Hip, Pelvis & Thigh Disorders Flashcards
Sacroiliitis
Etiology (what conditions is it associated with & lead to)
Symptoms & Signs
Etiology
- inflammatory condition of the sacroiliac joint (SI joint)
- can be a result of infection, chronic inflammation or trauma (direct injury or during pregnancy{pressure})
- associated with ankylosing spondylitis & Reiter’s Syndrome (a reactive arthritis 2/2 inflammation)
- over time can lead to : fiberosis of the joint itself, erosin and ossification (soft tissue becoming boney)
Symptoms
- recent trauma, infection, or pregnancy
- pain with prolonged standing
- difficulty climbing stairs
- lower back pain: usually can point directly to SI joint as the location
- weakness of affected side, stiffness (AM)
- extremely frusterating discomfort
Signs
- focal pain at SI joint; worse when palpated
- + FABER test
sacroiliitis
Diagnosis
Treatment
Diagnosis
MRI: gold standard: to see inflammation/bone marrow edema and abscess
X-ray: shows erosion of the joint (AP pelvis)
Labs: WBC (sepsis), ESR/CRP, blood cultures (infection), HLA-B27 (for ank. spond.)
Treatment: tailored to the precipitating event
Infection: admit; IV abx. & then oral Abx. +/- surgical
Trauma: rest, NSAIDS, steroid injections
Pregnancy: symptom managment
Larger spondylopathy: PT, NSAIDS, TNF inhibitors (if a process like AS)
Coccydyina/Coccyx Fracture
Etiology
Risk Factors
Etiology
- pain or fracture of the coccyx bone (tailbone)
- more common in females: because they have a coccyx more posteriorly located
Risk Factors
- obestiy (increase weight on sitting)
- pregnancy
- osteoperosis
- osteomyleitis
usually a result of Trauma: falls: leading to brusied, broken or disloaction & chronic inflammation
- can be repetitive trauma too (over time)
- childbirth
alwasy consider osteoarthritis here, metastatic bone disease & avascular necrosis
Coccydynia/Coccyx Fracture
Symptoms & Signs
Symptoms
- pain when sitting or leaning backwards
- pain when moving from sitting to standing
- discomfort/pain which is loaclized to the tailbone
- always assess infection, malignancy and pelvic disease additional symptoms
SIgns
- external palpation of the area = reproducable pain (HOWEVER, palpation of the surrouding area will NOT produce pain)
- can be painful on internal palation
- assess lumbosacral spine
Coccydyina/Coccyx Fracture
- Diagnosis
- Treatment
Diagnosis
- imaing not always necessary
- X-ray: if pain lasting > 2 months; get AP, lateral and sitting to standing
- MRI (malignacy risk) : inflammation, soft tissue issues
Treatment
Conservative: rest, coccygeal cushion, PT/massage
Fracture: conservative & it will heal
if persistent: local CSI (corticosteroid injection), raidofrequency, coccygectomy
should be treated by a specialist!!
Pelvic Fracture
Etiology
Risk Factors
How they Occur
Etiology
- can be a single (stable) fracture or two fractures (unstable)
- location of fracture can be in the ishium or illum or pubis of pelvis
- high mortaility rate: even moreso if open fracture (usually a trauma)
Risk Factors
- osteoporosis
- smoking
- a prior hysterectomy
- older age (> 60)
- gait disturbances (fall risk)
How They occur
- commonly a trauma: MVA, pedestrian struck or crush injury
- in the eldery, an isolate pubic rami is common due to fall off chair + OP (pubic rami = pubic bones)
Pelvic Fracture
Symptoms & Signs
Symptoms: this will be a trauma call
- always consider a pelvic fracture in those who have had serious blunt trauma & diffuse pain
- in elderly: pain after a fall with associated difficulty walking & sitting
- alwasys ask about last BM, urination, intake and LMP (pregnancy) as the assocaited structures are likely impacted too
Signs (pt. can be unconscious too if trauma)
- nonweight bearing
- unexplained hypotension
- elderly: examine spine, palpate pelvis & always chcek LE for neurovascular compromise (perfusion and dermatomes)
Pelvic Fracture
- Diagnosis
- Treatment
Diagnosis: stable v unstable hemodynamics pt. decides
STABLE: CT scan to see fracture pattern
UNSTABLE & Pelvic Binder on: FAST US + Xray
if GCS is > 13, no pelvic abd. or back pain/tenderness = no xray needed
Elderly fall: start with Xray (AP) and then CT for occult injury
Treatment
- determined by fracture pattern: ring, single bone or acetabular fracture
- immediate ortho consult, wrap pelvis in binder
Types of Pelvic Fractures (3)
Lateral compression : due to a MVA/t-bone or struck pedestrian
- fracture at pubic bone and at the illiac/sacral area on same side (think of side force)
- most common
Anterior-posterior compression aka open book
- think of a head on collision
- force comes from front; through oubic tuberule nad out the back through the ligaments holding the pelvis bottom
Vertical Shear : jump/fall from height
- affects 1 isde of the hip; through the illac/sarcal, pubic and ishum
compounds make up the rest
Femoral Shaft Fracture
Etiology
Symptoms & Signs
Etiology
- a fracture through the mid-shaft of the femur:
- think high energy trauma: younger (GSW)
- think mets or OP: older population (metastsis, osteogenic sarcoma, pathologic fractures)
Symptoms
- trauma call (mostly)
- severe pain, inability to weight bear, recent fall
- hear a “snap” in those with OP when sit-to-stand
Signs
- notable leg length discrepency
- deformity, swelling
- must performa neurovascualr exam: as massive bleeds inot the quad can create compartment syndrome
- always asses hemodynamic stability
Femoral Shaft Fracture
Diagnosis
type of fracture by pattern
Treatment
Diagnosis
- x-ray: gold standard; AP, full femur & AP knee (assess the joint) (try to get lateral too)
- CT: if comminuted (multiple pieces) and complex
Type of Fracture (Pattern)
- transverse
- linear
- nondisplaced (line up edges)
- displaced (dont line up)
- compudn (open)
- spiral
- greenstick (edges, peds.)
- communited (multiple pieces, shattered)
Treatment
- immediate ortho/trauma
- watch vitals for stability
- will need intramedullary nail placement
What is the difference between intracapsular and extracapsular fractures of the hip
INtracapsular: the head of the femur sits in the socket of the acetabulum; a fracutre within this “capusle” will result in a higher likelihood of necrosis & less visable brusing
separation between intra and extra = intertrochanteric line
Extracapsular: below the trochanteric line; more visable brusing
Femoral Neck Fracture
Etiology
Risk Factors
Symptoms and Signs
Etiology
- an intracapsular fracture of the femoral neck
- high mortality after this fracture
- low- energy: direct via fall; or indirect vai muscle pulling weak bone
- high-energy: MVA/fall
- stress frature: everyday stress leads to fracture/edema/swelling overtime
Risk Factors
- age
- poor health
- smoking/alcohol use
- previous fractures
- fall history
- low estrogen (OP)
Symptoms/history
- recent fall (find out if conscious or LOC, chest pain or prior syncope)
- prior hip pain, preinjury ambulation status should be known
- need to know how long they were down from the fall: assess hydration and the pressure ulcer!!
Signs
- intracapsular: meaning minial brusing
- intesen pain with ROM
- tender to palpate @ groin
- shortened limb with external rotation
- if it isnt displaced: they could weight bear
Femoral Neck Fracture
Diagnosis
Treatment
Diagnosis
- X-ray: gold standard: AP, lateral * cross table (medial)
- need to establish via x-ray if displaced or non-displaced
- CT: good for preop planning
- stress fracture: MRI can be good
Treatment
Non-operative: if they are low function (wheelchair bound,etc.) = NWB for 6 weeks (HIGH MORTALIT RISK)
Operative
- non-displacede: CRPP (closed reduction percut. pinning)
- displaced: ORIF or total hip
Intertrochanteric Fractures
Etiology
Symptoms and Signs
Etiology
- a fracture through the intertronchateric line (oblique, between greater and lesser)
- low-energy: 90% from a fall
- high-energy: MVA, tall fall
- extracapsular fracture
NO Stress fractures here: onyl stress fractures at the femoral neck
Symptoms & Signs
- still need to assess how long they were down and assoscaited events (fall, syncope, etc.)
- Extracapsular: therefore lots of brusing
- pain with ROM, and palpation
- shortened limb externally rotate
- can be WB if not displaced
Intertrochanteric Fractures
Diagnosis
Treatment
Diagnosis
X-ray: Gold Standard : AP, later, cross table & internla rotation
- establish if stabel v unstable intertronchanteric
- Stable = lined up well
- un-stable = not linign up (displaced significantly)
- CT: pre-op planning
- CBC: to check for active bleeding into thigh!!!
Treatment
Non-operative: for low demand pts, NWB x 6 weeks high mortality
Operative
- Stable: close reduction pinning
- Un-stable: ORIF or total hip
Femoral Head Fracture
Etiology
Presentation
Diagnosis
Treatment
Femoral Head Fractures: almost always assocaited with a hip dislocation: becuase the head is fracture as its moved out of acetabulum
- MVA: will be a trauma call
diagnosis
X-ray: AP + Judet 45degree
CT: after reduction
Treatment : based on fracture pattern
- stable = closed reduction + observation
- unstable = ORIF in young, total hip in older
Greater Trochanteric Fracture
Etiology
Presentation
Diagnosis
Treatment
Etiology
- occur rarely: due to eccentric muscle contration (too much force- weak bone)
Presentation
- recent fall, tender to palpate at the greater trochanter
Diagnosis
X-ray : gold standard
Treatment
- NWM 3-4 weeks
- if young pt + 1cm+ of displacement of the piece: ORIF
Lesser Trochanter Fracture
Etiology
(common sign of)
Presentation
Diagnosis
Treatment
Etiology
- an avulsion fracture (MC) of the lesser trochanter (tiny side of femur)
- in adolecence: usually due to an iliopsoas contracture
- in eldery/adults: this is PATHOGNOMIC FOR CANCER TO THE BONE: MM, lymphoma
Diagnosis
- X-ray : gold standard
Treatment
- NWB x 3-4 weeks
- arthroscopy
Hip Dislocation
Etiology
native v prostheic
Symptoms
Etiology
- very rare: if happening they will have other associated injuries
Native Hip
- due to high-energy trauma, MVA & posterior dislocation
- posterior (means they will be adductedand internally rotate)
- Symptoms: acute truama, pain, NWB, see deformity
Prosthetic Hip
- low-energy, atraumatic and from doing specific movements too close to surgery
- atraumatic, pain, NWB, clunk
Anterior displacement: the hip will be externally rotate and abducted & extended
posterior displacement: the hip will be internally rotated, adducted and flexed slightly
Hip Dislocation
Diagnosis
Treatment
Diagnosis
- x-ray: gold-standard : AP, Cross-table lateral
- CT for pre-op planning
Treatment
hip needs to be reduced IMMEDIATELY within 12 hours
- if unable to reduce, send to OR for attempt to reduce closed/open
- Abduction pillow needed for them while they heal
Avascualr Necrosis (AVN)
Etiology
Risk Factors
Etiology
- younger ( < 50)
- loss of blood supply to the head of the femur results in death of the bone : collaspe of cartilage & destruction of cortex
- a result of : genetics, metabolic & compromised blood supply (coag disorders, sickle cell, etc.)
RIsk Factors
- glucocorticoids
- bisphosphnoates
- alcohol (men)
- smoking
- post-renal transplant
- lupus (women)
- trauma, sickle cell, radiation, HIV
Avascular Necrosis (AVN)
Symptoms
Diagnosis
Treatment
Symptoms
- groin pain, with thigh and butt pain
- insidious in onset
- weightbearing and moving = painful
- noctural pain is common
Signs
- limited ROM & pain with ROM
- gait issues (compensatory hip swinging)
Diagnosis
- X-ray: AP, frog leg,lateral : see the density and sclerosis (white) within the femoral head
- MRI: early dx. can be seen with edema
Treatment
- can be an outpt. service to consult for surgery (replacement or joint sparing)
- immediate: NWB & pain control
- give vasodilators & bisphosphonates
Trochanteric Bursitis
Etiology
Risk Factors
Symtoms
Etiology
- extremely common, females
- the bursa which sits at the greater trochanter gets infalmmed due to repetitive overload it pinches under the glutes tendon –> bursisits can lead to tendonitis
Risk factors
- female
- knee/back pain (compensation)
- scoliosis, spinal stenosis
- arthritis of hip, knee and foot
- plantar fasciitis
Symptoms
- lateral hip pain at greater troch.
- pain with walking, standing and sit-to-stand
- NIGHTTIME PAIN: cant sleep on side
SIgns
- wathc gait: can compensate
- + FABER test
- pain when standing on one leg
Trochanteric Bursitis
Diagnosis
Treatment
Diagnosis
- US: show distended bursa
- MRI: rule OUT tendon rupture
- x-ray: rule out OA, FAI (impingment), necrosis and a fracutre
Treatment : usually self-limiting
- NSAIDS
- activity modification (PT)
- CSI: steroid injection
- treat comorbities
Femoroacetabular Impingment
Etiology
two types
Etiology
- overlap/running into of the femoral neck and the acetabular rim at the hip
- CAM: which is abnormal curvature of teh femoral head
- Pincer: “hook” of the acetabulum
- CAM morphology and high intesnit sports
SYmptoms
- insidious onset
- sudden episodes of increased pain
- pain worse at 90 degrees flex
- standing decreases the pain
Signs
- clicking with ROM: labral tear
- + FADIR test
FAI (femoroacetabular impig.)
Diagnosis
Treatment
Diagnosis
- X-ray: gold standard : AP pelvis, see CAM and Pincer or both
- MRI: pre-op plan & r/o tear
Treatment
- conserative: PT
- surgery: shae down
Illiotibial Band Syndrome
Etiology
Risk Factors
Symptoms
Etiolgy
- overUSE injury which causes inflammation and pain at the IT band: down to lateral knee
- runners/cycling
Risk Factors
- if they have weak knees: varum (bow-leg)
- running on gradient or increasing miles dramatically
Symptoms
- lateral joint line pain: knee: over the lateral femoral condlye
- pain is WORSE when the foot is striking the ground
Signs
- focal tenderness at the distal ITB
- + Noble test: lat decub postion and ROM
- assess hip and ankle mobility
IT band syndrome
Diagnosis
Treatment
Diagnosis
- can be made clinical
- US: show thicking of the band
- MRI: shown thickening and high signal
Treatment
- acute: rest ICE, NSAIDS
- subacute: PT
- Chronic: steroids, PRP injections
