Pathologies Related to the Pelvis and Hip I Flashcards
What is a pathological hip fx?
proximal femur fx, particularly the neck, due to disease
What is the etiology of a pathological hip fx?
Conditions with compromised bone
- Osteoporosis and Osteomalacia
- Osteogenesis Imperfecta- congenital and inherited brittle bone disease
- Paget’s disease- chronic bone disorder with abnormal bone turnover that results in bigger but softer bones
- Tumors
What is Paget’s disease?
chronic bone disorder with abnormal bone turnover that results in bigger but softer bones
What is Osteogenesis Imperfecta?
congenital and inherited brittle bone disease
What are risk factors for a pathological hip fx?
vary based on the above etiologies
What is the incidence/prevalence of pathogenic hip fx?
VARIES… but
- Mostly older
- European Americans
What is the pathogenesis of a pathological hip fx?
gradual weakening of bone resulting in fracture
What are some clinical manifestations of a pathological hip fx?
Fx S&S plus:
- Painful snap and possible giving way
- Groin and possibly anteromedial thigh P! and to the knee and lateral hip
- Increased: WBing
- Decreased: Non-WBing
What will we observe in a patient with a pathological hip fracture?
Shortened and excessively externally rotated LE due to displacement and pull of ERs, respectively
- Antalgic and asymmetrical gait
What will we find in ROM for a pathologcial hip fracture?
several limitations but particularly IR limitation
What special tests will be positive for a pathological hip fx?
(+) Patellar-pubic percussion
- Possible sign of the buttock
What is sign of the buttock?
collection of signs indicating a serious pathology
What is the etiology of sign of the buttock?
- Fracture
- Tumor
- Infection
- Hematoma
What will we find in the hx in someone with sign of the buttock?
possible cancer, infection, or fracture S&S
What will we observe with sign of the buttock?
gluteal swelling
What will we find with ROM in someone with sign of the buttock?
- Hip flx limitation the same no matter knee position with empty end feels
- Same degree of trunk flexion limitation in relation to femur and trunk position
What will we find with resisted testing with sign of the buttock?
weak and painful glutes
What kind of referral is sign of the buttock?
Urgent referral to MD but emergent if fracture due to possible displacement and
vascular compromise
What are the PT implications of a pathological hip fx?
Significant morbidity, mortality, and health issues arise from resulting sedentary
situation
When should people be having a DEXA scan?
Biological women at 65 yrs.
Biological men at 70 yrs
What kind of referral is a pathological hip fx?
Immobilize with emergent referral due to possible displacement and potential vascular compromise
What is osteonecrosis also known as?
aka avascular necrosis or AVN of the femoral head
What is the incidence/prevalence of osteonecrosis?
- May be bilateral in 60% of cases
- Older > younger individuals
What is the etiology and risk factors for osteonecrosis?
insufficient arterial supply to femoral head
associated with:
- Trauma
- Fx/dislocation
- Slipped femoral epiphysis or growth plate
Where does the ligamentum teres attach proximally and distally?
- Proximally in acetabulum
- Distally in fovea of the femoral head
What artery does the ligamentum teres contain to supply the head of the femur?
Medial epiphyseal a. to supply
head of femur
What other arteries aside from the medial epiphyseal artery supply the femoral head?
Femoral head also supplied by
medial and lateral circumflex aa.
What is the etiology of osteonecrosis?
Insufficient arterial supply to femoral head
What are some risk factors of osteonecrosis?
- Vascular abnormalities
- Toxicity i.e., 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
Is osteonecrosis gradual or sudden onset?
gradual
What is the pathogenesis of osteonecrosis?
- Ischemia leading to death of bony tissue
- Rapid progression to Age-related Joint Changes
- May involve labral tears
what will we find in the hx of patients with osteonecrosis?
- Groin and possibly anteromedial thigh P! and to the knee
- Intermittent but worsening with gradually and unknown
- Even occurring at rest due to ischemia
What will we observe with osteonecrosis?
antalgic and asymmetrical gait
What will we find with ROM of those with osteonecrosis?
ROM- limited IR, abduction, and flexion due to greater bony contact
What other condition S&S will be present with osteonecrosis?
Age-related Joint Change S&S
What is the referral of osteonecrosis if gradual onset??
Urgent referral to MD if gradual onset
If patient with osteonecrosis is referred to PT how do we proceed?
if referred for PT proceed with caution
What kind of PT measures can we do with those with osteonecrosis?
- Gait training with an assistive device is often necessary to protect the femur
- PT directed primarily at protection motion, improving circulation, and for bone and cartilage integrity; like age-related joint change Rx
What may happen with those with osteonecrosis?
May end up having a Hemi-arthroplasty or possibly a THA
What is Legg-Calve-Perthes?
- aka as coxa plana or flat hip
- AVN of the femoral head in children
What is the etiology of Legg-Calve-Perthes?
- Trauma
- Exposure to 2nd hand smoke
- Prenatal factors, i.e., genetics, endocrine, nutritional, or socioeconomic conditions
- Developmental dysfunction of bone or vasculature
What population is Legg-Calve-Perthes MOST common in?
MOST common in 5-8 yr. old Caucasian biological boys
What is the pathogenesis of Legg-Calve-Perthes?
impaired vascular supply to epiphyses (med/lat circumflex aa) that changes shape of the femoral head and acetabulum
What are PT clinical manifestations of Legg-Calve-Pethes?
- Vary in magnitude
- Gradual and unknown onset primarily
- If P!ful, groin and possibly anteromedial thigh P! and to the knee
- Increased with activity
- Decreased with rest
Is Legg-Calve-Perthes gradual or sudden onset?
gradual and unknown
What will we observe with Legg-Calve-Perthes?
- Antalgic and asymmetrical gait
- Muscle atrophy if long standing
What will we find in ROM with Legg-Calve-Perthes?
limited IR and aBd due to greater bony
contact
What is the referral with Legg-Calve-Perthes?
A long-term problem
- Urgent referral to MD if gradual
- Emergency referral to MD if trauma
- If referred for PT proceed with caution
How can we treat Legg-Calve-Perthes with PT?
- PT directed primarily at protected motion, improving circulation, and for bone and cartilage integrity
- Periodically, splinted, braced, or casted in slight abducted position
- Better femoral head contact with acetabulum
- Maintain and help better form femoral head in acetabulum as healing can occur
Why can we do gait training with Legg-Calve-Perthes?
Gait training with an assistive device is often necessary to protect the femoral neck
What is a complication with Legg-Calve-Perthes?
Complication: prone to contractures
What should we know about Legg-Calve-Pethes and Age related Joint changes?
Possible age-related joint change in early adulthood and 50% will develop age
related joint disease before 50 yrs. of age
What will MOST with Legg-Calve-Perthes need? What can happen earlier due to gait dysfunction?
MOST will need corrective surgery and/or early total hip arthroplasty
- Earlier LB and knee P! development in life due to gait dysfunction
- Kids tend to keep moving
- Adults tend to reduce activity
What is slipped capital epiphysis?
Anterior displacement of femoral neck on femoral head
- aka adolescent coxa vara
- MOST significant epiphyseal plate disorder of the LE
What is the etiology of slipped capital epiphysis?
- Mostly idiopathic
- Association with endocrine and renal disorders and Down Syndrome
- Hypothyroidism is MOST common
What do the risk factors for slipped capital epiphysis?
- create increased shear forces across epiphyseal plate
- Single MOST significant risk factor is obesity
- Biological male, rapid growth, radiation therapy, and femoral torsion
What is the incidence/prevalence of slipped capital epiphysis?
create increased shear forces across epiphyseal plate
- Single MOST significant risk factor is obesity
- Biological male, rapid growth, radiation therapy, and femoral torsion
What is the pathogenesis of slipped capital epiphysis?
- progressive displacement of femoral neck relative to the head through
the growth plate due to shear forces and/or weakened epiphyseal plate
How does slipped capital epiphysis come on?
- more likely gradual and unknown onset than trauma, but may seem benign like rolling in bed
What is the main complaint with slipped capital epiphysis?
groin and possibly anterolateral thigh pain and to the knee
What will we observe with slipped capital epiphysis?
- antalgic and asymmetrical
- externally rotated hip
- muscle atrophy if long standing
What will we find in ROM with slipped capital epiphysis?
- limited IR, abduction and flexion
- obligatory ER during flexion
What else can come along with slipped capital epiphysis? (other condition)
Possible sign of the buttock
When should a slipped capital epiphysis always be considered?
in peri-adolescent with atraumatic hip pain, particularly if associated with antalgic gait
What kind of referral is slipped capital epiphysis?
urgent referral to MD
What should we do if a patient with slipped capital epiphysis is referred to pt?
proceed with caution
How big can the slip be with a slipped capital epiphysis to still be referred to PT?
< 1 cm
What will the patient be doing when non WB when referred to PT with slipped capital epiphysis?
splinted in an abducted position with non-WB
What can we do with a patient referred to PT with slipped capital epiphysis do post -splinting?
- gait training with an AD is often necessary to protect the femoral neck
- PT directed primarily at protected motion, improving circulation and for bone and cartilage integrity
When is surgery required with a slipped capital epiphysis?
if slip > 1 cm
Why do we need surgery with a larger slipped capital epiphysis?
to avoid AVN or chrondrolysis (rapid loss of articular cartilage)
What are S&S of vascular insufficiency?
- coldness
- pale, blueish discoloration
- diminished pulses
- impaired capillary refill with nail bed recovery
- shiny skin
- hair loss
What are PT implications of a vascular insufficiency? How is it different with different types of onset?
- urgent referral with gradual onset
- emergency referral with acute onset
