Ortho/Rhuem: Exam 3 (Disorders of the Hip)
a shallow acetabulum
Hip dysplasia is defined as ____________________
Ability to subluxate or dislocate the hip with passive manipulation
Hip instability is defined as the ability to do what?
Patient is supine with hips and knees flexed. Apparent leg length discrepancy from the dislocated hip.
How do you assess the galeazzi sign?
Surgically
How do you treat legg-calve-perthes disease in patients 6 and older?
Plain x-rays (AP and frog leg lateral) Degree of displacement is generally measures on the x-ray
How would you diagnose a SCFE fracture?
Imaging is used to clarify unequivocal exam and monitor treatment progress - Ultrasound - optimal age 3 weeks - 5 months - Plain radiographs - optimal age after 3-6 mo (AP and frog leg lateral)
If clinical exam findings for hip dysplasia are clearly abnormal, no further imaging is necessary. However, when may imaging be useful for hip dysplasia?
Barlow test Apply posterior stress to hip in adducted, flexed position Positive if there is a "clunk" with subluxation out of the acetabulum
What test is this? Describe how you would perform it and how you would know if the test was positive
This is a Pavlik harness that is used in the treatment of developmental hip dysplasia before the age of 4 years old. Describe how the following should fit in order to to ensure a comfortable infant and effective results - chest strap: lower thorax - anterior strap: holds hips flexed - posterior strap: loose - calf strap: just below the knee - hips and knees flexed to 90 degrees
This is a ______________ harness that is used in the treatment of ________________ before the age of _____. Describe how the following should fit in order to to ensure a comfortable infant and effective results - chest strap - anterior strap - posterior strap - calf strap - hips and knees flexed to ______ degrees
Ddx: SCFE (might also consider Legg-Calve Perthes disease) Presentation: - 25% bilateral - may not have pain - pain may refer to knee or thigh when present - often present with limp - can be acute, chronic, or acute-on-chronic (exacerbation of symptoms that have been present) Exam: - limp, espeically if unilateral - positive trendelenburg sign - thigh atrophy - lack of full internal rotation - decreased ROM in all planes may be present also
13-year-old girl presents to the clinic with a painful left knee and a limp. Upon examination, she has a positive Trendelenburg sign, thigh atrophy, and lack of full internal rotation. What is your differential diagnosis?
Ddx: trochanteric bursitis Presentation: - pain over the lateral hip - may radiate down the lateral thigh - pain exacerbated by gait, activity, lying on the affected side, rising after prolonged sitting - pain can radiate - "psuedoradiculopathy" Exam: -Point tenderness directly over the greater trochanter (lateral hip) - Special tests can help rule out other conditions: FABER test (SI dysfunction), leg length measurement, foot inspection, (ped planus/pronation) neuro exam (radiculopathy), ROM of hip joint
35-year-old women presents to the clinic with lateral hip pain. She states that the pain radiates down her thigh and becomes worse after activity, laying on her side, or standing up after sitting at her desk during the day. What is your ddx? What exams can you use to support your diagnosis?
What you can order: - Labs (to rule out infection) - Plain film x-rays (AP pelvis, cross-table lateral) - MRI (more sensitive to pick up early change) Ddx: Avascular necrosis of the hip Treatment: - Conservative care is considered SURGERY (generally arthroplasty) - pain management is needed
47-year-old man came in complaining of hip pain and the inability to rotate his hip. You ordered an MRI. What else could/should you order? The MRI results are shown here. Based on the image, what is your diagnosis? How would you treat him?
Differential: Perthes Disease (if he were older (14-16), consider SCFE... as it has similar symptoms) Symptoms: - earliest sign is usually an intermittent limp, especially after exertion - pain - insidious, relatively mild, able to ambulate - pain often refers to the knee and thigh making this an easy to miss diagnosis Exam: -Knee exam should be normal - Limited hip internal rotation and abduction - limping with gait assessment - trendelenburg sign
7-year-old boy presents to the clinic with knee pain. His mother says that she has noticed him limping after playing in the yard with his siblings. In the past, it has usually gone away with rest, but for the past 3 days, it has been constant. The patient's knee exam is normal despite the chief complaint of knee pain. What is on your differential? What other exams can help diagnose?
Ddx: Avascular necrosis of the hip Symptoms: - limited ROM (internal and external rotation) - Pain - often radiates to the groin - pain usually exacerbated with activity, weight-bearing Exam - passive ROM is limited, painful (especially with forced internal rotation) - Distinct limitation of passive ABduction - can present with joint swelling in late disease
A 35-year-old female presents to the clinic with leg pain. She claims it starts in the hip but also radiates to her groin area. She finds it hard to rotate her leg in and out and she states the pain is worse with activity and weight-bearing. What is your ddx? What exams can you do to confirm your ddx?
A SCFE (slipped capital femoral epiphysis) is a fracture through the growth plate (physis) which results in slippage of the (overyling end of the femur) Boys: 14-16 Girls: 11 - 13 (premenarche) Males > females (3:2)
A SCFE (slipped capital femoral epiphysis) is a fracture through the _______________ which results in slippage of the _____________ Describe the age of onset and prevalence for girls vs boys
Acetabular remodeling potential rarely exists after 4 years of age.
Acetabular remodeling potential rarely exists after ___________ of age.
Answer: C, refer! If clinical exam findings are clearly abnormal, no further imaging is necessary
At a 2 mo well child visit, you find the infant has positive barlow and ortolani tests. What is your next step? a. nothing b. x-ray to confirm c. refer
3 months (<3 months = barlow and ortolani, >3 mo = galeazzi)
At what age do you switch from using the barlow and ortolani tests to using the galeazzi test?
Age: 30 - 50 Gender: Male to female 8:1 Etiology - traumatic - medications (chronic steroid use) - radiation/chemotherapy - slipped capital femoral epipysis
Avascular necrosis of the hip usually affects which age range? Which gender? What is the etiology?
- corticosteroid use - sickle cell disease - septic arthritis, subacute osteomyelitis - traumatic osteonecrosis from a fracture of dislocation - Infection (lab can rule this out)
Before diagnosing a patient with Legg-Calve Perthes disease, you must rule out other causes of osteonecrosis. What could these other causes be?
Dislocation (of the femoral head)
Complete loss of contact between the articular surfaces of the femoral head and the acetabulum is called _________________
Diagnosis - usually made clinically - x-rays to rule out joint / bony pathology (watch out for femoral neck stress fractures, especially in female runners) Treatment - NSAIDS (Naproxen 500 mg BID or Ibuprofen 600-800 mg TID) - Ice / Heat - Corticosteroid injection (very effective!) - Physical therapy - Correct leg length discrepancy (heel lift)
Describe how you would diagnose and treat trochanteric bursitis
- Mechanical factors: breech position and increased birth weight - Female predominance: attributed to estrogen-induced ligamentous laxity - Left sided predominance: attributed to fetal positioning of left hip against mother's lumbo-sacral spine - Native American predominance: attributed to hip extension/adduction positioning of swaddling
Describe in further detail the following risk factors for hip dysplasia: - Mechanical factors - Female predominance - Left-sided predominance - Native American predominance
- Stage 1: avascular necrosis - Stage 2: subchondral fracture, necrotic bone reabsorbed - Stage 3: reossification - Stage 4: healed
Describe the 4 stages of the legg-calve perthes disease process - Stage 1 - Stage 2 - Stage 3 - Stage 4
Acute: - abnormal gait, poor flexibility, strength imbalance leads to bursal friction and inflammation) - tendon overuse - direct trauma - pressure on the bursa Chronic - fibrosis and thickening of the bursal sac - tendinopathy with chronic overuse
Describe the difference between an acute and chronic trochanteric bursitis?
Plain film x-rays usually sufficient AP pelvis and cross table lateral views (frog leg is a bad idea because it will hurt the patient!) View of femur to include the knee
Describe the imaging for hip fractures. Why is frog-leg lateral not a good idea?
Boys: age 14 - 16 Girls: age 11-13 (pre-menarche) Presentation: - 25% bilateral - may not have pain - pain may refer to knee or thigh when present - often present with limp - can be acute, chronic, or acute-on-chronic (exacerbation of symptoms that have been present) Exam: - limp, especially if unilateral - positive trendelenburg sign - thigh atrophy - lack of full internal rotation - decreased ROM in all planes may be present also
Describe the presentation for a SCFE
Frog leg lateral
Describe this x-ray view
SCFE fracture Urgent orthopedic consultation is MANDATORY - goal is to prevent further slipping or avascular necrosis - most patients can return to activities 3-6 months post-op - good outcomes with early recognition and surgical treatment
Diagnose this patient based on this x-ray. How would you treat it?
Hip fracture Avascular necrosis
For which dx should you consider a cross table view?
Subluxation (of the femoral head)
Incomplete contact between the articular surfaces of the femoral head and acetabulum is called ________________
Legg-Calve Perthes disease is defined as childhood avascular necrosis (osteonecrosis) of the femoral head It usually occurs during ages 4-10, and boys(boys or girls) or more likely to get it by a 4:1 ratio. (overall, a rare condition)
Legg-Calve Perthes disease is defined as childhood _________________ of the femoral head It usually occurs during ages __________, and __________(boys or girls) or more likely to get it by a 4:1 ratio
petrie cast
Name this cast
Trendelenburg sign Can be indicative of Perthes disease (a sign of weak pelvis muscles) or SCFE fracture
Name this sign. What can it be indicative of?
Cannulated screws
Name this treatment for a hip fracture
Compression screws
Name this treatment for a hip fracture
Hemiarthroplasty
Name this treatment for a hip fracture
intramedullary nail
Name this treatment for a hip fracture
Associated with obesity, endocrine dysfunction, pituitary tumors/dysfunction, growth hormone therapy, and increased height
SCFE fractures are often associated with what?
Normal ambulatory development
Screenings for developmental hip dysplasia should be done at all well child visits until when?
The bursa over the lateral hip (otherwise known as the greater trochanteric bursitis) is associated with support for tendons of gluteus muscles, ITB, and tensor fasciae latae
The bursa over the lateral hip (otherwise known as the _______________________) is associated with support for ________________, _______________, and __________________________
The can impede proper development of the joint and cause hip dysplasia
The presence of the spherical head within the acetabulum is crucial for stimulating normal development of the acetabulum. If cartilage damage occurs from continued instability (subluxation or dislocation of the femoral head), what does this cause?
Outside of the joint
Trochaneric bursitis presents as lateral hip pain over the region of the greater trochanter. Is this pain coming from inside or outside of the joint?
False: abnormalities can be present at birth or they can present over time (can develop during childhood)
True or false: Hip dysplasia is always present at birth
True, it was historically referred to as inflammation, but may patient's lack inflammatory process
True or false: Trochanteric bursitis is not always an inflammatory process
- Limp (any limp in a child should be considered abnormal) - Limb length difference - Stiffness - Gait lurching to one side
What are 4 signs of hip dysplasia in an ambulatory child?
- OSTEOPOROSIS - smoking - alcohol use - high velocity trauma
What are common underlying risk factors for hip fractures?
1. tight muscles 2. obesity 3. leg length discrepancy (others include: direct trauma, muscle weakness, poor foot mechanisms, spine/SI dysfunction, hip or knee OA, recent change or increase in running)
What are the 3 main predisposing factors for trochanteric bursitis?
1. primary long term goal is to prevent secondary degenerative joint disease such as osteoarthritis 2. Restore and maintain motion 3. Pain control 4. Attaining a spherical femoral head with healing
What are the general goals of treatment for legg-calve perthes disease?
Unknown etiology, may result from rapid bone growth in relation to the blood supply, interrupted blood supply then leads to avascular necrosis
What causes legg-calve perthes disease?
Avascular necrosis of the femoral head (indicative of legg-calve-perthes disease)
What does this x-ray show?
Average age: 80 years old 80% of hip fractures occur in patients over the age of 60
What is the average age for hip fractures? 80% of hip fractures occur in patients over the age of _____
PETRIE CAST (with abduction bracing) (note: NOT NSAIDs --> this will probably be a question)
What is the first line treatment for legg-calve perthes disease for patients under 6 years old?
Galeazzi sign
What is the name of this sign?
Conservative care for a hip fracture is SURGERY Location helps determine treatment: femoral neck fractures of high risk of interruption of blood supply, and potential avascular necrosis
What is the treatment for a hip fracture?
FABER test (flexion, abduction, external rotation) Positive test (pain with the movement) is indicative of SI dysfunction
What is this test and what does a positive test indicate?
Ortolani Test Apply gentle upward stress on the lateral thigh and greater trochanter area with ith slow abduction Positive test if the dislocated and reducible hip will reduce with a described palpable "clunk."
What test is this? Describe how you would perform it and how you would know if the test was positive
When acetabular remodeling potential exists, the goal of treatment is to redirect the femoral head into the acetabulum with minimal force, avoiding complications of avascular necrosis and cartilage damage. We would do this by using a Pavlik Harness
When acetabular remodeling potential exists, the goal of treatment is to redirect the femoral head into the acetabulum with minimal force, avoiding _____________ and __________________. How would we do this?
2 mo: Barlow and Ortolani 4 mo: Galeazzi
You are assessing a 2 mo old infant for hip dysplasia. Which test/tests should you use? Which test will you use at the next well child visit at 4 months?
AP and frog leg lateral
You are monitoring the treatment of a 7 mo old baby that was recently diagnosed with hip dysplasia. You are using plain radiographs for imaging (optimal after 3 - 6 months). What radiograph views do you need?
Diagnosis requires imaging - AP pelvis, frog-leg lateral views (Will see flattening of the humeral head)
You are suspicious your 10 year old patient has perthes disease. He has a positive trendelenburg sign, has limited internal rotation and abduction of his hip, and knee pain. How can you diagnose this?
He will have to get surgery, and will be able to return to activities in 3-6 months. Basketball is out of the picture but he might be able to return to baseball! Good outcomes with early recognition and surgical treatment
You have just diagnosed a 15-year-old boy with an SCFE fracture. He is very concerned that he will not be able to play during his basketball season which starts next month or his baseball season which starts in 5 months. What should you tell him?
Patients under 6 years old are treated non-operatively. Rest, activity restriction, weight relief with a walker or crutches, gentle range of motion exercises NSAIDs - use only short term - a few days to a week as it can inhibit new bone formation Petrie cast with abduction bracing; Or brace (older patients are treated surgically)
You have just diagnosed a 5 year old with legg calve perthes disease. What is the treatment for this patient?
