Lower Extremity Disorders: Hip and Pelvis Workup and Treatment Flashcards
1
Q
What are the bones of the pelvis?
4
A
- Ilium
- Ischium
- Pubis
- Acetabulum
2
Q
What are the following parts of each of these:
- Ilium? 3
- Ischium? 2
- Pubis? 2
A
- Ilium
- Anterior Superior Iliac Spine
- Anterior Inferior Iliac Spine
- Posterior Inferior Iliac Spine - Ischium
- Ischial Spine
- Ischial Tuberosity - Pubis
- Pubic Symphysis
- Inferior and Superior Rami
3
Q
What are the parts of the femur?
5
A
- Head
- Neck
- Greater Trochanter
- Lesser Trochanter
- Shaft
4
Q
What are the ligaments of the hip?
3
A
5
Q
Nerves of Hip, Pelvis and Thigh
- What does the Sciatic nerve come out of?
- What is it responsible for?
- Where does the femoral nerve come out of?
- What is it responsible for?
- What does the lateral femoral cutaneous nerve come out of and what is it responsible for?
A
Sciatic Nerve
- L4-S3
2.
- Articular and Muscular
- Sensation
- External rotation and posterior thigh, foot
Femoral Nerve
- L2-4
4.
-Anterior thigh compartment
Lateral Femoral Cutaneous
- L3-4
- Sensory
6
Q
Blood Supply of the Hip
What are the two big vessels?
A
- Femoral Artery
- Artery of the ligamentum teres
7
Q
Avascular Necrosis
Interruption of Vascular supply of the femoral head
Risk factors?
A
- Fracture
- Steroids
- Coagulopathy
- Dislocation
- ETOH
- Sickle Cell
- SCFE
- Perthes
8
Q
Avascular Necrosis of femoral head
- Bilateral or unilateral?
- Prognosis?
- Tx? 2
A
- Commonly bilateral
- Prognosis- 70-80% collapse by 3 years
- Treatment
- Early- anticoag, ?bisphosphonates, decompression, treat cause
- Later- Surgery- decompression vs total hip vs arthrodesis
9
Q
Hip Bursae
are where? 3
A
- Trochanteric
- Greater trochanter and Iliotibial band - Ischial
- Ischial tuberosity and gluteus muscles - Iliopsoas
- Iliopsoas tendon and lesser trochanter extending upward into the iliac fossa beneath the iliacus muscle
10
Q
Musculotendinous Injuries
What are three things we should know when treating these?
3
A
- Very common
- Debilitating
- Recurrent
11
Q
A
Quad hematoma
12
Q
Hip Imaging
5
A
- X-rays
- Bone Scan (Flex, ExRot)
- CT
- MRI
- MRI Arthrogram
13
Q
What kind of Xrays are you going to want to get on Hips?
2
A
WEIGHT-BEARING AP
Frog leg
14
Q
ANTERIOR HIP PAIN DIFFERENTIAL
8
A
- Osteoarthritis
- Inflammatory Arthritis
- Muscle/tendon strain
- Tendinitis
- Femoral Neck Stress Fracture
- Obturator/Ilioinguinal nerve entrapment
- Osteitis Pubis
- Acetabular Labral tear
15
Q
HIP PAIN DIFFERENTIAL
- Pre-pubescent? 2
- Adolescent? 5
- Older? 8
A
- Pre-pubescent
- Legg Calve Perthes Dz
- Slipped Capital Femoral epiphysis - Adolescent
- Avulsion fracture
- Hip pointer
- Contusion
- Myositis Ossificans
- Femoral Neck Stress Fx - Older
- FAI – femoroacetabular impingement
- Osteoid Osteoma
- ITB Syndrome
- Trochanteric Bursitis
- Piriformis Syndrome
- Iliopsoas Bursitis
- Meralgia Paresthetica
- Osteoarthritis
16
Q
32 yo female recreational runner
- Previous dancer
- Gradual increase in distance and abdominal workouts
- Pain and snapping in groin and anterior hip with hip flexion and crunches
1. What is the Dx?
2. Evaluation? 2
3. Tx? 4
A
- ILIOPSOAS BURSITIS/TENDINOSIS
- Evaluation
- History and physical
- Consider X-ray or MRI to r/o other dx - Treatment
- Relative rest, stretch, consider NSAIDs
- Physical therapy
- Injection?
- Surgical referral?
17
Q
28 yo male skier
- Hip pain with deep click that persists 2 months after a fall
- Catching sensation
- Worse with deep flexion and raising from seated position
- Decreased ROM
1. Dx?
2. Evaluation? 3
3. Tx? 4
A
- ACETABULAR LABRUM TEAR
- Evaluation
- History and Physical
- Pain with FAdAxL (hip flex, add and axial load)
- Imaging: x-rays (neg)→ MRI arthrogram - Treatment
- Physical Therapy to maximize
- ROM and strength
- Corticosteroid injection?
- Surgical referral?
18
Q
52 yo woman with left lateral hip pain after a vacation at the beach
- Gradual onset
- No trauma or previous hx
- Painful laying on left side
1. Dx?
2. Evaluation? 2
3. Tx? 4
A
- Trochanteric bursitis
- Evaluation
History and Physical
- Point tender over lateral thigh, pain with Ober test
- Hx key: De-conditioned, significant increase in activity
3. Treatment - Ice, brief NSAIDs
- PT: stretch ITB, strengthen hip muscles
- Evaluate biomechanics – leg length and gait
- Corticosteroid injection
19
Q
Retired Navy CPO with progressive right hip and groin pain
- Associated decreased ROM
- Bowling game suffering
- No trauma, no other joint complaints
1. Dx?
2. Eval? 2
3. Tx? 4
A
- OSTEOARTHRITIS HIP
- Evaluation
- History and Physical
- X-rays – weight bearing - Treatment
- Physical therapy
- APAP > NSAIDs
- Hip injection (US guided) corticosteroid or viscosupplement
- Surgical referral if disabling
20
Q
13 yo female gymnast with increasing groin pain over the past 2 months
- Pain to jump, run, stretch, and land
- Increased pain with increased activity
- No acute trauma
1. Dx?
2. Eval? 4
3. Tx? 4
A
- PUBIC RAMUS STRESS FRACTURE
- Evaluation
- Point-tender left superior pubic ramus
- Non-tender adductors
- Normal hip exam
- Imaging: X-ray (prob neg) and Bone scan or MRI - Treatment
- Relative rest
- Non-painful activity
- Slow increase
- Address other factors
21
Q
STRESS FRACTURES
- Can occur anywhere but commonly in? 6
- Can be a sign of underlying problems in addition to overuse such as? 4
A
- Can occur anywhere
Commonly in
- feet,
- ankles,
- tibia,
- fibula,
- patella,
- femur,
2. Can be sign of underlying problems in addition to overuse, i.e.. - Estrogen deficiency,
- hormonal abnormalities,
- nutritional deficiencies, or
- metabolic disorders
22
Q
Stress fractures
- Progression?
- Hx? 3
- Xray findings?
- Secondary imaging? 2
- Key to tx?
A
- Gradual onset of pain with activity
- History:
- Increased intensity/duration of activity
- Change in footwear
- Change in surface - Initial x-rays are often negative
- Secondary studies:
- bone scan,
- MRI - Key to treatment is pain free ambulation/activity
23
Q
STRESS FRACTURES
HIP, PELVIS, THIGH
- Initial Management?
- Tx? 2
- Address causation how? 3
A
1.
- CRUTCHES pending imaging
- X-ray (prob neg)
- Bone Scan or MRI
2. Tx: - Inferior side: NON-painful activity, Gradual protected return to activity
- Superior side: Ortho referral, High risk for complete fracture
3. Address causation - Diet,
- activity level,
- maturity
24
Q
25 yo male soccer player with chronic right groin pain for the past several weeks
- Increased training in the past month
- Worse with right footed kicking and resisted adduction
1. Dx?
2. Evaluation? 3
3. Tx? 4
A
- Adductor Tendinopathy
- Evaluation
- Pain and stiffness gradually loosen up
- Pain with resisted adduction
- TTP medial groin at tendon insertion - Treatment
- Relative rest,
- ice,
- isometric and eccentric strengthening,
- physical therapy
25
22 yo college hockey player with left groin pain
- Progressive sx over past month
- Worse with skating and hip motion
- No specific trauma
1. Dx?
2. Eval? 2
3. Etology? 5
4. Tx?
1. ATHLETIC PUBALGIA/SPORTS HERNIA
2. Evaluation
- Pain in hernia region without palpable hernia
- Possible dilated superficial ring
3. Etiology: Injury to
- conjoined tendon,
- internal oblique,
- external oblique,
- transversalis fascia,
- inguinal ligament, etc.
4. Surgical referral
Find surgeon that does these!
26
22 yo college hockey player with left groin pain
Progressive sx over past month
Worse with skating and hip motion
No specific trauma
Whats the DDx for this? 5
1. Adductor Injury
2. Osteitis Pubis
3. Pelvis stress fracture
4. Nerve injury: Ilioinguinal and Obturator
5. Hernia
27
41 yo female with left buttocks pain
- Retired professional soccer player
- Insidious onset
- Pain to sit
- Increase after run
- Annoying!
Dx?
PIRIFORMIS
STRAIN
v SYNDROME
28
PIRIFORMIS STRAIN/SYNDROME
1. What would be positive for Hx? 3
2. What would be neg? 3
3. What would be positive on Physical? 3
4. What would be neg? 2
1. History +
- Previous back aches
- Points to left lower back and buttocks
- Some radiation of pain to hamstrings
2. History -
- No specific trauma
- No numbness
- No red flags
3. Physical +
- TTP left upper/outer buttocks
- Painful resisted ExtRot
- Painful passive IntRot
4. Physical -
- Normal sensory and strength
- Normal gait and appearance
29
1. What is the difference in PIRIFORMIS STRAIN v SYNDROME?
2. Tx? 4
1. Variable muscle and nerve relationship
- Strain: no sciatica
- Syndrome: +sciatica
2. Treatment
- Rule out other things
- Brief NSAIDs
- Stretch/strengthen
- PT: Core strength program/Don’t forget the feet
30
FEMUR FRACTURES- HEAD/NECK
1. Etiology?
2. Exam? 2
3. Tx? 4
4. HAVE TO THINK WHAT?
5. If young think what?
1. Etiology: fall (arrhythmia, osteoporosis, pathologic, sz, stroke)
2. Exam: r/o other injuries
- Shortened and ER
- IR elicits pain in hip and groin
3. Tx: Pins, ORIF, THA, hemi
4. Think DVT
5. If young, think AVN- 20%
31
What are the 6 types of Femur Head and Neck fxs?
32
Tx for Femur Fx?
33
What is this a picture of?
ORIF sub-troch Fx
34
What are these two?
35
FEMUR FRACTURES- SHAFT
1. What kind of force is involved?
2. Tx?
3. What are we worried about? 2
1. High forces involved
2. Treatment- surgical referral
3.
- Compartment Syndrome
- Bleeding!- traction/Vascular injury
36
1. What is compartment syndrome?
2. 75% are caused by?
3. Other causes? 7
4. TX?
1. a condition resulting from increased pressure within a confined body space, especially of the leg or forearm.
2. 75% Fractures
3.
- Crush,
- envenomation,
- immobilization,
- constrictive dressing,
- infection,
- burns tourniquets
- CECS
4. Treatment:
Release pressure
37
HIP DISLOCATION
1. Often caused by?
2. usually in who?
3. What will anterior dislocation look like? 2
4. What will posterior?
5. Tx?
6. Tx quickly/ASAP. Why? 2
7. What do we also have to think with this?
1. High energy trauma- MVA
2. Younger pts
3. Anterior
- Dashboard w/ thigh abducted
- ER
4. Posterior
- IR
5. Tx- reduction- ASAP
6.
- AVN,
- Sciatic injury (10%)
7. Think concomitant injury incl fx-dislocation
