rotator cuff tendon degeneration /subacromial bursitis at the shoulder
- Population U/S studies find degenerative tendon changes are common, and are often asymptomatic
Rx of GTPS (greater trochanteric pain syndrome)
- Corticosteroid injection (U/S guided)
- Oral NSAIDs can be trialled
- Simple analgesics (paracetamol)
- Hip abductor strengthening exercises.
