LE: Hip

Question 1

Hip Dislocation etiology

Answer 1

• The femoroacetabular joint is one tough joint
  – Rarely dislocates
• Requires huge forces or malformed joint

Question 2

Hip Dislocation presentation

Answer 2

– Lots of pain
– Immobility of the lower extremity
– Due to the high impact forces involved in a hip dislocation, pt’s
may have other traumatic complaints and associated injuries

Question 3

Hip Dislocation: posterior vs. anterior

Answer 3

Hip Dislocation

Question 4

Hip Dislocation PE - posterior dislocations

Answer 4

• Affected limb is shorter
• Hip is fixed in position
  – flexion, adduction, & internal rotation
• Assess distal pulses
• Assess sciatic and femoral nerves
• Check for sciatic nerve palsies
  (8-20% of patients)

Question 5

Hip Dislocation PE - anterior dislocations

Answer 5

• Affected limb is in some flexion, abduction, & external rotation
• Nerve injuries are less frequent than posterior - still check though

Question 6

Hip Dislocation PE - both dislocations

Answer 6

• Check pulses
• Check for abrasions and contusions of the skin
• Knee examination
• Check for an associated femur fracture

Question 7

Hip Dislocation
Diagnostics

Answer 7

X-rays
* AP of the pelvis
* AP and lateral of affected hip
* Also get knee and femur if suspected injury

Question 8

Hip Dislocation
Treatment

Answer 8

• Reduce ASAP to decrease risk of osteonecrosis
• Check for associated fractures before reduction
  – physical exam and x-rays
• Perform the reduction in a nontraumatic way
• Post reduction x-rays
• CT is used when available for evaluation of reduction and soft tissue
  or bony damage
• Document neural function before and after the reduction.
  – Crutch and assisted ambulation post reduction (WBAT)
• until pt is pain free (2-4 weeks post injury)

Question 9

Hip Dislocation
Adverse Outcomes

Answer 9

– Osteonecrosis (10% of pts)
– Capsular or labral tears
– Acetabular edge fractures
– Nerve damage
– Vascular damage
– Post traumatic arthritis

Question 10

Hip Fracture

Answer 10

• Surgical emergency in someone <60yo
• Often seen in osteoporotic pts
• Usually occur in the femoral neck or intertrochanteric region

Question 11

Hip fracture risk factors

Answer 11

– Advanced age (risk doubles q decade >50 yo)
– Dizziness, stroke, syncope, peripheral neuropathies, meds,
sedentary lifestyle, alcohol use, smoking
– Caucasian women 2-3 times more likely than other races

Question 12

Femoral neck fractures are also
_____ fxs

Answer 12

intracapsular

Question 13

Three areas of hip fractures

Answer 13

– Subcapital
– Transcervical
– Basicervica

Question 14

Intertrochanteric fractures are
_____

Answer 14

extracapsular

Question 15

What does it mean that Intertrochanteric fractures are extracapsular?

Answer 15

– Between the greater trochanter
and the lesser trochanter
– Subtrochanteric
* distal aspect of lesser trochanter
* distal to the greater trochanter

Question 16

Hip Fracture
Clinical Presentation

Answer 16

– Hx of a fall followed by pain in the affected side
– Inability to bear weight on affected side or ambulate
– Groin or buttock pain - worse with ambulation
– Elderly with pain in hip after a fall are treated as if they have a
fracture until proven otherwise

Question 17

Hip Fracture physical exam

Answer 17

– Affected limb tends to be externally
rotated and can be abducted
– If fx is displaced the limb will be
shortened
– Nondisplaced fractures rarely have any
deformity
– Inability to perform straight leg raise
– Extension at knee and rotation of limb
causes pain

Question 18

Hip Fracture diagnostics

Answer 18

– AP Pelvis
– AP of affected hip
– Lateral of hip
– AVOID Frog leg film for suspected fracture - Lots of pain
– MRI or CT if x-ray doesn’t show fx, but H&P suggests a fx

Question 19

Hip Fracture Treatment

Answer 19

– Surgical treatment for most
* Frail and nonsurgical candidates - immobility (slew of issues)
– Timely referral to orthopaedics
* Surgical delay should not be longer than 48 hours (inc. mortality)
– Surgical repair is determined by the fracture location
* Screw and slide plate
* Intramedullary nail
* Cannulated screws
* Total hip arthroplasty (THA)

Question 20

Greater Trochanteric Bursitis

Answer 20

Inflammation and hypertrophy of the Greater Troch Bursa

Question 21

Greater Trochanteric Bursitis etiology

Answer 21

• Lumbar spine disease
• Intra-articular hip pathology
• Leg length discrepancy
• Inflammatory arthritis
• Previous surgeries
• Overuse
• Idiopathic origin

Question 22

Greater Trochanteric Bursitis presentation

Answer 22

– Pain and tenderness over the greater trochanter
– Pain with almost any pressure over the lateral hip
– Sleeping is difficult
– Worse when first standing from sitting position

Question 23

Greater Trochanteric Bursitis PE

Answer 23

– Essential finding:
* Palpation of the greater trochanter with pt in the decubitus position, affected hip up.
* Pain increases with active abduction
– Pain above the trochanter suggests
tendinitis of the gluteus medius muscle
* Increased pain with adduction with internal
rotation
– Pain posterior to the Greater Troch
* Think piriformis and/or Obturator internus

Question 24

Greater Trochanteric Bursitis diagnostics

Answer 24

– X-ray - pelvis and lateral view of affected hip
* Necessary to rule out bony abnormalities and internal hip pathology
* May see calcium deposit above the trochanter
– MRI to evaluate soft tissue pathology and uncommon
conditions such as tumors, osteonecrosis of the femoral
head, or occult fractures

Question 25

Greater Trochanteric Bursitis treatment

Answer 25

– NSAIDs
– Activity modification
– IT band stretching
– Short-term use of cane
– Hip stretching and home strengthening
– Hip abduction strengthening (PT)
– Corticosteroid injection
– Surgery is rarely needed (bursectomy)

Question 26

Greater Trochanteric Bursitis adverse outcomes

Answer 26

– NSAID reaction
– Infection from injection (rare)
– Persistent pain
– Limp
– Sleep disturbances
– Bursectomy - can have a fluid accumulation and adhesions

Question 27

AVN of the hip epidemiology

Answer 27

• Between 30-50 yo
• Males > Females (3:1)
• 10K-20K new cases per year in
  the US
• Risk ↑ pts receiving high-dose
  steroids
• Accounts for 5-18% of THAs

Question 28

AVN of the hip risk factors

Answer 28

• Corticosteroid use
• Alcohol abuse
• Smoking
• Hip trauma
• Heavy workload
• Associated conditions
  – Chronic pancreatitis, chronic liver disease, crohn disease, systemic lupus erythematosus, sickle cell disease, metabolic
  lipid disorders, coagulation disorders, HIV, Cushing’s disease, radiation and/or chemotherapy, pregnancy

Question 29

AVN of the hip Etiology

Answer 29

– > 90% of nontraumatic osteonecrosis is secondary to:
* corticosteroid use
* alcohol abuse
– Traumatic AVN may be secondary to:
* Hip fx
* Slipped capital femoral epiphysis
* Hip dislocation
* Prior hip surgery

Question 30

AVN of the hip pathogenesis

Answer 30

– Osteocyte cell death due to disruption of vascular supply to
femoral head
* I.e., fat emboli
– Continued stress causing fx
* progressive collapse
– Degenerative changes
* articulation malalignment

Question 31

AVN of the hip presentation

Answer 31

– Early stage may be asymptomatic
– Painful hip with limited ROM
* Pain can radiate to the buttocks, knees, or anterolateral thigh
* worse with wt bearing, relieved by rest
– Symptoms usually insidious
– Hx of being on corticosteroids
– Hx of hip trauma, SCFE, dislocation, or surgery
– Hx of associated conditions
– Social hx of alcohol use, smoking, deep sea diving, heavy
workload

Question 32

AVN of the hip PE

Answer 32

– Pain and limited active ROM of the hip(s)
– Pain with:
* hip abduction
* Internal rotation
* Logrolling (passive internal and external rotation)

Question 33

AVN of the hip diagnostics

Answer 33

– Suspect in pts <50 yo with: * Groin pain * Hip pain * Thigh pain * Limited AROM
– X-ray * AP, Lateral, frog leg * Compare both sides * Crescent sign
– MRI * May confirm if early disease

Question 34

AVN of the hip Treatment

Answer 34

– PT best for early disease
– Medications
* alendronate - improve pain and function
* enoxaparin - prevent progression
– Surgical
* Core decompression
* THA

Question 35

AVN of the hip adverse outcomes

Answer 35

– subchondral sclerosis (scarring of articular cartilage)
– focal osteoporosis
– femoral head collapse
– DJD (osteoarthritis)

Question 36

Snapping hip etiology

Answer 36

• Tendons move over bony prominences
  – Most common is the iliotibial band sliding over greater trochanter
  – Iliopsoas sliding over the iliopectineal eminence of the pelvis
  – Intra-articular tears of the acetabulum

Question 37

Snapping hip clinical presentation

Answer 37

– Iliotibial (IT) band subluxation
* Subluxation of IT band due to walking or rotation of the hip
* Pain in the greater trochanteric area
* Some pts snap as they lay on unaffected side and rotate
affected leg internally or externally
– Iliopsoas tendon subluxation
* Felt in the groin when flexed hip is extended (i.e. standing
from chair)
* more annoying than painful
– Intra-articular acetabular tears
* more disabling, pts reach for support to ambulate or stand

Question 38

Snapping hip PE

Answer 38

– Re-create the snap
* Pt stands, rotates hip while adducted
* Can palpate and feel the snap over the greater trochanter
* Stand from sitting position may recreate iliopsoas snap
* A limp or restricted internal rotation suggest internal joint issue
– Ober test
* IT band tension
– Not just for snapping hip

Question 39

Snapping hip Diagnostics

Answer 39

– X-ray - AP and lateral of hip
* Rule out bony pathology
– CT arthrogram or MRA
* Intra-articular pathologies

Question 40

Snapping hip treatment

Answer 40

– Often painless, requiring no specific treatment
– Educate patient on the etiology
– Avoid provocative activities
– PT - exercise and stretching
– NSAIDs if needed
– Cortisone injections sparingly for rare cases
– Surgery in very rare cases to release the IT band
– Internal derangement (labral issues) may be assisted by
arthroscopy