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
