Orthopaedic Hip Conditions Flashcards
Which group of muscles attach onto the greater trochanter of the femur? The lesser trochanter?
Greater trochanter: Abductors and rotators of the hip
Lesser trochanter: Iliopsoas
What is the labrum of the hip and where does it lie?
Lies around the edge of the acetabulum
It’s a fibrocartilaginous structure that adds depth and stability to the hip joint, as well as assisting in the distribution of forces
Describe the blood supply to the hip
Profunda femoris artery gives off two branches at the hip:
- MFCA (medial femoral circumflex artery)
- LFCA (lateral femoral circumflex artery)
- Main blood supply to hip from the ascending head of the MFCA
What effect do intracapsular and extracapsular fractures have on the blood supply to the hip joint?
Extracapsular: blood supply may be maintained
Intracapsular: blood supply often disrupted
What is osteoarthritis of the hip joint? What bone changes are seen?
Progressive degeneration of AC around the hip joint, followed by secondary bone / joint changes
- Decreased joint space
- Roughening of bone (osteophytes etc.)
- Sclerosis of joint (whitening on X-Ray)
What are the symptoms of osteoarthritis affecting the hip joint?
- Pain (in groin / thigh / trochanteric region)
- Stiffness of hip joint (decreased ROM)
What is trochanteric bursitis? Where is the trochanteric bursa?
- Bursa is between the greater trochanter and iliotibial band
Trochanteric bursitis is inflammation & swelling of the trochanteric bursa, often due to friction between the sac and the trochanter & band
Symptoms / signs of trochanteric bursitis?
- Pain lying on side
- pain worsens on walking (+/- certain other movements)
- Tenderness over greater trochanter on palpation
- Pain on active abduction
What are some causes of trochanteric bursitis? Which groups are more likely to get it?
- More common in females
- Can be precipitated by trauma
- Often associated with overuse (athletes etc)
- Abnormal anatomy (scoliosis / hip muscle wasting / osteoarthritis)
Investigations for trochanteric bursitis?
X-Ray* (often to exclude osteoarthritis / may see trochanter abnormality)
- MRI
- USS (can also be therapeutic - guided steroid injection)
Management of trochanteric bursitis?
- NSAIDs (topical / oral)
- Physiotherapy
- Steroid injection*
- Surgery (bursectomy - not usually required)
What is avascular necrosis? Who tends to be affected? Which hip is more commonly affected?
- Death of the bone due to loss of blood supply
- More common in men & people aged 35-50
- 80% of cases tend to be bilateral, may be offset in time though
What are some risk factors for avascular necrosis?
Trauma:
- irradiation / fracture / dislocation
Systemic: (majority)
- Idiopathic
- Alcoholism
- Hypercoaguable states
- Steroids
- Haematological (sickle cell / lymphoma / leukemia)
- Caisson’s disease (divers / mine workers)
Describe the pathophysiology of avascular necrosis
- Coagulation of intraosseous microcirculation
- Venous thrombosis
- Retrograde arterial occlusion
- Intraosseous hypertension
- Reduced blood flow to femoral head
- Cell death
- Chondral fracture and collapse
- Head will often regenerate, but may have an irregular shape causing pain
Symptoms / signs of avascular necrosis?
- Insidious onset groin pain
- Pain worse with exertion (stairs / hills)
- Arthritis like examination: reduced ROM / stiffness
- Pain often seems disproportionate to examination findings
Investigations of Avascular Necrosis?
X-Ray: changes may only be visible once stage of bone collapse is reached
MRI*** (identifies earliest changes)
Radiological signs of avascular necrosis?
- Blackening of bone due to necrosis
- Crescent sign: flattening of femoral head + lytic linear region below chondral surface
- Osteophytes / cysts (later change)
Non-surgical management of avascular necrosis?
- Reduce weight bearing (crutches) + analgesics & NSAIDs
- Bisphosphonates
- Anticoagulants
- Physiotherapy
Surgical management of avascular necrosis?
Restore blood supply
- Core decompression to reduce venous hypertension
- Core decompression + Vascularized graft
- Rotational osteotomy: remove lesion from weight bearing area
- Hip replacement / fusion
What is femoroacetabular impingement? What can it lead to?
Impingement (rubbing against) of femoral neck against the anterior edge of the acetabulum
Can cause:
- Early onset secondary osteoarthritis
- Labral degeneration and tears
-
What are the two types of femoroacetabular impingement? Brief description of each
CAM lesion
- Deformity (lump) of neck of femur causes femur to impinge on edge of acetabulum
PINCER lesions:
- Anterosuperior acetabular rim overhang impinges on neck of femur
Presentation of femoroacetabular impingement?
- Groin pain, worse with flexion
- Limited ROM (reduced flexion & internal rotation)
- Pain on FADIR test: Flex, ADduct and internally rotate hip joint
Investigations of femoroacetabular impingement?
X-Ray
MRI
CT
Management of femoroacetabular impingement?
- Activity modification / Physiotherapy / NSAIDs
- Arthroscopy (shave down deformity)
- Open surgery: Resection / osteotomy
- Arthroplasty (resurfacing)
What type of labral tear is most common at the hip joint (direction)? What are some risk factors?
Anterosuperior tears
- femoroacetabular impingement
- Trauma
- Dysplasia
- Osteoarthritis
- Collagen disease (Ehlers Danlos)
Presentation of hip labral tears?
- Groin / hip pain. usually worse on specific movements, not present at all times
- Snapping / jamming sensation in hip
- Positive FABER test: flexion, ABduction, External Rotation of hip causes pain
Investigations of labrum tears of the hip?
MRI arthrogram* +/- contrast
X-Rays
Management of labrum tears of the hip?
- Activity modification / NSAIDs / Physio
- Steroid injection
- Arthroscopy (often in younger patients - repair / resect the labrum)
