Hip pathology

Question 1

OA on xray

Answer 1

Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts

Question 2

RF for OA

Answer 2

Age > 45 yrs old 
Female
Ethnicity - African
FHx 
Obesity 
Trauma 
Malalignment - developmental dysplasia 
Infection - sepsis 
Inflammatory arthritis - RA, ankylosing spondylitis 
Gout 
DM - charcot foot

Question 3

Presentation of OA

Answer 3

Ache exacerbated by movement, relieved by rest
Pain radiates to knee
Reduced ROM - difficulty putting socks on
Crepitus
Stiffness - less than 1 hr in morning

End stage OA:
Fixed flexion deformity
Trendelenurg gait

Question 4

Pathophysiology of OA

Answer 4

Non-inflammatory damage to the hyaline cartilage due to excessive uneven loading.

1. Swelling - increased proteoglycan synthesis
2. Flaking and fibrillation - softer and less elastic
3. Loss of hylaine cartilage
4. Eburnation - subchondral bone thickens

Question 5

Treatment of OA

Answer 5

Conservative:

• weight reduction
• avoid sports that precipitates pain
• walking aid
• analgesia
• hot water bottle
• strengthening + exercise

Surgery:

• arthroscopy
• total or hemiarthroplasty
• steroid injection

Question 6

3 types of NOF

Answer 6

Intracapsular - between head and intertrochanteric line

Extracapsular:

• intertrochanteric - involves lesser trochanter
• subtrochanteric - within 5cm of lesser trochancter

Question 7

Intracapsular fracture summary

Answer 7

Fracture of femoral neck involving capsule
Likely to disrupt the medial femoral circumflex artery causing avascular necrosis

Mx:

• hemiarthroplasty - if elderly with low mobility
• total hip replacement - if good mobility
• Cannulated screws - if less than 60 as hip replacement lasts 10 - 15 years

Question 8

RF for NOF fracture

Answer 8

Menopause - osteoporosis

Question 9

What position would NOF leg be in

Answer 9

Shortened
Slightly abducted
Externally rotated

Question 10

Symptoms of NOF fracture

Answer 10

Reduced mobility
Inability to bear weight
Pain in hip, groin and knee

Question 11

Most common way to dislocate hip

Answer 11

Posteriorly

Question 12

Causes of hip dislocation

Answer 12

Developmental dysplasia

Trauma - high energy

Question 13

Complications of hip dislocation

Answer 13

Sciatic nerve palsy

Question 14

Position of leg with dislocated hip

Answer 14

Shortened
Slightly flexed
Adducted
Internally rotated

Question 15

Central hip dislocation

Answer 15

Head of femur driven into acetabulum.
Always fracture and dislocation
Requires hemiarthroplasty or total hip replacement

Question 16

Investigations of hip fracture

Answer 16

AP and lateral hip Xray
Bloods - FBC, U+Es, coagulation, group + save, CK if rhabdomyolysis suspected
ECG - cause of fall
Urine dip - WCC - UTI may cause confusion and fall
CXR - anaesthetic
Hip Xray

Question 17

Shenton’s lines

Answer 17

If disturbed - fracture

Question 18

Extracapsular fracture mx

Answer 18

Internal fixation:

Intertrochanteric - Dynamic hip screw
Subtrochanteric - Inter medullary nail

Question 19

Protection against osteoporosis

Answer 19

Bisphophonates
Calcium and Vitamin D
Thyroid function control
Prevent falls

Question 20

Post surgery risks

Answer 20

DVT - TED compression stockings and LMWH bridging stopped 12 hrs before surgery

Question 21

How to assess mx of hip and knee OA

Answer 21

Oxford hip/knee score

Question 22

Ix for OA

Answer 22

Bloods - FBC, U+Es, LFTs, ESR, CRP

Xray

Question 23

Hand changes in OA

Answer 23

Herbeden’s nodes
Bouchard’s nodes
Square thumb

Question 24

Leg changes in OA

Answer 24

Fixed flexion deformity

Varus deformity

Question 25

RA

Answer 25

Autoimmune inflammatory response causing symmetrical polyarthropathy commonly of small joints

Question 26

RF for RA

Answer 26

Smoking Genetics - HLA DR 60+ yo Women

Question 27

Presentation of RA

Answer 27

``` Morning stiffness that occurs longer than 1 hr Swelling of joints especially hands Symmetrical Rheumatoid nodules Abnormal serum RF Erosions on Xray ```

Question 28

Tratment of RA

Answer 28

Conservative: - weight loss - Smoking cessation - occupational therapist Pharmacological: Paracetamol NSAIDS DMARDs

Question 29

DMARDS

Answer 29

Methotrexate - 1st line | Sulfasalazine

Question 30

Perthe's disease presentation and pathophysiology

Answer 30

Idiopathic avascular necrosis of femoral head ``` Presentation: Pre - puberty - 4 - 8 yo M>F 5:1 Progressive hip pain - weeks Limp Stiff and reduced ROM ```

Question 31

Septic arthritis presentation

Answer 31

Pyrexia Drowsiness Pain Limited ROM

Question 32

Developmental dysplasia

Answer 32

Congenital hip joint deformity in which the femoral head is or can be completely / partially displaced. More common in females Often identified in newborns with Barlow's test or Ortolani's test - unequal skin folds and leg length

Question 33

Transient synovitis

Answer 33

Acute hip pain associated with viral infection commonly in children ages 2 -10 yo Settles after 2-3 days

Question 34

SUFE

Answer 34

Slipped upper femoral epiphysis - postero - inferiorly - ages 10 - 15 - obese males Causes pain radiating to knee or distal thigh Loss of internal rotation of the leg in flexion Symptoms over weeks to months

Question 35

Garden classification of intracapsular NOF fractures

Answer 35

I - Non displaced, incomplete II - Non displaced, complete III - Partially displaced, complete IV - Fully displaced, complete

Question 36

Investigations for developmental dysplasia of hip

Answer 36

* Screening * Asymmetric skin folds * Limp / abnormal gait * US is v. specific

Question 37

Mx of developmental hip dysplasia

Answer 37

``` Mx: maintain abduction • Double nappies • Pavlik harness • Plaster hip spica • Open reduction: derotation varus osteotomy ```

Question 38

Perthe’s disease X-ray

Answer 38

Decreased femoral head size and flattening

Question 39

Complications of hip fracture

Answer 39

Joint dislocation Aseptic loosening Peri-prosthetic fracture Deep infection/prosthetic joint infection