Orthopaedic conditions of hip Flashcards
Describe the bony anatomy of the pelvis
Each hemi-pelvis = fusion of 3 bones (Ischium, Ileum and Pubis). Acetabulum = socket.
Describe the bony anatomy of the femur
Long Bone. Head – articulates with acetabulum. Neck – blood supply. Greater trochanter – attachment of abductors and rotators. Lesser trochanter – attachment for Psoas.
Describe the anatomy of the acetabulum
Acetabulum – part of the pelvis, cup-shaped socket. Labrum – fibrocartilaginous lining of acetabulum, deepens socket + adds stability.
Describe the blood supply of the hip
Profunda femoris – branches medial and lateral circumflex arteries. MFCA (major contributor to femoral head): 2 branches – ascend to head, transverse to form cruciate anastomosis. LFCA – 3 braches – ascending branch to joint capsule, transverse branch to cruciate anastomosis, descending branch.
What is the clinical significance of fractured neck of femur to blood supply?
NoF – primary blood supply enters via capsule. Fracture Neck of femur: Intracapsular fracture – blood supply disrupted; extracapsular fracture – blood supply maintained.
What are bursae?
Fluid filled sacs that reduce friction between tissues to allow smooth gliding.
Define osteoarthritis
Degenerative change of synovial joints: progressive loss of articular cartilage, secondary bony changes. Characterised by worsening pain and stiffness to affected joint – limiting everyday life.
What is trochanteric bursitis
Trochanteric bursa – fluid filled sac that sandwiched between hip abductors and ITB. Inflammation of this bursa causing swelling. F>M.
What are the causes of trochanteric bursitis?
Trauma. Over-use – athletes, often runners, repetitive movements. Abnormal movements – Distant problem e.g. scoliosis or Local problem – muscle wasting following surgery, total hip replacement, OA.
Describe the clinical presentation of trochanteric bursitis
Presents: Lateral hip pain, point tenderness.
Examination: LOOK – scars from previous surgery, muscle wasting (gluteals); FEEL – Tenderness at Greater Tuberosity; MOVE – worst pain in active abduction.
What investigations are used for trochanteric bursitis?
X-ray: may be normal, OA, THR, spine abnormalities
MRI – shows soft tissues and fluid
USS – can be therapeutic as well as diagnostic, guided injection.
What are the treatment options for trochanteric bursitis?
NSAIDs. Relative rest / activity modification.
Physiotherapy – correct posture, abnormal movements, stretching, strengthen muscles around joint.
Injection – CCS.
Surgery – bursectomy (rarely required)
What is avascular necrosis?
Death of bone due to loss of blood supply. M> F, avg. 35-50, 80% bilateral.
What are risk factors for avascular necrosis?
Trauma – irradiation, fracture (intracapsular #, femoral head blood supply), dislocation, iatrogenic.
Systemic – idiopathic, hypercoagulable states, steroids, haematological (sickle cell disease, lymphoma, leukaemia), Caisson’s disease, alcoholism.
Describe the pathology of idiopathic avascular necrosis
Intravascular coagulation is the final common pathway. Pathoanatomic cascade: coagulation of intraosseous microcirculation –> venous thrombosis –> retrograde arterial occlusion –> intraosseous hypertension –> reduced blood flow to head –> cell death –> chondral fracture and collapse.
What is the clinical presentation for avascular necrosis?
Symptoms: insidious onset of groin pain, Pain with stairs, walking uphill and impact activities, limp.
Examination: largely normal, may replicate early arthritis – reduced ROM (partial internal rotation), stiff joint.
What investigations can you use for avascular necrosis?
X-ray, MRI, CT, Radionuclide bone scan.
What are the non-operative treatment options for avascular necrosis?
Reduce weight-bearing. NSAIDs. Bisphosphonates – early AVN, controversial. Anticoagulants. Physiotherapy – maintain ROM, keep the ball round!
What are the surgical treatment options for avascular necrosis?
Restore blood supply – core decompression +/- vascularised graft. Move the lesion away from the weight bearing area – rotational osteotomy. Total hip Replacement.
What is Femoroacetabular Impingement (FAI)?
Common cause of hip pathology in younger patient, secondary OA. Anatomical phenomenon: Broadly divided into 2 categories – cam lesion (extra bone on head of femur resulting in bump), pincer (abnormally shaped socket that covers femoral head excessively); results in impingement of femoral neck against the anterior edge of acetabulum.
What are associated injuries to FAI?
Labral tear and degeneration. Cartilage damage and flap tear. Secondary hip OA.
What is the clinical presentation of FAI?
Groin pain – worse with flexion. Mechanical symptoms – block to movements, pain with certain manoeuvres such as getting out a chair, squatting and lunging.
Examination - reduced flexion and internal rotation. Positive FADIR test – Flexion, Adduction, Internal Rotation.
How would you investigate FAI?
X-ray – identify the bony pathology.
MRI – useful for assessing assoc. conditions – labral tears, articular cartilage damage.
What is the non-operative treatment for FAI?
Activity modification. NSAIDs. Physiotherapy – correct posture, strengthen muscles around joint.
What is the operative treatment for FAI?
Arthroscopy – shave down the defect, deal with labral tears, resect artic cartilage flaps.
Open surgery – resection, periacetabular osteotomy, hip arthroplasty – resurfacing and replacement.
What is labral tear and its causes?
Involves labrum (ring of cartilage) that surround outside rim of hip joint, most common anterosuperior tear. All age groups, common in active females. Causes – FAI, trauma, OA, dysplasia, collagen diseases – Ehlers-Danlos.
How does a labral tear present?
Groin or hip pain, snapping sensation, jamming or locking. Examination – can be normal, positive FABER test – Flexion, Abduction, External Rotation (Anterior tears).
How would you investigate a labral tear?
Ensure adequate imaging so identify any root causes of pathology. X-ray – OA, dysplasia. MRI Arthrogram – 92% sensitive. Diagnostic injection – local anaesthetic.
What are the treatment options for a labral tear?
Non-operative – activity modification, NSAIDs, Physiotherapy, steroid injection.
Operative: arthroscopy – repair, resection.
