Nonsurgical Hip Flashcards
Slipped Femoral Capital Epiphysis
Displacement of the femoral head on the femoral neck
30% are bilateral
11-13 y/o
Male > Female (3:2)
Goal of tx with slipped femoral capital epiphysis
movement of femoral head on neck creates abnormal biomechanics and pain
Would want to prevent osteonecrosis of femoral head
Usual tx for slipped femoral capital epiphysis
Sometimes casting is done for 12-24 weeks with limited success so Usual tx is surgical with single pin fixation or if severe internal fixation with traction
Cause of Slipped Femoral Capital Epiphysis
Idiopathic
Possible that a hormonal abnormalilty causes inc fibrous tissue in the growth plate
Often pt is overweight but not always
What movements are most impacted by slipped femoral capital epiphysis
Hip IR, Abduction, and Flexion are most affected ROM
Gait is antalgic or with a Trendelenberg gait pattern
Prognosis with slipped femoral capital epiphysis
Prognosis is for high likelihood of DJD
Congenital Hip Dislocation
Spontaneous dislocation before, during, or shortly after birth
Females > Males
Femoral head dislocates superiorly and laterally
33% of cases are bilateral
Cause of congenital hip dislocation
Usually delayed acetabulum development causing developmental dysplasia of the hip (DDH)
Pathology also includes femoral neck anteversion
Joint laxity, hormonal joint laxity, hip dysplasia or a breech position during pregnancy
Tests done immediately after birth
Ortolani test and Barlow maneuver
Earlier the dx the better the prognosis for normal gait and avoidance of DJD
Tx of congenital hip dislocation First 6 weeks 6 months - 6 years 7-10 After 11
For the first 6 weeks of life - positioning the hip in abduction, ER, and flexion through a double diaper or Pavlik Harness
From 6 months - 6 years - closed or open reduction is necessary and LE is immobilized
7-10 = if bilateral patient may be functionally OK or else surgical tx occurs
After 11 not surgical tx occurs unless they have degenerative changes
Legg Calve Perthes
Osteochondritis of the femoral capital epiphysis with eventual ossfication center necrosis
Flattening of the femoral head within the acetabulum occurs
Ages 2-12
Males > Females usually between 2-12 yrs
Caucasians 10 x more likely
Goals of tx with legg calve perthes
Prevent damage to femoral head, keep it as round as possible, let ossification center heal
Cause of Legg Calve Perthes
Unknown and deformities occur over a period of 2-5 years
Tx of legg calve perthes
Conservative tx ncludes traction during sleep time, casting for three months and bracing for 6-15 months
Surgical tx is used if conservative tx fails
Impact of legg calve perthes
Avasular necrosis of the femoral head occurs secondary to a subchondral fracture or occluded blood supply
Eventually the necrotic ossification tissue is replaced by normal disuse but the shape of the femoral head is not correct
To test for legg calve perthes
radiographs
Prognosis for legg calve perthes
if caught early the prognosis is good for no future hip problems
Transient Synovitis
An idiopathic, nonbacterial inflammation of synovial membrane
Not serious and needs no tx
Affects children before puberty - usually boys
Children demonstrate limping, hip pain, possible low grade temp
Most common cause of hip pain in children
Tx for transient synovitis
NSAIDS - usually children will be painfree within two weeks
How diagnose Transient Synovitis
radiographs done to rule out other pathology
Avascular necrosis
lack of blood circulation to the head of the femur causing breakdown of tissue and bone
Not a disease but occurs over time
Avascular necrosis is common with
prolonged steroid use and may be result of slipped femoral capital epiphysis
Also occurs with trauma
Patients with avascular necrosis are usually
asymmptomatic in early necrosis with slow developing pain in the groin and thigh and eventual loss of ROM and muscle spasm
Eventually they develop DJD and femoral degeneration
Tx for avascular necrosis
Conservative tx is NWB for 2-3 yrs in young patients
Most patients opt for surgical internal fixation of femoral head and grafts to revascularize the bone
Total hip arthroplasty is an option too
All patients with avascular necrosis develop -
Tests to diagnose
OA
Radiographs
Septic Hip/Arthritis
Medical emergency and needs immediate treatment
Can occur at any age but usually occurs in adults
If not treated for septic hip…
hip joint will be destroyed - pathogens include
Gonorrhea, H influenza, Staphylococcus, Steptococcus
Septic hip is divided into
gonococcal arthritis and non-gonococcal arthritis
Most common non- gonoccoal pathogens are H influenza, Stph and Strep
Degenerative Joint Disease
Breakdown of cartilage on the femur or acetabulum
Can be idiopathic or in response to injury or disease
Females > Males
Over age of 40
Subjective Complaints with DJD
Groin or trochanteric pain
Morning stiffness less than 30 min
Objective findings with DJD
Antalgic gait Loss of hip motion Weak abductors Crepitus Muscle spasm
Dx is confirmed with (DJD)
radiographs
Treatment for DJD
Conservative tx is symptom relief and stress control via medications, joint mobilization and stretching, assistive and adaptive equipment, and hip strneghtening
Surgical tx for DJD
Birminghman procedure for younger patients and total hip arthroplasty
Prognosis for DJD
Pain will increase as degeneration continues
Hip Pointers or Iliac Crest Contusion
Contusion of the iliac crest, ASIS, or both
Caused by trauma and can cause soft tissue damage to surrounding mm (RF, Sart, TFL, E/IO)
Avulsion needs to be ruled out
Tx for Hip pointer or iliac crest contusion
Prognosis
initial rest with gradual return to function
Prognosis is full recovery
Hip fractures
- Avulsion
- Subcapital
- Femoral neck
- Intertrochanteric
- Subtrochanteric
- Stress
Stress fracture
Insidious and often happen in individuals with osteoporosis, runners, elderly, patients with cancer, individuals with compromised nutrition
When do stress fractures occur
When osteoclastic activity outweights osteoblastic activity
Patient will complain of (stress fracture)
pain with weightbearing
Tx for stress fracture
rest but if fracture is through a major weight bearing area, ORIF might be necessary
Prognosis for stress fracture
good for return to activity but not if nutrition and training do not change
Subtrochanteric Fracture
Occur with major trauma primarily in elderly from falls and from other traumas in young people
Fractures are classified by degree of displacement and number of fragments of bone
Subejctive info Subtrochanteric Fracture
pt will show an acute onset of pain, inability to weightbear and a shortened and externally rotated LE
Tx for subtrochanteric fracture
ORIF
Prognosis for subtrochanteric fracture
poor for elderly to get to full function
mortality up to 80% within 2 years of the fracture
Intertrochanteric Fracture
Caused by falls and trauma
Classified by degree of displacement and location
Tx of Intertrochanteric fracture
ORIF
Prognosis of intertrochanteric fracture
Poor prognosis for return to function in elderly
Femoral neck (subcapital) fracture
More likley to have a sequelae of avascular necrosis secondary to the femoral circumflex artery
Classification of fractures (femoral neck)
Grade 1 = Incomplete
Grade 2 = Nondisplaced
Grade 3 = Partial Displacement
Grade 4 = Total displacement
Tx for femoral neck fracture
Most hip fractures are treated with ORIF but type of fixation depends on kind of fracture and its classification
Weightbearing status also depends on type of fracture, classification, and bone integrity
Avulsion Fracture
Caused by a strong muscle contraction resulting in pulling the muscle attachment and small amount of bone off a larger bone
Most common in athletes who still have open epiphyseal plates
Pain is localized to the muscle attachment and action with swelling, redness, and bruising
Diagnosis avulsion fracture
Radiographs are diagnositc choice to differentially diagnose an avulsion fracture versus muscle or tendon strain
Tx goals for avulsion fracture
Focus on proper healing with initial rest and gradual return to activity
Prognosis for avulsion fracture
Excellent for return to function and better than someone who had sustained a tendon tear or muscle tear
Hip dislocations - Anterior or Posterior
Can be ant or post depending on force direction
Considered a medical emergency secondary to structures that may be damaged by the force needed to dislocate
Not very common because of stability of hip but can occur with large trauma like MVA
Hip dislocations almost always damage
the labrum
Complications can occur like avascular necrosis or nerve damage
Posterior hip dislocation can impact the
Anterior can impact the
sciatic nerve
Femoral nerve
Tx for hip dislocation
Closed reduction under anesthesia if no fracture has occured and ORIF if fractures occur
Prognosis for hip dislocation
Full recovery is good if avascular necrosis does not occur
Femoral Acetabular Impingement
Syndrome of painful hip motion (usually flexion, adduction) that results from underlying bony abnormalities in the hip joint
Labral tears, DJD my be a result
2 deformities with femoral acetabular impingmeent
Cam Impingement = femoral head/neck protrusion
Pincer Impingement = acetabular coverage on the femoral head
When hip is flexed and adducted like when cross legs, acetabulum may pinch the bone and joint capsule and labrum causing pain
FAI can also be caused by muscle imbalances and capsular tightness
FAI is leading cause of
labral tears
Labral Tears
Usually caused by microtrauma or FAI, capsular laxity or hip dysplasia
Occur in highly active people ages 20-40
Subjective complaints
Generalized ant groin pain or clicking, locking or giving way
Diagnosis labral tear
No clincial exams with high validity
Radiographs, MRI, bone scan, intraarticular injectiosn might be used to rule out other problems
Tx for labral tear
Intraarticular injections to dec inflammation, PT for hip mobiliztaion, muscle balancing, lifestyle changes, and arthroscopic repair
If untreated, labral tears are thoguht to lead to
DJD
Hip bursitis
Inflammation of the bursa usually the greather troch, iliopectineal, or ischiogluteal
F > M
GT bursitis occurs most frequently in
30-40 y/o and is most common cause of hip pain
Subjective findings with hip bursitis
Tenderness is usually achy and diffuse in GT area with radiation to groin, glutes or thigh
Pain occurs with resisted abduction
With IP, IG, pain is at the site and area of bursa
Objective findings with hip bursitis
Gait is antalgic
Tx for hip bursitis
Rest, stress reduction, normalizing movement or postures, stretching and strnegthing are PT txs
Medical tx = injections and NSAIDS (non steroidal anti inflammatory drugs)
Greater Trochanteric Bursitis
Fairly common
May be caused by trauma, weak abductors, forceful adduction
ischial gluteal bursitis
Can be caused by over use of hamstrings, onto ischial tub, prolonged sitting
Iliopectineal bursitsi
can be caused by tight iliopsoas rubbing against bursa, an abnormal hip joint from RA or OA that causes irritation to bursa
Hip tendinopathy
Usually occurs in the tendons of greater troch or proximal hamstring
Cause = usually overuse
Pelvic obliquities and leg length discrepency can irritate GT tendons
Diagnosis of tendinopathy
Via palpaton and resisted contraction with occasional MRI
TX of tendinopathy
Depends on if it is tendonitits but usually always includes eccentric exercise
Muscle Strain
Tearing of a muscle
Usually ecchymosis occurs
Palpation to muscle would be painful
Common hip muscles to strain
Adductors, RF, Hamstrings
Two joint muscles are strained more commonly
Mechanism of muscle strain
Mechanism is usually forceful contraction as the muscle is lengthening or trauma
Inflammatory problem - best tx
Ice, STM, Painfree AROM, gait training
