Lower limb - Hip

Question 1

What is the most common cause of hip dislocation?

Answer 1

High-impact trauma, such as road traffic accidents (RTA) or contact sports, particularly when the hip is flexed

Question 2

Which type of hip dislocation is most common?

Answer 2

Posterior dislocation (90% of cases)

Question 3

What fractures are associated with hip dislocations?

Answer 3

Posterior acetabular wall fractures and femoral fractures

Question 4

What is the mechanism of injury for a posterior hip dislocation?

Answer 4

A force applied along the femur proximally, causing the femoral head to dislocate posteriorly, often with an acetabular rim fracture

Question 5

How does a posterior hip dislocation present?

Answer 5

The leg is
1. flexed
2. Internally rotated
3. adducted

Question 6

How does an anterior hip dislocation differ in presentation?

Answer 6

The leg is
1. externally rotated
2. abducted

Question 7

What is the first step in assessing a hip dislocation?

Answer 7

Neurovascular assessment, especially checking for sciatic nerve injury

Question 8

Which imaging modalities are used for diagnosis?

Answer 8

1. X-ray (initial) and CT scan after reduction if further injury is suspected

Question 9

What is the immediate treatment for a hip dislocation?

Answer 9

Urgent reduction of the dislocation

Question 10

What additional measures may be required in severe cases?

Answer 10

Traction stabilisation and surgical fixation if fractures are present

Question 11

What are the major complications of hip dislocation?

Answer 11

(1) Sciatic nerve palsy
= especially common in posterior dislocations

(2) Avascular necrosis (AVN) of the femoral head due to compromised blood supply

(3) Secondary osteoarthritis (OA) of the hip due to joint damage

Question 12

A 30-year-old male is brought to A&E following a high-speed motorbike accident. He reports severe hip pain and is unable to move his leg. On examination, his leg is flexed, internally rotated, and adducted

(A) Which nerve is at the highest risk of injury in this patient?

(B) What imaging should be performed first?

(C) If the femoral head is not in the acetabulum on X-ray, what is the next step?

Answer 12

A. Sciatic nerve – it runs posteriorly near the hip joint

B. X-ray of the pelvis

C. Urgent closed reduction under sedation or general anaesthesia

Question 13

A 25-year-old footballer is tackled while running. He feels a ‘pop’ in his hip and is unable to bear weight. Examination shows the leg is externally rotated, abducted, and slightly flexed

What is the most likely diagnosis and which structures are at risk?

Answer 13

Anterior hip dislocation

= Femoral nerve and vessels, leading to possible loss of knee extension and reduced blood supply

Question 14

How is an anterior dislocation managed?

Answer 14

Urgent closed reduction

Question 15

A 40-year-old man fell from a height three days ago. He had mild hip pain initially but continued walking. Now, he presents with worsening pain and an inability to move his leg. X-ray shows a posterior hip dislocation

Why is this a concerning presentation? and what is the most appropriate next step?

Answer 15

Delayed reduction increases the risk of avascular necrosis (AVN)

Urgent reduction (under 4 hours)

Question 16

What is the long-term management for a hip dislocation?

Answer 16

Physiotherapy

Question 17

A 64-year-old woman is brought into the emergency department via ambulance after a road traffic collision. She has been given morphine and paracetamol to manage her pain and is currently comfortable. On examination, her right leg is internally rotated and appears shorter than the left. She is noted to have significant bruising over the right buttock and thigh. Neurovascular examination shows altered sensation over the right posterior leg and foot and there is a weakness of dorsiflexion of the foot.

What injury has this patient likely sustained?

Answer 17

Posterior hip dislocation causing sciatic nerve injury

Question 18

A 90-year-old lady is brought to the emergency department by ambulance after falling over the rug in her bedroom. On examination, her left leg is shortened and internally rotated. Her carer states that the patient underwent left total hip arthroplasty four years ago and is taking amitriptyline for pain.

What is the most likely cause of the patient’s clinical findings?

Answer 18

Left sided hip dislocation

Question 19

Which population is most at risk of hip fractures?

Answer 19

Elderly osteoporotic females

Question 20

What is the classic clinical presentation of a hip fracture?

Answer 20

1. Shortened
   2.Externally rotated leg with pain
2. Especially in displaced fractures

Question 21

Can patients with a hip fracture still weight bear?

Answer 21

Yes, patients with non-displaced or incomplete fractures (especially intracapsular fractures) may still be able to bear weight

Question 22

What are the two main types of hip fractures based on location?

Answer 22

1. Intracapsular (within the joint capsule)
2. Extracapsular (outside the joint capsule)

Question 23

What are the two subtypes of extracapsular fractures?

Answer 23

Intertrochanteric and subtrochanteric

Question 24

Which classification system is commonly used for intracapsular fractures?

Answer 24

The Garden classification

Question 25

Which Garden types have the highest risk of avascular necrosis (AVN)?

Answer 25

Type III and Type IV (displaced fractures)

Question 26

How are undisplaced intracapsular fractures managed? (Intracapsular Hip Fracture)

Answer 26

(1) Internal fixation (e.g. screws) (2) Hemiarthroplasty if the patient is unfit for fixation.

Question 27

How are displaced intracapsular fractures managed?

Answer 27

Arthroplasty (hip replacement)

Question 28

When is total hip replacement (THR) preferred over hemiarthroplasty?

Answer 28

If the patient: 1. Was able to walk independently outdoors (with no more than a stick) 2. Has no cognitive impairment 3. Is medically fit for surgery

Question 29

What is the preferred treatment for a stable intertrochanteric fracture? (Extracapsular Hip Fracture)

Answer 29

Dynamic hip screw

Question 30

Which extracapsular fractures require an intramedullary device instead of a DHS?

Answer 30

Reverse oblique transverse subtrochanteric fractures

Question 31

What is the preferred treatment for a subtrochanteric hip fracture?

Answer 31

Intramedullary nail (IM nail) = for strong fixation and early mobilisation

Question 32

Why are intracapsular fractures at higher risk of AVN?

Answer 32

The blood supply to the femoral head runs up the neck, so a fracture can disrupt it

Question 33

What are common complications of hip fractures?

Answer 33

(1) AVN (2) Deep vein thrombosis (DVT) (3) Pneumonia (due to immobility) (4) Pressure ulcers (5) Non-union

Question 34

An 82-year-old woman with osteoporosis falls at home and is unable to get up. On examination, her right leg is shortened and externally rotated. She is in severe pain and unable to bear weight. (A) What is the most likely diagnosis? (B) What imaging should be done first?

Answer 34

A. Displaced intracapsular hip fracture (classic presentation) B. Pelvic X-ray to confirm the fracture.

Question 35

A 70-year-old man, previously independent and walking with a stick, falls while gardening. He has hip pain but can bear weight with some discomfort. X-ray shows a Garden Type II intracapsular fracture. (A) Why can this patient still bear weight? (B) How should this be managed?.

Answer 35

(A) The fracture is undisplaced, so the femoral head remains aligned (B) Internal fixation (eg, cannulated screws) to preserve the native hip joint

Question 36

A 78-year-old woman with a history of hypertension and type 2 diabetes falls downstairs. Her leg is shortened and externally rotated. X-ray shows an extracapsular, stable intertrochanteric fracture. What is the best surgical treatment?

Answer 36

Dynamic hip screw

Question 37

A 65-year-old man is involved in a high-speed cycling accident. X-ray reveals a reverse oblique subtrochanteric fracture. What is the preferred surgical treatment?

Answer 37

Intramedullary nail (IM nail) = To provide stronger fixation

Question 38

What complication is less of a concern in extracapsular fractures compared to intracapsular fractures?

Answer 38

AVN

Question 39

A 75-year-old woman is brought to the emergency department after slipping on ice. She has a painful right leg that is shortened and externally rotated, and she cannot weight bear. There is no breaking of the skin or neurovascular compromise. An x-ray is performed which shows a non-displaced subtrochanteric fracture. She lives independently and does not use any walking aids, has no history of cognitive impairment and is generally fit and well. What treatment option is most likely to be offered?

Answer 39

Intramedullary device

Question 40

Another name for trochanteric bursitis is what?

Answer 40

Greater trochanter pain syndrome

Question 41

What causes trochanteric bursitis?

Answer 41

Repetitive trauma from the iliotibial band (IT band) rubbing over the trochanteric bursa, leads to inflammation

Question 42

Which patient groups are most commonly affected by greater trochanter pain syndrome?

Answer 42

Young runners and older females

Question 43

How is gluteal cuff syndrome related to trochanteric bursitis?

Answer 43

The gluteus medius and minimus tendons are under high strain leading to (1) tendinopathy (2) degeneration (3) tears, which contribute to trochanteric pain

Question 44

What is the most common symptom of trochanteric bursitis?

Answer 44

Lateral hip pain, often worsened by lying on the affected side

Question 45

What are two key examination findings in trochanteric bursitis?

Answer 45

1. Tenderness over the greater trochanter 2. Pain with resisted hip abduction

Question 46

How can trochanteric bursitis be distinguished from hip joint pathology?

Answer 46

Trochanteric bursitis does not cause groin pain or loss of hip range of motion, whereas hip joint issues often do

Question 47

How long does trochanteric bursitis typically last?

Answer 47

Self limiting resolving in 12–18 months but can use NSAIDs for pain relief

Question 48

A 45-year-old woman with a history of chronic lateral hip pain presents after 6 months of physiotherapy and NSAID use with no improvement. She has significant difficulty with weight-bearing activities like walking and climbing stairs. The pain is still localised over the greater trochanter What should be considered next in management?

Answer 48

Corticosteroid injection into the bursa to manage persistent inflammation and pain

Question 49

'On examination, she has tenderness over the lateral aspect of the right hip and has pain on internal and external rotation of the hip' This suggests what?

Answer 49

Trochanteric bursitis

Question 50

A 23-year-old presents to her GP with worsening right hip pain. She describes the pain as a deep, aching sensation that is worse with activity, especially after hiking with her hiking club. She has been more active, with longer hikes and steeper terrains but denies any trauma The pain is disturbing her sleep, particularly when lying on her right side. She denies fever, weight loss, or night sweats. She has a past medical history of Crohn's disease On examination, there is tenderness over the greater trochanter of the right femur. Hip range of motion is mildly restricted due to pain, particularly with abduction and external rotation. What is the most appropriate management for the likely diagnosis?

Answer 50

Apply an ice pack for 10 minutes at a time every few hours

Question 51

A 65-year-old woman presents to her GP with progressively worsening lateral hip and thigh pain on the right side. The pain is worse on walking and she also finds it difficult to lie on the affected side as she goes to sleep. She has a past medical history of rheumatoid arthritis On examination, she has an antalgic gait on the right side. The surrounding skin of the hip is not swollen or red. There is tenderness during deep palpation over the greater trochanter and decreased active range of movement of the hip, but passive movement of the hip is normal. The GP suspects greater trochanteric pain syndrome. Which structure is most likely to be affected in this condition?

Answer 51

Trochanteric bursa

Question 52

A 59-year-old woman presents to the GP with a six-month history of worsening lateral hip pain, particularly at night when lying on the affected side. She also reports increased discomfort with prolonged walking, climbing stairs, and rising from a seated position. She denies any trauma or injury to the area. Her medical history includes hypertension, obesity (BMI 31), and osteoarthritis in the knees. On physical examination, there is localised tenderness over the greater trochanter, and a positive Ober’s test is noted. X-rays of the hip show no bony abnormalities. What is the most appropriate initial management for this patient?

Answer 52

NSAIDS

Question 53

Based on clinical signs, how can you differentiate between an intracapsular and an extracapsular hip fracture?

Answer 53

An intracapsular hip fracture typically has less swelling and bruising because the fracture is contained within the joint capsule In contrast, an extracapsular hip fracture often causes more swelling and bruising due to bleeding into the surrounding soft tissues

Question 54

Total hip replacement is for what fracture?

Answer 54

intracapsular hip fracture, displaced

Question 55

A dynamic hip screw is for what fracture?

Answer 55

extracapsular hip fracture, stable intertrochanteric

Question 56

An intramedullary device is for what fracture?

Answer 56

extracapsular hip fracture, subtrochanteric fracture

Question 57

Internal fixation fix is used for what fracture?

Answer 57

Intracapsular hip fracture, undisplaced

Question 58

A 78-year-old woman is admitted to the emergency department following a fall on her right hip. On examination, she is struggling to walk, she is tender around her right greater trochanter and her right leg is externally rotated and shortened. She has a background of osteoporosis, hypertension, and hypothyroidism. She can mobilise well with no aids. An X-ray shows a subtrochanteric femoral fracture. This is subsequently fixed with an intramedullary nail. What advice should she be given regarding weight-bearing?

Answer 58

Weight-bear immediately after the operation as tolerated

Question 59

An 83-year-old lady with a background of dementia is found on the floor of her nursing home. She is brought to the Emergency Department and complains of left-sided hip pain and is unable to weight bear. Plain films of the hip and pelvis are unremarkable. Despite adequate analgesia, she still complains bitterly of hip pain and remains non-weight-bearing. What is the next most appropriate action?

Answer 59

MRI of hip

Question 60

An 84-year-old lady presents to the emergency department (ED) via ambulance having fallen over in her room at the nursing home this morning. She is unable to weight bear and is in excruciating pain, with her leg shorted and externally rotated. An X-Ray is requested by the ED Registrar, and it shows a displaced intracapsular neck of femur fracture. The orthopaedic team is contacted and the orthopaedic senior house officer (SHO) states that he will come to the ED and admit the patient. Past medical history: Heart failure, mild Alzheimer's disease, kidney stones What is the most appropriate method of analgesia for the patient?

Answer 60

Iliofascial nerve block