Patho: Hip Flashcards
1
Q
Coxa Vara
A
- Normal neck/shaft angle of femur is 125 degrees.
- Coxa Vara angle is approx. 90 degrees.
- Places excessive stress through femoral epiphysis, shortens leg length.
- Bears more weight through next of femur then ball of femoral head.
- Vara is related to stress fx.
- Leg length differences are common
- Leg appears shorter
2
Q
Coxa Valga
A
- Leg appears longer
- Normal neck/shaft angle of femur is 125 degrees.
- Coxa Valga angle is greater than 125 degrees.
- Places excessive stress through femoral head, increases leg length.
3
Q
Femoral Anteversion
A
- Neck/shaft angle in transverse plane.
- Normal anteversion in an adult is 12-15 degrees.
- Greater than 15 degrees =anteverted
- Causes in-toeing, excessive hip IR.
- Test:X/Ray, Craig’s
4
Q
Femoral Retroversion
A
- Less than 15 degrees of anteversion= retroverted
- Causes out-toeing, excessive hip ER.
- Test:X/Ray, Craig’s
5
Q
Legg- Calve- Perthes
A
- congenital, no reason, start to decrease blood flow. Causes femoral head to become flat, leads to hip pain with weight bearing. Shorter steps.
- Pain referral common to the knee.
- S&S: Pain hip, thigh or knee, limping, loss of abduction, ext, and ER, thigh atrophy
- Avascular necrosis of the proximal femoral epiphysis with onset between 4-8 years boys>girls, 90% unilateral
- Tests: X/Ray, MRI
Management: Early detection enhances good outcomes.
Onset 6 yrs:
6
Q
SCFE Slipped Capital Femoral Epiphysis
A
- Femoral head/neck subluxation from a weakened epiphysis.
- the epiphysis gradually or suddenly slips downward and backward in relationship to the femoral neck.
7
Q
SCFE Etiology
A
- Most common boys 10-16, and girls 12-14
- Boys > girls 1.5:1
- African Americans 2.25 > Caucasians
- Left hip > right
- Obesity = risk factor
- Coxa vara= risk factor
- When onset < 10 y.o., endocrine disorder likely.
8
Q
SCFE Risk Factors
A
Risk factors may include:
- medications (such as steroids)
- thyroid problems (Hypothyroid)
- radiation treatment
- chemotherapy
- bone problems related to kidney disease
9
Q
SCFE Signs and Symptoms
A
- painful limp
- groin pain or knee pain
- Comfort by holding hip in slight flexion
- Can’t actively internally rotate hip
- Difficulty standing in single limb support
- During Passive flexion hip will move into ER.
10
Q
Dx of SCFE
A
Radiograph
- Surgery often requires screws to be placed and realign.
11
Q
FAI Femoral Acetabular Impingement
A
- The femur and the acetabulum repeatedly come into abnormal contact in certain hip positions as a result of an athlete’s particular anatomy combined with the demands of his sport.
- Can lead to bony issues such as spurring, and ultimately can result in damage to the labrum, as well as the cartilage surface over time.
- When FAI is found, bony spurs can be burred, or remodeled, to eliminate the presence of impingement.
- Osteophytes are causing a pinch.
As joint is getting unwanted friction osteocyte extra bone on femur. - Extra ledge on acetabelum is called pincer.
- Bone on bone pinching.
12
Q
FAI Types
A
- Cam, Pincer, Mixed
- Internal rotation jams in structures together.
FABERS is a good test to cause pain and figure out if they have a positive test.
13
Q
FAI Precursors
A
- Acetabular retroversion
- Previous HX of femoral neck fracture
- HX of SCFE
- HX of Legg-Calve-Perthes Disease
- Between age 25-60
- Many FAIs occur in athletes, especially if the sport demands the hip to work an end ROM.
14
Q
FAI Presentation/ Outcomes
A
- Dull, aching pain
- C Sign
- Positive FADIR
- Limited hip IR ROM with hip at 90 degrees flexion in supine
- Undiagnosed FAI likely leads to hip labral damage. Hip labral tear leads to OA
- C sign. Hip socket, deep to that position.
- Positive FADIR is a very good test. Specificity.
- Fairly new within the last 10 years. FAI leads to labral tear and labral tear leads to OS.
15
Q
5 causes of hip labral tears
A
- Trauma-isolated tear of labrum often from subluxing or dislocating femoral head in high velocity contact sport. The labrum only may be torn or these forces can cause injury to the femoral head and acetabular rim as well
- FAI
- Capsular laxity/hip hypermobility: Too much movement
- Dysplasia : Congenital too much coxa valga or vara.
- Degeneration
FAI can lead to this. Too little movement
Hip can tear due to labrum as well.
16
Q
Dx of Hip Labral Tears
A
Difficult Groin pain C Sign Limited or painful internal rotation and abduction \+FADIR’s \+ Faber’s test \+Hip Scour Test MRI/Arthogram or during an arthroscopic procedure
- OA, FAI, Labrum all can have same complaint.
- IR is most painful.
- FADIR: flexion, adduction, IR
- Hip Scour test: abduct hip
17
Q
Labral Tear Tx
A
- Rehab should be tried, 10-12 week protocol, prior to considering surgery:
Rehab goals
- Optimize hip alignment
- Work on stabilizing a hypermobile hip
- Work on joint mobes and soft tissue stretching on a hypomobile hip
- Limit activities during this time
- If symptoms cannot be controlled and sport function is limited, the athlete may need labral surgery
Hypermobile stabilizing PNF patterns.
18
Q
Labral Surgery
A
- Where is damaged piece, either repaired or resected (removed).
- Repairment is always in the patients best interest. Vascularity is along the periphery.
- Tear along edges, great repair candidate, if tear is on interior wont heal very well so removal is done.
- Since the labrum does provide protection for the joint surface itself, surgeons aim to preserve as much of the healthy tissue as possible.
- During surgery the damaged piece of labrum is either repaired or resected (removed), depending on the extent and location of damage.
19
Q
Hip Pointer
A
contusion to the unprotected iliac crest. Compression and crushing to soft tissue.
20
Q
Hip Pointer S & S
A
S&S:
- local pain, swelling, ecchymosis. Pain with trunk and hip motion, laughing, coughing, breathing.
Hip pointer, bad bruise over iliac crest. Blunt trauma.
Hip abduction, flexion, lat soreness due to many muscles that attach at iliac crest
21
Q
Hip Pointer Tx
A
Treatment:
- Ice, compression, NSAIDS, inactivity 2-3 days followed by MHP, US, TENS, gradual return to ROM exercises.
- Protective padding-doughnut or plastic shell. Up to 3 week recovery.
22
Q
Hamstring Strain/ tear or Avulsion Fx
A
- from excessive forcible contraction or stretch
S&S:
pain with active contraction, resistance and passive stretch. Weakness, ecchymosis, swelling.
R/O avulsion from ischium
R/O SI dysfunction - Articular problems: Previous disorders and problems on previous slides.
- Muscle diagnosis being able to palpate it, stretch it, know history, muscle test
- Avulsion a lot of pain. Will hate sitting.
- Really not going to be able to use hamstrings.
23
Q
Hamstring Strain Treatment
A
- Look at severity and decide grade 1,2, or 3.
- Grade 1 shut down 2-3 days. Ice, heat, stretching, weight bearing tolerance up. Worried about inflammation and pain
- Subacute want ROM back
- Chronic: want strength back and get back to functional movement
24
Q
Adductor Strain
A
- Common injury in activities that require quick changes of direction, or those that require quick propulsion and acceleration (hockey, football, soccer, high jump, breaststroke)
- “Groin pull”
Be able to palpate it resist, and stretch it.
Determine which one: Adductor longus Adductor brevis Adductor Magnus Pectineus Gracilis
Tx: Acute, subacute, chronic figure out what grade it is
25
Hip Sprains
- Uncommon due to the anatomic stability of this joint.
- Sprains take a violent force such as a violent twisting injury.
S&S:
- Acute pain, inability to circumduct thigh.
- Accessory Motion Tests:
AP Glide
PA Glide
Inferior Glide
Lateral Distraction
- Medical Tests: X/Ray, MRI- need to R/O fracture
RX: Gr2,3 Crutch walking as needed, gradual PRE progression when pain free.
- Accessory motion test is moving joint and checking motion.
- Ant roll post glide
- Iliofemoral ligament gives much more support in the front.
- Hip flexion 120 degrees post capsule becomes taught and stops femur from sliding anymore.
- Limited by post capsule, glut max, and hamstrings. AP glide will restore movement in flexion.
PA glide, extension of hip and external rotation.
Inf glide, abduction
- AP glide is most common.
26
Hip Dislocations
- MVA in vehicle and as pedestrian most common
- Rare in sports, usually occur with extreme force through long axis of femur when knee is flexed (football, rugby, water skiing, alpine ski, basketball, race car driving)
- Flexion is most common
27
Hip Dislocation Types
Anterior
- MOI: forced hip flexion, abduction, and external rotation
Posterior (most common mechanism)
- MOI: landing on a flexed knee while the hip is flexed, adducted, and internally rotated
28
Posterior Dislocation S & S
- Severe hip and thigh pain
- Referred pain in knee
- Hip positioned in flexion, adduction, and IR.
- Inability to walk
- Possible neurovascular complaints
29
Posterior Dislocation Medical Exams
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X-Ray
CT Scan
Good for soft tissue damage screening
MRI
Post injury 2-3 months out to screen for AVN
20% dislocations result in AVN
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30
Hip-dislocation Management
- Stabilize and transport to ER
- Need closed reduction within 24 hours
- Post reduction, the limb is held in traction 1-2 weeks
- 5-7 days post reduction, open chain AROM exercise is initiated
- Screen for AVN (Avascular Necrosis Femoral Head)
- High chair, no benches we don’t want flexion >90.
31
Hip Dislocation Complications
- Avascular necrosis femoral head (AVN)
- Acetabluar labral tear
- Hip OA is most common long term complication (50% of all patients)
32
Avulsions Fx's and Apophysitis
- Apophysitis- inflammation of the apophysis from overuse-often seen in long distance running-can lead to avulsion fx.
S&S:
- loss of strength, loss of hip motion, point tender.
- Apophysitis stress fx send it to doctor.
- Avulsion would be obvious due to severity of pain.
- Common with overuse and poor core control
33
Differentiate form Tendinopathy, strains, avulsions, and apophysitis'
- Tendinopathy: tendinitis not fixed after a few weeks and becomes long term. Hard to get tendon to heal due to not good blood flow.
34
Hip Stress Fractures
- Seen mostly in distance runners in femoral neck and pubic ramus. Effects women more than men (female athlete triad).
S&S:
- Groin pain, aching in thigh with activity. Hard to stand on 1 leg.
- Tests: X/Ray will be normal for 6-10 wks, Bone scan is best.
- Management: Rest, minimize weight bearing 2-5 months. Rehab
- Female athlete triad: disordered eating. Doesn’t eat properly or eat enough. Calorie burn much more then intake Messes up ammenorrhea.
- For more then 3 months inhibits ability to lay down calcium. Not necessarily anorexia, bulemia exc.
-Irritable spasming rectus abdominus
Crutches no weight bearing.
35
Femoral Fracture
- Direct trauma or indirect such as landing on a leg in an extended and rotated position.
S&S:
- sudden severe pain, loss of function, direct and indirect tenderness.
Tests:
Management:
Complication: AVN
36
Trochanteric Bursa
- MOI: inflammation of the bursa or gluteus medius from overuse, muscle imbalance, LLD, also seen with diseases such as SLE and RA.
S&S:
- lateral hip pain that may refer distally. Point tender
- Tests: Asymmetrical leg length, weak glut med, Tight TFL.
RX: RICE acutely, find the cause and correct!
Overuse from TFL or glut med.
SLE: Lupus collagen vascular disease attacking of own tissues.
RA rheumatoid arthritis
- Autoimmune disorder attacking self. Could be many joints at one time being inflamed.
Need ice.
37
Iliopectineal Bursa
- MOI: Excessive compression during hip flexion-typically in long distance runners.
S&S: deep Anterior hip pain, pain with deep palpation, pain with resisted hip flexion.
- Causes deep snapping of anterior hip
38
Snapping Hip Syndrome
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Is the snapping anterior or lateral?
- Anterior snapping with SLR and lower
Iliopectineal bursitis
Labral tears
- Lateral snapping
Proximal ITBand friction with or without pain associated with it. With pain, most likely gr troc bursitis
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39
Hip Replacement
- Joint replacement cemented or non-cemented.
- Surgical glue that seals right away.
- Ultimately replaced with natural bone if non-cemeted.
- Elderly need cemented so they aren’t bed ridden for 6 weeks.
- Do not want to cross hip at midline. No extension with IR.
- Don’t overflex or adduct them
40
Sports Hernia
- Imbalance in muscle strength hip adductors and RA and Obliques at insertion pubic ramus.
Males > females
- Groin pain
- Testicle pain
- Pain running, cutting
Ilioinguinal hernia: From lifting
Inciscional herna: After abdominal surgeries like c-section or abdosectimy.
Sports hernia: deep pain that may have the same look as pubic ramus stress fx.
- Deep pain cant get away from it and perform.
41
Sports Hernia Eval
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R/O true hernia= inguinal with palpation
- Dynamic tests
- Resisted oblique MMT
- Resisted Adductor tests
- Kicking with flexion/adduction
MRI
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