Intra-articular Hip Flashcards
What are 5 INTRA-articular causes of pn/sxs in the hip region?
- Acetabular labral lesions
- Hip OA
- Osteonecrosis
- Femoral fx
- Post- THA
Which portions of the hip labrum is considered the most innervated?
Anterior & Superior portions
(becomes less with aging)
What is the vascular supply like to the hip labrum?
limited vascular supply
what are the functions of the hip labrum?
- increase depth of hip jt
- disperse forces across the cartilage
- ensure optimal joint stability (though unable to undo the effect of boney dysplasia) –> further stabilization by hydrostatic fluid pressurization
- increased stability allows for more coordinated and efficient mm contraction
What is the labrum made up of?
fibrocartilage
Labral tears are classified based on location. which is the most common site for a labral tear?
a. Anterior
b. posterior
c. superior
d. combination
a. Anterior
(particularly common in pts w/ DJD)
(you see posterior with a lot of squatting postures in particular)
What is the etiology for acetabular labral lesions?
- Trauma
- FAIS
- Developmental Dysplasia of hip
- Capsular laxity
Trauma is a potential etiology for acetabular labral lesions. Describe the way in which trauma can lead to a labral lesion
- Trauma resulting in subluxation OR dislocation of femoral head
FAIS is a potential etiology for acetabular labral lesions. Describe how
FAIS is assoc w/ morphological alterations of femoral head or acetabular or both
What are the 2 types of FAI? And describe the difference
- Pincer impingement: excessive boney overhang of acetabulum, impingement in flexion
- Cam impingement: exostosis along femoral neck and head impinges labrum against acetabulum
Capsular laxity is a potential etiology for acetabular labral lesions. Describe how
Global (genetic) vs. local laxity (acquired)
Global - Ehlers-danlos syndrome, marfan’s syndrome
Local - excessive repeated ER w/ hip ext (freq w/ adolescent dancers and gymnasts)
What is the clinical presentation for a pt with acetabular labral lesion?
- Ant hip/groin pn, or C-sign
- Onset of pn = usu insidious (unelss trauma)
- Pn = constant dull, intermittent sharp pn (worse w/ activity)
- CLICKING, locking, catching, giving way
- Ant hip pn in sitting (FAIS)
- Aggravation w/ walking, pivoting, sitting, impact
What is the most consistent clinical sx for labral acetabular lesions?
CLICKING
What would you include in your exam for a pt with suspected acetabular labral lesion?
- Screen LQ (for potential biomechanical contributors)
- Assess function: gait, SLS, squat, dynamic activities as appropriate
- Core motor control hip/pelvis
- Hip ROM, flexibility & hip strength (abduction = primary!)
- Hip accessory mobility
- Special tests
What is the most common cause of hip pn in adults?
Hip OA!
Describe how Hip OA can be either primary or secondary
Primary: idiopathic
Secondary: traumatic OR result of congenital abnormalities that alter biomechanics
- hip dysplasia
- Shape of femoral head
- Leg-calve-perthes disease
- Congenital dislocation
- slipped capital femoral epiphysis
- Leg length difference
How would a pt with hip OA typically present clinically from their hx?
- Mod lat or ant hip pn w/ WB
- Pn can progress to ant thigh or knee region
- > 50 (more typical)
- Limited PROM in at least 2/6 directions (flex & IR primary)
- Morning hip stiffness, improves in < 1 hr (otherwise, consider RA and other pathologies, systemic presentations)
What nerves innervate the hip joint?
- Obturator
- Femoral
- Sciatic
What 3 locations do intra-articular hip disorders primarily refer to?
- Buttock (71%)
- Groin (55%)
- Ant thigh (27%)
What would you include in your exam of a pt with suspected hip OA? And what would you expect?
- Gait analysis
- Antalgic gait
- Excessive lumbar lordosis during
terminal stance (lack of hip ext) - Trunk lean toward AFFECTED side
(dec compressive muscle forces
acting on jt) - trendelenburg (pelvis drops on
contralateral side)
- trendelenburg (pelvis drops on
- Coxalgic gait (trunk leans over
affect leg w/ level pelvis)
- Hip ROM (expect a dec) - accessory mobility and flexibility (esp hip flexors)
- Assess mm strength/endurance
- Esp hip ABDductors, Ext rotators
What are self-reported Outcome measures for hip OA?
- WOMAC
- LEFS (MCID = 9 point change)
What is femoral osteonecrosis? (Avascular necrosis or aseptic necrosis)
= death of varying amounts of trabecular bone in femoral head
The etiology of femoral osteonecrosis/AVN is unknown but it can occur with….
- Trauma to femoral head (neck fx, femoral head dislocation)
- Vasculitis caused by inflammatory arthropathy (SLE,RA)
- Hx of alc abuse or corticosteroid use
- Idiopathic
- hx of sickle cell disease
- 30-50 yo (most common)
How would a pt’s hx clinically present if they have femoral osteonecrosis/ AVN?
- Gradual onset of pn, but can begin suddenly w/ collapse of femoral head (if sudden - severe loss of motion)
- Dull ache or throbbing in groin, lat hip, or buttock
- Pn can radiate into thigh and upper knee region (obturator n path)
- Initially, hip ROM = minimally affected –> leads to marked limitation in hip jt ROM and strength
T or F: 21-30% of ppl will die in the following year after a hip fx (and this increases with age….30% for 70 or older and 50% for 80 or older)
True
2x as many hip fxs occur in females of males? (2:1, specifically)
Females
T or F: a fx can cause a fall?
True
How would you expect a pt post-hip fx to present clinically?
- unable to move immediately after fall
- severe pn in hip or groin
- unable to WB on affected LE
- stiffness, bruising, swelling around hip
- apparent shortening of LE & ER of the LE
What special test would you include for a suspected hip fx?
Patellar-pubic compression test (SN 95%, SP 86%)
- test: distinct, sharp sound
+ test: dull sound
What are tx options for hip fxs?
- ORIF (open reduction internal fixation)
- Femoral neck fxs:
- Typically: ORIF
- Mortality = high (20-25%)
- Rehab needs to take place early!!
- Subtrochanteric & Intertrochanteric fxs:
- Better prog than intracapsular fxs
- Most common tx = ORIF
What are 6 potential complications following ORIF of hip?
- AVN
- Infection
- Arthritis
- Dislocation
- Coxa Vara or Valgus
- Nail penetration
T or F: nowadays, PTs get pts who are s/p THA up and moving the same day after their surgery
True, they are usu WBAT early post-op
What are the 2 most common approaches for THA?
- Posterolateral (most common)
- split glute max
- short lat rotators are partially cut and glute med retracted anteriorly
- hip dislocated post (by flex, add, IR)
- Anterolateral
- hip jt approached through interval btwn TFL and Glute med
- some portion of hip abd released from greater troch & hip dislocated ant (by ext & ER)
2006 cohrane review: insufficient evidence to recommend one over the other
When comparing cemented vs cementless fixation of prosthesis for hip replacement, which is now the preferred method, esp in younger pts?
Cementless
Following a THA, pts were prescribed NWB or PWB…. but today it is WBAT/FWB w/ an AD. What is the rationale for the change?
NWB and TDWB produces greater jt pressure than FWB due to co-contraction forces
FWB does not adversely affect boney ingrowth or prosthetic stability
What are 6 potential post-THA complications?
- DVT
- Component malalignment
- Infection
- Improper implant fixation to surrounding bone
- nerve palsy (both from surgical technique and from nerve blocks)
- prosthetic hip dislocation
T or F: there is a 50-75% chance of post-op DVT w/o prophylaxis
T
What are 4 ways you can prevent DVT following surgery?
- serial compression devices
- TED hose
- anti-coagulation meds
- ankle pumps
- early mobilization following surgery
What are precautions for a pt who just had a Posterolateral (most common) THA?
No hip flex > 90
No hip add past neutral
No hip IR past neutral
What are precautions for a pt who just had an anterolateral THA?
(Varies by surgeon)
Avoid Ext & ER, esp in combo
- A 2002 study found that use of hip precautions was not necessary when using an anterolateral approach
How long should a pt maintain THA precautions?
6-12 wks
*Directed by surgeon back upon operative process and hardware
**The incidence of dislocation is reduced by >95% after 12 wks!!
What are some long-term impairments that can occurs after THA (at 3 mo)?
- Ant hip, groin, back pn
- dec endurance, strength, ROM, flexibility
- gait deviations & dec bal
- activity lim
- dec ability to perform STS, stairs
- Disabilities: dec ability to participate in light sports and recreational activities
- LLD (possible causes: improper stem length, hip mm imbalance, muscle contractures & capsular tightness)
T or F: True LLD needs to be determined by x-ray
T
