Hips Don't Lie Flashcards
General Anatomy
Ball and socket joint
Mobility is sacrificed for stability
Ilio, Ischio and pubofemoral ligaments reinforce capsule
Proximal landmarks
Head
Neck
Trochanters
Vascular Anatomy
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
Hx
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
Pain from 1 of 4 locations
Hip joint
Soft tissue around hip
Pelvic bone
Referred from the LSP
Hip Joint pain - conditions
OA AVN RA Septic arthritis Fx / dislocations of hip Impingement
Hip joint pain - other locations
Groin pain
Anterior thigh
Buttock
Lateral thigh
Hip joint pain - exam
Decreased ROM (pain with hip flexion
Limp
Difficulty with weight bearing (traumatic injury)
Soft tissue pain - conditions
Bursitis
Lateral femoral cutaneous N. entrapment
Snapping hip syndrome
Tendonitis
Soft tissue pain - in general
Located to the lateral or anterolateral aspect of thigh
Exceptions
- adductor muscle injury - pain in groin
Hamstring injury - pain in buttock and posterior thigh
Pelvic bone - conditions
Pelvic fx
SI joint pain
Pelvic bone - definition
Pain to posterior buttock or thigh
LSP - conditions
Degenerative LSP
Strains
Disc herination
LSP - definition
Referred pain to the buttock and/or posterior thigh
May radiate down leg
Other causes of hip pain
Abdominal GU GYN Ca Infection Vascular
Does pain radiate blow the knee to foot?
Yes - nerve root
No - hip or bursitis / IT band
Does it hurt to touch?
Yes - bursitis / IT band
Is the pain deep, achy and non-tender to touch?
Yes - hip
Is there pain in the buttock that increases with activity and is relieved by rest?
Yes - stenosis vs. claudication
Does pain go away with just standing or do you have to sit?
Standing - claudication
Sitting or leaning forward - stenosis
PE - inspection
Swelling
Skin color
Deformity
PE - palpation
Point tenderness
Skin temperature
Deformity
Peripheral pulses
PE - ROM
AROM PROM Flexion / Extension Abduction / Adduction Thomas Test / Flexion contracture IR & ER with compression and distraction
PE - Muscle testing
Flexors
Extensors
Abductors
Adductors
PE - Special tests
Tendelenburg FABER Log roll Piriformis Test Scouring test Hamstring flexibility
FABER test
Cross legs like a #4 and push the knee downward
If painful - think hip
Could be SI joint
PE - Gait
Reciprocal
Antalgic
Trendelenburg
PE - Neuro
Strength
Sensation
DTR
Labs
CBC ESR CRP Rheumatoid Factor Joint aspiration Cell count Gram Stain Culture if septic joint is suspected
Imaging - X-ray
AP pelvis Frog lateral (externally rotated lateral)
Imaging - MRI
Most sensitive for AVN
Occult hip fx (MRI/CT)
Greater Trochanteric Bursitis - Presentation
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
Greater Trochanteric Bursitis - dx
AP and frog lateral radiographs to r/o bony abnormality
Occasionally rounded or irregular calcific deposits seen above trochanter at gluteus medius attachment
Greater Trochanteric Bursitis - tx
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
Hip strains - in general
Injuries to the muscles/tendons around the hip Consider possible sources - abdominals - hip flexors - hip adductors
Hip strains - causes
Overuse injuries
Vigorous muscular contraction while muscle is on stretch
Hip strains - presentation
Pain over injured muscle that is exacerbated when area continues to be used during strenuous activities
Location of pain specific to the muscle affected
Hip strains - dx
AP radiograph of pelvis and frog-lateral view of involved hip
R/o fx or other bony lesion
Hip strains - tx
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
Thigh strains - in general
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
Thigh strains - presentation of hamstring sprain
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
Thigh strains - presentation
Localized tenderness at site of injured muscle that becomes more diffuse
Possible ecchymosis
Thigh strains - presentation of Quad strain
Pain with flexion of the knee or with pt prone flexion of knee with hip in extension
Thigh strains - dx
Clinical
X-ray if avulsion is suspected
Thigh strains - tx
RICE
Rehab - stretching and strengthening
NSAIDs
Prevent long-term sequela
Thigh strains - long term sequela
Myositis ossificans
Chronic hamstring strain
Myositis ossificans
Muscular injury with calficiation
Hip impingement - in general
AKA - femoral acetabular impingement (FAI)
Injury to the acetabular labrum and cartilage
Typically younger adults (<50 yo)
Hip impingement - Clinically
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
FADIR
Flexion, adduction and internal rotation
Hip impingement - DX
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
Hip impingement - tx
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
AVN - in general
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
AVN - RF
Trauma Chronic alcoholism Sickle cell dz RA SLE Radiation tx Smoking Repetitive or long-term steroid use
AVN - Presentation
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
AVN - dx
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
Crescent sign
Well defined sclerotic region beneath articular surface representing subchondral fx
AVN - tx
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
OA - RF
Trauma Obesity Secondary to childhood hip dz (congenital hip dysplasia, slipped capital femoral epiphysis) Biomechanical abnormalities FHx AVN
OA - Patho
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
OA - Presentation
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
OA - Presentation of gait
As progresses pts develop limp Antalgic (short stance on painful leg) Abductor lurch (swaying the trunk far over affected hip)
OA - dx
AP & frog lateral
Initially, s/s may be more pronounced than radiographic findings
Joint space narrowing, osteophyte formation, subchondral cyst and subchondral sclerosis
OA - tx
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)
Hip dislocation - in general
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
Hip dislocation - Presentation
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
Hip dislocation - dx
AP view of pelvis
AP and lateral of femur, including knee
If acetabular fx, CT to further eval the extent of the fx
Hip dislocation - Tx
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
Hip dislocation - post reduction
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
Hip fx - in general
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
Hip fx - RF
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
Hip fx - Presentation
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
Hip fx - dx
Radiographs - AP - Cross table lateral MRI - occult fx
Hip fx - tx
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
Femoral shaft fx - MOI
Typically caused by high impact trauma (MVA)
Pathologic fx may occur but less common (ie osteopenia in elderly pt with low impact fall)
Femoral shaft fx - presentation
Severe thigh pain with obvious deformity
Typically unable to move or bear weight
Often with multi-system injuries
Femoral shaft fx - exam
Deformity Swelling Open fx NV status Joints above and below
Femoral shaft fx - dx
AP & lateral of affected extremity will reveal fx to femur
Get joints above and below
Femoral shaft fx - tx
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
Pelvis fx - in general
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
Pelvis fx - stable pelvic ring
Involve one side of pelvic ring
ie unilateral superior and inferior pubic rami fx
Pelvis fx - unstable pelvic ring
Disruption of pelvic ring at two sites
ie fx of superior and inferior rami with sacral or ilium fx
Pelvis fx - acetabular fx
Intra-articular injuries that can lead to post-traumatic arthritis
High-energy injuries
Pelvis fx - presentation (low energy)
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
Pelvis fx - presentation (high energy fx -acetabular and pelvic)
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
Pelvis fx - dx
Trauma - AP radiograph of chest - Lateral of CSP - AP of pelvis (then inlet, outlet, oblique) - CT Low impact - AP of pelvis
Pelvis fx - tx
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
