HIPS Flashcards
Articulating surfaces of the hip?
Head of femur
Acetabulum of the pelvis - has an acetabular labrum
Both covered in articualr cartilage
Intracapsular ligaments of the hip?
Ligament of head of femur
Extracapsular ligaments of the hip?
Anterior:
Iliofemoral ligament
Pubofemoral ligament
Posterior:
Ischiofemoral ligament
What is the ligament of head of femur? What does it contain?
It runs from the acetabular fossa to the fovea of the femur
It encloses a branch of the obturator artery
Where is the iliofemoral ligament found?
Arises from the anterior, inferior iliac spine and then bifurcates before inserting into the intertrochanteric line of the femur
Where is the pubofemoral ligament found?
Runs between the superior pubic rami and the intertrochanteric line of the femur anteriorly
Where is the ischiofemoral ligament found?
Runs between the body of the ischium and the greater trochanter of the femur posteriorly
Function of the iliofemoral ligament?
Prevents hyper extension of the hip joint
Function of the pubofemoral ligament?
Prevents excessive abduction and extension of the hip joint
Function of the ischiofemoral ligament?
Prevents hyper extension and holds the femoral head in the acetabulum
Arterial supply to the hip joint?
Medial and lateral circumflex femoral arteries that anatstamose at the base of the femoral neck to form a ring
The medial circumflex artery is repsonsible for the majority of the arterial supply
The artery to the head of femur and superior/infeiror gluteal arteries also provide some additional supply
Which nerves innervate the hip?
Sciatic, femoral and obturator nerves
Why can pain in the hip be referred to the knee?
As the sciatic femoral and obturator nerves supply both the hip and the knee
Stabilising factors for the hip?
Acetbulum is deep and encompasses nearly all of the head of femur
Acetabular labrum increases the depth and provides a larger articular surface
Iliofemoral, pubofemoral and ischiofemoral ligaments - have a unique spiral orientation which causes them to become tighter when the joint is extended
What movements can the hip do?
Flx/ext
Abd/add
Lateral and material rotation
Which muscles help carry out hip flexion?
Iliopsoas, rectus femoris, sartorius and pectineus
Which muscles help carry out hip extension?
Gluteus maximus
Hamstrings (Semimembranous, Semitendinous, Biceps femoris)
Which muscles help carry out hip abduction?
Gluteus medius and minimus
Piriformis
Tensor fascia latae
Which muscles help carry out hip adduction?
Adductor longus, brevis and Magnus
Pectineus
Gracilis
What does the degree to which flexion at the hip can occur depend on?
Whether the knee is flexed or not
When the knee is flexed, the hamstrings muscles are relaxed and the range of flexion is increased
What causes hip dislocations?
Trauma mostly - RTAs and significant falls from height
Can be a complication of total hip replacements
Congenital hip dislocations can be a cause - spectrum of DDH
What % of all hip dislocations do posterior dislocations account for?
90%
Position of leg following a posterior hip dislocation?
Affected leg is shortened, adducted and internally rotated
Position of leg following a anterior hip dislocation?
Leg is abducted and externally rotated
Types of hip dislocation?
Posterior
Anterior
Central
Clinical presentation of any hip dislocation?
Significant clunk/popping followed instantly by severe pain
Physical deformity
Inability to walk from pain
May be possible neurovascular injury
What is an important complication of posterior hip dislocations?
Sciatic nerve injury - in 10-20%
This is because the sciatic nerve runs posteriorly in the hip joint
Management of hip dislocations?
ABCDE approach
Analgesia
Reduction under GA within 4 hours
XR of hip following reduction
PT long term to strengthen surrounding g muscles
Why must reduction of a hip dislocation be done within 4 hours?
To reduce the risk of a vascular necrosis
Complications of hip dislocations?
Sciatic or femoral nerve injury
Avascular necrosis
Osteoarthritis: more common in older patients.
Recurrent dislocation: due to damage of supporting ligaments
Prognosis of hip dislocations?
2-3 months for hip to heal
Prognosis is best when the hip is reduced <12 hours post-injury and when there is less damage to the joint
What is avascular necrosis of the hip?
A type of osteonecrosis
Death of bone tissue secondary to loss of the blood supply which leads to bone destruction and loss of joint function
Possible causes of avascular necrosis of the femoral head?
Trauma - hip dislocations or fractures
Alcohol excess - can decrease blood supply to the bone
Chemotherapy
Long-term steroid use
Presentation of avascular necrosis of the hip?
initially asymptomatic
pain in the hip that may radiate to the groin or thigh. Aggravated by walking/climbing stairs and alleviated by rest.
Investigation for avascular necrosis of the hip?
MRI is investigation of choice
XR can be done but may be normal initially.
Possible findings on plain XR of the hip following avascular necrosis?
Osteopenia and micro fractures may be seen early on and then collapse of the articular surface may result in the crescent sign
Management of avascular necrosis of the hip?
Conservative management e.g. alcohol cessation, discontinuing steroids, analgesia
Core decompression - surgical drilling into ares of dead bone to reduce pressure and allow for increased blood flow
Joint replacement may be necessary
Epidemiology of hip fractures?
> 65,000 hip fractures each year in the UK
Becoming increasingly frequent due to an aging population
Mortality following a femoral neck fracture is up to 30% at 1 year
50% of pts become less independant following a hip fracture
What causes neck of femur fractures?
Low energy injuries are the most common type e.g. fall in frail older pt
Risk factors for neck of femur fracture?
Female
Increasing age
Osteoporosis
Where does a fracture occur for it to be considered a “neck of femur” fracture?
From subcapital region of the femoral head to 5cm distal to the less trochanter
What are the 2 distinct areas of the neck of femur?
Intracapsular and extra-capsular
What is the intra-capsular region of the neck of femur?
From the subcapital region of the femoral head to the basocervical region of the femoral neck, immediately proximal to the trochanters
What are the 2 regions of the extra-capsular region of the neck of femur?
Inter-trochanteric - between greater and lesser trochanter
Sub-trochanteric - from the lesser trochanter to 5cm distal to this point
Describe the blood supply to the neck of femur?
It is retrograde, passing from distal to proximal along the femoral neck to the femoral head…
The medial and lateral circumflex femoral arteries join the femoral neck just proximal to the intertrochanteric line. Branches of this artery run along the surface of the femoral neck within the capsule towards the femoral head
Which hip fractures are at greatest risk of avascular necrosis of the femoral head?
Displaced intra-capsular fractures - this is because they disrupt this blood supply to the femoral head
What is considered an intra-capsular hip fracture?
One which affects the femoral neck proximal to the intertrochanteric line
What classification is used for intra-capsular fractures?
Garden classification:
Grade 1 - incomplete fracture and non-displaced
Grade 2 - complete fracture and non-displaced
Grade 3 - partial displacement (trabeculae at an angle)
Grade 4 - full displacement (trabeculae are parallel)
Consider the garden system… which types of intracrapsular neck of femur fractures are most at risk of disrupting the blood supply?
Types 3 and 4 (any displaced fractures)
Management of a non-displaced intra-capsular neck of femur fracture?
Internal fixation with cannulated hip screws
Or hemiarthroplasty if unfit
Management of displaced intra-capsular neck of femur fractures?
Hemiarthroplasty
Total hip replacement
Which patients with displaced intracapsular hip fractures should be managed with a total hip replacement rather than a hemoartroplasty?
If they were able to walk independently out of doors with no more than the use of a stick and
are not cognitively impaired and
are medically fit for anaesthesia and the procedure.
What is a hemiarthroplasty?
It’s a partial hip replacement
Replacing the head of the femur but leaving the acetabulum in place
Cement is used to hold the stem of the prosthesis in the shaft of the femur
Management of intertrochanteric fractures?
Dynamic hip screw
What are dynamic hip screws?
A screw is inserted into the neck of the femur, a side plate and several cortical screws that are fisted into the proximal femoral shaft
Management of subtrochanteric neck of femur fractures?
Intramedullary device (a metal rod in the medullary cavity of the bone)
How do hip fractures present?
Often trauma followed by…
Pain in groin or hip, that may radiate to the knee
Not able to weight bear
Shortened, abducted and externally rotated leg
Investigations for suspected hip fracture?
Assess neurovascular status of leg
XR hip and pelvis (MRI or CT if XR is negative but fracture still suspected)
Bloods - FBC, U&Es, coagulation screen, group and save (CK if long lie)
Other investigations to discover reason for fall
What is a key sign on an XR that there is a hip fracture?
Disruption of Shenton’s line
Genera management of fractured neck of femur?
A-E assessment
Analgesia
Surgical management - within 48 hours of admission
Rehabilitation with PT and OT following surgery
Complications following a neck of femur fracture?
Joint dislocation
Avascular necrosis of femoral head
Aseptic loosening
Peri-prosthetic fracture
Infection
Development of leg length differences -> changes in gait or chronic pain
Mortality - 30% at 1 year
What usually causes an acetabular fracture?
High-energy injury e.g. RTA or fall from height
What are Morel-Lavellee lesions?
An internal devolving injury
The skin a nd subcutaneous tissues are abruptly separated from the underlying fascia due to trauma. A potential space is produced superficial to the fascia and can fill with fluid
Often associated with pelvic, acetabular and proximal femur fractures
What is greater trochanteric pain sundrome?
A regional pain syndrome in which chronic, intermittent pain is felt around the greater trochanter
Used to be known as trochanteric bursitis but now its shown that pain us due to micro injuries to the gluteal muscles and tendons
What causes greater trochanteric pain syndrome?
Inflammation or physical trauma in muscles/tendons/fascia/bursae in the hip:
Most commonly tendinopathy or a muscle tear of gluteus medius, minimus or a trochanteric bursitis
There is often co-existence of bursitis and tendinopathy
Less commonly it can be caused by ITB thickening or septic trochanteric bursitis
Main causative factors: repetitive activity, mechanical overload, training errors, sedentary lifestyle etc
Pathophysiology of greater trochanteric pain syndrome?
Repetitive friction between the greater trochanter and iliotibial band causes microtrauma in the greater trochanter at the level of infection with the gluteal tendons = inflammation, degeneralisation of tendons and increased tension on the ITB
Presentation of greater trochanteric pain syndrome?
Chronic lateral hip/thigh/buttock pain that can be intermittent or persistent
Onset is usually gradual and progressively worsens over time
Pain may radiate down the lateral aspect of the thigh, but not below the knee
Pain is aggravated by physical activity and pressure on that side of the body
Pain on palpation of greater trochanter
What tests can be done for greater trochanteric pain syndrome?
FABER test
FADER test
Resisted active abduction causes pain
Resisted internal and external rotation causes pain
What is the FABER test?
Hip Flexion ABduction and External Rotation test
The lateral malleolus of the test leg is placed above the patella of the contralateral leg, the pelvis stabilized via the opposite anterior superior iliac spine and the knee passively lowered so the hip moves into abduction and external rotation. If there is lateral hip pain, the test is positive for greater trochanteric pain syndrome
What is the FADER test?
Hip Flexion, ADuction and External Rotation test
With the person lying supine, the hip is passively flexed to 90°, adducted, and externally rotated to end of range. If there is lateral hip pain, the test is positive for greater trochanteric pain syndrome
Who is greater trochaneric pain syndrome most common in?
Women aged 50-70
Management of greater trochanteric pain syndrome?
Conservative - rest, ice, analgesia
Walking aids and devices
If conservative measures fail - consider peri-trochanteric corticosteroid injection and refer to PT
What is an iliopsoas abscess?
A collection of pus in the iliopsoas compartment
Primary causes of iliopsoas abscess?
Haematogenous spread of bacteria - most commonly staph aureus
Secondary causes of iliopsoas abscess?
Crohn’s - most common
Diverticulitis or colorectal cancer
UTI
GU cancers
Vertebral osteomyelitis
Femoral catheter
Lithotripsy
Endocarditis
IVDU
Mortality rate of iliopsoas abscess?
20% in secondary iliopsoas abscess
2.4% in primary
Features of iliopsoas abscess?
Fever
Back/flank pain
Limp
Weight loss
Specific test for iliopsoas inflammation?
Place hand proximal to the patient’s ipsilateral knee and ask patient to lift thigh against your hand. This will cause pain due to contraction of the psoas muscle.
Lie the patient on the normal side and hyperextend the affected hip. This should elicit pain as the psoas muscle is stretched.
Investigations for iliopsoas abscess?
Bloods - FBC, CRP, U&Es, septic screen
CT abdo is most commonly done
(MRI is gold standard)
Management of iliopsoas abscess?
Antibiotics
Percutaneous drainage - works in 90% of cases
If this fails then surgery can be indicated
Clinical features of OA of the hip?
Pain in the grain, lateral hip or deep in buttock - aggravated by weight-bearing and improved with rest. Worse towards the end of the day
Stiffness
Grinding/crunching sensation
Antalgic gait
ROM is reduced and passive movement painful
What is an acetabular lateral tear?
What causes them?
A tear in the acetabular labrum
Most commonly caused by direct traumas, sporting activities requiring frequent external rotations or hyperextension e.g. ballet
Presentation of acetabular labral tears?
Constant dull pain with periods of sharp pain that worsens during activity. Aggravated by walking, pivoting, prolonged sitting and impact activities
Clickly, locking, catching, giving way may occur
FADIR test positive
Presentation of hip RA?
Pain and stiffness that is worse after not moving e.g. when you wake up
Hip pain in children
Look at paeds
