CS 2 Unit 3 - Hip Conditions

What is osteonecrosis

osteocyte death in femoral head, inadequate vascular supply

MOI for osteonecrosis - traumatic

hip fracture or dislocation

MOI for osteonecrosis - nontraumatic

symptoms include - abrupt hip pain, decreased ROM, and stiffness

who does osteonecrosis affect - men or women

men (4:1)

what are some red flags for hip osteonecrosis

hx of corticosteroid use, alcohol abuse, sickle cell disease, and gaucher’s disease (a genetic disease in which fatty deposits accumulate in cells and certain organs including bone)

how many people annually have a proximal hip fracture

300k

what is the one year mortality rate for a proximal femur fracture

25%

90% of elderly hip fractures are due to what

low-energy falls

What are some risk factors for falls and hip fractures

age incidence increases with age, gender - increased incidence in females>males, social living, race, medical hx, fall risk, strength and endurance, rom, medication, bode density, diet, smoking, alcohol consumption, fluorinated water

what are the two classifications for hip fractures

intracapsular and extracapsular

intracapsular consists of what femur fractures

femoral head, subcapital, and femoral neck

intracapsular has more or less risk for injury to circumflex femoral artery

more

The femoral neck is common in older patients, they often have what procedure

THA (total hip arthroplasty) due to blood supply disruption

what fractures are a part of the extracapsular classification

intertrochanteric, subtrochanteric, and shaft fractures

which fracture is 50% of all proximal femur fractures and usually is an ORIF unless non-ambulator

intertrochanteric fracture

Why and who typically gets a THA

elderly patients, high rate of AVN, and ease of mobilization after

what is a hemiarthroplasty

replaces fractured ball side

what are the two types of hemiarthroplasty

unipolar and bipolar

who is a bipolar hemiarthroplasty used on

younger patient!

T/F 90% of THA last 10-12 years (survivorship)

F - 90% last 15-20 years

when recovering from a THA, do you want to PWB or WBAT

WBAT because of improved function without negative effect on surgical fixation

why is there greater than 1 PT visit/day for THA within the acute care setting

to predictive of achievement of basic function and D/C home

At 2 weeks, how far are they recovered from a THA

50-58% with a gait device

at 4 weeks of a THA, are they better or worse than before surgery

better! - return to driving

at 6 weeks THA, how much recovered

80-95%

in up to a year what can a pt with a THA do

conditioning, gait training, balance

what arthros are not allowed with an anterior approach THA

ext 20 deg, ER 50 deg, aDd to neutral

what arthos are not allowed in a posterior/posteroloateral apprach THA

no flx >90, IR, aDd

what activities should we think about for THA precautions

gait, sitting, transfers, lifting, stairs

how many weeks is the average precaution for THA

6 weeks

what percent and direction is most hip dislocation

85-90%, posterior

what is the MOI of a hip dislocation

hip flexed, some degree ADD, knee flexed

dislocating force - drives femoral head posteriorly

T/F is a dashboard injury in a MVC a MOI for a hip dislocation

true!

how does a hip dislocation present

posterior thigh, buttock pain, lower extremity shortened

positioning : flexed, ADD, IR

why is a reduction performed within 6-8 hours of a hip dislocation

reduce the risk of AVN to femoral head (10-15%)

what percentage of posterior dislocations have sciatic nerve involvement

10%

T/F posterior hip dislocations do not co-occur with femoral head fractures

false - they do!

a pipkin classification is what

non-surgical management for type 1 only

what are two operative managements for a femoral head fracture

fixation and arthroplasty

is an acetabular fracture a pelvic or hip fracture

pelvic fracture

MOI for acetabular fracture

high-energy trauma

treatment for acetabular fracture

ORIF - screws and plates

what are some precautions for acetabular fracture

touch-down WB, less pressure on the acetabulum than NWB

what percentage of all stress fractures are in the hip and pelvic region

8.8% - these include femoral neck, pubic rami, proximal femoral shaft

What imaging will see a stress fracture

bone scan, CT, MRI

what imaging will NOT see a stress fracture

radiograph

what is the prognosis for older adults with a stress fracture

at risk for non-union, deformity

prognosis for younger pts with a stress fracture

do well with protection, gradual return to activity

what percentage of adults in the US have hip OA

1.5%

clinical presentation of hip OA

pain in groin, anterior hip, lateral hip, and/or buttock

morning stiffness (<1 hr)

decreased IR and flexion (roughly 15 deg compared to contralateral side)

Primary classification of hip OA

without predisposing mechanical alignment factor

secondary classification of hip OA

result of another disease process, osteonecrosis, legg-calve-perthes. (idiopathic AVN - occurs in children), developmental dysplasia, SCFE, coxa cara/valga, hip fracture

treatment of hip OA

joint alignment, ROM, mm length and strength, modifiable environmental factors, adaptive equipment, education (weight loss)

pharmacologic treatment of hip OA

NSAIDS, intra-articular injections

Surgical treatment for hip OA

THA

level A evidence for Hip OA

manual therapy, flexibly, strengthening, and endurance exercises, dry needling

level b evidence to Hip OA

patient education, weight loss,

level c evidence for hip OA

functional, gait, and balance training

greater trochanteric pain syndrome includes

greater trochanteric bursitis, gluteal (med and/or min) tendinopathy (50%), ITB (external snapping hip syndrome)

8% of GTPS is what

true bursitis

what are risk factors of GTPS

obesity, age, OA of hip/knee, LBP, leg length discrepancy

what are risk factors of Greater trochanteric bursitis (GTB)

famle:male (2-4:1), arthritic conditions, leg length discrepency, age 40-60 y/oMO

what is the MOI for Greater trochanteric bursitis

Traumatic - fall onto hard surface

repetitive motion (flex/ext)

what is the clinical presentation

pain over lateral hip, tenderness to palpation at greater trochanter, “snapping hip syndrome”

what is treatment for greater trochanteric bursitis

non-op - rest, NSAIDS, injections. PT - manual therapy, ROM, strengthening

operative - debridement (medical removal of dead, damanged, or infected tissue) and relief of ITB

clinical criteria for diagnosis of trochanteric bursitis

BOTH - aching pain in lateral aspect of hip AND distinct tenderness around the GT

One of these

• pain at extreme of rot, aDb or aDd, especially positive FABER test

• pain on forced hip aBd

  • pseudoradiculopathy (pain extending down the lateral aspect of the thigh)

Snapping hip syndrome external reasons

ITB, TFL, gluteus maximus slide over GT

Assessment of snapping hip syndrome

hip flx with aDd with knee ext - is snapping reproduction

ober’s positive

snapping hip syndrome internal reason

iliopsoas over iliopectineal ridge or anterior capsulolabral complex and femoral head

assessment of snapping hip syndrome

extension of hip from flexed, aBd, ER position

Gluteal tendinopathy

glute med and or min

risk factors for gluteal tendinopathy

mechanical: overuse, sudden increase in activity, advanced aging, post-menopausal females, metabolic risk factors (DM), obesity

aggravating factors for gluteal tendinopathy

sidelying (night pain), increase stairs, walking uphill, prolonged sitting, sit-to-stand, ambulation, single-leg stance

treatment for gluteal tendinopathy

education, exercise

LEAP trial for gluteal tendinpathy

US guided corticosteroid injectino

education and exercise - 14 sessions of PT, hip ABD strengthening, tendon care

wait and see

education and exercise was more successful

greater trochanteric pain syndrome treatment

usually conservative - NSAIDs, weight loss, flexibility, strength, assess lower extremity biomechanics, aggravating positions, if above ineffective, injection

there is no one best treatment

proximal hamstring stains and avulsions

eccentric control of knee extension and hip flexion and poor gluteus maximum recruitment (overcompensation of the hamstrings)

what is the recurrence rate for a proximal hamstring strains and avulsions

12-62%

proximal hamstring avulsions at the ischial tuberosity

tenderness at origin, controversy on conservative vs operative care

femoro-acetabular impingement (FAI)

abutment between proximal femur and acetabular rim

• may be morphological changes to eithet

what are the different types of FAI

cam, pincer, combined

what is the 1st line for the alpha angle

center of femoral head through femoral neck

what is the 2nd line for alpha angle

center of femoral head to point where head-neck junction departs circle

for a CAM deformity there needs to be

>60 deg

lateral center edge anlge (LCEA)

line 1 - vertical from femoral head, line 2 - along edge of acetabulum

interpretation - <25 under coverage (dysplasia), 25-40 normal, >40 - over coverage (pincer)

clinical picture for a FAI

usually young - middle aged adults after minor trauma, often gradual onset with ant hip pain, increases with walking, sitting, athletic activities, positive impingement sign

Assessment for FAI

FADIR, hip apprehension test - external rot or ext hip

how many labral tears are with the groin/hip pain

22-25%

which locations is most labral tears

anterior - 86%

what is the MOI for labral tear

repetitive microtrauma - pivoting and twisting

trauma - extension and ER

FAI, capsular laxity, dysplasia, degenerative

Clinical presentation of labral tears

pain in groin or ant. hip with ant. tear (most common); buttock pain with post. tear

buckling, catching, painful clicking, restricted ROM, pain with sitting, limp/trendlenburg, positive impingement sign

management for a labral tear

similar to FAI

Pirifiromis syndrome is what nerve irritation of what muscle

sciatic nerve by the piriformis muscle

is piriformis syndrome easy or hard to diagnose

hard - must rule out lumbar spine

what is another syndrome that is due to sciatic nerve entrapment

hamstring syndrome

where is the sciatic nerve entraped in a hamstring syndrome

ischial tuberosity

what is the clinical presentation of piriformis syndrome

tenderness of glute region and surrounding tissues - can have referred leg symptoms

what are aggravating factors for piriformis syndrome

walking, ascend stairs, trunk rotation, repetitive or resisted ER (kicking a soccer ball)

what are some findings that one might present with piriformis syndrome

may have ER limb during gait, pain with compression, a thight or lengthened piriformis, weakness of glute max &/or med, rarely myotomal or DTR changes

what is treatment for piriformis syndrome

based on the cause / impairment