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Clin Med II - Ortho > Hips Don't Lie > Flashcards

Hips Don't Lie Flashcards

1
Q

General Anatomy

A

Ball and socket joint
Mobility is sacrificed for stability
Ilio, Ischio and pubofemoral ligaments reinforce capsule

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2
Q

Proximal landmarks

A

Head
Neck
Trochanters

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3
Q

Vascular Anatomy

A

Proximal femur - main blood supply comes from the retinacular, medial and lateral circumflex arteries (from the femoral and profunda femoris)
Small branch from the obturator A. in the ligamentum teres
Conditions that compromise blood flow lead to AVN

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4
Q

Hx

A 
Onset
Location
Radiation of pain
Involvement of other joints
Neurosensory changes
Trauma / MOI
Steroid / alcohol use
Current or recent Infection / fever
Hx femur fx, THA or sx
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5
Q

Pain from 1 of 4 locations

A

Hip joint
Soft tissue around hip
Pelvic bone
Referred from the LSP

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6
Q

Hip Joint pain - conditions

A 
OA
AVN
RA
Septic arthritis
Fx / dislocations of hip
Impingement
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7
Q

Hip joint pain - other locations

A

Groin pain
Anterior thigh
Buttock
Lateral thigh

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8
Q

Hip joint pain - exam

A

Decreased ROM (pain with hip flexion
Limp
Difficulty with weight bearing (traumatic injury)

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9
Q

Soft tissue pain - conditions

A

Bursitis
Lateral femoral cutaneous N. entrapment
Snapping hip syndrome
Tendonitis

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10
Q

Soft tissue pain - in general

A

Located to the lateral or anterolateral aspect of thigh
Exceptions
- adductor muscle injury - pain in groin
Hamstring injury - pain in buttock and posterior thigh

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11
Q

Pelvic bone - conditions

A

Pelvic fx

SI joint pain

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12
Q

Pelvic bone - definition

A

Pain to posterior buttock or thigh

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13
Q

LSP - conditions

A

Degenerative LSP
Strains
Disc herination

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14
Q

LSP - definition

A

Referred pain to the buttock and/or posterior thigh

May radiate down leg

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15
Q

Other causes of hip pain

A 
Abdominal
GU
GYN
Ca
Infection
Vascular
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16
Q

Does pain radiate blow the knee to foot?

A

Yes - nerve root

No - hip or bursitis / IT band

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17
Q

Does it hurt to touch?

A

Yes - bursitis / IT band

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18
Q

Is the pain deep, achy and non-tender to touch?

A

Yes - hip

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19
Q

Is there pain in the buttock that increases with activity and is relieved by rest?

A

Yes - stenosis vs. claudication

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20
Q

Does pain go away with just standing or do you have to sit?

A

Standing - claudication

Sitting or leaning forward - stenosis

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21
Q

PE - inspection

A

Swelling
Skin color
Deformity

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22
Q

PE - palpation

A

Point tenderness
Skin temperature
Deformity
Peripheral pulses

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23
Q

PE - ROM

A 
AROM
PROM
Flexion / Extension
Abduction / Adduction
Thomas Test / Flexion contracture
IR & ER with compression and distraction
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24
Q

PE - Muscle testing

A

Flexors
Extensors
Abductors
Adductors

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25
Q

PE - Special tests

A 
Tendelenburg
FABER
Log roll
Piriformis Test
Scouring test
Hamstring flexibility
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26
Q

FABER test

A

Cross legs like a #4 and push the knee downward
If painful - think hip
Could be SI joint

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27
Q

PE - Gait

A

Reciprocal
Antalgic
Trendelenburg

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28
Q

PE - Neuro

A

Strength
Sensation
DTR

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29
Q

Labs

A 
CBC
ESR
CRP
Rheumatoid Factor
Joint aspiration
Cell count
Gram Stain
Culture if septic joint is suspected
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30
Q

Imaging - X-ray

A 
AP pelvis
Frog lateral (externally rotated lateral)
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31
Q

Imaging - MRI

A

Most sensitive for AVN

Occult hip fx (MRI/CT)

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32
Q

Greater Trochanteric Bursitis - Presentation

A

VERY COMMON!!!
Point tenderness over the greater trochanter that may radiate into buttock or down the lateral aspect of the leg to knee
Unable to lay on that side
Worsened with rising from seated position, going up stairs
Pain exacerbated with
- active hip abduction
- adduction of hip or combined adduction with internal rotation
Check leg lengths

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33
Q

Greater Trochanteric Bursitis - dx

A

AP and frog lateral radiographs to r/o bony abnormality

Occasionally rounded or irregular calcific deposits seen above trochanter at gluteus medius attachment

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34
Q

Greater Trochanteric Bursitis - tx

A 
Heat
Ice
STRETCHING (IT band)
NSAIDs
Local coricosteroid injections
Assistive device (cane)
Activity modification
Hip abduction strenthening
Referral to ortho when tx fails, unsure of dx and/or suspected fx
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35
Q

Hip strains - in general

A 
Injuries to the muscles/tendons around the hip
Consider possible sources
- abdominals
- hip flexors 
- hip adductors
36
Q

Hip strains - causes

A

Overuse injuries

Vigorous muscular contraction while muscle is on stretch

37
Q

Hip strains - presentation

A

Pain over injured muscle that is exacerbated when area continues to be used during strenuous activities
Location of pain specific to the muscle affected

38
Q

Hip strains - dx

A

AP radiograph of pelvis and frog-lateral view of involved hip
R/o fx or other bony lesion

39
Q

Hip strains - tx

A

Initially - RICE and protected weight bearing with crutches
NSAIDs
Rehab - PROM, heat, e-stim, US, activity modification, home exercise program, strength, flexibility
- usually done in phases with return to sports-specific training and competition between weeks 4-6 post-injury

40
Q

Thigh strains - in general

A 
Hamstring strain (more common) - occurs when put on stretch during active contraction
Quad strain - Quad can happen this way too but, more often due to a direct blow during sporting event
41
Q

Thigh strains - presentation of hamstring sprain

A

Sudden onset of posterior thigh pain while running or other rapid movement
May report feeling a pop
Pain with combined flexion of hip and extension of knee

42
Q

Thigh strains - presentation

A

Localized tenderness at site of injured muscle that becomes more diffuse
Possible ecchymosis

43
Q

Thigh strains - presentation of Quad strain

A

Pain with flexion of the knee or with pt prone flexion of knee with hip in extension

44
Q

Thigh strains - dx

A

Clinical

X-ray if avulsion is suspected

45
Q

Thigh strains - tx

A

RICE
Rehab - stretching and strengthening
NSAIDs
Prevent long-term sequela

46
Q

Thigh strains - long term sequela

A

Myositis ossificans

Chronic hamstring strain

47
Q

Myositis ossificans

A

Muscular injury with calficiation

48
Q

Hip impingement - in general

A

AKA - femoral acetabular impingement (FAI)
Injury to the acetabular labrum and cartilage
Typically younger adults (<50 yo)

49
Q

Hip impingement - Clinically

A

Can occur acutely, but more likely to be progressive over time
Pain over lateral side of hip described as “deep”
- C sign
- pain in the extremes of motion
May experience catching, locking, clicking
Pain worsened with prolonged sitting, stairs, getting in/out of car, getting up from toilet, putting on shoes/socks , & rotational movement
Decreased flexion and IR
Positive FADIR

50
Q

FADIR

A

Flexion, adduction and internal rotation

51
Q

Hip impingement - DX

A

AP and lat hip radiographs
Normal joint space
CAM, pincer or combined impingement may be noted
MRI or CT
MR arthrography most accurate for labral tear

52
Q

Hip impingement - tx

A 
Acetaminophen / NSAIDs
Activity modification
Hip strengthening
Deep tissue massage
Intra-articular injections
Refer to ortho
- open and arthroscopic procedures done with early post-op mobilization and ROM
53
Q

AVN - in general

A

Characterized by the development of an area of bone necrosis in the femoral head
Following an initial infarction, collapse and fragmentation may occur, which leads to deformity of the femoral head and degenerative arthritis
10,000-20,000 new pts/yr
Normally occurs in the 3rd-5th decades
Often bil

54
Q

AVN - RF

A 
Trauma
Chronic alcoholism
Sickle cell dz
RA
SLE
Radiation tx
Smoking
Repetitive or long-term steroid use
55
Q

AVN - Presentation

A

Gradual onset of progressive pain to groin, lateral hip or buttock limp and loss of motion - pain is severe during the initial of the dz when bone death is occurring
Pain with attempted straight-leg raising and ROM of the hip
Decreased ROM specifically IR
Progressive limp - short stance; antalgic gait

56
Q

AVN - dx

A

Radiographs
- initially may be normal progressing to patchy areas of sclerosis and lucency
- eventually a crescent sign
- eventual collapse and change in the shape of the femoral head
If AVN suspected but x-ray is normal, get an MRI which reveal the lesions clearly - may want to consider MRI of the asymptomatic side too

57
Q

Crescent sign

A

Well defined sclerotic region beneath articular surface representing subchondral fx

58
Q

AVN - tx

A

Goal is to prevent collapse of femoral head and encourage repair of necrotic area
If radiographic evidence AVN or suspect AVN - REFER!!!
Minimal involvement - prolonged abstinence from weight-bearing by the use of crutches may allow regeneration of the involved segment
- other options for the pt w/o collapse: pulse magnetic electrical fields; sx tx - core decompression, vascularized fibular grafting; osterochondral allografting of the femoral head
After collapse has occurred, hip replacement is indicated

59
Q

OA - RF

A 
Trauma
Obesity
Secondary to childhood hip dz (congenital hip dysplasia, slipped capital femoral epiphysis)
Biomechanical abnormalities
FHx
AVN
60
Q

OA - Patho

A

The articular cartilage becomes progressively thinned and worn away
New bone proliferates around the femoral head and acetabulum creating osteophytes
Synovium becomes chronically thickened and congested

61
Q

OA - Presentation

A

Gradual onset of unilateral or bil groin or anterior thigh pain - Some with pain in buttock, lateral thigh or knee
Initially pain occurs only with WB activity, but gradually both frequency and intensity increases to pain at rest and at night - stiffness at rest that subsides with activity
As progresses pts develop decreased ROM - loss of IR is usually fist to occur; may also see decreased abduction; pain at endpoint of extremes of motion

62
Q

OA - Presentation of gait

A 
As progresses pts develop limp
Antalgic (short stance on painful leg) 
Abductor lurch (swaying the trunk far over affected hip)
63
Q

OA - dx

A

AP & frog lateral
Initially, s/s may be more pronounced than radiographic findings
Joint space narrowing, osteophyte formation, subchondral cyst and subchondral sclerosis

64
Q

OA - tx

A

Initially conservative tx which can decrease s/s and improve function
Acetaminophen / NSAIDs
Activity modifications
Cane/walker
Ice/heat
Gentle ROM and non-weight-bearing exercise (swimming, biking)
Correct obesity
If a variety of conservative tx fails, pt s/s progressing and/or believe pt would benefit from sx - refer!
Sx - Total hip arthroplasty (THR)

65
Q

Hip dislocation - in general

A

Usually the result of severe/high energy trauma (MVA) and usually in the posterior direction
Commonly results from direct trauma to knee while the hip and knee are flexed
Force drives femoral head out of joint in posterior direction (90%)
Frequently associated with fx of the posterior acetabular wall
Anterior dislocations are less common and result from a force to the knee with the thigh abducted and externally rotated

66
Q

Hip dislocation - Presentation

A

Motion extremely painful
Often unable to move LE
May have additional injuries to knee (ligaments often injured) abdomen, head, & chest
Assess NV status - Sciatic N. palsy may occur (peroneal division)
In posterior dislocations leg is shortened with hip flexed and held in ADduction and IR
In anterior dislocations leg held in mild flexion, ABduction and ER

67
Q

Hip dislocation - dx

A

AP view of pelvis
AP and lateral of femur, including knee
If acetabular fx, CT to further eval the extent of the fx

68
Q

Hip dislocation - Tx

A

Closed reduction is attempted ASAP
- risk of AVN
- often done in ER with conscious sedation
- post reduction films and frequently a CT are necessary
- document NV function before and after reduction
If closed reduction fails or if an acetabular fx is present of sufficient size to cause instability, or bony fragments, open reduction is indicated

69
Q

Hip dislocation - post reduction

A

Abduction pillow
Dislocation precautions
Weight bearing status depends on acetabular fx - if uncomplicated, crutch assistance with WBAT 2-4 weeks; then progression to abduction and extension exercises and progression to cane

70
Q

Hip fx - in general

A

Common injury in the elderly population specifically those with osteoporosis/osteropenia
Location and displacement of fx determine risk of vascular compromise
fx distal to the blood supply (intertrochanteric) do not typically disturb the blood supply
Fx (femoral neck) that occur proximal to these vessels (intracapsular) may compromise the blood supply, leading to nonunion and/or AVN

71
Q

Hip fx - RF

A 
Age is most important - frequency doubles with each decade beyond 50
Decreased proprioception
Increased falls (particularly on side)
Dizziness
Stroke
Syncope
Peripheral neuropathies
Meds
White women
Sedentary lifestyle
Smoking
Alcoholism
Dementia
Osteoporis
72
Q

Hip fx - Presentation

A

Elderly pt who has sustained a fall on hip followed by groin pain and inability to bear weight or ambulate - occasionally may be able to bear weight (does not r/o fx!)
Shortening and ER of the affected leg; may have no deformity in the case of pt with nondisplaced or stress fx
Unable to perform straight leg raise

73
Q

Hip fx - dx

A 
Radiographs
- AP
- Cross table lateral
MRI
- occult fx
74
Q

Hip fx - tx

A

Should be eval by orth and internist
Primary goal is to return the person to their pre-injury level of function ASAP
- medical complications frequently occur
- one year mortality 10-30%; pts often loses some degree of ambulatory capacity & functional independence
Semi-urgent sx w/i 24-48h
Displaced intracapsular fx in the elderly are best tx with hemiarthroplasty
Nondisplaced or impacted fx often tx conservatively or with pinning
Intertrochanteric fx are tx with ORIF or IM nail

75
Q

Femoral shaft fx - MOI

A

Typically caused by high impact trauma (MVA)

Pathologic fx may occur but less common (ie osteopenia in elderly pt with low impact fall)

76
Q

Femoral shaft fx - presentation

A

Severe thigh pain with obvious deformity
Typically unable to move or bear weight
Often with multi-system injuries

77
Q

Femoral shaft fx - exam

A 
Deformity
Swelling
Open fx
NV status
Joints above and below
78
Q

Femoral shaft fx - dx

A

AP & lateral of affected extremity will reveal fx to femur
Get joints above and below

79
Q

Femoral shaft fx - tx

A

Splint and immediate referral to ER
Sx - external fixation, traction, IM nailing
Decrease risk of adverse outcomes - fat embolism, infection (open fx), ARDs, DVT, and PE

80
Q

Pelvis fx - in general

A

Fx of the pelvic ring and acetabulum
Wide range - low impact and high impact injuries
Low impact - older pt, fall, non-sx & stable
High impact - massive blood loss, due to MVA with hemodynamic instability

81
Q

Pelvis fx - stable pelvic ring

A

Involve one side of pelvic ring

ie unilateral superior and inferior pubic rami fx

82
Q

Pelvis fx - unstable pelvic ring

A

Disruption of pelvic ring at two sites

ie fx of superior and inferior rami with sacral or ilium fx

83
Q

Pelvis fx - acetabular fx

A

Intra-articular injuries that can lead to post-traumatic arthritis
High-energy injuries

84
Q

Pelvis fx - presentation (low energy)

A

Groin pain
Lateral hip pain or buttock pain that is worsened with weight bearing or inability to bear weight
Pain with hip ROM and with straight leg raising
Antalgic gait

85
Q

Pelvis fx - presentation (high energy fx -acetabular and pelvic)

A

Tx in trauma center - ABC’s, pelvis for swelling, ecchymosis, deformity, lacerations, NV status, genitourinary injuries
Need to look for associated MSK injuries as well as injuries to the chest, abdomen and head

86
Q

Pelvis fx - dx

A 
Trauma
- AP radiograph of chest
- Lateral of CSP
- AP of pelvis (then inlet, outlet, oblique)
- CT
Low impact - AP of pelvis
87
Q

Pelvis fx - tx

A

Determined by degree of instability and presence of associated injuries
Low impact with stable pattern - common
- analgesics
- rest
- gait training for protected weight bearing with walker ~6 weeks for fx healing and improved pain
- eval / tx for osteoporosis
High impact - unstable pattern
- often life threatening, hemodynamic resuscitation and tx of injuries
- pelvic binding with sheet - temp measure
-skeletal traction
- sx tx once hemodynamically stable

Clin Med II - Ortho (13 decks)

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