Date post: | 12-Jan-2016 |
Category: |
Documents |
Upload: | harry-kelly |
View: | 221 times |
Download: | 0 times |
Hip joint is a ball-and-socket joint
It consists of the femoral head and the pelvic acetabulum
Resting postion: 30° flexion, 30° abduction, slight lateral rotation
Closed packed position: extension, medial rotation, and abduction
Capsular pattern: flexion, abduction, medial rotation
Attachment sites:
The greater trochanter – ◦ Abductor muscles: Gluteus medius and Gluteus
minimus◦ Obturator internus◦ Piriformis ◦ Quadratus femoris
The lesser trochanter- ◦ Hip flexor muscle: Iliopsoas
Flexion: 110° Extension: 10° Abduction: 30-50° Adduction: 30° Lateral Rotation: 40-60° Medial Rotation: 30°
Nerves that can affect muscle weakness and sensory alterations around the hip:
Sciatic Nerve: L4-S1 Superior Gluteal Nerve Fermoral Nerve: L2-L4 Obturator Nerve: L2-L4
Dislocation of the Hip Fracture of the Femur Fracture of the Pelvis Osteoarthritis Snapping Hip Strains Trochanteric Bursitis
Femoral head is displaced from the acetabulum
Posterior dislocation more common- 90%
Symptoms: ◦ Severe pain
Felt in the anterior aspect of the hip/ groin◦ Inability to move the LE
Physical Exam◦ Affected limb will appear shorter◦ Hip is in a fixed position of flexion, adduction, and
internal rotation Diagnostic Tests
◦ Radiograph to confirm
Differential Diagnosis◦ Fracture of the acetabulum◦ Fracture of the femoral shaft
Neaton’s Line- Imaginary line drawn from the ischial tuberosity of the pelvis to the ASIS of the pelvis on the same side◦ If greater trochanter is palpated well above the
line, positive for dislocation
Ortolani’s Sign – Pediatric Congential Hip Dislocation
Telescoping Sign- Pediatric Dislocated Hip
Usually due to high velocity injuries
Symptoms:◦ Severe pain in the thigh◦ Obvious deformity◦ Unable to move or bear weight on LE
Physical Exam◦ Inspect for deformity◦ Open injury
Diagnostic Test◦ radiograph
Differential Diagnosis◦ Fx of acetabulum◦ Malignant or metastatic lesion of femur◦ Osteomyelitis◦ Stress fracture of the femur
Fx of Femoral Neck
Common in elderly patients with osteoporosis◦ Chance of injury doubles every decade after 50 y.o.◦ Caucasian women are 2 times more likely to be
affected
Symptoms◦ Patients report a fall followed by the inability to
bear weight◦ Pain in the groin
Physical Exam◦ Pt. lies with the limb externally rotated, abducted
and shortened◦ Gentle rotation with the hip extended is painful
Diagnostic Tests◦ Radiograph, MRI
Differential Diagnosis◦ Pathologic fracture- due to tumor◦ Pelvic Fracture
Characterized by a dull, aching pain in the groin, lateral thigh, or buttocks region.
Pt. experiences morning stiffness with improvement with moderate activity, with increased pain with vigorous activity
Note a progressive limp, and limited ROM
Difficulty dressing and donning shoes
Physical Exam◦ Gait Abnormalities-
Antalgic Gait (short stance phase on the affected side) Trendelenburg Gait- develops with progressive loss of
cartilage Hip ROM is restricted
Differential Diagnosis◦ Ankylosing spondylitis◦ Gout◦ Infection◦ Osteoarthritis◦ Osteonecrosis◦ Reiter Syndrome◦ RA◦ Lupus◦ Trochanteric bursitis
Compression or entrapment of the lateral femoral cutaneous nerve is characterized by pain, burning, or hypoesthia over the lateral thigh
Causes:◦ Obesity◦ Compression from tight clothing or straps around
the waist (tool belt or backpack)◦ Trauma involving hip extension◦ Mild repetitive trauma over the nerve
Symptoms◦ Pain and dysesthesia in the anterolateral or lateral thigh that
sometimes extends to the lateral knee◦ Runners describe pain as “electric jab” when affected hip
extends
Physical Exam◦ NO muscle weakness- only a sensory nerve◦ Most reproducible spot of hypoestesia is above and lateral to
the knee with pressure
Differential Diagnosis◦ Lumbar disk herniation (L1-L4)◦ Trochanteric bursitis◦ Hip arthritis◦ Diabetes mellitus or other causes of peripheral neuropathy
Characterized by loss of articular cartilage of the hip joint
Symptoms◦ Gradual onset of anterior thigh or groin pain
(sometimes pain in the buttock or lateral thigh)◦ Initial pain only with activity, gradual increase in
frequency and intensity of pain◦ Decrease ROM◦ Difficulty dressing and donning shoes◦ Occasional limp and stiffness but little pain
Physical Exam◦ Earliest sign is loss of Internal Rotation◦ Decreased overall ROM◦ May develop a fixed External Rotation and Flexion
Contracture◦ Gait:
antalgic gait with decreased stance on affected leg Abductor Lurch- swaying the trunk far over the affected hip
Differential Diagnosis◦ Herniated lumbar disk◦ Inflammatory arthritis of the hip◦ Osteonecrosis of the femoral head◦ Trochanteric brusitis
Death of varying amounts of bone in the femoral head
Causative event may be traumatic disruption of the vascular supply to the femoral head or deficient circulation (sickle cell anemia)
Greatest frequency from 30-50 y.o.
Often bilateral
Risk Factors:◦ Hip dislocation◦ Femoral neck Fx◦ Alcohol abuse/Smoking◦ Sickle Cell Anemia◦ RA◦ Lupus
Symptoms◦ Slow onset of dull ache or a throbbing pain in the groin, lateral hip or
buttock area◦ Initial phase very painful during bone death◦ Secondary arthritis ◦ Limited ROM with progressive limp
Physical Exam◦ Pain with attempted SLR◦ ROM decreased especially in Internal Rotation◦ Gait:
Antalgic gait with short stance phase Trendelenburg gait once arthritis develops
Differential Diagnosis- Made with a radiograph◦ Fracture of the femoral neck◦ Muscle strain or groin pull◦ Osteoarthritis◦ Septic arthritis of the hip
Characterized by a snapping or popping sensation that occurs as tendons around the hip move over bony prominences
Most common site is iliotibial band snapping over greater trochanter
Also occurs when the iliopsoas tendon slides over the pectineal eminence of the pelvis
Symptoms:◦ Occurs with walking or rotation of the hip◦ Patients point to the trochanteric area◦ Iliopsoas snapping pain felt in the groin as the hip
extends from the flexed position (like rising from a chair)
Physical Exam◦ Recreate iliotibial band subluxation by having
patient stand and then rotate the hip while holding it in an adducted position- a snap can be palpated
◦ Iliopsoas snapping can be palpated as the hip extends from a flexed position
Differential Diagnosis◦ Osteoporsis ◦ Osteochondral loose body◦ Osteonecrosis of the femoral head
Cause is vigorous muscular contraction while the muscle is on stretch
Muscles to consider: abdominals, hip flexors(iliopsoas, sartorius, rectus femoris), and adductors
Symptoms:◦ Pain over the injured muscle
Physical Exam◦ Strain of Adductors- tenderness in the groin with
increase pain with passive abduction◦ Abdominals- increased pain when patient flexes trunk◦ Hip Flexor- pain is worse with flexion of the hip against
resistance, or passive extension of the hip◦ Iliopsoas- causes pain in deep groin or inner thigh◦ Proximal Sartorius- more superficial and lateral
Differential Diagnosis◦ Hip avulsion fracture◦ Osteonecrosis◦ Pelvic of femoral tumors
Inflammation and hypertrophy of the greater trochanteric bursa
Symptoms:◦ Pain and tenderness over the greater trochanter◦ Pain may radiate distally to knee or ankle but NOT
foot◦ Pain may radiate proximally to the buttock◦ Pain worse when first rising from the seated or
recumbent position◦ Pain recurs after walking >30 minutes◦ Night pain and inability to lie on affected side
Physical Exam◦ Palpate greater trochanter for point tenderness (this is
a must)◦ Pain exacerbated with active hip abduction◦ Increased discomfort with hip adduction
Differential Diagnosis◦ Gluteal Muscle Tendinitus- pain pattern may be
similar, however usually tenderness is ABOVE the trochanter
◦ Metastatic tumor◦ Osteoarthritis ◦ Sciatica◦ Snapping Hip
FABER test- Flexion Abduction External Rotation- positive test indicates hip joint dysfunction, possible iliopsoas spasm, or sacroiliac joint may be affected
Thomas Test-used to assess a hip flexion contracture, tight iliotibial band
Ober’s Test- tests tensor fasciae latae (iliotibial band) for contracture- can also suggest trochanteric bursitis if it is tender or femoral nerve pathology if neurological signs are present
Straight Leg Raise (SLR)- tight hamstrings, neurological symptoms could indicate lumbar disc dysfunction
Magee DJ. Orthopedic Physical Assessment. 4th ed. St. Louis: Saunders Elsevier. 2006: 425-465,879-903.
Griffin LY, ed. Essentials of Musculoskeletal Care. 3rd ed. Rosemont: American Academy of Orthopedic Surgeons. 2005:928-931