Orthopaedic hip conditions

Question 1

what point of the femur is the attachment for the abductors and rotators?

Answer 1

greater trochanter

Question 2

what point of the femur is the attachment of the psoas major?

Answer 2

lesser trochanter

Question 3

what type of structure is the labrum?

Answer 3

fibrocartilage

Question 4

what is the main blood supply of the hip joint?

Answer 4

branches of the profunda femoris to the capsule

- left and middle femoral circumflex arteries

Question 5

a patient presents with pain and worsening stiffness of the hip joint. what is the most likely diagnosis?

Answer 5

osteoarthritis of the hip

Question 6

where is the trochanteric bursa located?

Answer 6

between the hip abductors and the illiotibial band

Question 7

what are the causes of trochanteric bursitis?

Answer 7

trauma

overuse; (athletes, often runners, repetitive movements)

abnormal movements;

• distant problem i.e. scoliosis
• local problem (muscle wasting following surgery, total hip replacement, osteoarthritis)

Question 8

what is the presentation of trochanteric bursitis ?

Answer 8

localised pain in the lateral hip

Question 9

what is the clinical presentation like in trochanteric bursitis?

Answer 9

look:

• may have scars from previous usrgyer
• may have muscle wasting of gluteals

feel:
- tenderness over greater tuberosity

move:
- worst pain in active abduction

Question 10

what investigations would you carry out if you suspected trochanteric bursitis?

Answer 10

MRI
X-ray
USS (therapeutic as well as diagnostic i.e. guided injection)

Question 11

what is the treatment for trochanteric bursitis?

Answer 11

non-operative:

• NSAIDS
• rest / activity modification
• physiotherapy
• steroid injection

surgical:
- bursectomy

Question 12

what is avascular necrosis?

Answer 12

death of bone due to loss of blood supply

Question 13

in what age and sex is avascular necrosis more common?

Is it more commonly unilateral or bilateral?

Answer 13

females > males
age: 35-50yrs
80% bilateral

Question 14

what are the risk factors for avascular necrosis?

Answer 14

trauma i.e. intracapsular fracture 
systemic:
- idiopathic
- hypercoaguable states
- steroids
- haematological (sickle cell, lymphoma, leukaemia)
caisson's disease 
alcoholism

Question 15

briefly describe the pathway involved in development of idiopathic avascular necrosis.

Answer 15

coagulation of interosseous microcirculation
venous congestion
retrograde arterial thrombosis
intraosseous hypertension
reduced blood flow
cell death 
chondral fracture and collapse

Question 16

what is the presentation of avascular necrosis?

Answer 16

insidious onset of groin pain
pain with stairs, walking uphill and impact activities
limp

Question 17

what is the examination of someone with avascular necrosis like?

Answer 17

mostly normal

may present like early arthritis with stiffness and decreased range of motion (esp internal rotation)

Question 18

what action of the hip does avascular necrosis restrict?

Answer 18

internal rotation

Question 19

what are the treatments for avascular necrosis?

Answer 19

non-operative:

• reduce weight bearing
• NSAIDS
• bisphosphonates
• anti coagulants
• physiotherapy

surgery:

• core decompression (restore blood supply)
• rotation osteotomy
• total hip replacement (last resort)

Question 20

what are the 2 categories of femoral acetabular impingement ? (FAI)

Answer 20

cam lesion

pincer

Question 21

what is femoral acetabulum impingement? (FAI)

Answer 21

anatomical phenomenon which results in impingement of the femoral neck against the anterior edge of acetabulum

Question 22

what is the pathology in a cam lesion which causes FAI?

Answer 22

extra bone resulting in decreased femoral head:neck ratio

aspherical head

Question 23

in what type of patients is a cam lesion in FAI most commonly found?

Answer 23

usually in young athlete males who do a lot of hip flexion i.e. rowers

Question 24

what is the difference between cam lesion and pincer FAI?

Answer 24

cam lesion = femoral based impingement

piper = acetabulum based impingement

Question 25

in what patients does since FAI usually occur?

Answer 25

active females

Question 26

what is the pathology that causes pincer FAI?

Answer 26

abnormal acetabulum leading to;

• anteriosuperior rim overhang
• acetubular protrusion

Question 27

what are associated injuries with FAI?

Answer 27

label degeneration and tears
cartilage damage and flap tears
secondary hip osteoarthritis

Question 28

what is the presentation of FAI?

Answer 28

groin pain - worse with flexion
mechanical symptoms;
- block to movement
- pain with certain manoeuvres i.e. squatting, lunging, getting out of a chai

Question 29

what clinical signs are present with FAI?

Answer 29

positive FADIR test - flexion adduction and internal rotation

Question 30

what are the treatment options for FAI?

Answer 30

non-operative;

• activity modification
• NSAIDS
• physiotherapy

operative:

• arthroscopy
• resection
• periacetubular osteotomy
• hip arthroplasty

Question 31

in what group of patients is labral tear most commonly found in?

Answer 31

all age groups
commonly active females
- pincer FAI
- more flexible

Question 32

what are the causes of a labral tear?

Answer 32

FAI
trauma
osteoarthritis
dysplasia 
collagen diseases i.e. Ehlers-danlos syndrome
DDH

Question 33

what is the presentation of a labral tear of the hip?

Answer 33

extreme groin or hip pain
snapping sensation
jamming or locking of the hip

Question 34

what clinical sign may be positive on examination in a patient with a labral tear?

Answer 34

positive FABER test
- flexion, abduction, external rotation (for anterior tears)

examination can be normal

Question 35

what is the treatment for a labral tear?

Answer 35

non-operative:

• activity modification
• NSAIDS
• physiotherapy
• steroid injection

operative:
- arthroscopy (repair or resection)