LE- Hip and Knee Flashcards
Nerves of hip, pelvis and thigh?
- sciatic nerve: L4-S3 articular and muscular sensation external rotation and posterior thigh, foot - femoral nerve: L2-4 ant thigh compartment - lateral femoral cutaneous: L3-L4 sensory
What is the blood supply of the hip?
- femoral artery: profunda femoris circumflex - artery of ligamentum teres: post. division of obturator artery, femoral head
RFs for AVN? prognosis? sign? tx?
- interruption of vascular supply of femoral head:
fracture, dislocation, SCFE, steroids, ETOH, perthes, coag, sickle cell - commonly bilateral
- prognosis: 70-80% collapses in 3 yrs
- see crescent sign
- tx:
early: anticoag, bisphosphonates, decompression, tx cause
later: surgery: decompression vs total hip arthrodesis
Diff hip bursae?
- trochanteric: greater trochanter and iliotibial band - ischial: ischial tuberosity and gluteus muscles - iliopsoas: iliopsoas tendon and lesser trochanter extending upward into iliac fossa beneath iliacus muscle
Diff imaging for hips?
- xrays: wt bearing AP, frog leg - bone scan - CT - MRI - MRI arthrogram
Differential for anterior hip pain?
- OA
- inflammatory arthritis
- muscle/tendon strain
- tendonitis
- femoral neck stress fracture
- obturator/iliogunial nerve entrapment
- osteitis pubis
- acetabular labral tear
Hip pain differential based on age - younger pts?
pre-pubescent:
- legg calve perthes dz
- SCFE
adolescent:
- avulsion fracture
- hip pointer
- contusion
- myositis ossificans
- femoral neck stress fx
Hip pain diff based on age - older pts?
- FAI: femoroacetbaular impingement
- osteoid osteoma
- ITB syndrome
- trochanteric bursitis
- piriformis syndrome
- iliopsoas bursitis
- meralgia paresthetica
- OA
PT presents w/ hip pain = what other etiologies are possible other than hip?
- low back pain
- knee pain
- pelvic pathology (Gyn)
- intra-abdominal pathology
- 32yo female recreational runner
- previous dancer
- gradual increase in distance and abdominal workouts
- pain and snapping in groin and anterior hip w/ hip flexion and crunches
- dx? eval, tx?
- iliopsoas bursitis/tendinosis
- eval:
H and P, consider xray or MRI to r/o other Dx (shouldn’t need though) - tx:
relative rest, stretch, consider NSAIDs, PT, injection (occasionally), surgical referral
28 yo male skier, hip pain w/ deep click that persists 2 months after fall, catching sensation, worse w/ deep flexion and raising from seated position, decreased ROM.
- Dx?
- eval?
- tx?
- Acetabular labrum tear
- eval:
H and P
pain w/ FAdAxL (hip flex, add and axial load)
imaging: X-rays (if neg) - go to MRI arthrogram - tx:
PT to max ROM and strength
injections?
surgical referral if conservative tx fails
52 yo woman w/ L lateral hip pain after vacation at beach, gradual onset, no trauma or previous hx, painful laying on L side.
Dx?
Eval?
Tx?
- Trochanteric bursitis
- eval: H and P -
pt tender over lateral thigh, pain w/ Ober test, hx key***: de-conditioned, sig increase in activity - on xray: may see calcification on gluteal tendons (not usually made w/ xray-soft tissue issue)
- tx:
ice, bried NSAIDs
PT: stretch ITB, strengthen hip muscles
eval biomechanics: leg length and gait
injection: just come back for more, doesn’t solve problem
Retired navy CPO w/ progressive right hip and groin pain, assoc decreased ROM, bowling game suffering, no trauma, no other jt complaints.
Dx?
Eval?
Tx?
- OA of the hip
- eval:
H and P
X-rays: wt bearing - tx:
PT
APAP over NSAIDs
hip injection (US guided): corticosteroids or viscosupplement
surgical referral if disabling
13 YO female gymnast w/ increasing groin pain over past 2 months - pain to jump, run, stretch, and land - increased pain w/ increased activity - no acute trauma Dx? Eval? Tx?
- pubic ramus stress fracture
- eval:
pt tender left superior pubic ramus
non-tendor adductors
normal hip exam
imaging:
xray (prob neg)
bone scan or MRI - tx:
relative rest
non-painful activity
slow increase
address other factors
Where do stress fractures commonly occur? Can be sign of what underlying problems?
- feet, ankles, tibia, fibula, patella, femur, and/or others (ribs)
- can be sign of underlying problems in addition to overuse;
ex: estrogen deficiency, hormonal abnorm, nutritional deficiencies (female athlete triad), or metabolic disorders
(check vit D levels)
Why is stress fracture of hip so critical?
- blood supply
- pressure and torque on femoral neck can be superior or inferior - if on top fracture can open further due to wt bearing (only tx is new head)
History and studies done for stress fracture? Key to tx?
- gradual onset of pain w/ activity
- hx:
increased intensity/duration of activity
change in footwear
change in surface - initial xrays are often neg
- secondary studies: bone scan, MRI
- ket to tx: pain free ambulation/activity
Stress fractures of hip and pelvis - Tx?
- need to have high index of suspicion
- crutches pending imaging:
xrays (prob neg), bone scan or MRI - Tx:
if inferior side (MC): non-painful activity, gradual protected return to activity
superior side: ortho referral, high risk for complete fracture - address causation:
diet, activity level, maturity
25 yo male soccer player w/ chronic groin pain for past several weeks, increased training in past month, worse w/ right footed kicking and resisted adduction -
dx?
Eval?
tx?
- adductor tendinopathy
- eval:
pain and stiffness gradually loosen up, pain w/ resisted adduction, TTP medial groin at tendon insertion - tx:
relative rest, ice, isometric and eccentric strengthening, PT
22 YO college hockey player w/ left groin pain
- progressive sx over past month
- worse w/ skating and hip motion
- no specific trauma
- DDx?
- adductor injury
- osteitis pubis
- pelvis stress fracture
- nerve injury:
ilioinguinal
obturator - hernia
Eval and etiology of athletic pubalgia/sports hernia? Tx?
eval:
- pain in hernia, region w/o palpable hernia
- possible dilated superficial ring
etiology:
- injury to conjoined tendon, internal oblique, external oblique, transversalis fascia, inguinal ligaments
- surgical referal
41 yo female w/ left buttocks pain, retired pro soccer player, insidious onset, pain to sit, increase after run, just really annoying
- Hx:
previous back aches, no specific trauma, pts to L lower back and buttocks, some radiation of pain to hamstrings, no numbness, no red flags
- PE:
normal gait and appearance, TTP L upper/outer buttocks, painful resisted ExtRot, painful passive IntRot, normal sensory and strength
Most likely dx? Tx?
- either piriformis strain vs syndrome
- variable muscle and nerve relationship
- strain: no sciatica**
- syndrome: + sciatica
- tx:
R/O other findings
brief NSAIDs
stretch/strengthen
PT: core strength program
Femur fractures of head and neck: etiologies exam findings Tx What should you be thinking of?
- etiology: fall (arrhythmia, osteoporosis, pathologic, sz, stroke)
- fxnl status
- exam: r/o other injuries -
shortened and ER
IR elicits pain in hip and groin - tx: pins, ORIF, THA, hemi
- think DVT
- if young: think AVN (20%)
Presentation of shaft femur fractures?
- high forces involved (commonly polytrauma)
- bleeding: traction (vascular injury)
- tx: surgical referral
- compartment syndrome
Causes of compartment syndrome? Tx?
- 75% fractures
- crush, envenomation, immobilization, constructive dressing, infection, burns, tourniquets
- CEC (chronic exertional compartment syndrome - exercise induced, chronic)
- tx: release pressure
Hip dislocation etiology? Types?
Tx?
- high energy trauma (MVA)
- younger pts
- anterior: 10-15%, dashboard w/ thigh abducted, ER
- posterior: IR
- Tx: reduction ASAP, AVN, sciatic injury (10%)
- think concomitant injury including fx-dislocation
Causes of knee pain?
- meniscus
- ligament
- plica
- DJD
- RA
- synovitis
- infection
- patellar
- OCD
- PVNS
- Tumor
- AVN
- referred
- vascular
- radicular
- bruise
- sprain
- tendinitis
- osgood-schlatters
- tendon rupture
- chondromalacia
- bursitis
- loose body
- dislocation
Typical knee etiologies in teen pt (younger than 20)?
- PFS (95%)
- tendinitis (patellar)
- osgood-schlatters
- osteochondritis dissecans (OCD)
Typical knee etiologies in adult pt (20-48)?
- PFS
- meniscus tear
- ligament tear
- bursitis (prepatellar)
- tendinitis (IT band friction)
Typical knee etiologies in older pt (older than 48)?
- meniscus tear
- arthritis
- bursitis (pes)
Components on hx for knee complaint?
- onset of pain: DOI or when sx started
- location of pain: DDX (pt to pain): ant, medial, lat, post
- MOI: predicts injured structure - contact/noncontact, twisting, planted
- injury assoc events:
pop hear or felt
swelling after injury (immediate vs delayed)
catching/locking
buckling/instability - aggravating factors:
activities, changing positions, stairs, kneeling - relieving factors:
ice, rest, activity - tx tried:
meds, RICE, crutches - hx of prior knee injury or surgery
What should you think when pt comes in w/ noncontact injury w/ pop (knee injury)?
- ACL tear, patellar dislocation
contact injury w/ pop in the knee?
- MCL or LCL tear, meniscus tear, fracture
Acute swelling of knee ddx?
- ACL, PCL tear, fracture, knee dislocation, patellar dislocation
Lateral blow to the knee?
- MCL
Medial blow to the knee?
- LCL
Knee gave out or buckled?
- ACL tear, patellar dislocation
Fall onto flexed knee?
- PCL tear
PE of the knee?
- alleviate pt’s fears
- think anatomy
- general approach:
inspection
palpation
ROM
strength
special tests
neurovascular exam
12 yo female presents w/ nonspecific ant knee pain, worse w/ activities like running, squatting and jumping. May have some swelling. Losing confidence, no injury, occasional popping. What tests would you run? Dx? Tx?
Think patella
- medial and lateral patellar glide
- patellofemoral grind: pressure on superior patella as pt fires quads, pain is + exam
- patellar apprehension test:
apply medial forces to patella: forcing it laterally
apprehension is + indicating previous subluxation or dislocation
- PFS/chondromalacia
- dx: look for muscle imbalance, flexibility issues, feet, and alignment
- tx: NICER, patellar stabilizing brace, PT to correct deficits
18yo F bball player on breakaway layup goes down under basket w/ no one around - ends up on floor holding knee and screaming in pain, felt a pop, unable to continue. Experienced instability and increased stiffness.
Tests to run, Dx?
want to assess stability of 4 ligaments via applied stresses
- valgus and varus at 30 degrees flexion then full extension, abnorm exam is laxity or soft endpoint or pain
- ACL: lachman, anterior drawer, pivot shift
- PCL: sag sign and posterior drawer
- most likely ACL
Tests for MCL and LCL
bohler test:
- valgus for MCL
- varus for LCL
Tx for collateral ligament injuries?
- NICER
- brace
- pain free activity
- time:
2-8 wks based on grade, 1 yr for full maturation of scar in complete tear
Special tests for ACL?
- **lachman: supine, knee at 20-30 degrees flexion, and relaxed, greater than 5 mm anterior translation of tibia positive
- anterior drawer: supine, hip at 45 degrees, knee at 90 degrees, tibia directed towards examiner
- pivot shift: don’t do, causes pain and isn’t necessary, insensitive and inaccurate while awake
ACL tear common etiology? Dx, Tx?
- most are noncontact
- females more common
- muscle imbalance and mechanics: valgus load
- hx, exam, aspiration
- MRI (shouldn’t need)
- surgical vs non-op: age, activity, concomitant injury (most young athletes need surgery)
Special tests for PCL tear?
- sag sign:
same position as anterior drawer, thumb slides medial to patella into tibial condyle, + sign is lacking condyle - posterior drawer: posterior pressure on tibia, + is posterior translation of tibia
Etiology of PCL tear? Dx, Tx?
- hyperextension or posterior load (dashboard)
- hx, exam, +/- aspiration
- tx: PT, quad strengthening (bracing, occasionally surgery)
54yo M construction worker steps off ladder onto uneven ground and has knee twist and experiences immediate medial pain, develops some swelling, now having trouble w/ squatting, kneeling and climbing ladders. Most likely dx?
- meniscus tear
Special tests for meniscus injuries?
- full flexion: sensitivity 55-85%, spec: 29-67%
- jt line tenderness: sens: 76%, specificity: 29%
- McMurray: specificity 97%, sensitivity 52%
- apley’s compression test
- bounce test
- duck walk
Characteristics of meniscus injuries? Tx?
- medial common, but lateral is worse (more prone to arthritis)
- mechanical sxs
- pain and swelling
- confirm w MRI
- tx: arthroscopy w/ meniscectomy vs repair
14 yr old M soccer player presents to clinic w/ insidious onset of anterior knee pain. Localizes pain to patellar tendon. No swelling, no injury, progressive in nature. Most likely dx?
- pattelar tendonitis
Characteristics of patellar tendonitis (tendinosis/tendinopathy)? causes?
- jumper’s knee
- affects participants in explosive sports involving quick movements: BBall players MC affected, commonly in hikers on hills and unpredictable pain
- causes:
- excessive activitiy: esp a rapid increaes in frequency/intensity of training
- improper mechanics of training
- excessive wt on person w/ wt bearing exercise lifestyle
Tx of acute tendinopathy?
acutely:
- ice, NSAIDs
- PT: flexibility, eccentric exercises
- tx mechanics: heel lift or orthotic to control pronation, change activity stimulus
- immobilize if necessary: Cam walker for severe cases achilles tendonopathy
Tx of chronic tendinopathy?
not an inflammatory condition:
- traditional therapies may not be best approach
- NSAIDs have no role except anlagesia
- steroid injections decrease pain short term: no inflammation (so mech in ?)
possible effects on novasc. and accompanying nerves as sclerosing agent or as vasoconstrictor/hypoxia. No benefit w/ long term pain relief, consider for therapy to break pain cycle
- Relative rest:
- d/c painful activities
- avoid immobilization if possible
- progress through passive and active stretching to PROM to progressively increasing loads of AROM
Chronic tendinopathy possible etiologies?
may be red flag to assoc factors:
- nutrition
- malalignments: Q angle, hyperpronation/supination, limited ROM of nearby jt, pes caves, pes planus, ankle instability, impingement
- muscle prob: muscle weakness/imbalance, inflexibility
- training errors: poor technique, excessive force, repetitive loading, fast progression w/ high intensity, poor or inadequate equipment
- meds: fluoroquinolones, doxy, steroids
- systemic disease: psoriasis, SLE, hyperthyroid, DM
Why is too much rest a bad thing in chronic tendinopathy?
- regeneration and remodeling of collagen requires protected loading of tendon
- new collagen aligns along lines of stress
- rest results in poorly aligned collagen and healing
What is eccentric muscle training? Benefits of this?
- muscle lengthening while contracting - stretches to produce elastic energy, which can be stored
- mult studies of chronic patellar and achilles tendinopathy show efficacy: 12 wk program
- improvement in pain and fxn results from 3-18 months
- histo review shows normal tissue: induces cell activity response and repair
- used for prevention
40 yo M roofer presents w/ acute onset of knee swelling. Diffuse pain. Knee feels warm to touch. No injury. This happened 5 yrs ago as well, resolved w/ time. Currently unable to work. What should you do? Most likely dx?
- needle knee (used therapeutically and dx)
- could be gout, pseudogout, septic knee: aspiration will tell us
When would you needle a knee?
- atraumatic swollen knee
- want to r/o:
infection (heme/post-op), inflammation (RA, psoriasis), reactive (meniscus, DJD)
Dx tests for atraumatic swollen knee?
- jt fluid: send for - cell ct, diff, crystals, culture, gram stain:
- blood tests: CBC w/ diff, ESR, CRP
- radiographs: AP/Lat/Merchant
- situation specific tests:
lyme titer
PPD
echo for murmur
RF/ANA
rashes/mouth ulcers/back sxs/eye sxs
MRI and/or bone scan - or refer to rheum
Cell counts and ESR of reactive, inflamm, and infected knee?
- reactive:
cell ct 0-20L, - culture, ESR less than 30 - inflamm: 20-50K, - culture, ESR less than 50
- infection: cell greater than 50K, + culture, ESR greater than 100
Diff septic bursitis from septic arthritis?
- bursitis is red and angry looking, area of fluctuance. Knee moves pretty well. don’t aspirate jt through cellulitus
- septic jt: doesn’t look red, just swollen, very tender and any motion causes it severe pain
Diff therapeutic injections?
- corticosteroids: for advanced OA, and other noninfectious inflammatory arthritides (gout)
- delivery of viscosupp (OA)
- glucosamine: studies show weak benefit in pain relief w/ glucosamine +/- chondroitin, no harm except money
- studies haven’t supported benefit of hyaluronate injections over single cortisone injection, but have shown pain relief
Where should you give knee injections at?
- superior anterolateral approach
- go into the suprapatellar pouch
Tx of fibular shaft fracture? When should you refer on?
tx based on pt’s comfort:
- splint, cast, or walking boot for 3-4 wks
- then gradual return to activities
- complete healing about 6-8 wks
referral:
- comminuted
- significantly displaced
- assoc tibial fracture
- neurovascular injury
- be sure to eval syndesmosis appropriately - assoc ankle fracture
MC areas of tibial plateua fracture? Tx?
- 60% lateral
- 15% medial
- 25% bicondylar
- refer!!
- splint, NICER, non-wt bearing
- usually high velocity, traumatic fractures
Imaging for knee pain?
- if arthritis or fracture is on your list or you are going to refer pt, order:
standing AP both knees, laterals, merchant/sunrise view - for arthritis standing 30 degree AP also
Use of Knee MRI?
- 90-95% sensitive and specific
- useful to confirm dx
- but most dx can be made w/ an avg hx and careful exam
