Hip and Pelvis

Intertrochanteric fx are know as

extracapsular fx . Location between the base of the femoral neck and the distal aspect of the lesser trochanter.

Hip fracture ( proximal femur fracture) involves the

femoral neck OR the intertrochanteric region.

Adverse Outcome:Hip dislocation

Osteonecrosis (AVN) most common 10 % 2-3 years after Posttraumatic arthritis Chronic pain Sciatica or femoral nerve injury

Hip joint, consist of the articulation between?

1) femoral head 2) pelvic acetabulum

Acetabulum (socket) is formed by the

1) ilium, 2) ischium 3) and the pubis.

revascularization in

2 years

Adverse outcome: OA hip

Gastric, renal and hepatic problem due to long use of NSAIDs and acetaminophen. Neurovascular injury, thromboembolic events, infection, dislocations, fracture and leg-length inequality, loosening, chronic pain. Revision on the younger patient. Look for over sources of pain ( lumbar spine DJD, Knee pain etc.)

Adverse outcome: SCFE

AVN, premature hip OA, Chondrolysis.

Complications DD?

Adults will develope hip OA at early age (mid 30-40). complain of pain with weight bearing, limp, ROM limitation. Xray: Hip dysplasia and OA hip joint. Treatment: Hip replacement by total joint specialist.

Stress fracture are often misdiagnose or missed, and leads to catastrophic outcome!

Anatomic location of the fracture: Tension side located on the superior aspect of the proximal femoral neck. Most common in older patients and high tendency to displace. Compression side located inferior medial side of the femur. Most common in younger patients and usually do not displace.

Snapping or popping sensation of tendons around the hip move over bony prominences, most common

IT band over the Greater trochanter.

pt presents Pain in the groin inability bear weight/ambulate. PE: Limb externally rotated, abducted and shortened Unable straight leg raise, pain with light hip rotation.

Check for pulses and nerves Treat all hip pain elderly person after a fall as a hip fracture until proven otherwise.

Secondary cause

Child trauma, osteonecrosis, joint infection, trauma, dislocations, or other conditions.

Surgical Treatment:

Core decompression to decrease bone marrow pressure and increase blood flow. Bone graft. Arthroplasty/total hip replacement with femoral head collapse. Rehabilitation: Physical therapy. Adverse outcome: Pain, fractures and THA complications.

General term for injury of MUSCLE and TENDON around the hip. Symptoms: pain over injured muscle. Physical exam: Limited do to deep location of the muscles and tendon. Test: Xray and MRI.

Hip Strain Caused by vigorous muscular contraction while the muscle is on stretch. Treatment: Full recovery, WBAT, RICE and therapy 6 weeks treatment.

Proximal femur fracture

Hip fracture

socket is too shallow and the ball (thigh bone) may slip out of the socket, either part of the way or completely. One or both hips may be involved.

Development Dysplasia

White infant girl with congenital torticollis metatarsus adductus Breech presentation clubfoot ********Uneven skin folds of thigh or buttocks

Development Dysplasia Leg with hip problem may appear to turn out more Reduced movement on the side of the body with the dislocation Shorter leg on the side with the hip dislocation Waddling or limping while walking One shorter leg, so the child walks on their toes on one side and not the other side The child's lower back is rounded inward

Number one peds lawsuit!

Development Dysplasia Perform Ortalani and Barlow!

OBESE, AFRICAN AMERICAN ADOLECENT 11-13YEARS OLD MALES presents with pain and a limp. Since the pain is often located only in the thigh or knee, the diagnosis is often missed. It is important to remember that knee pain in the child can be secondary to hip disease. Limited internal rotation and abduction. Patient often holds the leg externally rotated when standing.

Diagnosis test: X-ray pelvis AP and frog leg and lateral views of the hip. Femoral head is displaced posteriorly and inferiorly in relation to femoral neck. Treatment: Non weight bearing until surgically stabilized with screws. Follow by physical therapy.

Military recruits/runners report vague pain in the groin, anterior thigh and knee. Increase with weight bearing activities and subsides after cessation. Physical exam: Pain at extreme range of motion or limited ROM, specially Internal rotation, occasional antalgic gait . Tenderness over proximal thigh or groin. Straight leg raise may reproduce pain. What imaging will you do?

Diagnosis test: Xray AP pelvis and lateral hip but they are not diagnostic in most patient. Radiograph changes appears 2-4 weeks later. BONE SCAN can detect stress fractures as soon as 24-48 hours after the injury. MRI extremely sensitive and should be considered in all patients with clinical evidence of stress fx with negative radiographs.

Anterior hip dislocations are 90% more common than posterior dislocations. T/F

False POSTERIOR ARE M/C hip dislocations

4-10 y/o white boys bilateral dull throbbing achy pain at knee or groin, limping worse at end of day. Limited abduction and internal rotation. Atrophy of affected leg. Diagnosis test: Xray AP and lateral, MRI.

Idiopathic osteonecrosis of femoral head in children LEGG-Calve-Perthes Disease Treament : Usually self-limiting with revascularization in 2 years. Tx protected weight-bearing, on occasions bracing, Hip abduction cast or osteotomy.

80 y/o white woman presents with hx of fall is osteoporotic, hx maternal hip fractures, excessive alcohol consumption, high caffeine intake, physical inactivity, low body weight, previous hip fracture, use of certain psychotropic medications, visual impairment, dementia, residence in an institution, and smoker. proximal femoral fractures

In younger patients, proximal femoral fractures are usually the result of high-energy physical trauma (e.g., high-speed motor vehicle accidents) and usually occur in the absence of disease. proximal femoral fractures

After 3 months Bracing is the treatment at early stage.

It is irreducible!

The Gold Standard is The X-ray AP pelvis and AP and frog leg lateral of the hip, in early stage is normal, late stage may show changes. Findings are patchy area of sclerotic bone.

MRI, bone scan.

Pt c/o gradual onset of anterior thigh or groin pain, pain referred to distal thigh or knee. Pain initially occurs with activity, and progress to pain at rest and at night. Decrease range of motion, particularly IR, no able to put on socks or shoes. Ambulatory capacity decreases as pain increase. Severe limp and stiffness. Antalgic gait, patient compensate by increasing lumbar spine extension to afford hip extension.

Osteoarthritis of hip: is the loss of articular cartilage in the hip joint Diagnosis test: X-ray AP pelvis and lateral hip. Narrowing joint space, osteophyte formation, subchondral cyst formation subchondral sclerosis.

Alcoholism, Smoking and steroid use RA and SLE are also implicated.

Osteonecrosis

GRADUAL onset dull pain in the groin and lateral hip that progresses and worsens to severe. Decreased range of motion particularly internal rotation. Antalgic gait is develop. ***PATHCY area of sclerotic bone.

Osteonecrosis May take months to a year for signs and symptoms to progress

Adverse outcome: Elderly men are twice as likely to die soon after a hip fracture than are elderly women. 31% of the men died within 1 year of sustaining a hip fracture in comparison, only 15% of the women in the study died within 1 year.

Osteonecrosis, nonunion fx, prosthesis loosening or dislocation, prosthesis FX, DVT, PE, Pneumonia, fear of falling, no able to ambulate, IM nail collapse.

Diagnosis Test: X-ray- AP view of pelvis a nd AP and lateral views of the femur

POSTERIOR (M/C) dislocation affected femoral head appears SMALLER than the contralateral. ANTERIOR dislocation affected femoral head appears LARGER. CT scan should be obtained if acetabulum fracture is suspected

Adverse outcome: Stress fx

Pain, osteonecrosis, nonunion, stress facture of the internal fixation.

Pt presents with hx MVA, PE reveals affected limb is short with fixed flexion, adduction and internal rotation. What do you suspect and first step?

Posterior hip dislocation: Assess distal pulses and sciatic and femoral nerve function. Nerve injury involvement.

Ortolani referred to as a clunk felt when the hip

REDUCES into the acetabulum, with the hip in ABDUCTION.

separation of the proximal femoral epiphysis through the growth plate

SCFE

Clinical Symptoms:

Snapping usually occurs with walking, laying on their side with affected side up. Test: have the patient re-created the action. Treatment: Exercise, strengthening, avoid provocative maneuvers and activity.

Dislocation of the hip is a severe injury? T/F

TRUE

Diagnostic test: X-ray of the pelvis and lateral views of the proximal femur. MRI should be obtained if xray is negative but history and physical suggest FX.

Treatment: Buck traction to affected side with 5 lbs. Intertrochanteric FX treated with either a screw and side plate or intramedullary rod. Nondisplaced or valgus impacted FX are treated with percutaneous fixation with 3 screws. Displace fx on the elderly and femoral neck fx are treated with partial or full prosthetic arthroplasty. Treatment: ABD wedge to prevent dislocation, physical therapy with partial weight bearing to full weight bearing. Rolling walker, Anticoagulant (mechanical and pharmacologic). Screen for osteoporosis and treat after recovery.

Stress Fx tx

Treatment: Displaced fx in the young patient are treated as surgical EMERGENCY and immediate anatomic reduction and internal fixation. Nondisplaced compression -side (medial side), cessation of activity and no weight bearing with crutches for 6-8 weeks until fracture healed. Internal fixation if symptoms persist or displacement or widening on follow up x-rays. Tension side: all are treated with internal fixation whether displaced or nondisplaced. Rehab: physical therapy after fracture healed.

Tx OA hip

Treatment: Initial treatment is nonsurgical, combination of acetaminophen, NSAIDs, activity modification and assistive device. Non-weight-bearing exercise (swimming or stationary bike).Corticosteroids intra-articular injection under fluoroscopic guidance and under sterile field. Surgical treatment: Total hip replacement will decrease pain as well as increase in function and is among the most cost effective medical intervention. Metal on metal hip resurfacing is mainly used on younger patients. Conventional total hip arthroplasty .

Hip dislocation Tx

Treatment: Medical emergency. Close reduction vs open reduction under anesthesia should be performed as soon as possible to decrease the risk of osteonecrosis. Repeat x-rays and post reduction CT. Neurovascular assessment. Rehab: Weight bearing as tolerated with crutches or rolling walker assistant. Physical therapy with hip abduction and extension exercises should begin 2-4 weeks after reduction and should continue until normal gait.

femoral SHAFT

Treatment: Partial to full weight bearing. Physical therapy, pharmacologic and mechanical anticoagulant, crutches or walker. Adverse outcome: FAT EMBOLISM. Adult respiratory distress, DVT, PE, multisystem organ failure, osteomyelitis, nonunion or malunion, chronic pain, limp, death.

femoral SHAFT

Treatment: temporary leg splint or skeletal (buck) traction to prevent shortening of the extremity and provide comfort. Surgery with open reduction internal fixator ORIF, external fixator, intramedullary rod ( IM rod), Plates and screws. Open fractures they urgently need to be cleansed and require immediate surgery to prevent infection.

Tx osteonecrosis

Treatment: treatment options before collapse are controversial. Conservative Medications NSAIDS. Meds to reduce fatty substances (lipids) that increase with steroid use. Meds to decrease coagulation in clotting disorders. Decrease weight bearing and exercises.

Inflammation of the greater trochanteric bursa secondary to injury, overused, hip OA or lumbar spine disease

Trochanteric bursitis

Pt presents w/ tenderness over greater trochanter. Pain is worse from rising from a sitting position and decrease with taking a few steps, but recurs after walking for half an hour. Night pain, no able to sleep on affected side. Physical Exam: Tenderness over greater trochanter to palpation and hip abduction.

Trochanteric bursitis Diagnosis Test: Xray AP pelvis and lateral hip with normal findings. Bone scan and MRI could be order in symptoms persists. Treatment: Nsaids, activity modification, physical therapy with abduction strengthening exercise. Corticosteroid with local anesthetic injection.

Stress fracture are usually the result of

a dynamic, continuing process rather than a single acute traumatic event.

Dislocation of the hip occurs when the femoral head is displaced from the acetabulum, and is caused by ?

a high energy trauma, such as MVA or fall from a height.

Anterior Dislocation:

affected limb is flex, abduction and external rotation. Asses distal pulses but nerve injury are less frequent.

Osteonecrosis: trauma, typically occurring after a displaced femoral neck fracture

and less frequently after a fracture-dislocation of the hip.

The hip is a ______ joint

ball and socket

Non-traumatic AVN occurs in a younger population and is commonly

bilateral.

Diagnosis test: X-ray AP and lateral of the femur. High energy trauma can disrupt adjacent joints, therefore x-ray of hip, knee and pelvis should be obtained.

femoral SHAFT

Pt c/o severe pain in the thigh with obvious deformity and unable to move.

femoral SHAFT fx Physical exam: Inspect for deformity, swelling, and open injuries. Evaluate and document vascular status of the limb to the distal fracture. Assess function of the femoral, peroneal and posterior tibial nerves. Patient may not be alert or able to respond to questions do to multisystem injuries.

Adverse outcome: FAT EMBOLISM

femoral SHAFT! Also: Adult respiratory distress, DVT, PE, multisystem organ failure, osteomyelitis, nonunion or malunion, chronic pain, limp, death.

Proximal Femur (ball) consists of the

femoral head and neck, greater and lesser trochanters

In most adults, fracture of the femoral SHAFT are caused by

high energy trauma, such as MVA. Low energy injuries such as simple falls are less common (screen patient for osteopenia or tumors).

Primary cause: OA hip

idiopathic. (Normal degeneration and aging process.)

Femoral neck fracture are know as

intracapsular fx disrupting the blood supply of the femoral head

GREATER trochanter (larger) is found on the _____ proximal femoral neck and is the site of attachment for ______ muscles including ______, and____

lateral, abductor ( gluteus medius and minimus).

LESSER trochanter (smaller) is found on the ______ aspect of the proximal femur is the site of attachment for the hip _______

medial flexors (Iliopsoas).

Barlow test performed with the hips in an ADDUCTED position, in which slight gentle POSTERIOR pressure is applied to the hips. A "clunk" should be felt as the hip

subluxates OUT of the acetabulum before 3 months. X-rays are negative.