pathologies related to pelvis & hip I - exam 2 Flashcards
what is a pathological hip fracture?
proximal femur fx, particularly of the neck, due to disease
causes of a pathological hip fx?
conditions with compromised bone
- osteoporosis and osteomalacia
- osteogenesis imperfecta (congenital and inherited brittle bone disease - peds)
- paget’s disease (chronic bone disorder w abnormal bone turnover that results in bigger but softer bones)
- tumors
may or may not involve a fall (break can cause fall or fall can cause break)
prevalence of pathological hip fx
mostly older
european americans
pathogenesis of pathological hip fx
gradual weakening of bone resulting in fx
S&S of pathological hip fx
fx S&S
painful snap and possible giving way
groin and possible anteromedial thigh P! to knee and lateral hip
– increased: WB
– decreased: non WB
what would you observe in someone with a pathological hip fx
shortened and excessively externally rotated LE due to displacement and pull of ERs
antalgic (painful) and asymmetrical gait
pathological hip fx:
- ROM:
- Special tests:
- several but particularly IR limitations
- (+) patellar-pubic percussion
possible sign of the buttock
what is the sign of the buttock? causes?
collection of signs indicating a serious pathology
fx
tumor
infection
hematoma
what would you find in your interview & scan for sign of the buttock?
- Hx
- Observation
- ROM
- Resisted
- possible cancer, infection or fx S&S
- gluteal swelling - one larger than the other
- hip flx limitation the same no matter knee position with empty ends feels. same degree of trunk flexion limitation in relation to femur and trunk position
- weak and painful glutes
what is the referral for someone with the sign of the buttock?
urgent referral to MD but emergent if fx due to possible displacement and/or vascular compromise
what can result from a sedentary situation in someone with a pathological hip fx?
significant morbidity, mortality and health issues
what referral for pathological hip fx?
immobilize w emergent referral due to possible displacement and potential vascular compromise
what is osteonecrosis and where is it located?
avascular necrosis (AVN) of the femoral head
true or false. osteonecrosis may be bilateral in 60% of the cases
true
who is more likely to get osteonecrosis?
older individuals
what is the cause of osteonecrosis?
insufficient arterial supply to femoral head associated with trauma
- fx/dislocation
- slipped femoral epiphysis/growth plate
where does the blood supply for the femoral head come from?
medial epiphyseal a. to supply head of femur
medial and lateral circumflex artery
what intracapsular ligament contains the blood supply of the femur head?
ligamentum teres
- attachments: acetabulum –> fovea of femoral head
what are secondary associations that could exist with osteonecrosis?
vascular abnormalities
toxicity (radiation, smoking, alcoholism)
sickle cell disease with a shortage of healthy oxygen carrying RBCs
chronic corticosteroid and oral contraceptive use
bone marrow pathology
metabolic syndrome (obesity, diabetes)
pathogenesis of osteonecrosis?
ischemia leading to death of bony tissue
rapid progression to age related joint changes
may involve labral tears
S&S of osteonecrosis
Hx -
observation -
groin and possibly anteromedial thigh P! and to the knee
– suddenly w trauma (possible sign of buttock)
– intermittent but worsening with gradually and unknown onset and occurring at rest due to ischemia
age related joint change – corticosteroid use
antalgic and asymmetrical gait
what referral for osteonecrosis?
urgent referral to MD
if a patient with osteonecrosis gets referred to PT, how do you proceed?
with caution!
gait training with an assistive device to protect the femur
PT directed primarily at protection motion, improving circulation, and for bone and cartilage integrity (similar to age related joint change Rx)
if PT doesn’t work well, what may a patient with osteonecrosis end up having to do?
hemi arthroplasty or possible THA
what is legg-calve perthes?
coxa plana or flat hip
AVN of femoral head in children
causes of legg-calve perthes?
trauma
exposure to 2nd hand smoke
prenatal factors (genetics, endocrine, nutritional, socioeconomic conditions)
developmental dysfunction of bone or vasculature
who is more likely to get legg-calve perthes?
most common in 5-8 year old caucasian boys
how does legg-calve-perthes happen?
impaired vascular supply to epiphyses that changes shape of the femoral head and acetabulum
S&S of legg-calve-perthes
vary in magnitude
gradual and unknown onset
antalgic and asymmetrical gait
if painful, groin and possibly anteromedial thigh P! and to the knee
– increased with activity
– decreased with rest
possible hip muscle atrophy
limited IR and ABD
true or false. legg-calve perthes is a short term problem
false
long term
what referral for legg-calve perthes
urgent
if a patient with legg-calve perthes is referred to PT, how do you proceed?
with caution!
- gait training with an assistive device to protect the femur
- PT directed primarily at protection motion, improving circulation, and for bone and cartilage integrity
- periodically, splinted, braced, or casted in an abducted position
–> better femoral head contact
–> maintain and help better form femoral head in acetabulum as healing can occur
–> prone to contractures
describe the relationship between legg-calve perthes and age related joint changes
these people will experience age related joint change in early adulthood and 50% will develop age related joint disease by 50 years old
most individuals with legg-calve perthes will need ____ and experience ____
corrective surgery and/or early total hip arthroplasty
earlier LB and knee P! development in life due to gait dysfunction
what is slipped capital epiphysis?
anterior displacement of femoral neck on femoral head
adolescent coxa vara
MOST significant epiphyseal plate disorder of the LE
what is the cause of slipped capital epiphysis?
mostly idiopathic (unknown)
association with endocrine and renal disorders and Down syndrome
what is the most common cause of slipped capital epiphysis?
hypothyroidism
what do risk factors of slipped capital epiphysis create?
increased shear forces across epiphyseal plate
what is the most significant risk factor of slipped capital epiphysis?
what are the 4 other risk factors?
obesity
male
rapid growth
radiation therapy
femoral torsion
who is more likely to get slipped capital epiphysis?
most common in early adolescence
African American boys
higher BMI
bilateral (1/3 of patients)
how does slipped capital epiphysis happen?
progressive displacement of femoral neck relative to the head through the growth plate due to shear forces and/or weakened epiphyseal plate
symptoms of slipped capital epiphysis
more likely gradual and unknown onset than trauma, but trauma may seem benign like rolling in bed
groin and possibly anteromedial thigh P! and to the knee
what would you observe in someone with slipped capital epiphysis? ROM?
antalgic and asymmetrical
ER hip
muscle atrophy if long standing
ROM:
- limited IR, abd, flex
- obligatory ER during flexion
possible sign of the buttock
if a peri-adolescent patient shows up to your clinic with atraumatic hip pain, particularly if associated with antalgic gait, what do you need to always consider?
slipped capital epiphysis
slipped capital epiphysis referral
urgent
what do you do for your patient with slipped capital epiphysis if the slip is < 1 cm
splinted in an abducted position with non-WBing
post splinting:
gait training with an assistive device is often necessary to protect the femoral neck
PT directed primarily at protected motion, improving circulation and for bone and cartilage integrity
- avoid AVN or chondrolysis (rapid loss of articular cartilage)
what is needed for a patient with slipped capital epiphysis if the slip is > 1 cm
surgery
what are vascular insufficiency S&S?
coldness
blueish or pale discoloration
diminished pulses
impaired capillary refill with nail bed recovery
shiny skin
hair loss
referral for vascular insufficiency
emergency
