Hip/Thigh/Pelvis Flashcards
What are the three bones that make up the innominate bone?
What ligaments how the pelvis together?
What vasculature is it important to monitor when the pelvis is involved in trauma?
Innominate:
- Ilium
- Pubis
- Ischium
Ligaments
Sacroiliac
Iliolumbar
Pubic symphysis
Sacrospinous
Sacrotuberous
Vasculature:
Abdominal aorta
Posterior venous plexus* - commonly injured in pelvic fractures
What is the standard imaging of the pelvis in trauma patients?
AP pelvis X-ray
What bones form the acetabulum of the hip?
What are the angles of the hip socket?
Which region of the joint capsule is the thickest? Which is the thinnest?
Fusion of ilium, ischium, and pubis.
Abducted 45 degrees, and anteverted 15 degrees
The joint capsule is thickest anteriorly. Due to the thinness of the posterior capsule - posterior dislocations are slightly more common
How does blood supply to the proximal femur change with age?
0-4 years: medial and lateral femoral circumflex artery as well as the ligamentum teres
Adults: sometimes entirely dependent on the medial femoral circumflex
What are the 5 muscle groups of the hips and which muscles belong to each?
Flexors:
Iliopsoas muscles
Rectus femoris
Sartorius
Extensors:
Semitendinous
Semimembranous
Biceps femoris
Gluteus Maximus
Abductors:
Gluteus Medius
Gluteus Minimus
Tensor Fascia Latae
Adductors:
Adductor Longus
Adductor Brevis
Adductor Magnus
Pectineus
Gracilis
External Rotators:
Piriformis
Superior gemellus
Obturator Internus
Inferior Gemellus
Obturator Externus
Quadratus Femoris
Describe the role of the acetabular labrum.
Deepens the acetabulum to increase stability
When performing a physical exam of the hip what are you looking for during
inspection
palpation
neurovascular status
range of motion
What special tests should be performed?
Inspection:
gait abnormalities
asymmetry in leg length
Trendelenberg sign (weak abductors when standing on ipsilateral leg causes contralateral hip drop)
Palpation:
tenderness
Neurovascular:
- *femoral** arteries
- *popliteal** arteries
- *dorsalis** pedis artery
- *posterior tibial** artery
Special Tests:
FADIR
FABER
OBER
Describe these tests and what they are testing for?
Trendelenberg sign
FADIR
FABER
OBER
Trendelenberg:
performed during inspection
patient stands on one foot, if standing on effected foot and the contralateral hip drops this suggests ipsilateral weakness of the abductors
FADIR:
Pt supine
hip is flexed, ADDucted, and internally rotated
suggests femoroacetabular impingement
FABER:
Pt supine
hip is flexed, ABducted, and externally rotated
suggests sacroiliac joint disease
Ober:
Pt lateral decubitus
Hip is extended and ADDucted
suggests tight IT band
What are the two types of femoracetabular impingements?
What populations do these occur in typically?
What can this lead to?
CAM IMPINGEMENT (young athletes) bump on the proximal anterolateral femoral neck
PINCER IMPINGMENT (middle aged women) overhang of the anterosuperior acetabulum
Can lead to premature hip degeneration
What are the typical symptoms of a femoracetabular impingments?
What are the physical exam findings?
What would you expect to see on AP hip X-rays?
What special film could you order to identify a CAM deformity?
What could be used to assess cartilage and labrum injury?
Symptoms:
pain with hip flexion or sitting sometimes with clicking and catching
Physical:
positive FADIR
Imaging:
CAM: pistol grip deformity (left image)
PINCER: crossover sign
alpha-angle (frog leg lateral): right image
line through center of head and neck with second line through center of head and bump
if greater than 55 degrees this identifies CAM deformity
MRI to show cartilage/labrum
What is the treatment for femoracetetabular impingements with minimal symptoms?
With symptomatic patients without arthritis?
Minimal symptoms:
PT, rest, and NSAIDS
Symptomatic no arthritis:
Arthroscopic labral debridement/repair
Arthroscopic osteoplasty
What is piriformis syndrome?
What are two variations of this?
What are the symptoms?
What are the treatments?
Compression of sciatic nerve by piriformis muscle
- Bipartisan piriformis (split piriformis)
- Aberrant sciatic nerve
pain in posterior gluteal region
FADIR may reproduce symptoms
Treatment
rest, stretching, NSAIDS
occassional injections
rarely surgery to release piriformis
What are the 3 types of snapping hips (coxa saltans)?
What exam findings would you expect?
What diagnostic imaging could be used?
How is this treated?
- External - IT band slipping over greater trochanter
- Internal - iliopsoas over the femoral head or iliopectineal ridge
- Intra-articular - loose bodies
Exam findings:
Observe IT band over greater trochanter
hear internal snapping
Diagnostic:
X-rays and MRIs rule out other
dynamic US to observe the motion
Treatment:
rest, NSAIDs, PT
surgery for recalcitrant cases
What comprises the pelvic ring?
What must occur for displacement?
What ligamentous structures are important to keep the ring in place?
What vasculature is responsible for most hemorrhaging?
Ring made of sacrum and 2 innominate bones with strong ligamentous structures
Disruption at 2 separate places for displacement
Posterior sacroiliac complexes stabilize
Posterior venous plexus responsible for most hemorrhaging
What are the 3 types of pelvic ring injuries?
What are the classifications of each based on?
Anterior-Posterior Compression (APC)
I: symphysis widening <2.5 cm
II: symphysis widening >2.5 cm
III: dislocation of SI joint
Lateral Compression (LC)
I: oblique rami fractures
II: rami fractures and ilium fx/dislocation
III: ipsilateral LC with contralateral APC (mess)
_Vertical Shear (VS)_ hypovolemic shock and mortality at 25%
What injuries typically result in acetabulum fractures?
Anatomically what are vasculature considerations?
High energy in young people and low energy falls in elderly
Corona mortis
anastamosis
external iliac (epigastric) arteries
Internal iliac (obturator) arteries
High risk area during surgery
What imaging is used to assess for acetabulum fractures?
AP pelvis and CT
Judet views (oblique)
Obturator view: anterior column and posterior wall
Iliac view: posterior column and anterior wall
What two anatomical lines are important when evaluating the anterior and posterior column of an acetabular fracture?
Iliopectineal line - anterior column
Ilioischial line - posterior column
Why does the US have the highest incidence of hip fractures?
What is the mortality of a hip fracture at 1 year? What is this closely related to?
What arterial supply is disrupted with every fracture?
What are the different locations of hip fractures?
Aging population
25-30% mortality at one year - closely related to mobility prior to injury
Medial circumflex artery
Locations:
femoral neck
greater trochanter
intertrochanter
subtrochanteric
What are presentations of hip osteoarthritis?
What imaging findings would you expect?
What is the treatment?
Presentations:
pain in hip and joint
functional limitations
limited ROM or pain with ROM
limb shortening
Imaging:
joint space narrowing
osteophyte formation (bone spurs)
subchondral sclerosis and cysts
Treatment:
NSAIDs
cane or walking stick
weight loss
activity mod
injections
Total hip arthroplasty in older
Hip resurfacing in younger
