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Hip

Orthopedics

QuestionAnswer
Hip Exam: Hx Trauma, OA, infection
Hip Exam: Inspection Gait; Scars; Swelling
Hip Exam: Palpation Iliopsoas bursa; Gr trochanter/ bursa; Ant iliac spine; Ischial tuberosity/ bursa
Hip Exam: ROM / Strength Hip flex/ ext; Abd/ addn; Int / ext rotation; resisted ROM for strength
Gait Analysis: Width of the gait: Normal =2-4 in heel to heel; Wide based gaits = instability
Gait Analysis: Ctr of gravity: Normal gait oscillates no more than 2 in. vertically; pain & mx weakness => pt shifts COG over affected hip
Gait Analysis: Knee position: S/B flexed in all phases of stance ex. heel strike; pt hikes up affected leg or swings it out & around to front
Gait Analysis: Pelvic shift: pelvis & trunk shift laterally 1 in. to wt bearing side
Gait Analysis: Pelvic shift: in gluteus mx weakness: lateral shift is accentuated to the side involved
Gait Analysis: Length of step: Ave length is 15 in. With age/ fatigue/ pathology: step is shortened
Gait Analysis: Cadence: Ave cadence is 90-120 steps/ min. With age/ fatigue/ pain: cadence is decreased to conserve energy
Gait Analysis: Pelvic rotation: Normal during swing phase = 40 degrees in leg that is moving forward; if pain or stiffness in hip, pelvis will not rotate normally
Antalgic gait: Limp from pain
Wide based gait = Instability from cerebellar disease or peripheral neuropathy
Steppage gait = Weak ankle dorsiflexors results in increase knee & hip flexion
Flat foot gait = Gastrocnemius/ Soleus weakness (S1-S2 radiculopathy)
Back Knee gait = Quadriceps weakness forces pt to push on thigh w/ hand to try to lock knee in stance phase
Trendelenberg (abduction lurch) gait = Gluteus medius weakness (L5); pt lurches toward weak side to place COG over hip
Extensor lurch = Gluteus max weakness (S1); pt thrusts thorax posteriorly to maintain hip extension
Foot Drop = Weakness of tibialis anterior (L4)
Pelvic Films: Pelvic ring fx is commonly: disrupted in 2 places
Pelvic Films: AP view: Inspect: inner & outer main ring cortices; 2 small obturator rings; acetabulum for step off; SI joint spaces s/b equal; symph pubis should align, < 5mm joint space
Pelvic Films: CT if: fx identified or suspected
High energy pelvis fx assoc with: organ & vascular laceration
Hip Films: Order: AP pelvis w/ both hip joints; Lateral of affected hip
Hip Films: Femoral Neck Smooth cortex w/ no buckle, step or ridge; Normal trabecular pattern; No transverse sclerotic lines
Hip Films: Intertrochanteric Region Cf to other hip; No lucency across the bone; No cortical defect
Hip fx: prevalence 90% in > 65 y.o. pt
Hip fx: Sx: Pain, shorter, rotated leg
Hip fx: Causes: Falls, MVA
Hip fx: Risk factors: Age, sex, nutrition, meds
Hip fx: Complications: PE, pneumonia
Femoral neck fx & hip dislocations prone to: AVN
Hip fx: Rx: Screws, partial or total hip replacement
Hip fx: Prevention: Calcium, activity, exercise, safety
Femoral Neck fx: Garden type I Incomplete fx w/ valgus impaction; ORIF
Femoral Neck fx: Garden type II Complete fx w/o displacement; ORIF
Femoral Neck fx: Garden type III Complete fx / partial displacement; Prosthetic replacement
Femoral Neck fx: Garden type IV Complete fx w/ total displacement; Prosthetic replacement
Femur fx: tx: Femoral neck ORIF
Femur fx: tx: Intertrochanteric ORIF
Femur fx: tx: Subtrochanteric Open or closed reduction; Interlocking nail or screw
Femur fx: tx: Femoral shaft Closed reduction & Nail
Femur fx: tx: Distal Femur ORIF with plate & screws
Femoral Stress fx: prevalence Thin, female endurance athletes (AAO)
Femoral Stress fx: Sx Groin pain with running, progressing to ADL pain
Femoral Stress fx: PE: Pain limits extremes of int. & ext. rotation
Femoral Stress fx: Dx: Xray may be negative; Bone scan pos in 2-8 days
Femoral Stress fx: most common area = Femoral neck
Femoral Stress fx: Rx: All displaced fx: ORIF
Femoral Stress fx: Rx: Non displaced medial fx: NWBA 6-8 weeks
Femoral Stress fx: Rx: All lateral fx: ORIF
Hip Dislocation: prevalence 90% are posterior
Hip Dislocation: PE: hip flexed, adducted & internally rotated
Hip Dislocation: Dx/ tx: Xray, pain relief, reduction; Poss N/V entrapment
Hip Dislocation: Allis Maneuver Anesthesia; Assistant stabilizes pelvis w/ pressure on iliac sp; Gently flex hip to 90; apply progressive traction to extremity; apply adduction/ internal rotation
Hip Osteoarthritis: Sx Achy pain over hip & ant groin; Loss of ROM
Hip Osteoarthritis: Xray Decreased Joint space; Sclerosis; Osteophytes
Hip Osteoarthritis: RX NSAIDs; Intraarticular injection; Hip replacement
Pelvic Apophyses = Separation or widening of apophysis
Avulsion fx of Hip: ASIS: MOI knee flexed & hip hyper-extended
Avulsion fx of Hip: ASIS: locus = origin of Sartorius
Avulsion fx of Hip: ASIS: PE: Pain over ASIS & with resisted hip flexion
Avulsion fx of Hip: ASIS: Dx: Xray may reveal avulsion fx
Avulsion fx of Hip: ASIS: Rx: RICE, progressive wt bearing, splint with knee flexed, ORIF for displaced fx
Avulsion fx of Hip: Ischial Tuberosity: locus = Origin of hamstring
Avulsion fx of Hip: Ischial Tuberosity: MOI: Vigorous hip flexion/ knee extension
Avulsion fx of Hip: Ischial Tuberosity: Sx: Pain in buttock
Avulsion fx of Hip: Ischial Tuberosity: PE: TTP at ischial tuberosity
Avulsion fx of Hip: Ischial Tuberosity: Rx: RICE, progressive wt bearing, ORIF for displace fx
Groin Pull: MOI Forced abduction during fall or collision
Groin Pull: Sx Pain at origin of adductors
Groin Pull: PE: Increased pain on resisted adduction
Groin Pull: DDx: Hernia, torsion
Groin Pull: Rx: Rest, ice, meds, stretching & strengthening
Hip Pointer injury: MOI Direct blow to iliac crest
Hip Pointer injury: PE: Swelling, tenderness, ecchymosis at iliac crest
Hip Pointer injury: Dx Xray to R/O fx
Hip Pointer injury: Rx: Ice, compression, pain meds; Progressive stretching
Legg-Calve-Perthes Dz: MOI Avascular necrosis of the femoral head
Legg-Calve-Perthes Dz: prevalence Child 2-11 y.o.
Legg-Calve-Perthes Dz: PE: Loss of int / ext rotation
Legg-Calve-Perthes Dz: Xray = Mottled femoral head
Legg-Calve-Perthes Dz: Rx: Containment of femoral head with bracing / casting
Legg-Calve-Perthes Dz: Outcome: self limiting, revascularization occurs in some
Slipped Capital Femoral Epiphysis: prevalence Obese, pre-pubescent boys > girls; 40% are bilateral; most are idiopathic
Slipped Capital Femoral Epiphysis: Sx Limp & hip, thigh, or knee pain; loss of IR, flexion, & abduction
Slipped Capital Femoral Epiphysis: Rx: surgical fixation & non wt bearing
Snapping Hip Syndrome: MOI 1: ITB snaps over Gr trochanter; 2: Iliopsoas tendon snaps over ASIS
Snapping Hip Syndrome: Sx: Hip pain worse with activity; Snapping with hip flexion
Snapping Hip Syndrome: PE: Pain with resisted hip flexion; Pain lateral with ITB, anterior with ASIS
Snapping Hip Syndrome: Rx: Ice, meds, activity modification, S&S, injection
Trochanteric Bursitis: Sx Pain over Gr trochanter when moving hip into full flexion; Extreme point tenderness; Pain at night lying on affected side
Trochanteric Bursitis: PE: Moving hip from extension to flexion reproduces pain; poss crepitus over trochanter; TTP over affected greater trochanter
Trochanteric Bursitis: Rx: Hip stretches, meds, injection
Transient Hip Synovitis: Sx Benign, non traumatic, self limiting hip pain; lasts 3-7 days
Transient Hip Synovitis: must R/O: septic hip; Legg-Calve-Perthes
Transient Hip Synovitis: Etiology Inflam immune response to URI; inc synovial fluid in hip joint causing pain
Transient Hip Synovitis: PE: Painful ROM; Joint held in flex, abd & ext rotation
Transient Hip Synovitis: Xray: Capsular swelling
Transient Hip Synovitis: Lab: WBC & ESR normal; Joint fluid aspiration is normal
Meralgia Paresthetica = Lateral femoral cutaneous n. entrapment; Exits pelvis near ASIS
Meralgia Paresthetica: Sx: Pain & burning over lateral thigh
Meralgia Paresthetica: Etiology: Obesity, tight clothing, repetitive trauma/ activity
Meralgia Paresthetica: Rx: Correct offending source; pain relief; chronic pain may need injection or surgical release
DDH = developmental dysplasia of the hip
Hip Pain: Other Causes DDH (Peds); Tumor; Osteosarcoma; Ewing; Metastatic dz; Multi myeloma
Positive Faber test suggests: hip disease, iliopsoas spasm, or sacroiliac disease
Hip pain exam: inspect, gait, palpate, Faber, SLR, pulses
Hip dx tests: wt bearing xray; bone scan if suspect fx/necrosis; MRI TOC for fx not seen in xray, and necrosis/ infxn/tumor; u/s for kids effusion
osteonecrosis Groin pain (less often thigh / buttock pain) = femoral head dz. Wt-bearing & pain w/motion, possibly rest/night pain; RF: steroids; dx: MRI sens > xray/scan
severe anterolateral hip tenderness, severe pain w/wt bearing, intolerance to passive hip rotation; xray normal (dx w/MRI) = occult hip fx (nondisplaced fx of femoral neck)
Hip pain DDx hip dysplasia; nerve entrapment; ankyl spondylosis; RA; lumbar disk pathology
Idiopathic AVN of femoral head; painless limp L-C-P dz (3-12 yo, M>F); tx abduction bracing
High energy pelvis fx is often associated with: organ & vascular laceration
Hip fx: prevalence 90% in > 65 y.o. pt
Hip fx: Sx: Pain, shorter, rotated leg
Hip fx: Complications: PE, pneumonia; Femoral neck fx & hip dislocations prone to AVN
Femoral Stress fx: prevalence Thin, female endurance athletes (AAO)
Femoral Stress fx: Sx Groin pain with running, progressing to ADL pain
Femoral Stress fx: Dx: Xray may be negative; Bone scan pos in 2-8 days
Femoral Stress fx: most common area = Femoral neck
Femoral Stress fx: Rx: All displaced fx: ORIF
Femoral Stress fx: Rx: Non displaced medial fx: NWBA 6-8 weeks
Femoral Stress fx: Rx: All lateral fx: ORIF
Hip Dislocation: prevalence 90% are posterior
Hip Dislocation: PE: hip flexed, adducted & internally rotated
Hip Dislocation: Allis Maneuver Anesthesia; Assistant stabilizes pelvis w/ pressure on iliac sp; Gently flex hip to 90; apply progressive traction to extremity; apply adduction/ internal rotation
Hip Osteoarthritis: RX NSAIDs; Intraarticular injection; Hip replacement
Avulsion fx of Hip: Ischial Tuberosity: MOI: Vigorous hip flexion/ knee extension
Hip Pointer injury: MOI Direct blow to iliac crest
Legg-Calve-Perthes Dz: Sx Insidious groin/ thigh pain; Limp; Loss of int / ext rotation
Snapping Hip Syndrome: MOI 1: ITB snaps over Gr trochanter; 2: Iliopsoas tendon snaps over ASIS
Snapping Hip Syndrome: PE: Pain with resisted hip flexion; Pain lateral with ITB, anterior with ASIS
Trochanteric Bursitis: Sx Pain over Gr trochanter when moving hip into full flexion; Extreme point tenderness; Pain at night lying on affected side; poss crepitus over trochanter
Trochanteric Bursitis: Rx: Hip stretches, meds, injection
Meralgia Paresthetica = Lateral femoral cutaneous n. entrapment; Exits pelvis near ASIS
Meralgia Paresthetica: Sx: Pain & burning over lateral thigh
DDH = developmental dysplasia of the hip
Hip Pain: Other Causes DDH (Peds); Tumor; Osteosarcoma; Ewing; Metastatic dz; Multi myeloma
Displacement of proximal femoral epiphysis due to disruption of growth plate = SCFE
Created by: Abarnard