Ortho: Hip Flashcards
Hip Pain the basics
Number of possible causes. Need to know the anatomy. Understand the character of the pain, the location, the consequence and movement of ROM, the consequence of walking, can the bony landmarks be palpated
First step in evaluating hip pain
Need an accurate history – need to exclude or understand activities that aggravate and relieve the pain. Determine the severity, frequency and patterns of radiation of the pain. Exact location of the pain is important. Pain in the groin or medial thigh is often due to hip disease. Pain in the lumbosacral spine may refer to the butt or lateral thigh.
Why is it important to assess hip problems as a child?
Because developmental dysplasia, SCFE, leg calve perthes disease, polio and trauma may lead to osteoarthrosis later in life
Why is it important to determine a history of osteoarthritis and inflammatory arthritis?
Osteoarthritis is exaccerbated by activity and relieve by rest. Mild arthritis may not be symptomatic until a certain level of activity is reached.
Stiffness common in
degenerative and inflammatory arthritis
Why is there groin pain if there is a problem with the hip?
because irritation of the capsule and/or synovial lining refers pain
No relief of pain despite a trial of rest- what else is going on?
Underlying inflammatory or infectious process should be considered
Worst it can be with hip pain
Metastatic or primary hip tumors. Intrapelvic pathology from the prostate, seminal vesicles, hernias, ovaries, gastrointestinal (GI) system, and vasculature should also be considered
Hip physical exam
Watch patient - how do they ease out of a chair, postures, walking speed. Evaluate three views - spine, leg alignment, leg lengths. Look for previous scars. Palpate the bony landmarks, Evaluate gait and make sense of it.
Apparent leg length is
the distance between the umbilicus to the medial malleolus. Pelvic obliquity causing an apparent leg-length discrepancy
True leg length is
The true leg length is the distance from the anterior superior iliac spine to the medial malleolus
Observing gait
Is it a mild, moderate or severe limp? Limp can be caused by pain, by the abductor (gluteus medius, gluteus minimus) weakness. Abductor weakness will have a trendelenburg lurch – positive or negative. Positive is when the pelvis tilts toward the unsupported side during a one-legged stance
ROM on exam do these positions
flexion, extension, adduction, abduction, internal rotation in extension, and external rotation in extension
Thomas test
check for hip flexion contractures; more specifically it tests for anterior or lateral capsular restrictions or hip flexor tightness
Ober test
tightness of the iliotibial band (iliotibial band syndrome) The patient lies on the uninvolved side with hip and knee flexed in a 90-degree angle. The examiner placed the knee in a 5° flexion angle, fully abducts the lower extremity that needs to be tested, then allows the force of gravity to adduct the extremity until the hip cannot adduct any further. Modified Ober’s test: The patient is positioned on the side of the unaffected leg with the hip in neutral position and the knee in full extension.
Ely’s test
determine if femoral nerve or root compression is present. The examination can also indicate a quadriceps muscle contracture or iliopsoas muscle strain.
Faber Test
to assess for the sacroiliac joint or hip joint being the source of the patient’s pain.
Imaging
Plain radiographs remain the primary diagnostic imaging tool for the evaluation of hip pathology. Views - low AP pelvis, AP hip, frog lateral, cross table lateral
det 45-degree oblique view
allow for easier visualization of the anterior (obturator oblique) and posterior (iliac oblique) columns. The false profile view allows for evaluation of anterior bony coverage of the femoral head in cases of acetabular dysplasia. Developmental dysplasia of the hip (DDH) is common. The up-sloping lateral edge of the acetabulum is characteristic for developmental dysplasia of the hip.
CT
Assessment of acetabular fractures, acetabular nonunions, femoral head fractures, subtle femoral neck fractures, neoplasia, and bone stock in the revision total hip arthroplasty setting. Due to its limited soft tissue contrast, CT has largely been replaced by MRI for detailed evaluation of the soft tissues around the hip.
Nuclear Scintigraphy
The role of bone scanning in the evaluation of hip pathology is similar to its role in the assessment of knee pain. It should always be used in conjunction with other imaging modalities due to its limited specificity
Magnetic Resonance Imaging
Unprecedented detail of the soft tissues around the hip joint. Despite the tremendous diagnostic capabilities of MRI, its ability to detect bony pathology is limited. Thus: conventional radiographs remain the imaging modality of choice for the screening of hip pathology.
C Sign
Cup the anterolateral hip with the thumb and forefinger in the shape of a C
Hip pain often localizes to one of these three regions
anterior hip and groin, posterior hip and butt, lateral hip
Modified Trendelenburg test (single leg stance phase)
The patient stands with feet shoulder width apart and lifts one leg. The examiner observes for a drop in the level of the iliac crest on the side of the lifted leg
Modified Trendelenburg
test- positive finding
2 cm drop in the level of the iliac crest, indicating weakness on the contralateral side. DD- Hip labral tear, transient synovitis, Legg-Calvé-Perthes disease, SCFE
Normal hip extension
Goes back 10 degrees
what tests would you do if you suspect femoracetabular impingement
FADIR, straight leg test, log roll, FABER
When to do an US Hip
tendons, bursitis, joint effusions. Good for imaging guided aspirations
FABER test
(flexion, abduction, external rotation; Patrick test) the examiner moves the leg into 45 degrees of flexion, then externally rotates and abducts the leg so that
the ankle rests proximal to the knee of the contralateral leg
FADIR test
(flexion, adduction, internal rotation; impingement test) The examiner passively moves the leg into
full flexion, then into adduction and internal rotation.
Hip labral tear
dull or sharp groin pain, 50 percent of patients have radiating pain to the lateral hip, anterior thigh and buttock. Occasionally begins after a trauma and is insidious. May have a painful click. +FABER, FADIR. Need MRI.
Greater trochanteric pain syndrome
pain over the greater trocanter causing lateral hip can be from IT band thickened bursitis, gluteal tears. Can have stiffness and be unable to sleep on affected side. Repetitive use, atraumatic, + ober test
Anterior hip and groin pain suggests
involvement of the hip joint itself. Will localize pain with the C sign
Risk factors for septic arthritis in adults include ?
Age older than 80 years, diabetes mellitus, rheumatoid arthritis, recent joint surgery, and hip or knee prostheses.
Patients with femoroacetabular impingement
are often young and physically active.
They describe insidious onset of pain that is
worse with sitting, rising from a seat, getting in or out of
a car, or leaning forward. The pain is located primarily
in the groin with occasional radiation to the lateral hip
and anterior thigh.
what tests would you do if you suspect femoracetabular impingement
FADIR, straight leg test, log roll
Log roll test
Patient’s leg is extended and relaxed on examination table as the examiner internally and externally rotates the leg (log roll).
FABER test (flexion, abduction, external rotation; Patrick test)
he examiner moves the leg into 45 degrees of flexion, then externally rotates and abducts the leg so that
the ankle rests proximal to the knee of the contralateral leg
Piriformis syndrome
causes buttock pain that is aggravated by sitting or walking, with or without ipsilateral (same side) radiation down the posterior thigh from sciatic nerve compression.
Best test to dx piriformis syndrome
Log roll. Also pain with palpation of sciatic notch can help with diagnosis
Occult or stress fracture of the hip
should be considered if trauma or repetitive weight-bearing exercise is involved, even if plain radiograph results are negative. Clinically, these injuries cause anterior hip or groin pain that is worse with activity.
Pain may be present with extremes of motion, active straight leg raise, the log roll test, or hopping. MRI is useful for the detection of occult traumatic fractures and stress fractures not seen on plain radiographs.
Acute onset of atraumatic anterior hip pain that results in impaired weight bearing should raise suspicion for ?
transient synovitis and septic arthritis
Risk factors for septic arthritis in adults include ?
ge older than 80 years, diabetes mellitus, rheumatoid arthritis, recent joint surgery, and hip or knee prostheses.
what should be used evaluate the risk of septic arthritis?
assess for fever, complete blood count, erythrocyte sedimentation rate, and C-reactive protein level
What to order to differentiate septic arthritis and transient synovitis
MRI
Legg-Calvé-Perthes disease
idiopathis necrosis of femoral head. Mostly kids 2-12. If adults get it, because of other stuff- lupus, sickle cell, HIV, smoking, ETOH, steroid use
Legg-Calvé-Perthes disease presentation, what to order?
pain is presenting symptom. Insidious pain and ROM get more limited. Order MRI
Piriformis syndrome
causes buttock pain that is aggravated by sitting or walking, with or without ipsilateral radiation down the posterior thigh from sciatic nerve compression.
Best test to dx piriformis syndrome
Log roll
Hip labral tear
dull or sharp groin pain, 50 percent of patients have radiating pain to the lateral hip, anterior thigh and buttock. Occasionally begins after a trauma and is insidious. May have a painful click. +FABER, FADIR. Need MRI.
Unlike sciatica from disc herniation, piriformis syn-
drome and ischiofemoral impingement are exacerbated by
active external hip rotation. MRI is useful for diagnosing these conditions.
Greater trochanteric pain syndrome
pain over the greater trocanter causing lateral hip can be from IT band thickened bursitis, gluteal tears. Can have stiffness and be unable to sleep on affected side. Repetitive use, atraumatic,
Ober test
The patient is positioned on his or her side, with the unaffected hip on the examination table. The examiner stands behind the patient with one hand on the patient’s hip, and the other hand supporting the lower leg.
(A) To evaluate the tensor fasciae latae: The hip and knee are held at 0 degrees of extension and allowed to passively adduct with gravity. (B) The gluteus medius: The hip is held at 0 degrees of extension and 45 to 90 degrees of knee flexion. (C) The gluteus maximus: The shoulders are rotated back toward the table, with the
hip in flexion and knee in extension
Initial evaluation of any cause of hip pain
Plain film radiography Plain films can also identify causes of referred hip pain, such as sacroiliitis, but may not detect or accurately characterize some hip fractures and bone marrow edema associated with early avascular necrosis (AVN) or early osteomyelitis.
When to use a CT
most useful in the setting of trauma, for preoperative planning, and for evaluation and guiding percutaneous biopsy of tumors.
When to use an MRI
accurately evaluates the bone marrow, joint space, neurovascular structures, and soft tissues. MRI is the modality of choice for suspected femoral fracture not demonstrated radiographically, osteochondral injuries, muscle injuries, joint effusion, early diagnosis and staging of AVN
Radionuclide bone scan
Often nonspecific. Radionuclide bone scan is reserved for suspected fracture or AVN not demonstrated by plain film radiography when MRI is not available or is contraindicated
Ultrasound
Hip effusions and bursal or periarticular fluid collections are readily identified. Evaluation of the tendons and muscles
Lateral hip pain
Unlikely to be due to hip joint disease. Lateral hip pain that is aggravated by direct pressure is the classic pattern of trochanteric bursitis. Can also be due to the femur with metastatic disease if progressive, aggravated by pressure and affecting weight bearing. If with paresthesias then meralgia paresthetica (lateral femoral cutaneous nerve entrapment).
Anterior hip or groin pain
primary involvement of the hip joint itself
A gradual onset of pain in association with variable degrees of impaired movement
osteoarthritis
Acute groin pain associated with impairment of weight bearing
may be caused by osteonecrosis (particularly in the setting of risk factors such as glucocorticoid use), occult fracture (eg, following trauma), acute synovitis, or, uncommonly, septic arthritis.
non hip causes of anterior hip pain
inguinal hernial or lower abdominal pathology
Gluteal posterior hip pain
Least common. sacroiliac joint disease, lumbar radiculopathy, herpes zoster
Anterior thigh pain
Unless the pain can be reproduced by passive rotation (hip joint), by applying torque to the thigh (femur), or by maneuvers designed to elicit radicular symptoms (eg, straight leg raising), diagnostic imaging is often needed to determine a precise cause.
Most common conditions affecting the hip
trochanteric and gluteus medius bursitis, osteoarthritis and femur fractures
Femoral neck bony prominences that project out of it
greater and lesser trochanter
What attaches to the greater trochanter
abductor muscles - gluteus medius and gluteus minimus
Main hip extenders
gluteus maximus and hamstrings
Major hip flexor
ilipsoas muscle
Iliotibial band
from hip to knee along the whole femur
Tendon
bone to muscle
Ligament
bone to bone
Labrum
lining around the acetabulum when injured will cause pain and clicking
Adductor
inner thigh muscle pulls in leg
Trochanter bursitis
inflammed bursa on greater trochanter. Pain is lateral and aggravated by direct pressure. Can range from mild morning stiffness to unable to sleep on the affected side. Gait abnormalities can ca use this including leg length disparity, knee arthritis, ankle sprain all change gait. Point tenderness on greater trochanter.
Ischeal tuberosity
what you sit on both sides, can have bursitis here
Bursa
sac of tissue with fluid inside that lubricates an area and decreased friction
Ilopsoas muscle
flexes hip from lower spine to inside the femur
Rectus femoris
on femoral bone right in the middle of the quad
Sartorius
small strap from pelvis to knee to upper tibia
Hamstring
extends hip and pulls back from under hip to top of knee
Osteoarthritis of the hip
Increased pain w or after use and improvement with rest. Usually over 40 years. Can progress including to pain at night. Aggravated by movement. Morning stiffness.
Constant pain in the hip
Infectious hip, inflammatory or neoplastic process
Progressive lateral hip pain aggravated by direct pressure and weight bearing can be
metastatic cancer, need radiographic testing to r/o bone invovement
Meralgia paresthetica
lateral hip – the lateral femoral nerve is compressed. Numbness and tingling to burning pain over the upper outer thigh localized lateral upper thigh
Lateral radiculopathy
L4-L5 lateral pain radiating down the leg and into the foot with or without foot numbness
glucocorticoid use, excessive alcohol think of ruling out this out with hip pain
osteonecrosis esp if anterior groin pain
anterior hip pain not aggravated by direct pressure or flexion of the hip suggests
inguinal hernia, lower abdominal pathology
posterior hip pain can be from
sacroiliac joint dysfunction, lumbar radiculopathy, herpes zoster. need radiographic testing
lower anterior thigh pain
number of causes need xray
Occult hip fracture
hip tenderness is severe with even partial weight beearing and intolerance to passive rotation of the hip, need MRI cant see on plain film
Trendelenberg gait
Shift torso over affected hip to decrease the pain. Caused by weakness of the gluteus medius muscle and weak abductor muscles supplied by the gluteal nerve
Short leg limp
secondary to leg discrepancy, increase of the up and down movement of the head and shoulder as the body falls down on the short leg and then rises on the long leg
Squatting can be impaired by
advanced hip arthritis, moderate to severe bursitis and any condition reducing strength of muscles
Pelvic obliquity
Place hands on top of iliac crest and estimate level of the pelvis. Asymmetry w leg length discrepancy, pelvic fx and scoliosis
