Hip Trauma: AVN, THR, Dislocation, Greater Trochanter Pain Syndrome

Question 1

AVN
-causes
-presentation
-investigations
-management

Answer 1

Long term CS
Chemo
ETOH excess
Trauma

Asymptomatic => pain in affected joint (anterior)

Osteopenia, microfractures => collapse of articular surface (crescent sign)

Xray
MRI

Joint replacement

Question 2

Hip fractures
-risk factors
-classification
-presentation
-investigations

Answer 2

Older women with osteoporosis
Past #
Falls
Smoking, ETOH, physical inactivity

Intracapsular - femoral head/neck
Extracapsular - inter/subtrochanteric
Garden classification - 3, 4 have blood supply disruption

Pain, short and externally rotated leg
If non-displaced/incomplete => may weight bear

AP, L Xray
MRI if inconclusive

Question 3

Hip fracture
-management

Answer 3

Intracapsular
Undisplaced
-IF
-Hemi - unfit

Displaced => THR or Hemi
-THR if independent walking with no more than stick, no cognitive impairment, surgically/anaesthetic fitness

Extracapaular
Stable intratrochanteric - DHS
Reverse oblique, transverse, subtrochanteric - IMD

Post surgery => full weight bearing immediately

Question 4

Hip fracture
-fracture specific complications and how to address them

Answer 4

Nonunion => revision surgery, bone grafts, bone stimulating agents

Malunion => surgical correction to restore function, reduce pain

AVN => joint preservation/replacement

Hardware related complications => reoperation
-implant failure, loose, migration leading to persistent pain

Leg length discrepancy => if symptomatic and significant, surgery
-gait abnormalities, potential back pain

Question 5

Hip dislocation
-most common types and presentation
-management
-complications

Answer 5

MAJORITY POSTERIOR - short, adducted, internal rotation
Anterior - abducted, external rotation, leg not short
May involve sciatic/femoral nerve injury

A-E assessment
Analgesia
Reduction under GA within 4hrs to reduce AN risk
-takes 2-3months to fully heal after traumatic dislocations
-prognosis best when reduced U12hrs after injury

Sciatic/femoral nerve injury
AVN
Osteoarthritis
Recurrent dislocations

Question 6

Greater trochanteric pain syndrome/trochanteric bursitis
-pathophysiology
-presentation

Answer 6

Muscle and tendon injury of gluteus medius/minimus, inflammation of trochanteric bursa

Chronic, intermittent lateral hip/thigh/buttock pain worsened by
-weight bearing activity - action of GMed/Min
-lying on affected side
-palpation
Some radiation to knee
Positive Trendelenburg

Clinical diagnosis

Self limiting
Reduce compressive forces on greater trochanter and gluteal tendons
-weight loss
-rest, avoiding excess hip adduction
Strengthen gluteal muscles (hip abductors)
-physio
Analgesia - paracetamol, NSAID, icepacks

Question 7

Acetabular labral tear
-what is it
-presentation
-investigations
-management

Answer 7

Damage to the cartilage of acetabulum
-often anterior
-sudden major trauma
-repeated minor trauma
Risk factor for premature OA

Hip/groin pain => worsens with time
exacerbated by prolonged walking, sitting, activity
Snapping sensation around hip
Locking, reduced ROM

MR arthrogram with contrast
GOLD STANDARD - diagnostic laparoscopy

Physio - strengthening around hip, thigh, back
-limit activity that triggers pain
NSAIDs, IAS

Surgical repair if
-tear found on arthoscopy
-4wks of symptoms with findings on MRA

Question 8

Femoroacetabular impingement
-what is it
-presentation
-investigations
-management

Answer 8

Abnormal contact between femoral head and aceetabulum causing damage to labrum and pain
-abnormal bone development
INCREASED RISK OF LABRAL TEAR AND OA

Groin pain, exacerbated by specific activities
Snapping, locking, clicking
Reduced ROM

Physical examination - recreate pain
Xray, CT - bony abnormalities
MRI - acetabular abnormalities

NSAIDs
Surgery - joint damaged by FAI and no improvement with NSAIDs
-arthoscopy