LE: Hip Flashcards
Hip Dislocation etiology
- The femoroacetabular joint is one tough joint
– Rarely dislocates - Requires huge forces or malformed joint
Hip Dislocation presentation
– 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
Hip Dislocation: posterior vs. anterior
Hip Dislocation
Hip Dislocation PE - posterior dislocations
- 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)
Hip Dislocation PE - anterior dislocations
- Affected limb is in some flexion, abduction, & external rotation
- Nerve injuries are less frequent than posterior - still check though
Hip Dislocation PE - both dislocations
- Check pulses
- Check for abrasions and contusions of the skin
- Knee examination
- Check for an associated femur fracture
Hip Dislocation
Diagnostics
X-rays
* AP of the pelvis
* AP and lateral of affected hip
* Also get knee and femur if suspected injury
Hip Dislocation
Treatment
- 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)
Hip Dislocation
Adverse Outcomes
– Osteonecrosis (10% of pts)
– Capsular or labral tears
– Acetabular edge fractures
– Nerve damage
– Vascular damage
– Post traumatic arthritis
Hip Fracture
- Surgical emergency in someone <60yo
- Often seen in osteoporotic pts
- Usually occur in the femoral neck or intertrochanteric region
Hip fracture risk factors
– 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
Femoral neck fractures are also
_____ fxs
intracapsular
Three areas of hip fractures
– Subcapital
– Transcervical
– Basicervica
Intertrochanteric fractures are
_____
extracapsular
What does it mean that Intertrochanteric fractures are extracapsular?
– Between the greater trochanter
and the lesser trochanter
– Subtrochanteric
* distal aspect of lesser trochanter
* distal to the greater trochanter
Hip Fracture
Clinical Presentation
– 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
Hip Fracture physical exam
– 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
Hip Fracture diagnostics
– 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
Hip Fracture Treatment
– 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)
Greater Trochanteric Bursitis
Inflammation and hypertrophy of the Greater Troch Bursa
Greater Trochanteric Bursitis etiology
- Lumbar spine disease
- Intra-articular hip pathology
- Leg length discrepancy
- Inflammatory arthritis
- Previous surgeries
- Overuse
- Idiopathic origin
Greater Trochanteric Bursitis presentation
– 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
Greater Trochanteric Bursitis PE
– 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
Greater Trochanteric Bursitis diagnostics
– 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
Greater Trochanteric Bursitis treatment
– 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)
Greater Trochanteric Bursitis adverse outcomes
– NSAID reaction
– Infection from injection (rare)
– Persistent pain
– Limp
– Sleep disturbances
– Bursectomy - can have a fluid accumulation and adhesions
AVN of the hip epidemiology
- 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
AVN of the hip risk factors
- 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
AVN of the hip Etiology
– > 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
AVN of the hip pathogenesis
– 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
AVN of the hip presentation
– 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
AVN of the hip PE
– Pain and limited active ROM of the hip(s)
– Pain with:
* hip abduction
* Internal rotation
* Logrolling (passive internal and external rotation)
AVN of the hip diagnostics
– 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
AVN of the hip Treatment
– PT best for early disease
– Medications
* alendronate - improve pain and function
* enoxaparin - prevent progression
– Surgical
* Core decompression
* THA
AVN of the hip adverse outcomes
– subchondral sclerosis (scarring of articular cartilage)
– focal osteoporosis
– femoral head collapse
– DJD (osteoarthritis)
Snapping hip etiology
- 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
Snapping hip clinical presentation
– 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
Snapping hip PE
– 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
Snapping hip Diagnostics
– X-ray - AP and lateral of hip
* Rule out bony pathology
– CT arthrogram or MRA
* Intra-articular pathologies
Snapping hip treatment
– 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
