THEP 1: Hip Anatomy and Pathologies

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Questions and Answers

Which of the following structures is NOT considered a primary stabilizer of the hip joint?

  • Acetabular labrum
  • Strong capsule
  • Ligamentum teres
  • Iliopsoas muscle (correct)

The hip joint is classified as which type of joint based on its structure and movement?

  • Condyloid joint
  • Pivot joint
  • Ball and socket joint (correct)
  • Hinge joint

In osteoarthritis of the hip, pain is typically described as:

  • Exacerbated by activity and relieved by rest (correct)
  • Worse in the morning and improves with activity
  • Constant and unremitting, even at rest
  • Sharp, shooting pain radiating down the leg

Which of the following is typically considered the initial management strategy for osteoarthritis of the hip?

<p>Rest and activity modification (B)</p> Signup and view all the answers

A patient with advanced osteoarthritis of the hip is considering hip replacement surgery. What is a typical expected outcome regarding pain relief?

<p>Excellent pain relief in most cases (A)</p> Signup and view all the answers

Which surgical approach to the hip is most likely to be associated with a higher risk of posterior hip dislocation?

<p>Posterior approach (A)</p> Signup and view all the answers

Which of the following is an intraoperative complication specifically related to cemented hip arthroplasty?

<p>Cement related hypotension (D)</p> Signup and view all the answers

Which of the following is a late postoperative complication following hip arthroplasty?

<p>Osteolysis (A)</p> Signup and view all the answers

What is the most common type of hip fracture in the elderly population?

<p>Intertrochanteric fracture (C)</p> Signup and view all the answers

An intracapsular neck of femur fracture is concerning due to the risk of avascular necrosis (AVN). Which of the following is a primary reason for this increased AVN risk?

<p>Disruption of blood supply to the femoral head (C)</p> Signup and view all the answers

According to the Garden classification for intracapsular neck of femur fractures, a Garden III or IV fracture is considered:

<p>Displaced (D)</p> Signup and view all the answers

In the management of a displaced intracapsular neck of femur fracture in an elderly patient with limited life expectancy, which surgical option is often preferred?

<p>Hemiarthroplasty (A)</p> Signup and view all the answers

What is the primary concern regarding the 'femoral calcar' in intertrochanteric fractures?

<p>Its integrity is crucial for fracture stability in weight-bearing (A)</p> Signup and view all the answers

According to the Evans classification of intertrochanteric fractures, which type is considered unstable due to loss of posterolateral support?

<p>Type III (B)</p> Signup and view all the answers

Subtrochanteric fractures are defined as fractures occurring within what distance below the lesser trochanter?

<p>0-5 cm (A)</p> Signup and view all the answers

In pre-hospital care for a suspected hip fracture, what is a key initial step in the integrated care pathway?

<p>Hydration of the patient (B)</p> Signup and view all the answers

According to BOA Blue Book Guidelines, patients with hip fractures should ideally be admitted to an acute orthopaedic ward within what timeframe of hospital presentation?

<p>4 hours (C)</p> Signup and view all the answers

What is a typical radiographic finding in osteoarthritis of the hip?

<p>Osteophytes (B)</p> Signup and view all the answers

In rheumatoid arthritis of the hip, which radiographic feature is most indicative of the inflammatory nature of the condition?

<p>Periarticular soft tissue swelling (A)</p> Signup and view all the answers

For diagnosing Developmental Dysplasia of the Hip (DDH) in infants younger than 6 months, which imaging modality is preferred?

<p>Ultrasound (A)</p> Signup and view all the answers

A lateral center edge angle (Wiberg angle) of less than 15 degrees on hip radiograph is indicative of:

<p>Hip dysplasia (C)</p> Signup and view all the answers

What does the term 'femoral head extrusion index' in DDH refer to?

<p>The ratio of femoral head uncovered by acetabulum to the total femoral head (D)</p> Signup and view all the answers

Pelvic osteotomies, such as the Bernese periacetabular osteotomy, are primarily performed to treat:

<p>Developmental Dysplasia of the Hip (DDH) (C)</p> Signup and view all the answers

Slipped Upper Femoral Epiphysis (SUFE) is characterized by slippage of the metaphysis relative to the epiphysis at which anatomical location?

<p>Proximal femoral physis (A)</p> Signup and view all the answers

What is the typical initial treatment for Slipped Upper Femoral Epiphysis (SUFE)?

<p>Percutaneous in-situ pinning (D)</p> Signup and view all the answers

Femoroacetabular Impingement (FAI) is best described as:

<p>Abnormal contact between the femur and acetabulum (D)</p> Signup and view all the answers

Which imaging modality is considered most useful for assessing chondral and labral damage in Femoroacetabular Impingement (FAI)?

<p>MRI or MR Arthrogram (C)</p> Signup and view all the answers

In Femoroacetabular Impingement (FAI), 'Cam' impingement primarily involves:

<p>A bony prominence at the femoral head-neck junction (B)</p> Signup and view all the answers

Hip arthroscopy for Femoroacetabular Impingement (FAI) is most likely to provide a better outcome in patients:

<p>With minimal to no chondral damage (C)</p> Signup and view all the answers

According to the Irish Hip Fracture Database, approximately what percentage of patients with hip fractures are discharged directly home?

<p>25% (B)</p> Signup and view all the answers

Flashcards

Hip Joint

A ball and socket joint between the head of the femur and the lunate surface of the acetabulum.

Acetabular Labrum

A fibrocartilaginous ring that attaches to the bony rim of the acetabulum, encircling the hip joint.

Ligamentum Teres

A ligament that originates from the non-articular acetabular fossa and inserts onto the head of the femur, providing stability to the hip joint.

Hip Ligaments

Extra articular stability provided by strong ligaments. Includes Iliofemoral, Ischiofemoral & Puboferoral Ligaments

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Hip Joint Capsule Weakness

The capsule is weaker posteriorly and is therefore prone to dislocation in that direction in high energy trauma.

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Bony congruety

Stability of hip joint due to bony congruity and acetabular labrum.

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Osteoarthritis of the Hip

Commonly presents in patients over 40 years old. Pain is the most common presenting symptom.

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Initial OA Management

Restricting activities that exacerbate pain, using NSAIDs, core stability exercises to strengthen hip-girdle muscles & weight loss.

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Radiology of the hip

Plain film X-Ray / Radiograph, MRI, MR Arthrogram

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Hip Arthroplasty

Hip joint replacement can be very successful, with a low complication rate and excellent pain relief for the patient.

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Intracapsular Fracture

A fracture that occurs within the joint capsule of the hip. It includes femoral head and neck fractures.

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Garden Classification

A classification system for intracapsular neck fractures of the femur.

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Undisplaced femur fracture management

Involves cannulation screws or DHS (+ derotation screw to stabilise).

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Displaced Femur Fracture

These patients should be managed with ORIF or arthroplasty. Time to surgery is key.

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Avascular Necrosis (AVN)

Loss of blood supply to the bone that can occur after a hip fracture, leading to bone death.

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Extracapsular Fracture

A fracture that occurs outside the joint capsule of the hip.

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Subtrochanteric Fracture

A fracture involving the area from 0-5cm below the lesser trochanter.

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Femoral calcar

Key to understanding stability of intertrochanteric fractures is femoral calcar.

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Evans Classification

Type l = undisplaced 2-part (STABLE). Type ll = displaced 2-part (STABLE). Type lll = 3-part with loss of posterolateral support (UNSTABLE).

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Emergency Hip Fracture Pathway

Patients with simple fall and medically stable should be investigated in the emergency department.

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Hip X-rays

X-rays are important in diagnosis of hip fractures as clinical manifestations are not always obvious.

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Osteoarthritis Features

Loss of joint space, osteophytes, subchondral cysts, subchondral sclerosis.

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Rheumatoid arthritis features

Periarticular soft tissue swelling, joint space narrowing, erosions, juxta-articular osteopaenia.

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Developmental Dysplasia of the Hip

A disorder of abnormal development resulting in dysplasia, subluxation and possible dislocation of hip secondary to capsular laxity & mechanical instability

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DDH Diagnosing Dysplasia

Lateral centre edge angle is <15.

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Total Hip Arthroplasty

High rate of total hip arthroplast.

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Slipped Upper Femoral Epiphysis

Common Proximal femur Condition that leads to slippage of the metaphysis relative to the epiphysis

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Femoroacetabular Impingement

Abnormal contact between femur & acetabulum

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FAI Hip Improvement

Improves pain, hip scores, patient satisfaction. Better outcome with no chondral damage

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FAI Aims

Aim to treat pain; Ultimately determined by Chondral damage

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Study Notes

  • With this lecture, THEP 1 Anatomy & Clinical MSK lectures need to be revised
  • Must understand hip pathologies
  • Must understand the investigation and management of hip pathologies

Anatomy of the Hip

  • Ball and socket joint is between the head of the femur and the lunate surface of the acetabulum
  • The acetabular labrum encircles
  • The ligamentum teres from the non-articular acetabular fossa to the head provides stability
  • There is a strong capsule
  • Iliofemoral, Ischiofemoral & Puboferoral Ligaments provide extra articular stability
  • The capsule is strong and attached along the edge of the acetabulum and transverse acetabular ligament proximally
  • Distally attached along intertrochanteric line anteriorly and 1.5cm proximal to intertrochanteric crest posteriorly
  • The capsule is weaker posteriorly, so dislocation is prone to happen in that direction in high energy trauma

Stability of Hip Joint

  • Bony congruety and acetabular labrum provide stability
  • Strong ligaments assist stability
  • Surrounding muscles provide dynamic stabilisation

Common Hip Joint Pathologies

  • Arthritis, predominantly Osteoarthritis, and Rheumatoid Arthritis mainly managed by Rheumatology
  • DMARDs demonstrate huge success in modern medicine
  • Fractures of the hip are common
  • Hip replacement surgery can provide some complications
  • DDH: Developmental Dysplasia of the Hip
  • SUFE: Slipped Upper Femoral Epiphysis
  • FAI: Femoro Acetabular Impingement

Osteoarthritis of the Hip

  • Commonly presents in patients over 40 years old
  • Pain is the most common presenting symptom
  • Pain is usually exacerbated by activity and relieved by rest
  • As the disease process advances, pain may progress to night pain, and functional activity may become limited
  • There is usually associated groin pain

Clinical Examination of the hip

  • Gait assessment is required
  • Involves FABER
  • And FAIR tests
  • Pain assessment at extremes of ROM
  • History of paediatric hip

Radiology and investigations

  • Plain film X Ray / Radiograph in the majority of cases
  • MRI
  • MR Arthrogram

Initial Management of OA

  • Rest is key
  • Modify activities to reduce strain
  • Reduce impact sports
  • Use NSAIDs to manage pain
  • Physio for core stability and hip girdle exercises
  • Weight loss

Definitive Management

  • Hip replacement has a very high success rate
  • Low complication rate
  • Provides excellent pain relief
  • Length of stay is 2-3 days
  • 25 year survivorship is 78%: >80 years, 100%: <40 years, 67%

Outcomes

  • Patient satisfaction is 90% at 4 years
  • Implant survival is 95% at 20 years (>65 years) and risk of major complication <5%

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