S3 - Hip Conditions Flashcards
- *‘Pulled hamstring’:**
- What action can it be caused by: When is it more likely to occur?
- What exactly happens to the muscle when it is ‘pulled’
What action can it be caused by: When is it more likely to occur?
A pulled hamstring tends to occur during sudden muscular exertion that results in stretching of the posterior thigh muscles e.g. jumping, sprinting and lunging. It is relatively common in footballers
and athletes, especially if proper warm-up exercises have not been performed beforehand.
What exactly happens to the muscle when it is ‘pulled’:
Sudden tension on the hamstrings results in either a muscle sprain, a partial tear or a complete tear of the origin of the hamstring muscles from the ischial tuberosity, sometimes accompanied by avulsion of a fragment of bone.
- *Osteoarthiritis**
- Age group
- Definition and explanation
- Most common joints affected
- Primary and Secondary OA meaning
- Primary OA causes
- Secondary OA causes
- Symptoms of OA in any joint include
Osteoarthritis (OA) is the most common disease affecting synovial joints worldwide.
Age group:
It most commonly affects the elderly; 20-30% of people over the age of 70 suffer from OA of the hip.
Defintion/explanation:
It is traditionally referred to pathologically as a degenerative disorder arising from the breakdown of articular hyaline cartilage. It is also defined clinically as a clinical syndrome comprising joint pain accompanied by functional limitation and reduced Quality of Life.
OA is a chronic disease of the musculoskeletal system without systemic involvement (i.e. no involvement of eyes, skin, etc) and is non-inflammatory.
Most common joints affected:
The most common joints affected are the hips, knees, cervical
spine, lumbar spine and small joints of the hands.
Primary and Secondary OA:
OA can be classified into primary osteoarthritis in which the cause is unknown, and secondary osteoarthritis in which there is a known precipitating cause.
The risk factors for primary osteoarthritis include:
Age
Female sex
Ethnicity (e.g. increased risk in African-American, American Indian or Hispanic women compared with Caucasian Americans)
Genetics (OA runs in families)
Nutrition e.g. consumption of a diet rich in Vitamins C and E (antioxidants) may provide some protection against OA.
Examples of specific causes of secondary osteoarthritis include:
Obesity
Trauma (including sports and occupational risk factors)
Malalignment e.g. Developmental dysplasia of the hip (previously referred to
as congenital hip dislocation)
Infection e.g. septic arthritis, tuberculosis
Inflammatory arthritis e.g. rheumatoid arthritis, ankylosing spondylitis
Metabolic disorders affecting the joints e.g. gout
Haematological disorders e.g. haemophilia with haemarthrosis
(bleeding into joints)
Endocrine abnormalities e.g. diabetes with neurovascular impairment,
which can lead to chronic malalignment of the articular surfaces
(Charcot joint) and secondary osteoarthritis
Symptoms of OA in any joint include:
A deep aching joint pain, exacerbated by use
Reduced range of motion and crepitus (grinding)
Stiffness during rest (morning stiffness, usually lasting < 1 hour)
Pathology of osteoarthiritis (OA)
Preciptating risk factors (e.g. obesity) leads to excessive loading of joint and damage to articular cartilage
->
increased proteoglycan synthesis by chondrocytes (attempts to repait the damage)
->
overtime, proteoglycan content falls, flasking and fibrillation of articular cartilage
->
erosion of cartilage down to the bone (reducing joint space)
Altered joint biomechanics - 3
- Subchondral sclerosis
- Subchondral bone cysts
- Osteophytes
- Reduced joint space
Osteoarthritis of the hip
- Symptoms
- Treatments
Symptoms:
Joint stiffness (typically occurs getting out of bed and when standing up after sitting down for a long time)
Pain in the hip, gluteal and groin regions radiating to the knee (via the obturator nerve)
Mechanical pain (pain accentuated by mobilisation or weight-bearing)
Crepitus (a grating sound or crunching/crackling sensation on movement of the joint)
Reduced mobility e.g. difficulty walking, difficulty putting on socks and shoes, getting in and out of a car / the bath etc.
- *Treatment:
- ** Weight reduction
- Activity modification (avoiding activities that precipitate symptoms)
- Walking-stick or walking frame may also be used to reduce the load through arthritic joint whilst walking
- Medication: Analgesia (e.g. paracetomol), Anti-inflammatories (NSAIDs, COX-2 inbitors)
- Steroidal injections (corticosteroids) to reduce swelling and thereby alleviate shoulder stiffness and pain
- Hyaluronic acid injections to increase lubrication and possibly promote cartilage repair
- Operation - Total hip replacement
- *Fracture of NOF**
- # NOF are classified as…
- Why is this classification important?
- Ages for the different classification of fracture
- Avascular necrosis - management
- Symptoms and signs
- *Fracture of NOF classified as:**
- Intracapsular
- Extracapsular (divided into trochanteric/intertrochanteric and subtrochanteric)
Why is this classification important:
This classification is extremely important as the site of the fracture has implications for the blood supply, and therefore the viability, of the femoral head.
- Intracapsular fractures are likely to disrupt the ascending cervical (retinacular) branches of the medial femoral circumflex artery (MFCA). Due to the inability of the Artery of the Ligamentum Teres to sustain the metabolic demand of the
femoral head, there is a high risk of avascular necrosis of the bone. This risk is increased if the fracture is displaced.
- With extracapsular fractures, the retinacular arterial supply to the femoral head is likely to remain intact.
- *Age:
- Intracapsular fractures** are more common in the elderly, especially postmenopausal women with osteoporotic bone. They often occur after a minor fall.
- *- Extracapsular fractures** tend to affect the young and middle-aged population and are usually the result of significant traumatic force e.g. a road traffic collision.
Intracapsular fractures are more common in the elderly, especially postmenopausal
women with osteoporotic bone. They often occur after a minor fall.
Extracapsular fractures tend to affect the young and middle-aged population and
are usually the result of significant traumatic force e.g. a road traffic collision.
Avascular necrosis - management
Due to the high risk of avascular necrosis, a displaced intracapsular fracture in an older person is usually treated by surgical replacement of the femoral head (either hemiarthroplasty [femoral head only] or total hip replacement [head and acetabular cup]). [You should learn this, but do not need to know any further
details of the surgical management of #NOF at this stage of the course.]
Symptoms:
- Reduced mobility/sudden inability to bear weight on the limb
- Pain which may be felt in hip, groin and/or knee
Signs: SABRE
- Shortened
- Abducted
- Externally rotated
There is exacerbation of pain on palpation of the greater trochanter and pain is exacerbated by rotation of the hip
*if suspect hip is fractured, avoid vigorous examination as risk of displacing the fracture
In a #NOF, why is it at the ‘certain’ position (covered in last flashcard)
-> hip shortened, abducted and externally rotated in a displaced #NOF?
- Laterally (externally) rotated: short lateral rotators of the hip (piriformis, obturator internus, superior and inferior gemellus, quadratus femoris) contract. The iliopsoas also now acts as a lateral rotator of the femur as it pulls the lesser trochanter anteriorly about the new axis of rotation, so the femoral shaft rotates externally
- Abduct the femur: Strong abductors that attach to the greater trochanter (gluteus medius and minimus) abduct the femur distal to the fracture site
- Shortening of the limb: the strong muscles of the thigh pull the distal fragment of the femur upwards, include rectus femoris, adductor magnus and the hamstring muscle
- *Dislocation of the hip**
- Define
- Two main ‘causes’ of dislocation
3 types of dislocation
# Define: Dislocation of the hip is defined as the head of the femur being fully displaced out of the cup-shaped acetabulum of the pelvis
- *2 main causes:
- Congenital:**Developmental dysplasia of the hip (DDH) was formerly known as Congenital Dislocation of the Hip (CDH). It was renamed as there are varying degrees of displacement (not all are dislocated) and the condition can develop after birth so is not always congenital.
- *- Traumatic:** hip dislocation may be traumatic. An acute traumatic hip dislocation is a severe injury, most commonly seen in 16 to 40 year-olds involved in high-speed road traffic collisions. It takes a massive amount of force to dislocate a normal hip.
- *3 types of dislocation:**
- Posterior dislocation
- Anterior dislocation
- Central dislocation
3 types of hip dislocation
- Posterior dislocation: Most common cause, one common long-term affect
- Anterior dislocation
- Central dislocation: What happens, notice on examination, risk of this…
Posterior dislocation:
90% of hip dislocations are posterior. The most common cause is the knee impacting the dashboard during a road traffic collision. The affected limb will be shortened and held in a position of flexion, adduction and internal (medial) rotation.
-> A sciatic nerve palsy is present in 8-20% of cases.
Anterior dislocation:
The limb is held in a position of external rotation and
abduction with slight flexion. Femoral nerve palsies can be present but are uncommon.
Central dislocation:
The head of the femur is driven into the pelvis through the
acetabulum. It is always a fracture-dislocation. The femoral head is palpable on rectal examination and there is a high risk of intrapelvic haemorrhage due to disruption of the pelvic venous plexuses. This can be a life-threatening injury
3 types of hip dislocations - Position of the leg
Posterior hip dislocation:
- Shortened (pulled upwards by extensors)
- Adducted (by adductors) *
- Internally rotated by gluteus minimus and medius *
*opposite to anterior hip dislocation
- *Anterior hip dislocation: SABRE (same as #NOF)**
- Shortened
- ABducted
- Externally rotated
- Slight flexion
Central hip dislocation:
Femoral head is palpable on rectal exam (femoral head driven through acetabulum)
High risk of intrapelvic haemorrhage
