Ortho LE Flashcards
Differential diagnosis for hip pain
o Osteoarthritis o Trochanteric Bursitis o Low back pain or sciatica o Osteonecrosis o Snapping hip syndrome
trochanteric bursitis
o Pain and tenderness over the greater trochanteric bursa.
o Pain often worse when first rising from a seated position and may feel better after taking a few steps.
o Patients often cannot lie on the affected side due to pain.
o Can radiate down lateral aspect of leg
o How do you find this out?? Ask pt where pain is and palpate
o Exam: point tenderness over lateral greater trochanter. May have some discomfort with external rotation of hip.
o Diagnostics: Xray (why?) (what do you order?)
o Treatment: NSAIDS, Physical therapy (what should they stretch), Injection of local anesthetic and corticosteroid
injection of local anesthetic and corticosteroid
o Usually mix approx 1-2 ml of corticosteroid with 8-9 ml of local anesthetic (I personally like Kenalog 40/0.5 Marcaine/1% Lidocaine)
o Position patient on their side with affected hip up
o Target area where patient is most point tender
o Using sterile technique: Insert needle deep into tissue, move needle around until patient feels pressure or pain- that’s the money spot. Then slowly begin injecting fluid.
o Might be worth repositioning needle and working it around the area to find other “hot spots” using technique described above
snapping hip syndrome
o Snapping sensation that occurs as tendons move over bony prominences (Most common IT band snapping over greater trochanter)
o Typically occurs while walking or with hip rotation
o Can occur in the groin
o Exam: palpate the snapping sensation over lateral aspect of hip as patient adducts and rotates the hip
o Diagnostics: Xray (of course!)
o Treatment: NSAIDs, Physical Therapy, possible injection
osteoarthritis of the hip
o Loss of articular cartilage in the hip joint (Result of trauma, infection, heredity)
o Classic presentation: gradual onset of groin pain
o Night pain associated with severe arthritis
o Limited motion in the hip
o Can have pain in buttock or lateral aspect of the thigh
o it provides both a cushion & slick surface for movement
o consistency of the extracellular matrix allows the tissue to bear mechanical stresses without permanent distortion; shock-absorbing because it is resilient; smooth surface allows sliding against it
osteoarthritis of the hip
o Exam: loss of internal rotation (early sign) can progress to loss of flexion and extension (Antalgic gait, Pain at night)
o Diagnostics: Xray look for joint space narrowing, osteophytes, cyst formation or sclerosis of bone
o Treatment: NSAIDs, therapeutic arthrogram (just inject lidocaine and corticosteroid), Total Hip Replacement (at end stage)
osteonecrosis (AVN)
o Death of trabecular bone in femoral head
o Unknown cause
o Occurs with greater frequency in third through fifth decade.
o Associated with history of trauma, alcohol abuse, corticosteroid use, rheumatoid arthritis or lupus (systemic lupus erythematosus).
o IV steroids or systemic
o Ultimately due to loss of blood supply
o Also called AVN
o Average age onset is 38 yo
o Mostly male
o 20% d/t dislocation
o incidence of AVN in undisplaced femoral neck fractures is 11%;
o Exam: pain with either internal/external rotation and/or abduction of hip
o Diagnostics: Xray findings include sclerosis of femoral head (MRI of bilat hips to confirm diagnosis if unclear from Xray findings, MRI IS DEFINITIVE TEST FOR AVN)
o Treatment: typically Total Hip Replacement
blood supply to hip
o Ex: femoral neck fx
o frx disrupts intraosseous cervical vessels
lateral view of the hip
- because AP views of the hip may be difficult to interpret, it is necessary to
evaluate frog-leg lateral x-rays of the femoral head;- cross-table lateral x-ray is not satisfactory because architectural details
of the femoral head are obscured by the soft tissues that overlie this area; - lateral radiographs also allow staging purposes since it is often anterior segment
of the femoral head that first collapses or exhibits the crescent sign;
Classification of Disease, 2 systems if interested look up on Wheeless
- cross-table lateral x-ray is not satisfactory because architectural details
MRI
o magnetic resonance imaging is probably the most accurate imaging modality for dx of AVN of femoral head;
- MRI imaging is also used to outline the area of involvement;
low back bain/sciatica
o Very often confused with “hip pain”
o Be specific with patients about location of pain when gathering history.
o Pain that radiates down the leg and starts in the low back and/or gluteal area often d/t sciatic nerve irritation.
o NSAIDs and Physical Therapy often good initial advice for treatment.
knee problems
o Osteoarthritis
o Meniscal Injuries
o Ligament injuries
o Muscular injuries
osteoarthritis of the knee
o Most common form of knee arthritis
o Wear and tear of cartilage, often cumulative over time.
o “ Bone on bone”
o Most common condition I see in clinic for patients over age of approx 40 years old.
o Increased incidence associated with: family history, obesity, hx of trauma to knee joint, increased age.
o Knees can take 4x your body weight
osteoarthritis of the knee
o History may include symptoms of joint line pain, feeling of instability, pain @ nighttime and swelling.
o Patients may also present with swelling in knee and lower extremity.
o Often no single incident can be related back to the start of symptoms.
o Pain with changes in the weather
physical exam: knee osteoarthritis
o Tenderness to palpation along joint line
o Pain with extremes of motion- often can be limited d/t swelling.
o Varus or valgus deformity to the knee
o Crepitus with extension of knee may indicate patellofemoral compartment involvement.
diagnostic tests: knee osteoarthritis
Xrays
- Standing AP, sunrise (merchant) views and lateral of affected side
- 3 compartments to knee: medial, lateral and patellofemoral
- Findings: Joint space narrowing in one or more of the 3 compartments
- Also have associated osteophytic changes, sclerotic areas or cyst formation.
MRI
-Not usually necessary unless suspect soft tissue involvement ie: meniscal or ligament
