Hip, Pelvis and Thigh Problems: Anatomy, Evaluation and Management - PowerPoint PPT Presentation

About This Presentation
Title:

Hip, Pelvis and Thigh Problems: Anatomy, Evaluation and Management

Description:

Anatomy, Evaluation and Management Kevin deWeber, MD, FAAFP Director, Sports Medicine Fellowship USUHS Family Medicine (credits to LTC Erik A. Dahl MD for some s) – PowerPoint PPT presentation

Number of Views:422
Avg rating:3.0/5.0
Slides: 85
Provided by: Rodn158
Learn more at: http://sonoranhealth.org
Category:

less

Transcript and Presenter's Notes

Title: Hip, Pelvis and Thigh Problems: Anatomy, Evaluation and Management


1
Hip, Pelvis and Thigh Problems Anatomy,
Evaluation and Management
  • Kevin deWeber, MD, FAAFP
  • Director, Sports Medicine Fellowship
  • USUHS Family Medicine
  • (credits to LTC Erik A. Dahl MD for some slides)

2
Objectives
  • Review pertinent hip, pelvis and thigh anatomy
  • Describe clinical presentation of injuries
  • Review best examination techniques for the hip
  • Briefly outline treatment for common conditions

3
Hip Examination
  • Anatomy
  • History
  • Physical Examination
  • Radiology and Laboratory

4
BONY ANATOMY
5
(No Transcript)
6
(No Transcript)
7
(No Transcript)
8
Hip Capsule Ligaments
Iliopsoas bursa
9
(No Transcript)
10
(No Transcript)
11
(No Transcript)
12
Bursae
  • Trochanteric bursa
  • Between the greater trochanter and ITB
  • Ischial bursa
  • Between the ischial tuberosity and the overlying
    gluteus muscle
  • Iliopsoas bursa
  • Between the iliopsoas tendon and the lesser
    trochanter, extending upward into the iliac fossa
    beneath the iliacus muscle
  • Largest bursa in the body

13
Hip - Anatomy
  • Multiaxial ball socket joint
  • Acetabulum1/2 sphere
  • Femoral head2/3 sphere
  • Strong ligaments capsule
  • Maximally stable

14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
History
  • Age
  • infancy congenital hip dysplasia
  • 3-12 year old boys Legg-Calve-Perthes, SCFE,
    acute synovitis
  • middle age elderly osteoarthritis
  • Mechanism of injury
  • land on outside hip
  • land on knee
  • repetitive loading

18
History
  • Pain details
  • location
  • snapping
  • progression of symptoms
  • exacerbating factors
  • alleviating factors
  • Weakness
  • Occupation, Sport

19
Observation
  • Gait
  • Posture
  • Balance
  • Limb position
  • shortened, adducted, medially rotated
  • abducted, laterally rotated
  • shortened, laterally rotated
  • Leg shortening

20
Inspection
  • Pelvic unleveling (iliac crest levels)
  • Pelvic rotation (PSIS levels)
  • If asymmetric, measure leg lengths

21
Leg Length Measurements
  • Eyeball method
  • Measurement method

22
Anterior Palpation
Iliopsoas bursa
23
(No Transcript)
24
Posterior Palpation
25
Sciatic nerve palpation
26
Range of Motion pearls
  • Quick screen w/ Log-roll IR/ER
  • pain may be from intra-articular fracture,
    synovitis, or infection
  • Decreased IR
  • First plane to be painful in OA

27
Range of Motion
  • Flexion 110 to 120 degrees
  • Extension 10 to 15 degrees

28
  • Abduction 30 to 50 degrees
  • Adduction 30 degrees

29
  • External rotation 40 to 60 degrees
  • Internal rotation 30 to 40 degrees

30
Examination
  • Strength testing
  • isometric
  • eccentric
  • knee extension
  • knee flexion

31
Hip Flexion Strength
Iliopsoas, rectus femoris, sartorius, tensor
fascia lata, pectineus
32
Hip Extension Strength
Hamstrings, gluteus maximus
33
Hip Adduction Strength
Adductor longus, adductor brevis, adductor
magnus, gracilis, pectineus, oburator externus
34
Hip Abduction Testing
Gluteus medius, gluteus minimus, tensor fascia
lata
35
Internal Rotation Strength
Gluteus medius, gluteus minimus, tensor fascia
lata
36
External Rotation Strength
Piriformis, Obturator internus externus,
Superior/inferior Gemelli, Quadratus femoris,
Gluteus maximus
37
Abdominal strength
38
Special Tests
  • Patricks Test(FAbER)
  • hip joint
  • SI joint

39
Gaenslens Sign
Pain at ipsilateral SIJ is positive test
40
Special Tests
  • modified Thomas Test
  • hip flexor and quad flexibility

41
Special Tests
  • Ober Test
  • iliotibial band flexibility

42
Special Tests
  • Piriformis Test
  • Piriformis flexibility or pain

43
Special Tests
  • Popliteal Angle
  • Hamstring flexibilty

44
(No Transcript)
45
Special Tests
  • Labral Injury
  • FAdAxL flexion, Adduction, Axial Load some
    IR/ER
  • pain /- click

46
True Hip Pain Misdiagnosis Common
  • The patients studied by Lesher's team received
    hip injections for pain. Prior to hip injecton,
    patients told doctors where they felt pain
  • Buttocks 71
  • Thigh 57
  • Groin 55
  • Lower leg 22
  • Foot 6
  • Knee 2
  • SOURCE John Lesher, M.D. 22nd Annual Meeting of
    the American Academy of Pain Medicine, San Diego,
    Feb. 22-25, 2006. News release, American Academy
    of Pain Medicine.

47
Think outside the pelvis!
  • Abdominal exam
  • Obturator and Iliopsoas signs
  • Back exam
  • Pelvic exam in females
  • Hip joint problems can radiate to KNEE

48
Diagnostic Imaging
  • Radiographs
  • Anterior-Posterior view
  • Frog leg view
  • STANDING films to r/o early OA
  • Bone scan stress fxs
  • CT subtle fractures
  • MRI soft tissue, stress fx
  • Arthrogram labral tears

49
Approach to hip problems
  • Better anatomy knowledge ? better diagnoses
  • Differentiate Anterior, Lateral, and Posterior
    Hip Pain
  • Develop an appropriate differential based on the
    location and the exam
  • Consider AGE in DDx

50
Margo K, et al. Evaluation and management of hip
pain An algorithmic approach J Fam Pract. 2003,
528
51
Common Hip Problems by Age
  • Newborn Congenital dislcation of hip
  • Age 2-8 AVN of hip (Legg-Calve-Perthes),
    sysnovitis
  • Age10-14 Slipped Cap Fem Epiphysis
  • Age 14-25 Stress Fracture
  • Age 20-40 Labral Tear
  • Age gt40 Osteoarthritis

52
Anterior Hip Pain
  • Differential Dx
  • Osteoarthritis
  • Muscle strains or tendinopathy
  • Stress fracture (femoral neck, pubis)
  • Sports hernia
  • Osteitis pubis
  • Acetabular labral tears
  • Obturator or ilioinguinal nerve entrapment
  • Meralgia paresthetica (may be lateral)
  • Inflammatory arthritis
  • Iliac crest apophysitis
  • AVN of femoral head

53
Lateral Hip Pain
  • Differential Dx
  • Greater trochanteric bursitis
  • ITB
  • Meralgia paresthetica
  • OA, labral tear, AVN
  • TFL or gluteus medius strain

54
(No Transcript)
55
Posterior Hip Pain
  • Differential Dx
  • Lumbar spine disease and radicolopathy
  • Eval for red flags
  • Sacroiliac joint disorders
  • Hip extensor strain or tendinopathy
  • Glut max, hamstrings
  • External rotator strain
  • Piriformis strain or syndrome
  • Aortoiliac vascular occlusive disease (rare)

56
(No Transcript)
57
Specific Conditions
58
Osteitis Pubis
  • Repetitive trauma to pubic symphysis due to
    overuse
  • Running/cutting, esp soccer, football,
    basketball
  • S/Sx insidious onset dull anterior groin pain
    may radiate TTP over PS /- pain w/ resisted
    Adduction or passive Abduction
  • Xrays helpful
  • Tx relative rest, brief NSAID, cross-tng,
    stretching/strength rehab,
  • consider steroid injection

59
Hip Pointer
  • Contusion to the iliac crest
  • S/Sx pain, swelling, and ecchymosis
  • severe limit to motion
  • /- palpable hematoma
  • Xrays to r/o fractures
  • TX rest, ice, compression, ?benefit from
    steroid/lido inj after acute phase, progressive
    ROM, strength rehab
  • RTP padding over area

60
Piriformis Syndrome
  • Pain due to sciatic nerve compression at
    piriformis
  • Cause trauma, prolonged sitting, overuse
    anomalies in 15-20
  • S/Sx
  • dull buttock pain /- radiation into leg
  • TTP over mid-buttock
  • Pain worse with passive IR or resisted ER
  • -Tx relative rest, ER stretching, /- steroid
    injection

61
Trochanteric bursitis
  • Causes
  • friction between IT band, glut medius/minimus/max
    and greater trochanter common in running w/
    improper biomechanics and overtraining
  • direct blows
  • S/Sx
  • local pain, tenderness over the greater
    trochanter
  • Eval for leg length discrep, adductor/abductor
    muscle imbalance, hyperpronation
  • Tx relative rest, ice, brief NSAID, ITB
    stretching, /- steroid injection
  • Address biomechanical defects above

62
Ischial bursitis
  • Cause excessive friction over ischial
    tuberosity, or direct blow (hematoma, scarring)
  • S/Sx pain with sitting, TTP over ischial
    tuberosity, pain w/ passive hip flexion and
    active/resistive hip extension
  • Xray to r/o fractures in traumatic hx
  • Tx
  • Ice, padding, brief NSAID
  • Prolonged steroid injection
  • Refractory surgical excision

63
Iliopsoas bursitis
  • Cause overuse of hip flexors
  • S/Sx
  • anterior hip pain, /- snap
  • preferred position of hip in flex/ER,
  • TTP to deep palpation anteriorly,
  • pain with passive hip extension
  • Tx relative rest, ice, brief NSAID, stretching
    of iliopsoas,
  • /- steroid injection (preferably w/ guidance)

64
Sports hernia
  • TTP lower abd wall
  • No palpable hernias
  • Co-incident injuries
  • Adductor tendinopathy
  • Osteitis pubis
  • Imaging consider MRI to r/o other conditions
  • Dynamic US helpful?
  • Tx relative rest, flexibility, strength ?
    surgery if refractory

65
Muscle strains
  • Adductors, gluteals, quads, hamstring tears
    usually from overstretching during eccentric
    contraction, esp when muscle fatigued
  • Risk factors
  • Early in season
  • Muscle imbalance, inflexibility, inadequate
    warmup
  • S/Sx localized pain and TTP, /- swelling or
    ecchymosis , rarely palpable muscle defect, and
    decreased ROM
  • Graded I, II, III similar to sprains
  • Xrays to r/o avulsion fxs if near muscle origins
    MRI if suspected complete tear
  • Tx PRICEMM, Rehab (ROM?strength?cardio?sport-spe
    cific tng)

66
(No Transcript)
67
Quadriceps Contusions
  • Direct blow to muscle causes tissue damage
  • S/Sx localized TTP, /-ecchymosis
  • Grade I knee flexion gt90
  • Grade II knee flexion 45-90
  • Grade III knee flexion lt45
  • Tx PRICE avoid NSAID 48 hrs
  • Max knee flexion, wrap in place 24 hrs
  • Crutches, gradual WB, rehab (ROM?strength)
  • RTP when FROM, 90 strength, activity w/o pain
  • Complications
  • Compartment syndrome (acute)
  • Myositis ossificans (chronic)
  • Slowly enlarging mass, redness, increasing pain
  • Xrays 3-4 weeks, BS/US sooner

68
Stress Fractures
  • Caused by repetitive overuse stresses
  • RFs training errors, females, inadequate
    footwear, intrinsic factors
  • Pelvic, femoral neck, femoral shaft
  • S/Sx insidious pain w/ activity /- local TTP
    or pain w/ hop test, /- decreased ROM
  • Xrays first, MRI or BS if neg but suspected
  • Tx
  • Femoral immediate NWB, Ortho referral
  • Tension side?surgery
  • Pelvic/femoral shaft painless relative rest
    graduated WB, strength/stretching rehab, address
    other RFs

69
(No Transcript)
70
Hip fractures
  • Most common through femoral neck, various
    traumatic causes
  • S/Sx pain, swelling, and loss of function
  • Involved leg shortened and externally rotated
  • Tx Ortho referral, surgery

71
Hip Dislocation
  • Femoral head usually goes posteriorly
  • common mechanism knee to dashboard during
    traffic collision
  • S/Sx extreme pain, obvious deformity, unwilling
    to move the extremity position typically
    flexion, adduction, and internal rotation (FAdIR)
  • Tx emergent reduction in ER under sedation
    (Ortho STAT!)

72
AVN of Femoral Head
  • Causes
  • Trauma fxs, hip dislocation, surgery
  • Medical conditions (numerous)
  • S/Sx nonspecific hip pain, may radiate to knee
    exam may be relatively unremarkable, with decr
    IR/ER as dz advances
  • Xrays usually diagnostic gt3mo duration MRI or BS
    if normal
  • Tx make pt NWB and refer to Ortho
  • Conservative tx vs hip replacement depending on
    severity

73
Conditions in adolescents and children
74
Pelvic Apophysitis
THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO. 1
- JANUARY 2001
75
Pelvic Apophysitis
  • Cause overuse at tendinous insertion at
    apophysis
  • Iliac crest gt ASIS, AIIS, lesser troch, greater
    troch, ischial tuberosity
  • S/Sx localized pain, TTP, pain w/ passive
    stretch of attached muscle
  • Xrays to r/o avulsion fxs
  • Tx relative rest (rare crutches), ice, brief
    NSAID?, cross training, strength rehab,
    flexibility

76
Pelvic Avulsion Fractures
  • Caused by violent contraction of the attaching
    muscle in skeletally immature athlete
  • Sprint, jump, soccer, gymnast, dancer, football
  • Ischial tuberosity gt AIIS gt ASIS gt iliac crest,
    lesser troch, greater troch
  • S/Sx sudden pain /- pop, poor ROM, local pain
    and TTP /- muscle bulging away from the
    attachment
  • Xrays needed to eval size/displacement
  • Tx PRICEMM, progressive rehab
  • Ortho referral if displacement gt2 cm

77
Slipped Capital Femoral Epiphysis (SCFE)
  • Slippage of femoral epiphysis laterally off
    femoral head
  • Most prevalent ages 9-15, esp overweight
  • Bilateral up to 50
  • S/Sx insidious poorly localized hip/groin pain
    /- radiation to knee, worse w/ activ
  • May have limited IR
  • Xrays usually diagnostic MRI early if neg but dz
    suspected
  • Tx immed NWB, Ortho referral, surgery

78
Klines Line tangent to superior femoral neck on
AP view
Abnormal Less or no transsection of physis
Normal transsection of physis
79
(No Transcript)
80
(No Transcript)
81
Legg-Calve-Perthes Dz
  • Avascular necrosis of proximal femoral epiphysis
  • Most prevalent ages 4-9, males 41
  • Develops slowly
  • S/Sx intermittent deep hip pain worse w/
    activity, /- radiating to groin, ant/med thigh,
    knee
  • limping, decreased ROM, and hip flexor tightness
    may be noted
  • Xrays usually diagnostic MRI or BS early if xray
    neg but AVN suspected
  • Tx Ortho referral crutches, pain meds

82
Acute Transient (Toxic) Synovitis
  • inflammatory process of hip w/ chronic irritation
    and excess secretion of synovial fluid within the
    capsule ? cause
  • Most common dx in limping child lt10, but its a
    Dx of exclusion
  • r/o septic arthritis, SCFE, stress fx, etc.
  • Xrays normal MRI helpful ruling out other causes
  • Labs normal CBC, CRP
  • S/Sx pain w/ walking, low-grade fever
  • Tx relative rest, analgesics

83
Conclusion
  • Know your anatomy
  • Know why youre doing an exam

84
References
  • Birrer R. and OConnor F. Sports Medicine for the
    Primary Care Physician. Boca Raton CRC Press,
    2004.
  • Greene W. Essentials of Musculoskeletal Care.
    Rosemont American Academy of Orthopaedic
    Surgeons, 2001.
  • Hoppenfeld S. Physical Examination of the Spine
    and Extremities. East Norwalk Appleton-Century-Cr
    ofts, 197659-74.
  • Lillegard W. Evaluation of Knee Injuries. In W
    Lillegard (ed), Handbook of Sports Medicine.
    Boston Butterworth-Heinemann, 1999 233-249.
  • Netter F. Atlas of Human Anatomy. West Caldwell
    CIBA-Geigy, 1989.
  • Tandeter H. et al. Acute Knee Injuries Use of
    Decision Rules for Selective Radiograph Ordering.
    American Family Physician. Dec 1999 60
    2599-608. (For Radiograph Images)
Write a Comment
User Comments (0)
About PowerShow.com