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MSK > Lecture 6 Clinical correlates of hip > Flashcards

Lecture 6 Clinical correlates of hip Flashcards

1
Q

How would you test to see if your patient had a superior gluteal nerve injury?

A

-the superior gluteal nerve supplies the abductors of the hip (gluteus medius/minimus)
-ask them to stand on their injured lower limb
-if pelvis on unsupported side descends= positive Trendelenburg sign
(usually the gluteus minimus/medius contract, preventing tilting of pelvis on unsupported side)

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2
Q

How do pulled hamstrings occur?

A
  • Sudden muscular exertion resulting in stretching of posterior thigh muscles (jumping, sprinting, lunging)
  • common in footballers/athletes, especially if not warmed up
  • tension on hamstrings results in muscle sprain, partial/complete tear of origin of hamstring muscles from ischial tuberosity, avulsion fracture
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3
Q

What is an avulsion fracture?

A

Injury to bone where tendon/ligament attaches to bone

tendon/ligament pulls off a piece of bone

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4
Q

What is osteoarthritis?

A

Most common disease affecting synovial joints

  • degenerative disorder arising from the breakdown of hyaline cartilage
  • chronic disease, non-inflammatory
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5
Q

What age range does osteoarthritis affect & what are the symptoms?

A

Elderly

  • joint pain
  • functional limitation
  • reduced quality of life
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6
Q

What are the common joints affected by osteoarthritis?

A
  • hips
  • knees
  • cervial/lumbar spine
  • small joints of the hand
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7
Q

What are the different classes of osteoarthritis?

A

Primary: cause is unknown
Secondary: known precipitating cause

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8
Q

What are the risk factors of primary osteoarthritis?

A
  • age
  • female sex
  • ethnicity (increased risk in african-americans, american indian, hispanic)
  • genetics
  • nutrition (consumption of vit C&E may help)
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9
Q

What are some secondary causes of osteoarthritis?

A
  • obesity
  • trauma (including sports)
  • malalignment (developmental dysplasia of hip- congenital hip displacement)
  • infection (TB, septic arthritis)
  • inflammatory arthritis (rheumatoid, ankylosing spondylitis)
  • metabolic disorders affecting joints (gout)
  • haematological disorders (bleeding into joints)
  • endocrine abnormalities (diabetes with neurovascular impairment-chronic malalignment of articular surfaces)
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10
Q

Symptoms of osteoarthritis?

A
  • deep aching joint pain, worsened by use
  • reduced range of motion
  • crepitus (grinding)
  • stiffness during rest
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11
Q

What leads to hyaline damage?

A

Uneven loading of the joint due to risk factors

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12
Q

What happens to the hyaline cartilage?

A
  • becomes swollen due to increased proteoglycan synthesis by chondrocytes, with increased number of chondrocytes differentiating from chondroprogenitor cells (reflects attempt to repair cartilage)
  • proteoglycan content gradually falls as disease progresses
  • cartilage softens and loses elasticity
  • flaking and fibrillation seen
  • cartilage becomes eroded down to the bone resulting in loss of joint space
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13
Q

What does the surface changes in osteoarthritis trigger?

A

Alter the distribution of biomechanical forces

  • subchondral bone responds with vascular invasion and increased cellularity: becoming thicker and denser
  • subchondral bone may undergo cystic degeneration to form subchondral bone cysts (fluid filled spots in bone) which make the bones weak, attributes to osseous necrosis/intrusion of synovial fluid
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14
Q

What is eburnation?

A

Subchondral bone responds with vascular invasion and increased cellularity: becoming thicker and denser
(subchondral sclerosis: hardening of bone just below cartilage surface)

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15
Q

What occurs at articular margin of the bones?

A

Osseous metaplasia of connective tissue

-irregular outgrowth of new bone (osteophytes)

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16
Q

What are the 4 signs of osteoarthritis on an X-Ray?

A
  • reduced joint space
  • subchondral sclerosis
  • bone cysts
  • osteophytes
17
Q

Which sex is osteoarthritis of the hip most common?

A

Males over 40

18
Q

Symptoms of osteoarthritis in the hip?

A
  • joint stiffness (getting out of bed/ after sitting)
  • pain in hip/gluteal/groin regions, radiating down to knee via obturator nerve
  • mechanical pain (pain accentuated by mobilisation/weight bearing)
  • crepitus (grating/crunching)
  • redcued mobility
19
Q

How is osteoarthritis of the hip diagnosed?

A
  • clinical presentation (signs/symptoms)

- supported by X-Ray changes

20
Q

How can you treat/cure osteoarthritis of the hip?

A

-weight reduction (if overweight)
-activity modification
-walking stick/frame to reduce load through arthritic joint
-muscle strengthening exercises/orthotic footwear can rebalance a misaligned load through the joint
-analgesia-paracetomol/anti-inflammtories-NSAIDS /nutritional supplements
-steroid injections into joint to reduce swelling, alleviating stiffness/pain
-hyaluronic acids injections: increase lubraction, promote cartilage repair
Only cure is total hip replacement

21
Q

What region is classed as being a fracture to the neck of the femur?

A

-up to 5 cm below lesser trochanter

22
Q

What are fractured NOF’s classed as?

A
  • intracapsular

- extracapsular (intertrochanteric, subtrochanteric)

23
Q

Which fracture is most likely to disrupt blood supply to the femoral head?

A

Intracapsular

  • disrupts ascending cervical branches of medial femoral circumflex artery
  • due to inability of artery of ligamentum teres to sustain metabolic demand of the head, high risk of avascular necrosis of the bone, especially if the fracture is displaced
24
Q

In whom are extra/intracapsular ligaments more common?

A

Intra: elderly/postmenopausal women- osteoporic bone

Extra: young population- traumatic force

25
Q

How is a displaced intracapsular fracture treated?

A

-surgical replacement of femoral head
Hemiarthroplasty: femoral head only
Total hip replacement

26
Q

Why is the mortaility increasing due to NOF?

A

Often seen in the elderly with other co-morbidities

27
Q

Symptoms of NOF?

A
  • reduced mobility
  • sudden inability to bear weight on the limb
  • pain in hip/groin/knee
28
Q

What does it look like if the fracture is displaced?

A
  • shortened leg
  • abducted
  • externally rotated
  • exacerbation of pain of palpitation of greater trochanter/rotation of hip
29
Q

Why should you avoid vigorous examination on a suspected hip fracture?

A

Risk of displacing the fracture

30
Q

What is dislocation of the hip?

A

Femur being fully displaced out of the acetabulum

31
Q

What causes hip dislocation?

A

Congenital: developmental displasia (used to be congenital dislocation of hip- renamed as varyin degrees of displacement and can occur after birth)

Trauma: road traffic collisions, massive amount of force required

32
Q

Symptoms of hip dislocation:

A
  • extremely painful

- resists any movement of limb

33
Q

What are the types of hip displacement?

A 
Posterior (90% of dislocations)
-impact of dashboard and knee during collision
-sciatic nerve palsy occurs sometimes
Anterior
Central
34
Q

What will the leg look like after a posterior hip dislocation?

A
  • shortened
  • flexion
  • adduction
  • medial rotation
35
Q

Why does the leg look shortened, externally rotated and abducted when in a displaced NOF?

A

Shaft of femur moves independently of the hip joint

  • the axis of rotation of femur that usually passes obliquely (slanted) through head & down neck of femur, shifts to pass through greater trochanter and vertically along femoral shaft
  • short lateral rotators (piriformis, obturator internus, gemelli, quadratus fermoris) contract, laterally rotating the leg
  • iliopsoas acts as a lateral rotator pulling the lesser trochanter anteriorly about new axis of rotation
  • abductors (gluteus medius/minimus) abduct femur, and rotate greater trochanter laterally
  • shortening of limb is due to muscles of the thigh pulling the distal fragment of femur upwards
36
Q

Why does shortening & internal rotation of the hip occur in dislocation of hip?

A
  • femoral head is pushed back and lies on lateral surface of ilium
  • head of femur is then pulled upwards by strong extensors (gluteus max/hamstrings) causing limb shortening
  • anterior fibres of gluteus medius/minimus pull on greater trochanter causing the femur to rotate medially
37
Q

What does the limb look like in anterior dislocation of hip?

A
  • limb held in position of external rotation and abduction, slight flexion
  • femoral nerve palsies are rare
38
Q

What occurs in central dislocationof hip?

A
  • head of femur driven into pelvis through the acetabulum
  • always a fracture dislocation
  • femoral head is palpable of rectal examination
  • high risk of intrapelvic haemorrhage due to disruption of pelvic venous plexuses
  • can be life-threatening

MSK (12 decks)

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