The Hip and Pelvis

Question 1

Describe the articular surfaces of the hip joint?

Answer 1

Created by the acetabulum of the pelvis and head of the femur. faces laterally, anteriorly, and inferiorly.

Question 2

What is the angle of inclination of the femur?

Answer 2

It begins at approximately150* in infancts and decreases to 125* in adults, 120* in elderly people.

Question 3

Define Coxa valga and coxa valgum.

Answer 3

Coxa valga: the thigh deviates laterally and the angle of inclination is >150.
Coxa vara: the thigh deviates medially and the angle of inclination is <120

Question 4

What is the angle of torsion of the femur?

Answer 4

it is anterior to the condyle. Approx 40* in infants and decreases to approximately 12 to 15* in adults An increase is called anteversion, while a decrease is called retroversion.

Question 5

How is the angle of torsion of the femur normally assessed?

Answer 5

using Craig’s test. Patient is prone with the knee flexed to 90* and the leg is rotated until the greater troachanter is parallel to the table. The angle is measured by the angle of the lower leg to the vertical.

Question 6

Which ligaments contribute to hip stability?

Answer 6

two ligaments reinforce the hip anteriorly:
iliofemoral ligament which is Y shaped ligament of Bigelow and the stronger of the two. Limits hip hyperextension.
The pubofemoral ligament checks hip abduction and extension

One ligament, the ishiofemoral ligament is located posteriorly and limits hip ext

Question 7

Describe normal hip ROM.

Answer 7

Flex: 135*
ext: 30*
abd: 50*
add: 30*
ER: 60*
IR: 45*
At least 110* of flexion is needed to tie the shoe

Question 8

Name the muscles that cross the hip joint.

Answer 8

Flexors: iliopsoas, rectus femoris, TFL, sartorius, pectineus, adductor brevis and longus, oblique fibers of adductor magnus

Extensors: glute max, HS groups

Abductors: glute medius, glute minimus, TFL, upper fibers of glute max

Adductors: adductor magnus, adductor longus, adductor brevis, pectineus, gracilis

ER: obturator externis, obturator internus, quad femoris, piriformis, superior and inferior gemellus, glute max, sartorius, and biceps femoris

IR: glute minimus, TFLanterior fibers of glute medius, semimembranosus, semitendinosus

Question 9

What is inversion of muscle action?

Answer 9

muscles that cross a joint with 3 degrees of freedom may have alternate or even opposite actions.
Ex: all adductors of the hip are also flexors (except magnus) with the hip in neutral. In flexion, they become extensors.
The piriformis is an ER in neutral but changes action at 60* of flexion and becomes a IR

Question 10

What changes occur to the hip muscles following an AKA?

Answer 10

Muscles will atrophy. If the IT band is fixed, there is an increased risk of developing an abduction contracture but there is also improved extensor torque to improve propulsion and avoid hip flexion contracture

Question 11

How much force is unloaded with cane use?

Answer 11

When used in the opposite hand, force is decreased by 40%

Question 12

How are muscle strains classified?

Answer 12

Grade I: little tissue disruption and low grade inflammation. Strong and painful, no loss of ROM

Grade 2: some disruption but not complete. Weak and painful, decreased ROM

Grade 3: complete rupture. Complete loss of strength, with a palpable or visible defect

Question 13

How do gluteus medius strains occur?

Answer 13

Pain is commonly located just proximal to the attachment of the greater trochanter and is reproduced with resisted abduction. May be confused with bursitis which is painless with resisted abduction. The two can occur together.

Question 14

What treatment is effective in treating groin pulls?

Answer 14

Passive PT (massage, stretching, modalities) has been found to be ineffective. Active strengthening is effecive. Tyler had developed a program emphasizing eccentric resistive exercise, balance training, and core strengthening

Question 15

What is a sports hernia?

Answer 15

Most likely is an overuse syndrome that results in shearing that weakens the inguinal wall musculature

Question 16

What is the most frequently strained muscle in the body?

Answer 16

Hamstrings. Sherry and Best found that a rehab program needs to include progressive agility and trunk stabilization exercises to avoid reinjury.

Question 17

How is HS length assessed?

Answer 17

The 90/90 degree straight leg raise, the tripod sign (sits with knees over the table and knee is passively extended. If shortened, arms go back). SLR has been found to be very reliable but not good at differentiating between elastic and inelastic posterior hip structures

Question 18

How is rectus femoris length measured?

Answer 18

The Thomas test (supine with one knee flexed to chest and the test leg is hung over the edge. if the test knee rests in less than 90* flexion, tightness is present)
The Ely Test: Prone passive flexion of knee, looking for hip flexion that indicates rectus femoris tightness

Question 19

Describe the treatment for muscle strain?

Answer 19

Stage 1: Rice
Stage 2: use gentle ROM, isometrics, and modalities
Stage 3: once isometrics are pain-free, continue with stage 2 and add pain free isotonic exercises. Include stretching and aerobic activity.
Stage 4: once ROM is nearly full and strength is 75% of normal, begin sport specific exercises
Stage 5: return to sport

Question 20

Describe trochanteric bursitis.

Answer 20

Women are more commonly affected because of increased breadth of the pelvis, and it most commonly occurs in middle-aged and older people. There are 3 bursae (one between the glute max and GT, one between glute medius and GT, one between glute max and medius). Onset caused by overuse is gradual with aching at GT and lateral thigh.

Question 21

What are the symptoms of trochanteric bursitis?

Answer 21

Pain in lateral thigh. Possible snapping of lateral hip with tight IT bands. Pain is provoked by ascending stairs and lying on affected side. Resisted testing may be painful as well as resisted hip ext and ER. Palpation may be less painful with muscle contraction.

Question 22

How is trochanteric bursitis?

Answer 22

Using pillows between the knees in the sidelying position. Strengthen to correct muscle imbalance. CP to help reduce exercise induced inflammation. Examination may include the Ober’s Test.

Question 23

How does iliopectineal/iliopsoas bursitis develop?

Answer 23

lies deep to the iliopsoas tendon anterior to the hip. Commonly results from OA or RA, overuse, or trauma. Clinical findings include pain at the anterior hip, lower ab pain, psoatic gait with the hip ER, adducted, and flexed.

Question 24

Describe the treatment for ilipectineal bursitis.

Answer 24

US/IFC, ER strengthening

Question 25

What is the sign of the buttock?

Answer 25

pain in the buttock that limits hip flexion equally regardless of knee position. Could be a sign of something bad.

Question 26

How are contusions classified?

Answer 26

Approx the same scheme as muscle strains.

Question 27

What is a hip pointer?

Answer 27

A contusion of the lateral hip which results from a blow to the iliac crest, often impacting the TFL and causes a hematoma. Tx initially with RICE. NSAIDS should be held for 48 hours due to blood-thinning properties. Return to sport is allowed in 1 week for grade 1 injuries and for up to 6 weeks for grade 3.

Question 28

How is myositis ossificans treated?

Answer 28

Early treatment consists of rest, gentle ROM. Aggressive passive stretching should be avoided for 4 months after injury.

Question 29

What is snapping hip syndrome?

Answer 29

Most commonly, the cause of external coxa saltans is snapping of the ITB or glute max over the greater trochanter.

Question 30

How is piriformis syndrome assessed?

Answer 30

Frieberg Test: Passive IR of hip with pt supine and legs extended
Piriformis/FAIR test (flexion, adduction/IR). Approx 80% sensitivity and specificity

Question 31

Define meralgia paresthetica.

Answer 31

A nerve entrapment of the superficial branch of the lateral femoral cutaneous nerve next to the ASIS, with pain in anterior lateral thigh. Pain is often caused by tight clothes or pregnancy. Diagnosed with Tinel sign just medial to ASIS.

Question 32

What is HS syndrome?

Answer 32

the sciatic nerve becomes entrapped by adhesions in the proximal HS following repetitive strains. Seen most commonly in hurdlers and sprinters.

Question 33

Describe the Garden classification of femoral neck fractures.

Answer 33

Type I - partial, nondisplaced
Type II: full, nondisplaced
Type III: full, displaced 50%.
Grade 1 & 2 may be treated with 3 percutaneously placed pins. Type 3 and 4 are treated with hemiarthroplasty

Question 34

What is the difference between unipolar and bipolar hemiarthroplasties?

Answer 34

unipolar: only femoral head is replaced
bipolar: femoral head is replaced and snaps into a rotating shell which sits in the acetabulum

Question 35

Describe the mortality rate of hip fractures.

Answer 35

Approx 10% to 30% in the first year after fracture. After one year, the rate declines.

Question 36

What features distinguish a stable pelvis vs an unstable pelvis?

Answer 36

Fractures that lie entirely outside of the ring (ex: inferior pubic rami fractures) are stable. Only one disruption of the pelvic ring is usually stable, but two or more are unstable.

Question 37

What is a Malgaigne fracture?

Answer 37

a double vertical fracture of the pelvis, typically superior and inferior pubic rami fractures associated with an ipsilateral SI dislocation

Question 38

What are presenting symptoms of a patient with a hip dislocation?

Answer 38

90% are posterior secondary to the mechanism of dislocation and a weak posterior capsule. Presents with a limb that is flexed, adducted, and IR. Anterior dislocations are shortened, abducted, and ER.

Question 39

Describe various approaches to THA.

Answer 39

Anterolateral: incision is made between TFL and vastus lateralis. abductors are left intact usually (GT osteotomy) and posterior dislocations are more rare. This is a harder approach and active abduction or WB may be delayed depending on approach

lateral: incision is made in TFL, glute medius, glute minimus and vastus lateralis
posterolateral: most common, simplest approach. Leaves abductors intact. incision through glute max and small hip ER

Question 40

What are common THA complications?

Answer 40

Posterior dislocations. DVT (10-20% chance even with preventive therapy.

Question 41

Can patients with THA return to sport?

Answer 41

Most golfers return in 3-4 months, and most doctors request patients to use a cart.

Question 42

What is normal gait velocity in the community?

Answer 42

City engineers use 1.22 m/s at traffic signal crossing times

Question 43

What is the post-op WB status of a THA?

Answer 43

Cemented replacements can WBAT typically. Patients with ingrowth replacements are PWB or TTWB for 6 weeks