Hip joint
•
History
IPEEP
Age: >70 or postmenopausal woman, there is an increased
chance of neck fracture
• Hip Joint Pain:
• Groin pain that may radiate to the Ant. Thigh & knee
• Usually increased with activity (OA)
• Pain over greater trochanter is typically trochanteric
bursitis
• The buttock is not the hip! Buttock pain is typically from
the sciatic nerve or lumbar spine
• Limping can be due to:
• Pain (as in antalgic limp)
• Shortening of one of the limbs
• Weakness in abductors (trendelenburg gait).
Added
Examination
•
Look:
• Gait
• Masses / Scars / Lesions / Signs of trauma or
previous surgery
• Bony alignment (rotation, leg length)
• Muscle bulk and symmetry at the hip and knee
• Feel:
• Tenderness
• Assessing for fractures & Injuries
• Move
Special Tests
 Thomas’s Test
Measures fixed flexion deformity (incomplete extension)
- place your hand under ptn’ lumbar spine
- passively flex both LL (hips & knees) as far as possible
- you should feel that lumber spine lordosis got eliminated
- now ask the ptn to extend the test hip
- Incomplete extension indicates fixed flexion deformity
Special Tests
• Shortening (Leg Length Discrepancy)
• Ask the pt to lie supine and stretch both
legs as possible
• Measure with tape:
• From Umbilicus to medial malleolus: the
apparent length
• From ASIS to medial malleolis: the ‘true length’
In hip fractures the affected leg is often
shortened and externally rotated.
Special Tests
 Trendelenburg Sign
- Ask the ptn to stand on one knee leg for 30 seconds
- Repeat with the other leg
- Watch the iliac crest on each side if it moves up or down
The Trendelenburg sign is said to be positive if, when standing on
one leg, the pelvis drops on the side opposite to the stance leg.
Special Tests
 Trendelenburg Sign
 The weakness is present on the side of the stance leg. The body is not able to maintain the
center of gravity on the side of the stance leg. Normally, the body shifts the weight to the
stance leg, allowing the shift of the center of gravity and consequently stabilizing or
balancing the body. However, in this scenario, when the patient/person lifts the opposing
leg, the shift is not created and the patient/person cannot maintain balance leading to
instability.
 It is positive in:
- Weakness / paralysis in hip abductors.
- Marked proximal dislocation / subluxation of the hip.
- Shortening of femoral neck.
- Any painful disorder of the hip.
SCFE
Slipped capital femoral epiphysis
Physis layers:
• A. Reserve layer
• B. Proliferative zone
• C. Zone of hypertrophy
• D. Zone of calcification
SCFE
• A displacement through
the growth plate of the
immature hip occurs
during the rapid growth
period in the hypertrophic
zone of the physis
• The femoral head remains
in the acetabulum; the
neck displaces anteriorly
and rotates externally.
INCIDENCE
• 1:30000
• BLACK
• MALE
• LT HIP
• BILAT 25%
• BILAT IN
ENDOCRIOPATHIES
>70%
Risk factor
• obesity
• acetabular retroversion
and femoral
retroversion
• history of previous
radiation therapy to the
femoral head region
• ENDOCRIOPATHIES
• Down syndrome
Clinical Features
1.
2.
3.
4.
5.
6.
Pain : in the groin and around the knee.
Limp (intermittent).
Shortening of the affected limb (1-2 cm).
The limb is in external rotation.
Flexion, abduction, medial rotation are limited.
External rotation, adduction are increased.
investigation
growth plate widening
klein line
southwick angle
• MRI is useful in diagnosing ―pre-slip‖ hips.
An abnormally widened physis with
surrounding edematous changes on MRI are
suggestive of pre-slip hips.
• MRI is helpful in the evaluation of
osteonecrosis afterward.
Grading
Grading severity of SCFE according to AP and Lateral
X-ray views
Stable or unstable
• It is important to determine if the lesion is stable or
unstable:
1. Stable SCFEs allow the patient to walk with or
without crutches (walking aids).
2. Unstable SCFEs do not allow the patient to
ambulate at all; these cases carry a higher rate of
complication, particularly of AVN
Complications
1.
2.
3.
4.
Avascular necrosis
Chondrolysis
Osteoarthritis
Coxa vara (is a deformity of the
hip, whereby the angle between
the ball and the shaft of the
femur is reduced to less than
120 degrees)
5. Slipping of the opposite hip
Treatment
Mild Cases:
•
Epiphysis fixation by screw
Severe Cases:
•
In-situ fixation correction of the
deformity by subtrochantric
osteotomy
X-ray of a hip following operative percutaneous fixation of a
slipped capital femoral epiphysis
Perthes'
disease
Definition
• Avascular necrosis of growing capital
femoral epiphysis
• Self limiting disorder of the hip produced
by ischemia and varying degrees of
necrosis of femoral head followed by
revascularization
Blood supply of femoral head
Infants
• Inferior metaphyseal a
• Lat epiphyseal
• Lig teres _ insignificant
4m-4y
• Lat epiphyseal
• Med epiphyseal dec in
number
4y-7y
• Epiphyseal plate forms
a barrier to
metaphyseal vessels
Pre adolescent
After 7 y arteries of lig
teres become more
prominent
Epidemiology
• 1 : 10,000
• : ……………4:1
• Bilateral .... 12%(é diff.stages).
• Age : 4-8 years is most common
age of presentation
• White Boys
Risk factor
• positive family history
• low birth weight
• Last child
• abnormal birth
presentation
• Child for old parents
• Passive smocking
Waldensrorm classification
• The vascular bony nucleus of the capital
epiphysis undergoes…necrosis …then the
necrotic bone …fragments as it
revascularizes as the dead bone is cleared
• The fragmented part begins reossifying and
after ossification …it remodels trying to
regain its shape
CLASSIFICATION
Lateral pillar
• Herring et al
• 1992
• Ap veiw only
• Fragmentation
stage
Lateral pillar
• Demarcated from
the central portion
of the head by a
lucent line
• 5-30% of the
femoral head
• If no lucent
demarcation line
it the lateral 25%
Type a
Type b
Type c
Type b/c
<8y
>8 Y
A/B----NO TTT
A-----NO TTT
BC----TTT??!!
B/BC----TTT
C----TTT??!!
C---TTT??!!
Perfusion mri
Non operative ttt of lcpd
• Maintain motion
–Physiotherapy
–Short term casting or bracing
–Add release
• bisphosphonate
Varus derotation osteotomy
Salter innominate osteotomy
shelf acetabuloplasty.
Some surgeons, consider it as 1ry containment
&do it éin 6mo of the disease
Advantages:
• It does not alter the neck shaft angle.
• Decrease the tendency to stiffness of the hip
joint.
Disadvantages:
• Possibility of damage of the lateral acetabular
epiphysis
Hip Dislocation
Hip Dislocation (traumatic)
• Occurs when the head of femur slips out of its socket in the
hip bone (pelvis).
• 90% of patients femur is pushed out of its socket posteriorly
→ leaves the hip in a fixed position, bent and twisted in
toward the middle of the body.
• Femur can also slip out of its socket anteriorly → the hip will
be bent only slightly, and the leg will twist out and away from
the middle.
• Very painful
• Patients are unable to move the leg
• If there is nerve damage, may not have any feeling in the foot
or ankle area.
Causes
• Serious morbidity can be associated with hip dislocations.
• Direct force trauma (minor or major force) to the thigh is the
most common cause of hip dislocation.
• High energy trauma (motor vehicle accidents, pedestrians
being struck by automobiles).
• This type of injury also is associated with high-energy impact
athletic events (American football, rugby, water skiing)
• Children may have a hip dislocation due to relatively minor
trauma.
Posterior Hip Dislocation (90%)
•
Posterior dislocations occur
when the knee and hip are
flexed and a posterior force is
applied at the knee while the leg
is in adducted position.
• Posterior hip dislocations occur
typically during RTAs, when
the knees of the front-seat
occupant strike the dashboard.
Signs & Symptoms
1. Pain in the hip and buttock area.
2. The affected limb is shortened, adducted, and internally
rotated, with the hip and knee held in slight flexion.
3. Patient may be unable to walk or adduct the leg.
4. Signs of vascular or sciatic nerve injury may be present:
• Pain in hip, buttock, and posterior leg
• Loss of sensation in posterior leg and foot
• Loss of dorsiflexion (peroneal branch) or plantar flexion
(tibial branch)
• Loss of DTRs at the ankle.
• Local hematoma in vascular injury.
Management
Bigelow maneuver
Allis maneuver
Under GA
While an assistant stabilizes the pelvis
with direct pressure, Flex the hip and
knee to 90° and pulls the thigh
vertically upward.
Complications
1.
2.
3.
4.
Sciatic nerve injury.
Vascular injury (hematoma).
Avascular necrosis.
Osteoarthritis
Indications for Open Reduction
1. Irreducible dislocation
2. Persistent instability of the joint following reduction
(fracture-dislocation of the posterior acetabulum)
3. Fracture of the femoral head or shaft
4. Neurovascular deficits that occur after closed
reduction
Osteoarthritis
Osteoarthritis
• degenerative disease
of the knee joint that
causes progressive
loss of articular
cartilage
avascular
aneural
alymphatic
A. Trauma
• 1. Acute
• 2. Chronic (occupational,
sports)
B. Congenital or developmental
• 1. Localized diseases: LeggCalve-Perthes, congenital hip
dislocation, slipped epiphysis
• 2. Mechanical factors: unequal
lower extremity length,
valgus/varus deformity,
hypermobility syndromes
• 3. Bone dysplasias: epiphyseal
dysplasia, spondyloepiphyseal
dysplasia,
osteonychondystrophy
C. Metabolic
• 1. Ochronosis (alkaptonuria)
• 2. Hemochromatosis
• 3. Wilson's disease
• 4. Gaucher's disease
D. Endocrine
• 1. Acromegaly
• 2. Hyperparathyroidism
• 3. Diabetes mellitus
• 4. Obesity
• 5. Hypothyroidism
E. Calcium deposition diseases
• 1. Calcium pyrophosphate dihydrate
deposition
• 2. Apatite arthropathy
F. Other bone and joint diseases
• 1. Localized: fracture, avascular
necrosis, infection, gout
• 2. Diffuse: rheumatoid (inflammatory)
arthritis, Paget's disease, osteopetrosis,
osteochondritis
• G. Neuropathic (Charcot joints)
H. Endemic
• 1. Kashin-Beck
• 2. Mseleni
I. Miscellaneous
• 1. Frostbite
• 2. Caisson's disease
• 3. Hemoglobinopathies
Osteoarthritis
• Chronic degenerative disorder in which there is
– Progressive articular hyaline cartilage destruction
– New bone formation
– Remodeling of joint contour
• Accompanied by new cartilage and bone proliferation
at the joint margins.
Causes
• Most common non-traumatic
disorder of the hip in middle and
late age. Healthy fit and over 50
years of age.
• In younger patients
– Acetabular dysplasia
– Coxa vara
– Slipped epiphysis
• Secondary osteoarthritis arthritis
is seen in older patients after
– RA
– Avascular necrosis
– Paget’s disease
Pathology
• Area of maximal loading (top of the joint) shows
marked changes:
1. Articular cartilage becomes soft & fibrillated.
2. Underlying bone shows cyst formation & sclerosis.
• At the margins of the joint there are the characteristic
osteophytes.
• Synovial hypertrophy and capsular fibrosis.
Clinical features
1. Pain: felt in the groin and radiates to the knee
typically after periods of activity, later it becomes
constant and disturbs sleep.
2. Stiffness.
3. Deep tenderness
4. Restricted movements
5. Limping.
6. Muscle wasting.
X–ray
• Earliest sign is a decreased joint space.
• Later signs are
– Subarticular sclerosis
– Cyst formation
– Osteophytes at the edges of the joint
• Osteoarthritis of the
hip showing joint
space narrowing at
the weight bearing
surface and
osteophyte
formation.
Treatment
• Mainly symptomatic.
1. Analgesics.
2. Use of a walking stick.
3. Preserve movement and stability by performing exercises
within the range of comfort.
4. Joint manipulation sometimes relieves pain for long periods.
5. Changing life style to reduce impact loading on the affected
hip (Climbing up and down the stairs, carrying heavy
weights)
Operative Treatment
• Indicated in:
• Severe pain
• Progressive decrease in joint movement
• Increase difficulty with activities of daily living
• X-ray signs showing progressive joint
deterioration.
– The procedure of choice is total hip
replacement.
Developmental dysplasia of the
hip (DDH)
The spectrum of abnormal
growth of the developing hip,
(ranging from acetabular
dysplasia, hip subluxation,
hip dislocation, or hip
instability)
Risk factor
➢ Frank breech presentation
➢ Femal
➢ First born
➢ Family hx
➢ Fluid abnormality (Oligohydramnios)
➢ Feet deformity (metatarsus adductus)
➢ Fetal anomalies
➢ Faulty Habits (Swaddling)
➢ Facial asymmetry (Torticollis)
*Epidemiology
1-20:1000 neonatal hip instability
2-80% of affected children are female.
3-The left hip is more commonly involved (60%)
Pathology
.
actabulum
femur
= Shallow, dysplastic.
= Anteverted deficient anterolaterally.
= = May deficient posteriorly.
= New false acetabulum.
= Delayed ossific nucleus
= Coxa valgus
= Anteversion of the proximal
femur
= Deformed shape of the head.
Extra articular
Intra-articular
Tight psoas tendon
Tight adductor
muscles
Short abductors
-Wide lax redundant capsule
2-Pulvinar (fibro-fatty tissue)
3-Thick elongated ligamentum teres
4-Infolded thick labrum inside (Inverted
limbus)
5-Thick transverse acetabular ligament.
6-Narrow inferior capsule by the Psoas.
Clinical Manifestations
The clinical presentation varies with age and type of DDH.
1-Incomplete dislocation
Pre walking:
– limitation of abduction while changing nappy.
– Skin fold asymmetry (not specific)
Post walking:
– limping
– tiptoe gait (in unilateral DDH),
– LLD
– waddling gait (in bilateral DDH).
2-In acetabular dysplasia: Asymptomatic
Diagnosis
Barlow test
•
•
•
Provocative test that attempts to dislocate an
unstable hip.
Flexion ,adduction, posteriorly.
Click
Ortolani test
1. It is a maneuver to reduce a recently dislocated hip.
2. Flexion, abduction, anteriorly.
Galeazzi’s sign
Von rosen view:
• Hips abducted 45º & medially rotated.
• We draw a line through the central axis of the femoral shaft.
• Normal hip (ossific nucleus) will be inside the acetabulum.
• Dislocated hip it will be above acetabulum.
Horizontal line of Hilgenreiner:
• Drawn between upper ends of tri-radiate cartilage of the acetabulum.
Vertical line of perkins:
• Drawn from the lateral edge of the acetabulum vertical to horizontal line.
4 quadrants:
• Normal hip: the ossification center of the femoral hip lower medial
quadrant.
• Dislocated hip: upper lateral quadrant.
Acetabular index:
• Angle between horizontal line of hilgenreiner and the line between the 2
edges of the acetabulum.
• Normal hip 20-30º
• Dilocated or dysplastic hip ≥ 30º
Shenton’s line:
• Semicircle between femoral neck and upper arm of obturator foramen, in
dislocated hip this line is broken.
Von rosen view
Treatment
• The earlier the better.
• Best time for treatment is in newborn period.
• It depends on the device and age of the patient.
• Goal is to:
1. Flex and abduct hips.
2. Reduce femoral head and maintaining it.
• 1-6 months use Pavlik Harness.
• 6 months -1 year use hip spika.
• 1 – 3 years → traction, adductor tenotomy, surgical
closed reduction, salter innominate osteotomy.