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Orthopaedics Surgery > Will Blakeney- The Hip > Flashcards

Will Blakeney- The Hip Flashcards

1
Q

What ligaments make up the hip?

A

Iliofemoral
Pubofemoral
Ischiofemoral

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2
Q

What muscles are the abductors of the hip?

A

Superior gluteal nerve:
- Gluteus medius
- Gluteus minimus

Inferior gluteal nerve:
- Gluteus maximus

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3
Q

What are the adductors of the hip?

A

Mostly obturator nerve

Adductor longus
Adductor magnus: dual innervation because adductor but also posterior so sciatic nerve too
Pectineus: also femoral nerve
Adductor brevis

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4
Q

What muscles are the hip flexors?

A

Rectus femoris= femoral nerve
Iliopsoas = femoral nerve + lumber L23

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5
Q

What are the extensors of the hip?

A

Hamstrings = sciatic
Gluteus maximus = inferior gluteal

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6
Q

What are the short external rotators?

A

Piriformis
Superior gemellus
Inferior gemellus
Obturator internus
Quadratus femoris

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7
Q

What is the blood supply to the femoral head?

A

medial and lateral femoral artery = extra-capsular arterial ring and the branch going up to the head are the retinacular arteries

The obturator artery provides a branch called foveal artery which goes into the head. This stops being patent by adulthood –> ligamentum teres

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8
Q

What history do you take from the patient?

A

Age, weight, family Hx
Onset and progression of symptoms
Pain
Stiffness, crepitus, locking
Walking distance, support
Effect on ADLs and job

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9
Q

What are the pain patterns for different hip pain sites?

A

Anterior:
- Enthesitis of the ASIS
- True hip pain is more around the groin/inguinal ligament, iliopsoasbursitis is also here
- Meralgia paresthetica is lower down the thigh

Posterior:
- Sacro-iliac pain is superior-lateral to the bum crack x
- Buttock pain is referred pain from the lumbosacral plexus
- Bottom of buttock is ischiogluteal bursitis
- Sciatica is going down the lef
- Trochanteric bursitis is basically right where you can feel the greater trochanter

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10
Q

What things should you look for on Ex

A

Muscle atrophy
Limb asymmetry
Scars
Swelling
Spinal alignment: lumbar lordosis/scoliosis
True and functional leg length discrepancy
Gait

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11
Q

What is antalgic gait

A

Patient spends less time on the painful limb so that stance phase is reduced when the painful side is in contact with the floor

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12
Q

What is stiff leg gait

A

When the hip flex/extension is lost or markedly restriction, the patient will circumduct and swing their leg. Achieved by the recruitment of more spinal movement

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13
Q

What is short leg gait

A

When the patient is weight-bearing on the shorter leg, he or she hips down

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14
Q

What is the trendelenburg gait

A

With each step forward the patient takes with the affected limb they lurch towards the unaffected limb

‘rolling over’ on their hip as they walk

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15
Q

What is the Trendelenburg test

A

Finger on each ASIS
pt on one leg

Normal: pelvis on unsupported leg is pulled up (finger goes up)

Positive trendelenburg: pelvis drops on unsupported side (finger falls), they throw their body onto the other side

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16
Q

What are some causes of a positive trendelenburg sign

A

Normally abductor problems!!

  1. Problem with the motor
    - Abductor muscle weakness
    - Superior gluteal nerve palsy
  2. Problem with the lever arm
    - Shortening of the femoral neck
    - Abductor tendon rupture
  3. Problem with the fulcrum
    - Pain from the intra-articular pathology
17
Q

What is the thomas test

A

Rule out hip flexion contracture

  1. Patient supine
  2. Examiner puts hand under spine to identify lumbar lordosis
  3. Examiner gets the patient to maximally flex the unaffected hip- obliterate the lumbar lordosis, pelvis should be neutral position
  4. Examiner then puts the other leg in extension. If deformity you can’t put it in full extension without the pelvis pointing
18
Q

What is FADDIR

A

Flexion/Adduction/internal Rotation
- Hip at 90 degrees of flexion, adduction and IR

Positive test: anterior or anteromedial pain

Good for labrum pathology! Indicative of impingement of anterior and anterolateral part of femoral neck against superior and anterior acetabular rim

19
Q

What is the DDx of hip pain

A
  1. Intra-articular hip pathology
    - Osteoarthritis of the hip e.g.
  2. Extra-articular hip pathology
    e.g. abductor tendonitis
  3. Pathology remote to hip joint
    e.g. lumbar spine facet joint osteoarthritis
20
Q

Other way to think about hip pain DDx

A

IN MSK
- Trochanteric bursitis (Gmed/min tendon problems)
- GlutMed tendinitis
- Stress #
- Osteitis pubis
- Iliopsoas tendinitis or bursitity
- Iliopsoas abscess
- Adductor longus strain or tendinitis
- Referred from spine
- Metastatic disease

OUTSIDE MSK:
- Inguinal hernia
- Inguinal lymphadenopathy
- GIT
- Genitourinary
- Gynaeo

21
Q

What are neural causes of hip pain?

A

Consider which nerve/nerve root is affected

22
Q

What are some causes of anterior hip pain?

A

Intra-articular
- OA
- Inflamm arthritis
- Fracture
- Tumour
- Avascular necrosis of fem head
- Acetabular labral tear
- Articular cartilage injuries
- Ligamentum teres injuries

Extra-articular:
- Hip flexor strain
- Iliopsoas bursitis
- Snapping him syndromes
- Avulsions/apophysitis

23
Q

What are some causes of lateral hip pain

A
  • greater trochanteric bursitits
  • Glut med tendinopathy/dysfunction
  • IT band syndrome
  • meralgia paresthetica
24
Q

What are some cuases of posterior hip pain

A
  • Referred from lumbar spine
  • Piriformis syndrome
  • Sacro-iliac joint dysfunction
  • High hamstring strain or ischial tuberosity avulsion (lots of bruising)
25
Q

What are the causes of OA

A

MECHANICAL:
- Developmental dysplasia of the hip = under-coverage
- Femoro-acetabular impingement (over-coverage)
- Perthes disease, slipped capital femoral epiphysis (loss of sphericity)
- Post-traumatic (loss of congruency)

NON-MECHANICAL:
- Avascular necrosis of the femoral head
- Ank spon
- Inflamm arthritis (RA, psoriatic, SLE)
- Primary disorders of cartilage and synovium (synovial chondromatosis)

26
Q

What are the X-ray signs of OA

A
  1. loss of joint space
  2. osteophyte formation
  3. Subchondral sclerosis (the whitening at the joint border)
  4. Subchondral cysts
27
Q

What is the non-operative Mx of OA?

A
  • Rest or activity modifications (low impact stuff)
  • Losing weight can reduce stress on hup
  • Using a walking stick/walker to improve mobility and independence
  • Physiotherapy to improve strength and movement in hip
  • Pain killers (like NSAIDs) or panadol can reduce inflamm and pain
28
Q

What is the operative mx of hip OA

A

Hemi or THR

29
Q

What is the distrubtuon of NOF #

A

Bimodal

Older: low energy trauma
Younger: high energy trauma

30
Q

What are the RFs for NOF #

A

Advanced age
Female
Caucasian
Small stature
low BMD
Exisiting problems; impaired vision, poor balance, neurological conditions, malnutrition, malignancy

31
Q

What does the leg of a ‘classic’ presentation of NOF # look like

A

Shortened and externally rotated

32
Q

How do you manage a NOF #

A

Depends on location: femoral head, femoral neck, trochanteric, subtrochanteric

33
Q

What is the initial Mx of NOF #

A

Medical stabilisation
Rehydration
Analgesia: nerve block
DVT prophylaxis
Skin protection

Do surgery <24hrs for better outcomes

34
Q

What is gluteal tendinopathy?

A

The most prevalent of all lower limb tendinopathies

Incorporates greater trochanteric bursitis + IT band syndrome

35
Q

What is the clinical presentation of gluteal tendinopathy?

A
  • Lateral hip pain of gradual onset
  • Changes in work load or physical activity
  • Pain can progress to night pain (prohibiting sleeping on the affected side)
  • Single leg loading tasks- walking/running, standing on one leg to dress, climbing stairs/hills
  • Stiffness with extending hip when getting out of a chair
36
Q

What Ix do you do for gluteal tendinopathy?

A

MRI –> full thickness tear of abductor tendon

37
Q

How do you manage gluteal tendinopathy

A

Hip abductor and flexor strengthening
Decreased peak hip adduction in running (increasing cadence)
Corticosteroid injection (may cause further tendon degeneration)
Surgical repair of torn gluteus maximus and minimus tendons

Orthopaedics Surgery (3 decks)

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