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).
