Hip & Thigh Flashcards
Outline the history of hip pain.
Location: groin, buttock
- ant. = femoral nerve
- pos. = sciatic nerve
- lat. = superior gluteal nerve
- “inside” = obturator nerve
Timing:
- rest = biological pain
- exercise = mechanical pain
Progression:
- acute/traumatic
- gradual/degenerative
Night pain
Outline the history of hip stiffness.
Start-up stiffness = occurs in morning/after period of rest but improves after beginning activity
Difficulty reaching foot (thigh flexion req. - differentiate from knee stiffness)
Getting in/out of car/bath
Outline the red flags of hip pain.
Severe night pain
Inability to bear weight
Hx of malignancy
Rapid deterioration of symptoms
Outline the examination of the hip.
LOOK: wasting, alignment and orientation, scars, limb length, gait
FEEL:
- tenderness: greater trochanter, areas of hip
- pulses: pos. tibial, dorsalis pedis
MOVE:
- flexion/extension
- abduction/adduction
- external/internal rotation
Special tests:
- psoas snapping
- ITB snapping
- hip impingement
Describe the features of different types of gait.
Antalgic = short stance phase on affected side, lurch of trunk towards affected side
Trendelenburg = pelvis on opposite side drops, trunk lurches towards affected side
Short leg = up on long leg, down on short leg
Fixed flexion = hyperextended lumbr spine so bum sticks out, positive Thomas test
Outline the special tests of the hip.
Psoas snapping = patient lies on unaffected side with pad under buttock so affected hip is held in adduction, knee flexed whilst hip actively flexed and extended —-> iliotibial band flicking over rgeater trochanter in snapping hip syndrome
ITB snapping = patient lies on unaffected side with hip and knee flexed at 90 degrees, examiner puts knees at 5 degrees flexion and fully abducts limb —> tight ITB causes leg to remain abducted and patient experiences lat. knee pain
Hip impingement = flex hip and internally rotate —> recreates hip pain when the labrum of the acetabulum is impinged by osteophytes of the femoral head/acetabulum
What are the examination features of hip fracture?
Hx of trauma
Severe pain
Inability to weight bear
What are the examination features of hip OA?
Gradual onset and progression
Pain/stiffness/lack of function
Other features of OA e.g. Heberden’s nodes
X-ray features e.g. subchondral cysts, reduced joint space, osteophytes, sclerosis
What is trochanteric bursitis?
Minor tears in surrounding muscles or fascia OR inflamed bursa causes pain in other thigh and hip
Differentials: degeneration, tendinitis, referred back pain
What is femoral acetabular impingement?
Osteophytes developing around femoral head/acetabulum cause tearing of labrum so labrum becomes trapped under acetabulum
Pain with flexion, adduction, and internal rotation
What are the features of hip infection?
S&S = severe pain, systemic sepsis, very stiff and unable to bear weight
Ix = normal X-ray, USS shows fluid, increased CRP and WCCs, increased temp.
Young = confused with growing pains or transient synovitis
Risk of destroying cartilage
Urgent decompression and washout req.
What are the features of developmental hip dysplasia?
Shallow acetabulum prevents femoral head from firmly fitting acetabulum +/- stretched ligaments
Causes hip instability
Screened for using Barlow’s and Ortolani’s tests
Diagnosed at birth —> put in Pavlik harness to hold hips in abduction and flexion for 12wks
What is Barlow’s test?
Adduction and depression of femur dislocates hip in developmental hip dysplasia
What is Ortolani’s test?
Elevation and abduction of femur relocates a dislocated hip
What is Perthes’ disease?
Avascular necrosis of growing bone compreses living cartilage, causing osteochondritis of proximal femoral epiphysis causing osteonecrosis of femoral head
What is slipped upper femoral epiphysis?
Fracture in growth plate of upper femoral epiphysis
Femoral epiphysis slips, head remains in acetabulum but neck displaces anteriorly and externally rotates
What lines of on an X-ray can hint at a hip or pelvic fracture?
Line through centre of femoral heads (cutting through greater trochanters) should be equal on both sides
Line through ischial tuberosities (cutting through lesser trochanters) should be equal on both sides
Shenton’s line: medial edge of femoral neck curving into superior pubic ramus
Iliopectineal line
Ilioischial line
What are the margins of the capsule of the femur?
Ant. = intertrochanteric line
Pos. = 1 finger superomedial to intertrochanteric crest
What is the management of an undisplaced intracapsular neck of femur fracture in a young fit patient?
Attempt to fix with dynamic hip screw
30% change of avascular necrosis —> screw slides out of end of barrel —> total hip replacement indicated
What is the management of an intracapsular neck of femur fracture in an old patient not fit for multiple operations?
Total hip replacement IF:
- able to mobilise independently with no aids other thn stick
- no cognitive impairment
- fit for anaesthesia and surgical procedure
What are the complications of a total hip replacement?
Will fail eventually (depends on activity and weight)
Dislocation
Infection
What are the signs of a NOF fracture and why?
Externally rotated, adducted, shortened leg
Iliopsoas (usually flexes, adducts, and internally rotates hip) axis of rotation changed by fracture —> externally rotates
What is the management of an extracapsular fracture in a young patient?
Extramedullary fixation
Sliding hip screw
What is the management of an extracapsular fracture in an old patient?
Intramedullary nail OR hip replacement
What are the complications of hip fixation?
- fibrous noun-union (failure to achieve adequate mechanical stabilisation so screws slide out)
- late avascular necrosis
- acetabular erosion
- dislocaton
- fracture
- infection
etc.
What is the management of femoral fractures?
Reduce fracture early
- initally with skin traction e.g. Thomas splint
- internal fixation: intramedullary nail
OR open reduction internal fixation (ORIF)
What is the management of patellar fractures?
Straight leg raise:
- positive = conservative Mx
- negative = ORIF or tension band wire
