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*Surgery > Hip-Thigh-Pelvis > Flashcards

Hip-Thigh-Pelvis Flashcards

1
Q

What bones make up each innominate?

A

Ilium, pubis, ischium

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2
Q

What are the pelvic ligaments? (5)

A

Sacroiliac, iliolumbar, pubic symphisis, sacrospinous, sacrotuberous

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3
Q

What vasculature is relevant to pelvic anatomy?

A

Abdominal Aorta, Posterior venous plexus (injured during pelvic fractures)

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4
Q

Pelvis Imaging

A

AP of pelvis (trauma standard), Inlet and outlet views

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5
Q

What are some of the relevant landmarks in a pelvic AP?

A

SI joint, iliac crest, ASIS, AIIS, PSIS, PIIS, Superior ramus, Obturator foramen, Ischial Tuberosity, Pubic symphisis, Fovea, Greater/lesser trochanters, Femoral head/neck/fovea, acetabulum, Greater sciatic notch, 5th Lumbar vertebrae, sacrum

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6
Q

Describe the Anatomy of the Hip

A

Socket (acetabulum) is formed by fusion of ilium, ischium and pubis. It is abducted 45* and anteverted 15*. The joint capsule is thick anteriorly.

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7
Q

Compare Femoral Blood supply in child vs adult

A

0-4 years: medial and lateral femoral circumflex and ligamentum teres; Adults: medial femoral circumflex artery

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8
Q

Name the five muscle groups acting on the hip

A

extensors, flexors, abductors, adductors, external rotators

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9
Q

Acetabular Labrum

A

acts to deepen the acetabulum and increase hip stability

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10
Q

Hip Examination

A

Inspection ( leg length discrepancy, gait abnormality, trendelnburg), Palpation, Neurovascular exam, ROM, Special tests

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11
Q

Trendelenburg Test

A

Abductor weakness causing contraleral hip drop when standing on the affected limb

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12
Q

FADIR

A

Flexion, ADduction, Internal Rotation; Positive in femoralacetabular impingement (FAI)

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13
Q

FABER

A

Flexion, ABduction, External Rotation; Positive for SI joint disease

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14
Q

Ober

A

Lateral decubitis, hip extended then abducted; Tight IT Band

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15
Q

FAI (Femoralacetabular Impingement)

A

characterized by abnormal contact b/n femur and acetabulum. 2 types: Cam impingement and Pincer Impingement; premature hip degradation

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16
Q

Cam Impingement

A

Type of FAI that is femur based due to broad femoral neck (young athletes) and usually involves superolateral aspect; AP Hip: pistol grip deformity

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17
Q

Pincer Impingement

A

Type of FAI that is acetabular based due to anterosuperior overhang (middle-aged women); AP Hip: crossover sign

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18
Q

FAI Presentation

A

Sx: Hip/groin pain with flexion, sitting and occasionally mechanically. Exam: reveals limited hip flexion and internal rotation. AP Hip. Frog leg lateral view. MRI for cartilage/labrum assessment.

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19
Q

What is considered a + finding on Frog-legged lateral hip?

A

A angle. Line 1- center of head and neck, line 2- center of head and bump. >55* indicates possible deformity

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20
Q

FAI Treatment

A

PT, rest, NSAIDs for minimally sx. Surgical tx for sx patients WITH mechanical sx WITHOUT arthritis. Arthoscopic labral debridement/repair with osteoplasty (remove neck bump or overhang)

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21
Q

Piriformis Syndrome

A

• Compression of the sciatic nerve by the piriformis muscle. • Compression occurs anterior to the piriformis • Other variations may exist • Bipartite piriformis • Aberrant sciatic nerve • Pain in posterior gluteal region with variable neurogenic symptoms • FADIR places piriformis on stretch and may reproduce symptoms. • Treatment is rest, stretching, NSAIDS, occasional injection and rarely surgery to release the piriformis

22
Q

Snapping Hip (Coxa Saltans)

A
  1. External snapping hip – IT band over the greater trochanter 2. Internal snapping hip – Iliopsoas over the femoral head or iliopectineal ridge 3. Intra-articular snapping hip – loose bodies • Exam – observe IT band over GT, may hear internal snapping • X-rays and MRI to rule out other pathology. Consider dynamic ultrasound • Treat with activity modification, NSAIDS, PT • Surgery for recalcitrant cases
23
Q

Pelvic Ring Injuries

A 
• Very high morbidity and mortality. • 15% for closed fractures, 50% for open fractures • High energy blunt trauma • Often associated with chest injuries, long bone fractures, spine fractures, urologic, head and abdominal injuries  • “Ring” made of sacrum and two
innominate bones stabilized by strong
ligamentous structures
• Displacement occurs when ring is
disrupted in two separate places
• Posterior sacroiliac complex is
important
• Posterior venous plexus responsible for
most hemorrhaging.
24
Q

Young-Burgess Classification

A

• APC (Anterior-Posterior compression) • I: symphysis widening 2.5 cm • III: dislocation of the SI joint • LC (Lateral Compression) • I: oblique rami fractures • II: rami fractures and ilium fracture/dislocation • III: ipsilateral LC with contralateral APC (“windswept”) • VS (Vertical Shear) • Hypovolemic shock and mortality (25%)

25
Q

Pelvic Ring Injury Evaluation

A

Xray: AP, Inlet, Outlet; CT; Labs

26
Q

Pelvic ring Injury Treatment

A

Resucitation, pelvic binder, external fixation, ORIF

27
Q

ORIF (treatment)

A

If pubic diastasis is > 2.5 cm, SI joint displacement > 1 cm, open fractures, or post-partum diastasis > 4-6 cm. • Displaced and unstable fractures
• Surgical approach depends on fracture
type and pattern
• Clinical outcomes closely associated with
reduction of the articular surface

28
Q

Acetabular Fractures

A 
• High energy trauma in young adults
or low energy falls in older adults
• Anatomy
• 45° lateral inclination and 15°
anteversion
• Supported by two “columns” of bone
• Anterior and Posterior
• Corona mortis – anastamosis between
external iliac (epigastric) and internal
iliac (obturator) arteries
29
Q

Evaluation of Acetabulum Fractures

A

• AP pelvis and Judet views (45° rotated) • Obturator oblique – anterior column/posterior wall • Iliac oblique – posterior column/anterior wall • CT of the pelvis

30
Q

Radiograph Eval of Ace Fracture

A

Radiographic evaluation • Ilioischial line – posterior column • Iliopectineal line – anterior column

31
Q

Non-operative Tx of Ace Fracturs

A

• Protected weight bearing 6-8 weeks • Indicated for high surgical risk patients • Minimally displaced or stable fractures

32
Q

Hip Dislocation

A 
Rare; Posterior (90%)
• Occurs with axial loading the femur with
hip flexion and adduction
Anterior
• Abduction and external rotation of the hip
• Inferior – obturator
• Superior – pubic
Radiographs and CT to determine
direction
• CT should be obtained post-reduction
• Femoral head fractures, loose bodies,
acetabulum fractures
33
Q

Tx of Hip Dislocation

A

• Closed reduction within 6 hours • Risk of avascular necrosis (AVN) • Up to 40% • Increases with delay • Post reduction of the hip • Protected weight bearing

34
Q

Femoral Neck Fracture

A 
• U.S. has highest incidence of hip
fractures
• Increasing due to aging population
• 25-30% mortality at one year
• Closely related to pre-injury mobility
• Blood supply of femoral head is through
the medial femoral circumflex artery; Disrupted with fracture
Presentation
• Depends on the fracture pattern and
displacement
• Pain in hip or groin
• Limb shortened and externally rotated
• May present with ipsilateral femoral shaft
fracture (5% of the time)
35
Q

Garden Classification

A

• Type I – incomplete, valgus impacted • Type II – complete, non-displaced • Type III – complete, partially displaced • Type IV – complete, displaced

36
Q

Treatment of Femoral Neck Fractures

A

Non-operative treatment (Reserved for non-surgical candidates), ORIF (Young patients with displaced fracture • Considered surgical emergency • Reduction must be anatomic to reduce risk of AVN), Cannulated screw fixation (Garden I and II in older patients), Hemiarthroplasty (partial hip replacement, Debilitated, elderly patients • Without pre-existing arthritis), Total hip arthroplasty (Garden III and IV in older patients • Results more predictable than hemiarthroplasty)

37
Q

Intertrochanteric Femur Fractures

A

Extracapsular fracture of the proximal femur between the greater and lesser trochanters • Mostly lower energy falls in older patients • Present with painful shortened, externally rotated limb • Surgical timing • Within 48 hours will decrease mortality at one year • Must be performed when medically stabilized/optimized with medical comanagement

38
Q

Tx of Intertrochanteric Femur Fracture

A

Non-operative treatment (Reserved for non-surgical candidates), Sliding hip screw (Failure related to the tip-apex distance >25 mm), Intramedullary hip screw (Equivalent outcomes • More indications in more severe fractures)

39
Q

Femoral Shaft Fractures

A

• High energy injuries, high speed motor vehicle crashes, younger patient population • Associated with femoral neck fracture (5%) • Often “missed” (up to 30%) • Evaluation similar to trauma evaluation • Present with pain in thigh • Record neurovascular examination • Radiographs • Should include entire femur including the hip

40
Q

Tx of Femoral Shaft Fractures

A

Antegrade intramedullary nail (Considered the “gold standard” • Performed within 24 hours will decrease pulmonary complications • Exception in the setting of head injury and multitrauma), Retrograde intramedullary nail (ipsilateral femoral neck fracture • Floating knee (ipsilateral tibial shaft fracture) • Ipsilateral acetabulum fracture), External fixation (Temporary fixation in multi-trauma, vascular injury, severe open fracture)

41
Q

Hip Osteoarthritis

A

• Pain in the hip and groin region leading to functional limitations • Limited ROM, pain with motion, limb shortening • Radiographs: joint space narrowing, osteophyte formation, subchondral sclerosis and cysts. • Treatment: NSAIDS, cane or stick, weight loss, activity modification, injections • If recalcitrant, consider hip resurfacing in young patients and total hip arthroplasty in older patients

42
Q

Femoral Head Avascular Necrosis

A

• Disruption of the blood supply of the femoral head leading to bone necrosis • Present in 10% of total hip arthroplasties; Bilateral in 80%; Direct or indirect

43
Q

Direct Avascular Femoral Head Necrosis

A

irradiation, trauma, blood disorders (leukemia, lymphoma), decompression sickenss, sickle cell disease

44
Q

Indirect Avascular Femoral Head Necrosis

A

Alcoholism, hypercoaguable states, steroids, Systemic Lupus erythematosus, transplants, viral disorder, protease inhibitor, idiopathic

45
Q

Evaluation and Tx of Fem Head Avascular Necrosis

A

Evaluation includes radiographs and MRI • Ficat Classification • Treatment • Pre-collapse: core decompression • Post-collapse: total hip arthroplasty

46
Q

Total Hip Arthroplasty- Direct Anterior

A

• Interval between fascia lata and sartorius • Does not violate the abductor musculature • Lower risk of dislocation (compared to posterior)

47
Q

Total Hip Arthroplasty- Direct Lateral

A

• Splits the vastus lateralis and the gluteus medius • May lead to postoperative limp

48
Q

Total Hip Arthroplasty- Posterior Approach

A

• Releases the short external rotators • Risk of dislocation reduced with repair

49
Q

Total Hip Rehab

A

Depends on approach • Posterior: avoid flexion beyond 90, extreme internal rotation, adduction beyond midline • Lateral: avoid extension, extreme external rotation, adduction • Anterior: avoid bridging, extension, extreme external rotation, adduction; Pain management with multimodal approach
• Physical therapy until patient is independent
with ADLs, ambulation, transfers

50
Q

Total Hip Complications

A

• Aseptic Loosening • Loosening of the femoral component due to osteolysis • Begins with prosthesis micromotion, particular wear debris, then macrophageactivated osteolysis • Pain with weightbearing • Radiographs of the hip reveal a 2 mm rim of lucency around the femoral component • Labs often normal (ESR, CRP) • Bone scan will reveal increased uptake • Treat with revision THA if symptomatic

*Surgery (9 decks)

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