Lecture 2 Flashcards
If its pissed off ____ in an acute setting
Calm it down
Have a good rule of thumb for what to do when something is acute, subacute and chronic
KNOW: If a patient has lateral hip pain, we should be able to rattle of 2-4 really good hypothesis for what could be happening. Then we try to weed it down through a subjective.
what are some good questions to ask on a subjective examine about the patients pain?
“How would you rate your pain on a scale of 1-10”
“Is it deep or superficial”
“Give me a discription of your pain, is it deep and achy or numb and tingling etc.”
KNOW: Social determinants are a key part of the history. Social economic status goes a long well in determining how they’ll do.
KNOW: In the history get the patient to tell you why they’re in today
KNOW: In this history make sure to ask them the duration of the symptoms
What is irritability of pain
What causes the issue
How bad is the issue
How long does it take for it calm down (how much you can poke the bear before the bear pokes back)
Is pain that is an 8/10 but goes away fast highly irritable?
No
Is 5/10 pain that lingers for 2 hours irritable?
Yes
KNOW: pt history is in the subjective
KNOW: Mechanism of injury (MOI) - what brough on the injury originally should be in the patient history
KNOW: Nature of injury is in history
Is it insidious –> did they just wake up with it. Has it been getting worse over the last 3 months, what have you done in the last 3 months differently than before.
What is leg calve perthes?
What three substances increase the risk of osteonecrosis
Tobacco, alc, steroid
What is Legg-Calve-Perthes
Gender / age
Avascular necrosis of the femoral head
Happens around 3-12 in males (think younger)
Normally male
What does Ortolani test test for? How is it done
Hip displsia
Relocates femoral head (reduces)
What is the Barlow test? How is it done
Hip Displsia
Dislocates femoral head
What ages typically get SCFE? Gender?
10-16 (so younger)
Male (think around puberty)
What gender gets more hip dysplsia?
Female
What sex and age group is most likely to get femoral neck fractures?
Older females
What is the MOI (mechanism of injury) for trochanteric bursitis?
Why?
Fall on outside of hip
Because you land on the bursea and it gets inflamed
Subluxation defintion?
Partial dislocation
What two problems can falling on the knee cause
Subluxation / Acetabular labral tear (posterior)
What normally causes femoral stress fractures?
Repetitive loading (think running)
NOTE: this is especially likly to happen if they’ve changed their shoes, running style, or location they’re running (really any change)
A runner comes in with new onset pain. What would your first question be?
Has there been any changes to your running environment / shoes?
What time of day is hip OA the worst?
In the mornings
Why would prolonged sitting make OA worse?
Because its just stationary and it takes movement to bring out the synovial fluid
Why would prolonged sitting bring on femoriacetabular impingement symptoms?
Because they’re in that prolonged flexed position - this pinches that labrum
What are the two types of deformities for FAI? Define each
Cam = femoral neck
Pincer = acetabular rim
Both pinch down on the labrum
What happens to hip OA with movement?
It gets better (synovial fluid comes in and losens it up)
My patient is 25 years old with anterior hip pain. Am I thinking FAI or OA?
FAI. Older patients typically get OA
An older patient says that they can no longer externally rotate their leg to put socks on anymore. What diagnosis and I most likely thinking of?
Hip OA
What typically causes femoral acetabular impingement?
Some kind of trauma
KNOW: FAI, labrum, groin pain can all be brough on with movement (especially closing down space in groin)
What two issues cause buttock pain
posterior labral tear
Lumbar problem (more likely)
Over active adductors could cause pain where
could cause adductor pain
Pelvic instability could cause pain where?
Adductor pain (think about them getting pulled?)
What could cause lateral hip pain? (3)
Lateral Trochanteric busitis, glute med tendon, L4 nerve root pain
There is pain coming from the patients groin and medial side of thigh to knee. Give me two hip diagnosis
Labral tear
Anterior FAI
The patients pain is in their lower back and lateral side of hip. They report kind of a shooting sinsation down the hip. What is the most likely diagnosis?
Lumbar spine issue
What is a tell tale sign of a labral tear?
Clicking
Especially if they have a pinching poking pain thats kind of deep and hurts when sitting for an extended period of time
Clicking VS Snapping
Snapping = think one surface rubbing over another surface. Think a rubber band rubber over your fingers you get tension tension tension then a little pop with some relief
Clicking is everytime were moving were feeling something shifting (rolling shoulder)
If theres lots of clicking or clunking in the knee what are we thinking?
Meniscus issue
* especially if they have a catching sensation
What are two common sights in the hip the have internal snapping
What position causes this
ilioposas tendon
iliofemoral ligament (connects ilium and femur)
Especially when going into extension from 45 degrees of flexion - espically w/ hip abduction and ER
NOTE: since the tendons run on the inside this position would essentially be tightening up these tendons/ligaments. Its going to be tight tight tight then snap
iliopsoas tendon
What causes external snapping in the hip?
What position causes this
Tight iliotibial band or glute max tendon rolling over glute max
Flexion to extension especially w/ IR (this position makes it the tightest
What are two intra articukar hip problems
What are two symptoms of this
Acetabular labral tear
Loose bodies
Clicking / sharp pain
Whats the difference between MCID and MCD?
MCD minimal detectable change: what is a statistical difference
MCID: Minimal clinical important difference - what matters to me or the patient functionally. Takes into subjective and objective (what is most important to us)
* Every test has one of these - its how much imporovement is statistically significant
On the Numeric Pain Rating Scale (NPRS) what is the MCID (minimal clinical important difference)
2/10
So if they said 6/10 is there pain oirginally and now its 4/10 its a statistically significant difference (because the MCID also works on questionaires)
NOTE: getting a statistically significant change could be a good goal to set
* “Under promis over deliver - set higher time than you need”
Is a higher or lower score on higher Extremity Function Scale good
Higher score is good (higher score on functional score is a good thing)
How many 0-4 questions is the lower extremity function scale test?
What kind of people is this best for?
20 questions (max 80 points)
Functional middle of the road individuals
Hip disability and osteoarthritis outcome score is used for ______
(HOOS)
KNOW: its 40 items with 5 subscales (pain, symptoms, ADLs, sports recreation, quality of life)
OA
Note: this does not encompass the entire LE but specifically the hip (the questions are all hip specific)
What does the Lower Extremity Functional Scale measure?
NOT JUST HIP BUT ALSO ENTIRE LE
20 questions about a patients ability to do day to day tasks (very generalized)
Which test is good for middle aged and younger patients with hip pain. Includes ADLs and Sports questions (26 questions). Hip disability and osteoarthritits outcome score (HOOS) or Hip outcome score (HOS)
HOS. The HOOS is specifically taylored to patients w/ Hip OA
What kind of question does the Patient Specific Functional Scale ask?
“Please identify up to 3 important activities that you are unable to do or are having difficulty with as a result of your problem)
NOTE: This is directed at the entire body (duh)
What are the two biggest red flags for cancer
Hx of cancer followed by Wt Loss
What is Burnies point?
Where the appendix is
Where is burnies point?
2/3 of the way from the naval to ASIS
What kind of pressure do we put over burnies point to test for appendicitis?
Rebound style (poke and release)
KNOW: Some questions we would ask pt’s w/ colon cancer = cancer history / family hx / stool color / bowel movements / black tare like stool (not fresh blood)
Why would we be worried about a fever
potential infection
KNOW: night pain is a red flag along with fever
KNOW: Symptoms unchanged w/ movement = red flag
KNOW: Symptoms related to the menstrual cycle = red flag
Patient comes in and presents symptoms of right thigh / groin + testicular pain. They mention that they’ve been running a fever for a few days and have recently had the onset of vausea & vomiting. What is the diagnosis. what test would we use
Appendicits
Press on McBurneys point
What age group typically gets colon cancer?
50+
Remember, you get screened for this at 50 so this makes sense
Dark blood in stool leads us to think what
colon cancer
What substance increases the risk for colon cancer?
Smoking
What does the fulcrum test look for?
femoral fractures
What ligament is normally involved in avasucular necrosis of the hip?
Ligamentum teres
KNOW: KNOW YOUR IMAGING STUFF
What is the patellar-pubic percussion test listing for?
How is it set up
What are we listening for / diagnose
Pubic symphysis
tap on knee listen to pubic symphysis
Listening for a dullniss (not crisp) / side to side differences. Diagnosis hip fractures
How is the resisted straight leg raise test set up?
What are we looking to find w/ this test. How do we know if we’ve found this?
Whats another possibility from this test
pt in long sitting on a table w/ arms behind them. They lift their leg up (keeping it staright utilizing hip flexors) while you push down.
Looking to find labral pain. We know if we’ve found this because their symptoms will be clicking or catching in the anterior hip. We are essnentially stressing the iliopsoas tendon which pulls on the labrum creating that clicking
This test can also yield pain in the lower quarter abdomin. We just want to know that we are thinking that it is something else
A Resisted straight Leg Raise Test is a differential diagnose to find what two potential things
Labral issue (anterior / groin pain w/ clicking)
Some viserial lower quarter issue in the abdomin
positive = pain
What is the most common thing to clue us in to a patient having avascular hip necrosis?
It being on the other side as well
Is hip avasular necrosis slow onset or sudden onset?
Fast
The bone immediately starts dying w/o blood
KNOW: Trauma causes avascular necrosis (the blood supply gets cut off)
KNOW: Corticosteroid use causes avascular necrosis
Does avascular necrosis get better or worse w/ weight bearing?
Worse - its hard to walk on a dying leg (could even start to see a trendelenburg)
What 3 places is pain referred to from avascular necrosis?
1) Groin
2) Thigh
3) Medial knee
What age group typically gets Legg-Calve-Perthes?
Pediatric (3-12)
What motion does Legg-Calve-Perthes affect the most?
Internal rotation (I think because its where the femoral head has the most contact w/ the acetabulum)
What motion is most affected by SCFE?
IR
Patients w/ SCFE normally stand in what position when weight bearing?
ER (remember - IR is painful)
A patient comes in with the inability to urinate and has sudden back pain. What are we thinking they have?
Cauda equina syndrome
What is central spinal stenosis?
When the central canal shrinks and compresses the spinal cord
What two non traumatic things typicall cause cauda equina syndrome?
What traumatic thing causes it
Central spinal stenosis / Prolapsed lumbar disc
Fall on butt could cause this
Should we fix posture
If its not broke dont fix it
Posture does not always relate to pain
Is posture always related to pain?
No
What is genu valgum
Knees going into valgus (going in)
Which sex typically has a wider pelvis
Wide hips causes genu valgus which causes
Trochanteric bursitis (because the hip is essnetiallly being pulled at the head laterally –> pushing on the bursa which flares it up)
Notice how the hips push out onto the bursa at the hip
A patient arrives at your clinic complaining of hip pain. You note excessive genu valgum. Where would you expect this pain to be and what is the most likely diagnosis?
Pain is expected on the lateral thigh due to troachanteric bursitis
What side should the cane be on? (affected or non affected)
should be on the non affected side (opposite the affected)
What is the leg length discrepency measurement?
ASIS –> medial malleolus
NOTE: pattella facing in could indicate a femoral shaft rotation or genuvalgum
What kind of arthritis is obesity related to?
OA
What does the iliposas do (2)
Hip flexion (not weight bearing)
Trunk flexion (weight bearing)
What motion might a tight ilipsoas make you do?
Diviation of spine to same side (look at a picture - if the muscle is tight its naturally going to make you devivate to that side)
The patient has a naturally shorter right leg than left and you notice that leg is in some IR and adduction. You also notice a more prominent greater trochanter. What is are guess at what they have?
Traumatic posterior hip dislocation
What are we thinking if the patient comes in with a limb shorted and is in external rotation?
Intertrochanteric fracture
Do most individuals have some leg length discrepency?
If so, what is an abnormal one? (test)
Yes most people have some leg length discrepency - however its nor abnormal unless its greater than 1.5CM
Why is it hard to detect swelling in the hip?
Because most people have significant adipose tissue / muscle there
A patient comes in with a leg length discrepency. Which way is there pelvis dropped to
Does this cause genu valgum or varum?
Pelvis dropped toward affected side
Causes genu valgum (hip essentially collapses down causing knee to invert in)
Also causes flat foot
KNOW: You can check for leg length discrepencys by having them hooklying in supine
What is the angle of inclination?
Angle between the neck of the femur and the shaft of them femur
(Think of it like how much the head of the femur is inclined)
What is coxa valga?
Think of it being at the level of the coccyx
ITs an increased angle of inclination (140+)
Would cova valga or vara cause a shorter leg?
Vara = shorter leg because the angle of inclination is smaller
What is a normal inclination angle?
125
an angle of inclination less than ____ causes coxa vara
105
An angle of inclination greater than ____ causes coxa valga
140 (subtract 15 to get normal then 15 less for vara)
What is femoral anteversion?
Femoral head / neck being turned further with respect to the shaft. The head is essentially coming off the shaft in a more anterior position creating a larger angle with respect to the greater trochanter.
Does antiversion or retroversion cause a decrease in ER
Antiversion
What movement is limited by anti version? Why?
ER
Because that femoral head is essentially already put in some IR (because the litteraly head is shifted, the foot / leg isnt) - so when you try to do it you can’t get as far
Why does antiversion cause a shorter leg
Because it starts you in internal rotation.
When you’re in internal rotation you knee naturally drips in creating that shorter leg
Whats more common, antiversion or retroversion problems?
antiversion
What does Craiges test measure?
Amount of avilable external for internal rotation (typically used to retro / antiversion patients)
Why does retroversion give you a longer leg
because it naturally starts you in excessive external rotation
That external rotation puts your leg in varus which gives you the appearance of having a taller leg
What creates a shorter leg. Anteversion or retroversion?
Retroversion
What is the comparable sign?
The pain that they came in with
what is resisted provocation
Pre-curser to MMT
What does the Thomas test do?
Lets you differenitiate between rec fem or iliposoas causing the issue
What specific muscle is faulty if the patient has a trendelenburg sign?
Glute med
(abduction)
Hip drops on the weak side for trendelenburg side (I think)
If the pain in the leg is further from the hamstring tendon what does that mean for the amount of time it takes them to get back?
Longer time
If I compress your femoral head and it causes pain what are a few diagnosis I could be thinking
avascular necoris
RA
what is the cross over sign associated w/
Associated w/ FAI
What imaging do we use for soft tissue issues?
MRI
What imaging do we use for tendons?
Ultrasound
