Ortho hip conditions Flashcards
What are the key pathologies of the (adult) hip?
OA of hip
Bursitis
AVN
Impingement (FAI)
Labral tear
Describe the structure of the pelvis
Hemipelvis made up of 3 bones - ischium, ileum & pubis
Hemipelvis joined together by the pubic symphysis (anteriorly) and the sacrum (posteriorly)
What type of joint is the hip joint?
Synovial ball & socket
What anatomical features does the acetabulum (socket of hip bone) have to add stability?
Describe the structure of these
1) Acetabular labrum - fibrocartilagious lining of acetabulum. Deepens socket & adds stability.
2) Ligaments (x2)
What are the ligaments of the hip?
1) Ligamentum teres - HoF to acetabular notch
2) Transverse ligament - completes the circle of the labrum (note it is not shown in the photo)
Identify the bits
yis
Give an overview of the blood supply to the hip joint
Blood supply from 2 main arteries…
MFCA - Medial femoral circumflex artery
LFCA - Lateral femoral circumfelx artery
These are branches of the Profunda femoris (deep femoral artery)
Describe the distribution of the MFCA
Medial femoral circumflex artery
Major contributor to the femoral head blood supply
Has 2 branches:
- one ascends to head
- one transverses to cruciate anastomosis
Describe the distribution of the LFCA
Lateral femoral circumflex artery
Less important to hip joint…
Has 3 branches:
- ascending branch to joint capsule
- transverse branch to cruciate anastomosis
- descending branch
Aside from the LFCA & MFCA - what other arteries supply the head of femur?
Artery of ligamentum teres - theres an artery inside the ligament
Nutrient arteries of the bone
Heres a nice wee diagram
What is the clinical relevance of the blood supply to the neck & head of the femur?
Fractures risk disrupting blood supply (and causing AVN)
As a general rule:
- Intracapsular fractures = blood supply disruption
- Extracapsular = all good
What is the typical presentation for osteoarthritis of the Hip?
Chronic history of groin pain & stiffness - worsened by exercise & relieved by rest
Pain may radiate down to knee on affected side
(see lecture on OA)
What is trochanteric bursitis?
Describe the relevant anatomy
Trochanteric bursitis (aka Greater T pain syndrome)
Inflammation of the Bursa located over the greater trochanter of the femur
The trochanteric bursa is sandwiched between the insertions of the gluteus medius & minimus (hip abductors) - and is overran by the IT band of Tensor fasciae latae
What are the risk factors for Trochanteric bursitis?
Female
Over-use (athletes etc)
Abnormal movments due to other problem:
- distant problem eg scoliosis
- muscle wasting following surgery
- THR
- OA of hip
Describe the presentation and specific exam findings for trochanteric bursitis
Well localised, lateral hip pain
On examination:
- tenderness over greater trochanter
- painful active abduction
- +/- scars from surgery, gluteal muscle wasting etc
How can trochanteric bursitis be investigated?
Think it can be diagnosed clinically but:
X-ray
MRI
US
How is trochanteric bursitis treated?
First order:
- activity modifcation / rest
- NSAIDs
- physiotherapy
If above fails:
- US guided steroid injections
If all else fails:
- Bursectomy
What is AVN?
Avascular necrosis - death of bone due to disruption in blood supply
What are the risk factors/causes of AVN?
Trauma:
- irradiation
- fractures (intracapsular)
- dislocations
- iatrogenic
Systemic:
- idiopathic
- hypercoagulability
- haematological
- steroids
- Caisson’s disease
- alcoholism
What haematological conditions predispose someone to AVN?
Hypercoagulable states
Sickle cell disease
Lymphoma
Leukaemia
What is Caisson’s disease?
Decompression sickness - aka The bends
Happens to divers
Describe the epidemiology of AVN
Males > females
35-50 y/o
80% bilateral
Describe the typical presentation of AVN
Insidious onset of groin pain
Pain especially on exercise/impact activities
Limp
(similar to OA)
What features on examination could you see with AVN
Largely normal
May have reduced ROM - especially on internal rotation
How is AVN investigated?
MRI is best
X-ray
Describe the treatment of early AVN
Non-operative:
- reduce weight bearing
- NSAIDs
- bisphosphonates?
- anticoagulants
- physio
Describe the treatment of bad AVN
If serious enough - surgery is indicated:
- Core decompression +/- vascularised graft
- Rotational osteotomy
- THR if above fail/not possible
What happens in Femoroacetabular impingement (FAI)?
Who does it affect?
What condition does it predispose to?
Impingement of femoral neck against anterior edge of acetabulum
Affects younger patients
Causes secondary OA of hip
What causes FAI?
What are the 2 categories of FAI related to this?
Anatomical phenomenon - in which there is reduced space between the femoral neck & anterior edge of acetabulum
2 causes of this:
Cam lesion - typically males, bulged femoral neck
Pincer - typically females, abnormally deep acetabulum (kinda)
What injuries are associated with FAI?
Labral degeneration & tears
Cartilage damage & flap tears
Secondary OA of hip
Describe the presentation of FAI?
Groin pain - worse on flexion
What findings on examination may indicate FAI?
Reduced flexion & internal rotation
Positive FADIR test - pain on:
- Flexion
- ADduction
- Internal Rotation
What investigations can you do for FAI?
X-ray - identifies bony pathology
MRI - identifies any associated labral tears & cartilage damage
Give an overview of the treatment of FAI
Non-operative - NSAIDs, activity mod, physio
Operative:
- Arthroscopy
- Open surgery
- resection
- periacetabular osteotomy
- hip arthroplasty
What is the most common type of labral tear?
Anterosuperior
What are risk factors for labral tears?
FAI (esp pincer)
Trauma
OA
Dysplasia (I assume DDH)
Collagen diseases (eg Ehlers-danlos)
Describe the presentation of a labral tear
“Snapping sensation” - followed by:
Hip/groin pain
Locking/jamming of hip
What would you find on examination of someone with a labral tear?
May be normal…
Positive FABER test - pain on:
- Flexion
- ABduction
- External Rotation
Compare the FADIR & FABER test…
FADIR - flexion, adduction, internal rotation - +ve indicates FAI
FABER - flexion, abduction, ext rotation - +ve indicates anterior labral tears
What investigations can you do for Labral tears
MRI arthrogram
Diagnostic injection of local anaesthetic
X-ray - will identify causes such as OA, dysplasia
How are labral tears treated?
Non-operative:
- usual shite - NSAIDs, physio, activity modification
- steroid injections
Operative:
- arthroscopic repair / resection
