E1: hip & pelvis

what muscles are part of the hip flexor group?

iliopsoas

sartorius

rectus femoris

controlled by femoral nerve

what muscles are part of the hip adductor group?

gracilis

pectineus

adductor longus, brevis, magnus

controlled by obturator nerve

what muscles are part of the hip abductor group?

gluteus medius & minimus

controlled by superior gluteal nerve

what muscles are part of the hip extensor group?

gluteus maximum (inferior gluteal nerve)

hamstring muscles (tibial nerve)

what is the Thomas test?

flexion contracture when the opposite leg is extended and hip flexor tightness when the opposite leg is flexed

what does the Ober test examine?

iliotibial band (ITB) contracture

what does the Barlow test examine?

congenital hip dysplasia by adducting and laterally dislocating

what does the Ortolani test examine?

congenital hip dysplasia by abducting and pulling the femur forward to reduce the joint

what does the Trendelenburg test examine?

the contralateral gluteus medius muscle

what does the Scouring test examine?

labral pathology, loose body or other internal derangment

to measure true leg length discrepancy, you measure from the ______ to the ________

ASIS to medial/lateral malleolus

to measure apparent leg length discrepancy, you measure from the ______ to the __________-

umbilicus to the medial/lateral malleolus

what are causes of a fractured sacrococcygeal?

childbirth

fall on their bottom

what is the most common symptom for a sacrococcygeal fx?

pain with sitting

what is the treatment for a sacrococcygeal fx?

Warm Sitz bath

soft doughnut shaped pillow

NSAIDs

avoid constipation

what does a stable pelvic ring fx include?

one side of the pelvic ring

what does a unstable pelvic ring fx include?

disruption of the ring at 2 sites (usually d/t high velocity trauma)

what are symptoms of pelvic fxs?

pain in the groin w/ attempts to WB or inability to WB

pain localized to groin, lateral hip or buttock

what is seen on physical exam of a pelvic fx?

pain w ROM and attempted SLR

antalgic gait pattern

neurovascualr status of LEs

what is the treatment for low-energy pelvic fxs?

analgesics, rest

gait training

prevent skin breakdowns and DVTs

what is the treatment for high-energy pelvic fx?

ABCs

tourniquet sheet to prevent further bleeding

what are complications of pelvic fxs?

nerve damage

femoral artery/vein damage

male urethra damage

internal organ damage → bladder rupture, rectal rupture, uterine rupture, placental abruption, urethral tear

urethral injuries are usually due to?

fracture of the pelvis

what are clinical findings of urethral injuries?

signs of anterior pelvis fx present

pubic symphysis is tender and boggu

perineal/scortal hematoma

blood in urethral opening

tender, mobile or high prostate

what is the diagnostic test for urethral injuries?

retrograde urethrogram

what is the treatment for urethral injuries?

suprapubic cystostomy

bladder rupture is usually caused by?

pelvic fx

what are clinical findings of bladder rupture?

blood in the urethral meatus

lower abdominal/pubic area pain

what are clinical findings of pelvic trauma?

tenderness, crepitance, hematomas

what is the treatment for pelvic trauma?

treatment of hemorrhage

ortho referral

what is Wolff's law?

the bone remodels according to the forces applied

what does the teres ligament connect?

top of femoral head to tissue inside the acetabular joint

what is the blood supply to the femoral head?

medial femoral circumflex artery

what does a fx of the proximal femur involve?

femoral neck and intertrochanter region

what fx disrupts the blood supply to the femoral head and commonly result in nonunion and osteonecrosis/AVN?

femoral neck fx (aka intercapsular hip fx)

what is a risk of intertrochanteric hip fxs?

shortening of the limb and malunion

what are symptoms of a proximal femur fx?

hip pain in groin

inability to bear weight

referred pain to the knee

↓ ROM

what is a complication of proximal femur fxs?

avascular necrosis

what is seen on physical exam on a proximal femur fx?

displaced femoral neck/intertrochanteric fx when supine

leg is shortened

rotating hip will cause pain

unable to do SLR

what is the treatment for proximal femur fx?

surgical intervention w/in 48 hrs

intertrochanteric → ORIF

displaced → hip hemi-arthroplasty/THA

thromboembolic prophylaxis

what are absolute CI for post-op hip precautions?

flexion (past 90 degrees)

ADDuction

internal rotation

they can re-dislocate their hip if these movements are done

- this is only for the first 6 wks after surgery

what are causes for femoral shaft fx?

high-energy trauma (MVA)

low-energy injuries (simple fall)

what can pathologic femoral shaft fxs be caused by?

biphosphonates

when does a femoral shaft fx occur?

when the bone in weakened by osteopenia or tumors

a fx of the femoral shaft includes what regions?

from subtrochanteric region to supracondylar area

what are symptoms of a femoral shaft fx?

severe pain in the thigh

obvious deformity

inability to move or bear weight

multisystem injuries (high-energy)

if a femoral shaft fx is due to high-energy trauma, what areas should get a x-ray?

hip

knee

pelvis

what is the treatment for femoral shaft fxs?

immediate temporary splinting

skeletal traction → prevents shortening of limb

surgery

a stress fracture of the femoral neck mainly occurs in?

military recruits & runners

how are femoral neck fxs classified?

based on location

where do femoral neck fxs occur in the elderly?

superior aspect of proximal femoral neck

- easily displace

where do femoral neck fxs occur in younger pts?

inferior medial aspect of the femur

what are symptoms of a femoral neck fx?

vague pain in groin, anterior thigh or knee associated w activity or weight bearing

pain subsides with rest

what is seen on physical exam of a femoral neck fx?

pain at extreme ROM (mainly IR)

antalgic gait

tenderness at the proximal thigh/groin

soft tissue irritation to the area

resisted SLR maneuver, may produce pain in groin/thigh

what are the 3 types of stress fractures?

compression → inferior-medial aspect of femoral neck

tension → superior-lateral aspect of femoral neck

displaced → fx all the way through & bones don't line up

what is the most sensitive diagnostic test for stress fx of the femoral neck?

MRI

what is the treatment for a non-displaced compression-side fx of the femoral neck?

NWB & cessation of activity

serial radiographs

what is the treatment for tension-side fx of the femoral neck?

surgery (they tend to displace)

what is the treatment for a displaced femoral neck fx?

surgical emergency

what is the use of dislocation of the hip (femoral head displaced form acetabulum)?

MVA or fall

is posterior or anterior hip dislocation more common?

posterior

what are clinical findings of hip dislocation?

pain

immobility of the LE

associated head, abd and chest injuries

what nerve functions should be tested with posterior hip dislocation?

sciatic and femoral nerves

what is seen on x-ray of a posterior hip dislocation?

size of affected femoral head appears smaller than the contralateral, normal femoral head

what is seen on x-ray of an anterior hip dislocation?

size of affected femoral head appears larger that the contralateral normal femoral head

what are diagnostic tests for hip dislocations?

x-ray

CT → determines fx pattern

what is the treatment for hip dislocations?

acute traumatic = emergency

reduction ASAP to ↓ risk of osteonecrosis

what is the post-reduction treatment for hip dislocations?

gait training w crutches WBAT

hip abduction & extension exercises

what muscles of the hip are often strained?

hip flexors and adductors

what is the symptoms of hip strains?

pain over the injured muscle being exacerbated

tenderness to groin or inner thigh

resisted muscle testing increases pain

what are the diagnostic tests for hip strains?

x-ray = AP & frog leg views

MRI

what is the treatment for hip strains?

activity modification

NSAIDs

PT

what are symptoms of hamstring strains?

"pop" or pain in posterior thigh

- common in athletes

what is the treatment for hamstring strains?

RICE

NSAIDs

PT

what syndrome is caused by inflammation & irritation of the distal portion of the iliotibial tendon by rubbing against the lateral femoral condyle and if often an overuse injury form repetitive flexion & extension of the knee?

ilitotibial band syndrome (ITBS)

what are symptoms of ITBS?

pain to lateral aspect of knee (Gerdy's triangle)

↑ pain w running/cycling

↓ pain w rest and stretching of IT band

what is the treatment for ITBS?

rest

heat before stretching, ice after stretching

PT

NSAIDs

no improvement = ortho referral for injection/surgery

what are symptoms of ischial bursitis?

hip pain that is ↑ w sitting

tenderness w pressure over ischial bursa

what is the diagnostic test for ischial bursitis?

MRI pelvis

inflammation of the greater trochanteric bursa causing symptoms of hip pain increased w walking/climbing and tenderness w pressure over the greater trochanter bursa

greater trochanteric bursitis

what are S&S of avascular necrosis?

gradual onset of hip pain 4-6 mos

slight limp w walk

↑ groin pain w internal rotation

what are causes for avascular necrosis?

femoral neck/head fx

alcoholism

long term steroid use

progressive displacement of the upper portion of the femur occurs in relation to the capital femoral epiphysis which occurs thru the physis during adolescent growth

slipped capital femoral epiphysis

what are S&S of slipped capital femoral epiphysis?

adolescent M>F

obese

pain in groin, medial thigh and knee

AA > caucasians or hispanics

↓ internal rotation

trandelenburg's gait, antalgic gait

what is seen on x-ray of slipped capital femoral epiphysis?

apparent varus angulation of epiphysis ("ice cream falling of its cone")

Kline lines → loss of intersection of epiphysis by femoral neck

pistol grip deformity (chronic stage)

a hip disorder caused by avascular necrosis of the femoral head resulting in symptoms of a limp, limited abduction & IR, trendelenburg's gait, atrophy of thigh/calf/buttocks and leg length inequality

Legg-Calve-Perthes disease

how is the blood supply to the femoral head affected with Legg-Calve-Perthes disease?

its blocked

what is the treatment for Legg-Calve-perthes disease?

activity restriction

analgesics

PT to ↑ ROM/function

long leg bracing w spreader bar

surgery → tenotomy, osteotomy

burning pain with pins and needles occurring in the distribution of the lateral cuteness nerve of the thigh d/t the nerve being trapped medial to the ASIS

Meralgia paresthetica

what are causes of Merlagia Paresthetica?

obesity

compression of tight clothes

trauma

anterior surgical approaches

tumors (rare)

what are symptoms of Meralgia Paresthetica?

pain & dysesthesia in anterolateral or lateral thigh, may radiate to lateral knee

aching in the groin area

"electric jab" when hip extends during running

what is seen on physical exam of Meralgia Paresthetica?

hypoesthesia/dysthesia along nerve distribution

burning

tapping/pressure medial to ASIS

muscle weakness, abnormal reflexes

what is the treatment for Meralgia Paresthetica?

remove source of compression

weight loss

local anesthetic + cortisone injection

gabapentin

surgery

what are S&S of OA of the hip?

achey pain over hip

pain in anterior groin that radiate to medial knee

↓ ROM of hip flexion