Orthopaedic hip and knee conditions Flashcards
What 3 bones comprise the hemipelvis?
Ischium
Ileum
Pubis
How are the 2 hemipelvis joined?
Sacrum posteriorly
Pubis symphysis anteriorly.
What are some important features of the femur?
Head - articulates with acetabulum on pelvis.
Neck - blood supply
Greater trochanter - attachment for abductors and rotators.
Lesser trochanter - attachment for psoas.
What is the labrum?
Fibrocartilaginous lining of acetabulum that helps to deepen the socket and add stability to hip joint.
What is the blood supply to the femur?
Profunda femoris - 2 branches medial and later circumflex arteries. These are major suppliers to femoral head.
Medial circumflex artery has 2 branches that ascend to head and transverse to form cruciate anastomoses.
Lateral circumflex artery has 3 branches, an ascending and descending branch and one which transverses to cruciate anastomoses.
Blood supply enters femur via capsule.
What is trochanteric bursitis?
Inflammation of the fluid filled sac that is sandwiched between hip abductors and IT band.
F>M.
What are some causes trochanteric bursitis?
Trauma
Over-use - athletes, repetitive movements.
Abnormal movements - distal problem e.g. scoliosis.
Local problem - muscle wasting following surgery, total hip replacement, OA.
How does trochanteric bursitis present?
Pain in lateral hip Point tenderness. May have scars from previous surgery May have muscle wasting (gluteals) Tenderness at greater tuberosity. Worst pain in active abduction.
What investigations would you carry out for trochanteric bursitis?
X-ray
MRI
Ultrasound
What is the treatment for trochanteric bursitis?
NSAIDs Relative rest/ activity modification. Physio - correct posture, stretching, strengthen muscles. Injection - corticosteroids Surgery - bursectomy
What is avascular necrosis?
Death of bone due to loss of blood supply.
M>F
80% bilateral.
What are some causes of avascular necrosis?
Trauma - irradiation, fracture, dislocation, iatrogenic.
Idiopathic
Hypercoagulable states
Steroids
Haematological - sickle cell disease, lymphoma, leukaemia.
Caisson’s disease
Alcoholism
How does avascular necrosis present?
Insidious onset of groin pain
Pain with stairs, walking uphill and impact activities.
Limp.
Examination largely normal
May replicate early arthritis - reduced ROM and stiff joint.
What is the treatment for avascular necrosis?
Reduce weight bearing NSAIDs Bisphosphonates Anticoagulants Physiotherapy Surgery - restore blood supply, core decompression, rotational osteotomy, total hip replacement.
What is femoroacetabular impingement?
Extra bone grow along either 1 or 2 bones that form hip joint. Results in impingement of femoral neck against anterior edge of acetabulum.
Cam lesion or pincer (acetabulum rim overhang).
How does femoroacetabular impingement present?
Groin pain which is worse with flexion.
Mechanical symptoms - block to movement, pain with getting out of chair, squatting, lunging.
Reduced flexion and internal rotation.
Positive FADIR test (flexion, adduction, internal rotation).
What is the treatment for femoroacetabular impingement?
Activity modification
NSAIDs
Physiotherapy - correct posture, strengthen muscles around joint.
Arthroscopy - to shave down defect, deal with labral tears, reset cartilage flaps.
Open surgery - resection, periacetabular osteotomy, hip resurfacing or replacement.
What is a labral tear?
Tear within labrum of acetabulum.
What are some causes of a labral tear?
Femoroacetabular impingement. 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.
What investigations would you carry out for a labral tear?
X-ray
MRI arthorgram
Diagnostic injection
What is the treatment for a labral tear?
Activity modification NSAIDs Physiotherapy Steroid injection Arthroscopy - repair, resection.
What are the key muscles surrounding the knee?
Quadriceps - extensors
Hamstrings - flexors
What ligaments surround the knee?
Anterior cruciate ligament
Posterior cruciate ligament
Lateral collateral ligament
Medial collateral ligament
What menisci are present around the knee?
Specialised C shaped cartilages.
Medial attached to deep MCL.
Lateral.
They aid force transmission and increase stability.
What is a meniscal tear?
Teat within one of the menisci.
What are some causes of meniscal tear?
Twisting especially in deep flexion.
OA
Medial meniscal tears are more common as they are more fixed.
How does a meniscal tear present?
Pain Clicking Locking Intermittent swelling Effusion Tender joint line at point of tear. mechanical block to movement McMurrays test positive Fail deep squat Thassaly's test positive
What is the treatment for meniscal tears?
Rest
NSAIDs
Physiotherapy
Arthroscopy - repair, resection.
Where does the ACL run between?
Tibial eminences and lateral wall of intercondylar notch of femur.
What is the blood supply of the ACL?
Middle geniculate artery.
What is the innervation of the ACL?
Posterior articular nerve which is a branch of tibial.
What is the function of the ACL?
Primary restraint to anterior translation of the tibia relative to femur.
Secondary restraint to tibial rotation and various/valgus stress.
What is a common cause of ACL tear?
Non-contact pivot injury.
How does. ACL tear present?
Heard a pop or crack Immediate swelling Cant walk in a straight line Deep pain Effusion Anterior draw Lachmann's test Pivot shift (best done under anaesthetic).
What is the treatment for ACL tear?
Focussed quadricep programme.
ACL reconstruction with hamstring graft, +/- partial meniscectomy +/- ligament repair or augmentation.
What is the function of the MCL?
Superficial - primary restraint to valgus stress.
Deep - contributes in full knee extension, attached to medial meniscus and is continuous with joint capsule.
What is the commonest cause of MCL tear?
Contact related severe valgus stress.
How does MCL tear present?
Heard a pop or a crack Severe pain on medial side. Unable to continue playing Bruising medial to knee Localised swelling. Tender medial joint line Tender femoral insertion of MCL. Painful in full extension opening on valgus stress.
What is the treatment for MCL tear?
Rest NSAIDs Physiotherapy Brace for comfort Operative for severe tears or failed non operative. Repair or reconstruction.
What is Osteochondritis?
Pathological lesion affecting articular cartilage and subchondral bone.
2 forms; juvenile (while growth plates still open) and adult.
What are some causes of osteochondritis dissecans?
Hereditary
Traumatic
Vascular (adult form)
How does osteochondritis dissecans present?
Activity related pain that is poorly localised. Recurrent effusions Mechanical symptoms - locking, block to full movement. Examination may be normal Effusion Localised tenderness Stiffness Wilson's test
What is the treatment for Osteochondritis Dissecans?
Restricted weight bearing
ROM brace
Arthroscopy - sunchondral drilling, fixation of loose fragments.
Open fixation
