Orthopedics Hip Flashcards
1
Q
Normal Anatomy Hip
A
2
Q
Hip Physical Exam Inspection
- Inspection
- Both hips appear s______.
- S____ is intact about both hips without erythema.
- Leg-l______
- ASIS → Medial malleolus
- Also screen for low back…
- LBP T _ _ ?
- S______ leg raise
- FABER =
A
- Inspection
- Both hips appear symmetric.
- Skin is intact about both hips without erythema.
- Leg-lengths
- ASIS (anterior superior iliac spine) → Medial malleolus (bump on inner side of ankle)
- Also screen for low back…
- LBP TTP?
- Straight leg raise
- FABER = used to identify the presence of hip pathology by attempting to reproduce pain in the hip, lumbar spine or sacroiliac region. examiner applies a posteriorly directed force against the medial knee of the bent leg towards the table top. A positive test occurs when groin pain or buttock pain is produced.
3
Q
Tenderness to palpation
- Greater tr_______?
- (or pain deepercentral/gr_____ → joint)
Range of Motion
- Look for sy_____
- _____ Extension → Flexion
- Internal Rotation / External Rotation
- Cr_____?
- St______?
A
- Greater trochanter?
- (or pain deeper/central/groin → joint)
- Look for symmetry
- Full Extension → Flexion
- Internal Rotation / External Rotation
- Crepitus?
- Stability?
4
Q
Strength/Sensation
- Compare bilaterally (flex/ext/IR/ER)
- Check distal
- Ankle/toe d____ and p_____ flexion
- Distal ___sation (generally DP/SP/TN)
- ________ nerve → branches into the tibial nerve and common peroneal nerve (which splits into DP/SP)
A
- Compare bilaterally (flex/ext/IR/ER)
- Check distal
- Ankle/toe dorsi and plantar flexion
- Distal sensation (generally deep peroneal/superficial peroneal/tibial nerve)
- Sciatic nerve → branches into the tibial nerve and common peroneal nerve (which splits into DP/SP)
5
Q
Common Conditions Hip
(5)
A
Trochanteric Bursitis / Iliotibial band syndrome
Snapping hip
Femoroacetabular impingement
Hip dysplasia
Hip arthritis
6
Q
Trochanteric Bursitis/Iliotibial Band Syndrome
- Pain at the “_____” of the hip
- Usually extends to the outside of the thigh area.
- Early stages, the pain is usually described as sh_____ and in_____.
- Later, the pain may become more of an a____ and spread across a ______ area of the hip
- Usually extends to the outside of the thigh area.
A
- Pain at the “point” of the hip
- Usually extends to the outside of the thigh area.
- Early stages, the pain is usually described as sharp and intense.
- Later, the pain may become more of an ache and spread across a larger area of the hip
- Usually extends to the outside of the thigh area.
7
Q
Trochanteric Bursitis / Iliotibial band syndrome
- Typically worse at _____ (lying on affected side), or after prolonged periods of activity and/or sitting on ______ surfaces.
- More common in gender (1) and _____-aged or ______ people.
- Causes
- Repetitive ______secondary to iliotibial _____ tr_____ over the trochanteric _____.
- Bursa is superficial to the hip abductor muscles and deep to the iliotibial band
A
- Typically worse at night (lying on affected side), or after prolonged periods of activity and/or sitting on hard surfaces.
- More common in women and middle-aged or elderly people.
- Causes
- Repetitive trauma secondary to iliotibial band tracking over the trochanteric bursa.
- Bursa is superficial to the hip abductor muscles and deep to the iliotibial band
8
Q
Trochanteric Bursitis / Iliotibial band syndrome: H&P
- History / Symptoms
- ______ sided hip pain (_____ not involved)
- Physical Exam
- Tenderness to palpation over greater _______
- ____ /symmetric joint ROM
- ______ neurovascular exam
A
- History / Symptoms
- Lateral sided hip pain (joint not involved)
- Physical Exam
- Tenderness to palpation over greater trochanter
- Full / symmetric joint ROM
- Normal neurovascular exam
9
Q
Trochanteric Bursitis Imaging
- XR/Imaging:
- (1) (clinical diagnosis)
- But in cases of persistent pain, XRs can be useful to rule-out concomitant hip ______
- MRI can be helpful to confirm diagnosis and rule-out abductor t_____ (although treatment is rarely altered from the results of the imaging)
A
- XR/Imaging:
- Not really necessary or helpful (clinical diagnosis)
- But in cases of persistent pain, XRs can be useful to rule-out concomitant hip arthritis
- MRI can be helpful to confirm diagnosis and rule-out abductor tears (although treatment is rarely altered from the results of the imaging)
10
Q
Trochanteric Bursitis Treatment
- Non-operative
- N_____
- Activity ______ / protection
- Avoid / modify ag______ activities
- P_ / home exercises / stretching
- S_____ injections
- If initial treatments are not helping
- Operative
- Very ______
- Often arthroscopic now, _____ectomy / debridement
- Refer
- Symptoms not ________ to NSAIDs, PT, activity modification
A
- Non-operative
- NSAIDs
- Activity modification / protection
- Avoid / modify aggravating activities
- PT / home exercises / stretching
- Steroid injections
- If initial treatments are not helping
- Operative
- Very rare
- Often arthroscopic now, bursectomy / debridement
- Refer
- Symptoms not responsive to NSAIDs, PT, activity modification
11
Q
Snapping Hip
- Snapping sensation in the hip that comprises of 3 entities:
- _____ snapping hip (ITB/abductors)
- ______ snapping hip (iliopsoas)
- intra-_______ snapping hip (intra-articular)
- Diagnosis of external and internal snapping hip is generally made _______ with specific physical examination maneuvers.
- Advanced imaging is generally required to diagnose _______ snapping hip.
- Usually h___less (and p___less), but can be annoying
- And for external snapping, can be a precursor to b______
- More common in common in ath____ and da_____in their teens or twenties
A
- Snapping sensation in the hip that comprises of 3 entities:
- external snapping hip (ITB/abductors)
- internal snapping hip (iliopsoas)
- intra-articular snapping hip (intra-articular)
- Diagnosis of external and internal snapping hip is generally made clinically with specific physical examination maneuvers.
- Advanced imaging is generally required to diagnose intra-articular snapping hip.
- Usually harmless (and painless), but can be annoying
- And for external snapping, can be a precursor to bursitis
- More common in common in athletes and dancers in their teens or twenties
12
Q
Snapping Hip History and Symptoms
- L_____ sided hip sn______ and/p____ (if external)
- Gr____/central (if internal or intra-articular)
- Patient is often able to re_____ the snapping
- Worse with ac______
- A cl_____ or lo______ sensation → more indicative of intra-________ pathology
A
- Lateral sided hip snapping and/pain (if external)
- Groin/central (if internal or intra-articular)
- Patient is often able to reproduce the snapping
- Worse with activity
- A clicking or locking sensation → more indicative of intra-articular pathology
13
Q
Snapping Hip Physical Exam
-
Classical dogma (although not always easy to replicate…)
- “External snapping one can ____ from across the room, while internal one may _____ from across the room”
- External: Palpate GT as hip is actively flexed; applying ______ likely stops the snapping, confirming diagnosis
- Internal: Snapping is reproduced by passively moving hip from a ______ and _______ rotated position to an _____ and ______ rotated position
A
- Classical dogma (although not always easy to replicate…)
- “External snapping one can see from across the room, while internal one may hear from across the room”
- External: Palpate GT as hip is actively flexed; applying pressure likely stops the snapping, confirming diagnosis
- Internal: Snapping is reproduced by passively moving hip from a flexed and externally rotated position to an extended and internally rotated position
14
Q
Snapping Hip Imaging
- XR:
- AP P_____, AP/lateral ____
- Typically done but not really necessary (______ diagnosis)
- Can rule-out radio-dense intra-articular _____ bo____, cal______, ar_____
- MRI:
- Recal_____ cases only
- Useful to rule-out intra-______ pathology
- Often performed as an arthro_____ study
- May show inflamed b_______
A
- XR:
- AP Pelvis, AP/lateral hip
- Typically done but not really necessary (clinical diagnosis)
- Can rule-out radio-dense intra-articular loose bodies, calcifications, arthritis
- MRI:
- Recalcitrant cases only
- Useful to rule-out intra-articular pathology
- Often performed as an arthrogram study
- May show inflamed bursa
15
Q
Snapping Hip Imaging
- Ultrasound:
- _____ done
- Can be a dynamic study which may de______ the snapping band in either internal or external snapping
- May be used to localize a diagnostic challenge ______ into the trochanteric bursa (external), the iliopsoas sheath (internal), or intra-articular space.
A
- Ultrasound:
- Rarely done
- Can be a dynamic study which may demonstrate the snapping band in either internal or external snapping
- May be used to localize a diagnostic challenge injection into the trochanteric bursa (external), the iliopsoas sheath (internal), or intra-articular space.
16
Q
Snapping Hip Treatment
- Often painless and require no treatment (re______)
- Non-operative
- A____ modification / protection
- Avoid / modify aggravating activities
- N______
- P_ / home ex_____/ str_____
- Steroid in_____
- If initial treatments are not helping
- A____ modification / protection
- Operative
- Very ____
- External: ex_____ of GT bursa with __-plasty of ITB
- Internal: r_______ of iliopsoas tendon
- Intra-articular: hip _____scopy with removal of loose bo____, la_____ debridement/repair
- Very ____
- Refer
- Symptoms ____ responsive to NSAIDs, PT, activity modification
A
- Often painless and require no treatment (reassurance)
- Non-operative
- Activity modification / protection
- Avoid / modify aggravating activities
- NSAIDs
- PT / home exercises / stretching
- Steroid injections
- If initial treatments are not helping
- Activity modification / protection
- Operative
- Very rare
- External: excision of GT bursa with z-plasty of ITB
- Internal: release of iliopsoas tendon
- Intra-articular: hip arthroscopy with removal of loose bodies, labral debridement/repair
- Very rare
- Refer
- Symptoms not responsive to NSAIDs, PT, activity modification
17
Q
Femoroacetabular Impingement (FAI)
- FAI = abnormal contact between the _____ and ______ which may lead to l_____ damage, various degrees of chondral injury and progressive hip pain.
- Diagnosis: is made radiographically with hip radiographs showing an aspherical femoral (____ impingement) or anterosuperior acetabular overhang (_____ impingement), or a combination of both.
- Treatment: nonoperative or operative depending on the chronicity of sy____, patient a___, patient activity de_____, and development of secondary in____ to the hip joint (i.e. labral ____, secondary osteo_____).
- _____ in general population and often __symptomatic
- May become more apparent with participation in activities requiring ex______ range of motion (ballet, gymnastics, martial arts)
A
- FAI = abnormal contact between the femur and acetabulum which may lead to labral damage, various degrees of chondral injury and progressive hip pain.
- Diagnosis is made radiographically with hip radiographs showing an aspherical femoral (Cam impingement) or anterosuperior acetabular overhang (Pincer impingement), or a combination of both.
- Treatment: nonoperative or operative depending on the chronicity of symptoms, patient age, patient activity demands, and development of secondary insult to the hip joint (i.e. labral tear, secondary osteoarthritis).
- Common in general population and often asymptomatic
- May become more apparent with participation in activities requiring extreme range of motion (ballet, gymnastics, martial arts)
18
Q
Cam Vs. Pincer Impingement
A
Cam Impingement = Left pic
Pincer Impingement = Right pic
19
Q
Femoroacetabular Impingement H&P
- History / Symptoms
- Activity related groin or hip p___, exacerbated by hip ____ion
- Difficulty s______
- Mechanical hip symptoms of cl____ or po_______
- Can present with gl____ or trochanteric pain
- Due to aberrant g____ mechanics
- Physical Exam
- Motion
- limited hip ____ion (<90 degrees), especially with _______ rotation (<5 degrees)
- anterior impingement test =
- Motion
A
- History / Symptoms
- Activity related groin or hip pain, exacerbated by hip flexion
- Difficulty sitting
- Mechanical hip symptoms of clicking or popping
- Can present with gluteal or trochanteric pain
- Due to aberrant gait mechanics
- Physical Exam
- Motion
- limited hip flexion (<90 degrees), especially with internal rotation (<5 degrees)
- anterior impingement test (flexion, adduction, internal rotation) elicits pain
- Motion
20
Q
Femoroacetablur Impingment Inspection
- _______ rotated extremity
- Can be due to post S _ _ _ deformity
A
- Externally rotated extremity
- post SCFE
21
Q
Femoroacetabular Impingement: Studies
- XR:
- Recommended views
- _ _ with true _____ view (hip placed in 15 degrees of internal rotation)
- Optional views
- _____ or modified Dunn view, False profile view to assess _______ coverage of the femoral head
- Recommended views
- CT
- Provides _____ detail of bony structural abnormalities
- Surgical pl______
- MRI:
- Best modality to assess l_____ and ar_____ pathology
A
- XR:
- Recommended views
- AP with true lateral view (hip placed in 15 degrees of internal rotation)
- Optional views
- Dunn or modified Dunn view, False profile view to assess anterior coverage of the femoral head
- Recommended views
- CT
- Provides more detail of bony structural abnormalities
- Surgical planning
- MRI:
- Best modality to assess labral and articular pathology
22
Q
Femoroacetabular Impingement Treatment
- Often pain____ and require __ treatment (reassurance)
- Non-operative
- Activity m______ / pr_____
- Avoid / modify ag______ activities
- Rx (1)
- _ _ / home ex_____ / st_____
- (1)
- If initial treatments are not helping
- Activity m______ / pr_____
- Operative
- Symptomatic mechanical symptoms / failure of non-op treatments
- ___ (or minimal) arthritis
- Typically addressed ______scopically (although recent data shows open and arthroscopic procedures have similar outcomes)
- Goals: sh_____ down cam and pincer lesions, debride or repair l______
- Refer
- Symptoms not responsive to (3)
A
- Often painless and require no treatment (reassurance)
- Non-operative
- Activity modification / protection
- Avoid / modify aggravating activities
- NSAIDs
- PT / home exercises / stretching
- Steroid injections
- If initial treatments are not helping
- Activity modification / protection
- Operative
- Symptomatic mechanical symptoms / failure of non-op treatments
- No (or minimal) arthritis
- Typically addressed arthroscopically (although recent data shows open and arthroscopic procedures have similar outcomes)
- Goals: shave down cam and pincer lesions, debride or repair labrum
- Refer
- Symptoms not responsive to NSAIDs, PT, activity modification
23
Q
Hip Dysplasia
- Developmental Dysplasia of the Hip is a disorder of abnormal ______ resulting in dysplasia, sub____, and possible dis_____ of the hip secondary to capsular ____ity and mechanical in_______.
- What does dysplasia mean?
- Greek root “plasis” meaning molding/con_______
- So → abnormal mol____ or development of the hip
A
- Developmental Dysplasia of the Hip is a disorder of abnormal development resulting in dysplasia, subluxation, and possible dislocation of the hip secondary to capsular laxity and mechanical instability.
- What does dysplasia mean?
- Greek root “plasis” meaning molding/conformation
- So → abnormal molding or development of the hip
24
Q
Hip Dysplasia
- Diagnosis can be confirmed with (1) in the first __ months and then with (1) after femoral head ___ification occurs (~ _-_ months).
- Treatment varies from Pavlik _______ to surgical re_____ and ____teotomies depending on the age of the patient, underlying etiology, and the severity of dysplasia.
A
- Diagnosis can be confirmed with ultrasonography in the first 4 months and then with radiographs after femoral head ossification occurs (~ 4-6 months).
- Treatment varies from Pavlik bracing to surgical reduction and osteotomies depending on the age of the patient, underlying etiology, and the severity of dysplasia.
27
Q
Hip Dysplasia Risk Factors
- _____born
- Due to unstretched uterus and tight abdominal structures compressing the uterus
- ______ gender
- Due to increased ligamentous laxity that transiently exists as the result of circulating maternal hormones and the estrogens produced by the fetal uterus
- ______ position
- More commonly seen in female children, firstborn children, and pregnancies complicated by _____hydramnios
- Higher risk of DDH with f____/single breech position compared to f______ breech position
- Other: family _____, oligohydramnios, m____somia
A
- Firstborn
- Due to unstretched uterus and tight abdominal structures compressing the uterus
- Female
- Due to increased ligamentous laxity that transiently exists as the result of circulating maternal hormones and the estrogens produced by the fetal uterus
- Breech
- More commonly seen in female children, firstborn children, and pregnancies complicated by oligohydramnios
- Higher risk of DDH with frank/single breech position compared to footling breech position
- Other: family history, oligohydramnios, macrosomia (large babies)
29
Q
Barlow and Ortolani
-
(1): dislocates a dislocatable hip by adduction and depression of flexed femur
- “Click of exit”
-
(1): reduces a dislocated hip by elevation and abduction of the flexed femur
- “Click of entry”
-
NOTE: Be very ______.
- Hold the legs as if they are a “ripe tomato”
- Barlow and Ortolani are rarely positive after 3-months due to the soft-tissue _______ that form around the hip
A
-
Barlow: dislocates a dislocatable hip by adduction and depression of flexed femur
- “Click of exit”
-
Ortolani (Legs Out): reduces a dislocated hip by elevation and abduction of the flexed femur
- “Click of entry”
-
NOTE: Be very gentle.
- Hold the legs as if they are a “ripe tomato”
- Barlow and Ortolani are rarely positive after 3-months due to the soft-tissue contractures that form around the hip
30
Q
Galeazzi Sign (or Allis sign)
- Apparent limb _____ _______ due to a unilateral dislocated hip with hip flexed at ___ degrees and ____ on the table
- Femur appears ________ on dislocated side
A
- Apparent limb length discrepancy due to a unilateral dislocated hip with hip flexed at 90 degrees and feet on the table
- Femur appears shortened on dislocated side
33
Q
Hip Dysplasia Imaging
(1) Primary modality 4-6 mo after the femoral head begins to ossify (~6-8 months old)
-
_________ line
- Horizontal line through the right and left triradiate cartilage
- Femoral head ossification should be inferior to this line
-
_______ line
- Line perpendicular to Hilgenreiner’s line through a point at the lateral margin of the acetabulum
- Femoral head ossification should be medial to this line
-
________ line
- Arc along the inferior border of the femoral neck and the superior margin of the obturator foramen
- Arc line should be continuous
A
- X-ray = Primary modality 4-6 mo after the femoral head begins to ossify (~6-8 months old)
-
Hilgenreiner’s line
- Horizontal line through the right and left triradiate cartilage
- Femoral head ossification should be inferior to this line
-
Perkin’s line
- Line perpendicular to Hilgenreiner’s line through a point at the lateral margin of the acetabulum
- Femoral head ossification should be medial to this line
-
Shenton’s line
- Arc along the inferior border of the femoral neck and the superior margin of the obturator foramen
- Arc line should be continuous
36
Q
Hip Dysplasia Non-Op Treatment
-
___duction splinting/bracing (1)*
- Indications
- < __ months old and red______ hip
- Contraindicated in _____tologic (irreducible) hip dislocations and patients with sp___ bi_____ or sp_______
- Requires normal _______ function for successful outcome
- Indications
-
_________ reduction and spica _______
- Indications
- 6-18 months old
- Failure of Pavlik treatment
- Trivia: Definition of spica: a bandage that is applied in successive V-shaped crossings and is used to immobilize a limb especially at a joint
- Indications
A
-
Abduction splinting/bracing (Pavlik harness)
- Indications
- < 6 months old and reducible hip
- Contraindicated in teratologic (irreducible) hip dislocations and patients with spina bifida or spasticity
- Requires normal muscle function for successful outcomes
- Indications
-
Closed reduction and spica casting
- Indications
- 6-18 months old
- Failure of Pavlik treatment
- Trivia: Definition of spica: a bandage that is applied in successive V-shaped crossings and is used to immobilize a limb especially at a joint
- Indications
37
Q
Hip Dysplasia Operative Treatment
- Usually after ___-months when ______ treatments have failed
- Options
- _____ reduction and (1)
- _____ reduction and ______ osteotomy
- ______ reduction and _______ osteotomy
- When to refer?
- All cases of suspected hip ________
A
- Usually after 18-months when closed treatments have failed
- Options
- Open reduction and spica casting
- Open reduction and femoral osteotomy
- Open reduction and pelvic osteotomy
- Refer
- All cases of suspected hip dislocation
38
Q
Hip Arthritis
Hip Osteoarthritis is ______ disease of the hip joint that causes progressive loss of articular _______ of the (1) and (1).
- Diagnosis can be made with plain (1) of the hip.
-
Treatment
- Observation, NSAIDs, and corticosteroids for m______ disease / symptoms patients.
- Hip ______ is indicated for progressive symptoms with s______ degenerative disease.
A
Hip Osteoarthritis is degenerative disease of the hip joint that causes progressive loss of articular cartilage of the femoral head and acetabulum.
- Diagnosis can be made with plain radiographs of the hip.
-
Treatment
- Observation, NSAIDs, and corticosteroids for minimally disease / symptoms patients.
- Hip arthroplasty is indicated for progressive symptoms with severe degenerative disease.
39
Q
Hip Arthritis Risk Factors
- Modifiable
- Tr_____
- Heavy ph_____ work
- High-impact sp_____
- Non-modifiable
- Gender (_+>__)
- A___
- Ge_______
- De_______ or acquired deformities
- DDH
- SCFE
- Legg-Calve-Perthes disease
- FAI
- Etiology: Controversial → regardless of the cause, the end-result is the same ( w___ and deg_____ of the cartilage)
A
- Modifiable
- Trauma
- Heavy physical work
- High-impact sports
- Non-modifiable
- Gender (F>M)
- Age
- Genetics
- Developmental or acquired deformities
- DDH
- SCFE
- Legg-Calve-Perthes disease
- FAI
- Etiology: Controversial → regardless of the cause, the end-result is the same (wearing and degeneration of the cartilage)
41
Q
Hip Arthritis PE
- Physical Exam
- Inspection
- Body ha____, g____, leg-length __________, s___ (scars?)
- Inspection
- Motion
- Lack of full extension (>___ degrees flexion contracture)
- Lack of full flexion (flexion < ___-100 degrees)
- Limited ________ rotation* (compare to other side)
A
- Physical Exam
- Inspection
- Body habitus, gait, leg-length discrepancy, skin (scars?)
- Inspection
- Motion
- Lack of full extension (>5 degrees flexion contracture)
- Lack of full flexion (flexion < 90-100 degrees)
- Limited internal rotation* (compare to other side)
42
Q
Hip Arthritis Imaging
- (1)
- Recommended views
- St______ AP pelvis
- (1) + (1)
- Recommended views
- Look for:
- Joint space ______
- Osteo_____
- Subchondral sc_____
- Subchondral c_____
A
- XR:
- Recommended views
- Standing AP pelvis
- AP + lateral hip
- Recommended views
- Look for:
- Joint space narrowing
- Osteophytes
- Subchondral sclerosis
- Subchondral cysts
44
Q
Hip Arthritis Operative Treatment
- Younger patients / less severe DJD
- (1), (1) (rare)
- Older patients / more severe disease
- (1)* / resurfacing
- When to refer?
A
- Younger patients / less severe DJD
- Arthroscopy, Osteotomy (rare)
- Older patients / more severe disease
- Total hip replacement / resurfacing
- Refer
- Symptoms not responsive to NSAIDs, PT, activity modification
