quiz #3 – hip

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BPT
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76892
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quiz #3 – hip
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2011-04-03 10:36:40
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orthopedics
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orthopedics
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  1. Range of Motion for These Activities
  2. shoe tying
    120° of flexion
  3. putting on pants
    90° of flexion
  4. sitting
    115° of flexion
  5. stairs – up
    70
  6. going downstairs
    40°
  7. Anatomical Considerations
  8. open packed position
    • 30° of flexion
    • 30° of abduction
    • slight external rotation
  9. close packed position of the hip
    • extension
    • abduction
    • internal rotation
  10. capsular pattern
    • motion lose first
    • flexion – abduction – internal rotation (order varies)
    • internal rotation and extension most obviously lost function, abduction, external rotation
  11. common hip impairments
  12. functional range of motion loss
    internal rotation and extension most, then abduction
  13. decreased extensibility
    iliopsoas, external rotators (piriformis), external rotator's( piriformis), it flexors and hamstrings
  14. manual muscle testing loss
    • extension
    • abduction
    • external rotation
  15. a functional problem – foot pronated, flexed.hip, adducted, IR
    medial collapse
  16. History Is Key
  17. what is information you need to gather?
    • age of patient
    • where it hurts
    • how did you hurt it?
    • how often
    • previous treatments
    • signs and symptoms
  18. hip pain usually hurts.... Where?
    generally in front flexion crease, groin area
  19. what are some things to watch for an exam
    • getting in and out of the chair
    • taking shoes on and off
    • city hip impingement test
    • figure 4
    • leg length
    • palpation
  20. hip impingement test
    hip up to 90/90, internal rotation, -will generally produce pain if you have hip problems
  21. hip and back referral pains
  22. some common joints that refer pain to the hip
    SI joint, pain at iliac crest, greater trochanter bursitis
  23. Hip Outcome Measures
  24. what are some examples of hip outcomes?
    • Harris hip for THA
    • Woomac or HOOS = inbetween scales
  25. External Snapping Hip
  26. symptoms
    • IT band and anterior glut max slides over greater trochanter
    • lie posterior with extension and slides anterior with flexion
  27. diagnosis
    • history
    • physical exam
    • dynamic US to see the snapping
  28. progression
    IT band friction syndome leads to bursitis
  29. Labral Tears
  30. symptoms
    • pain
    • catching
    • snapping
    • activity related pain
  31. etiology
    • history of trauma
    • idiopathic
    • hyper mobile
    • femoral acetabular impingement
  32. exam findings
    positive hip impingement sign
  33. test
    • MRI
    • Arthrogram
  34. intervention
    hip arthroscopic or surgical hip dislocation
  35. rehab
    • nonweightbearing with crutches for five days
    • cardiovascular exercise with arm bike
    • proprioceptive training of lower extremity after five days
    • full Pass the range of motion with in two weeks
    • after five weeks gentle running
    • full training after 10 weeks
  36. hypermobility
    • predisposes to labral micro trauma, degeneration or separation
    • could be secondary to underlying soft tissue disorder – Marfans Sydrome, or Ehlers-Danlos syndrome
    • ballet or gymnastics could could induce
  37. Femoral Acetabular Impingement
  38. three types
    • femoral head abnormally shaped
    • acetabulum covers too much
    • both femoral head misshape and excessive acetabulum coverage
  39. CAM type- FH abdnormall shaped
    • caused by shear forces of the neck portion of FH against acetabulum
    • anterior superior cartilage loss over the femoral head and dome
  40. Pincer type lesion
    • repetitive contact stresses of normal femoral head against abnormal acetabular rim
    • results and degeneration, ossification, and caring of the anterior superior portion of the labrum and posterior inferior contre-coup pattern of cartilage loss
    • Acetabular labrum fails first causing degeneration and eventual ossification – worsening over coverage
  41. predisposing positions
    • acetabular protrusion
    • acetabular retroversion
    • malunion of acetabular fx
  42. Groin Strain
  43. characteristics
    muscle tendon junction of abductor longus and gracilis, most common cause of groin pain
  44. differential diagnosis
    • sports hernia
    • osteoarthritis of the hip
    • labral tears
  45. recovery
    must have full pain-free range of motion and 70% of straight to return to activity – 4 to 6 weeks
  46. intervention
    active functional exercise> Modalities
  47. Osteitis Pubis (common)
  48. characteristics
    repetitive shearing forces on pubic synthesis causing pain could be from decreased internal rotation or SI joint mobility causing forces across pubic synthesis
  49. who does this happen to?
    • usually in soccer players
    • ARF
    • rugby
  50. recovery
    self-limiting... 9 months to a year to resolve
  51. Trochanter Bursitis
  52. symptoms
    pain over and superior to greater trochanter that may radiate laterally to knee
  53. etiology
    • trauma
    • overuse
    • often contralateral of bad knee
  54. exam findings
    • side lying
    • positive Ober's test
    • most have tight abductors and TFL
    • pseudo-Trendelenburg
    • want to evaluate in three planes
  55. treatment
    • NSAIDs
    • exercise
    • stretching
    • corticosteroid injections
    • rarely surgery
  56. other hip bursitis
    • iliopectineal bursitis
    • iliopsoas
    • anterior hip difficult to treat, often after THA
    • Ischiogluteal bursitis: Tailor or Weaver bottom..US/Phono/ionto, padding
  57. Hip Pointer
  58. symptoms
    after injury patient flexes forward and toward sided pain
  59. etiology
    • low to the top of iliac crest
    • TLF is usually impacted and hematoma results
  60. treatment
    • ice
    • NSAIDs
    • light stretching into directions opposite pain position
    • preventative padding
  61. prognosis
    • return to activity one week if mild
    • return to activity six weeks is severe
  62. Piriformis Syndrome
  63. symptoms
    pain in the butt, posterior leg,can radiate to calf
  64. differential diagnosis
    L5/S1 radiculopathy
  65. cause
    entrapment of sciatic nerve in piriformis – difficult to diagnose
  66. treatment
    • stretch piriformis
    • exercise internal rotator, flexors, abductors
    • light stretching of extension, abduction, external rotation
    • neutral tension techniques
  67. Nerve Entrapments
  68. obturator
    • pelvic fracture
    • hernia to obturator formen
    • medial groin pain
    • adductor weakness
  69. lateral femoral cutaneous
    • meralgia parasthetica
    • obesity
    • tight belts
    • trauma
    • physical therapy/injections
    • no motor weakness
    • just sensory
  70. sciatic nerve
    • postsurgical
    • Fibular
    • tibial, or both; fubular drop foot
  71. ilionguinal
    after hernia repair, appendectomy, or by trauma and excessive ab training; numbness/pain in testicle or labia
  72. Avulsion Injuries
  73. etiology
    • usually for stretching and flexibility... Sprinters, hurdlers, adolescent athletes
    • eccentric muscle contraction
  74. different spots
    ASIS
    AIIS
    lesser trochanter
    greater trochanter
    • ASIS = Sartorius
    • AIIS = practice for Morris
    • lesser trochanter = iliopsoas
    • greater trochanter = gluteus medius or piriformis
  75. treatment
    • protected weight-bearing
    • avoid high forces that place stresses at site of injury
    • surgery is significantly displaced
    • shut down and treat like fracture; six – eight weeks
  76. Myositis Ossification's
  77. characteristics
    bone forming within muscles
  78. treatment
    • no well-defined protocol
    • aggressive stretching/exercising can accelerate, so you want to be gradual and less aggressive when stretching
  79. intervention
    surgery or radiation may be necessary if condition progresses
  80. Metastatic Disease
  81. symptoms
    • pain with fabulation, rest, and night pain
    • point tender
  82. etiology
    • history of tumor
    • common metastasis with lung, breast, prostate cancers
  83. testing
    X-Ray, bone scan, MRI
  84. other
    may be referred by PCPs as "pain, evaluate and treat"
  85. hip degenerative joint disease
  86. goals of treatment
    will eventually require surgery so want to get them strong, flexible, and increase cardiovascular fitness, can't cure them
  87. treatment
    • increase range of motion and manual muscle strength >>> Especially with extension, internal rotation, and abduction
    • balance and gait training
    • traction at hip
    • endurance and cardiovascular wellness
    • address functional activities – need outcome measurements
  88. surgical hip dislocation
  89. risks
    • avascular necrosis
    • greater trochanter non-union
    • pain from hardware
  90. prognosis
    • decrease impingement and pain
    • stoppe degeneration
    • preventive need of THA
  91. intervention
    • TTWB x 6-8 weeks until osteotomy heals
    • <70 degrees
    • anterior hip dislocation precautions
  92. precautions
    if already have arthritis then cannot be a candidate
  93. Avascular Necrosis
  94. interruption of?
    femoral head blood supply – 90% –medial femoral circumflex; 10% ligament of head of teres
  95. advanced stages
    collapse of subchondral bones supporting the overlying cartilage
  96. presents as
    acute onset of severe hip pain – may be bilateral
  97. metabolic causes
    • steroids
    • renal disease
    • thyroid
    • alcoholics
  98. imaging
    • MRI early
    • X ray in advanced stages
  99. treatment
    • pre-collapse; observation, core decompression, fibular vascularized autograft
    • post-collapse; total hip, hip resurfacing
  100. stress fractures
  101. common places
    femoral neck compression (green – treated conservatively) or tension ( read – needs to be treated with pinning), pubis, ramus, sacrum
  102. causes
    • recent changes in mileage
    • intensity
    • surface
    • shoes and training
    • disordered eating
    • menstrual cycle and age of menarche
  103. symptoms
    • insidious onset
    • early on pain with activity
    • later on pain at rest to pain with internal rotation
  104. testing
    • MRI = gold standard
    • T-1 fat is white
    • T-2 water is white so can see swelling
  105. treatment
    • relative rest – cycling, deep well running, swimming, going
    • surgery; femoral neck or inter-trochanter fracture
    • Cross training to promote blood flow without stress
  106. Hip Fracture
  107. common causes
    20 – 40 = high-energy trauma ( watch for AVN) >60 = low-energy trauma (falls)
  108. types of fractures
    • femoral neck
    • inter trochanteric
    • subtrochanteric
  109. symptoms
    knee pain
  110. Healing
    elderly: simple fracture = 6-8 weeks, severe fracture = 3 months
  111. Intracapsular fx
    • femoral neck fracture
    • risk of AVN
    • surgery; nondisplaced or valigus impact=screws; displaced:hemiarthroplasty, bipolar or THA
  112. extra capsular fracture
    • intertrochanteric
    • surgery;hip compressions screw, intramedullary hip screw
  113. mortality
    • 10 – 40% in first year
    • about 1/2 of those from deep vein thrombosis
  114. weight bearing Considerations for Hip Fractures
    • NWB - 0% body weight – need Walker/crutches
    • TDWB (touch down) -10 – 20% BW ( need Walker/crutches)
    • PWB – 30% BW (need Walker/crutches)
    • 50% WB – 50% BW ( need cane)
    • FWB – 70 – 100% (can/no device)
  115. considerations for hardware
    • different hardware devices allow different amounts of weight bearing
    • screws, plates, rods, can usually allow more weight bearing the nails
    • cemented can wait there more than non-cemented
  116. rehab protocol
  117. day 1 – 2
    • Quad sets, hamstring sets, ankle pumps, glut sets, AAROM of flexion, abduction, abduction
    • Heel slides, bed mobility transfers, upper extremity exercises
    • initiate ambulation – stay away from internal/external rotation because could move fracture
  118. day 3- 7
    • SLR in all directions, like Quad sets
    • ADL devices
    • sit in chair, sit stand, ambulate twice a day
  119. week 1-2
    probably home health
    • independent transfers and bedroom
    • ambulate 50 feet and have home program
    • if they don't fit these criteria then extended rehab facility
  120. week 2 +
    • standing 4 way hip; focus on glut/hip MMT
    • progress from Walker to cane
    • bike, pool, treadmill
  121. HIP OA
  122. causes
    Femoral-Acetabular impingement, posttraumatic, DDH, Perthes
  123. symptoms
    groin or buttock pain, decreased internal rotation
  124. exam findings
    • find location
    • extent and type of pain
    • restricted motion
  125. testing
    • x-ray; show joint deterioration
    • lab test; rule out other diseases
  126. treatment
    • NSAIDs
    • weight loss
    • exercise
    • activity modification
    • AD
    • joint replacement surgery
  127. goals
    • control pain and symptoms
    • increase function
    • educate patients and families
  128. Inflammatory Diseases
  129. causes
    rheumatoid, lupus, other systemic diseases
  130. symptoms
    • morning stiffness
    • many involved joints
  131. treatment
    • pharmacological
    • AD
    • exercise
    • surgery
  132. lifestyle changes
  133. exercise regularly –
    low-impact, range of motion, pacing your activities

    exercise nourishes Cartledge, keeps bones strong, joints limber, strengthens muscles, prolongs joint life
  134. weight-loss, control
    3 pounds of pressure on joints for every pound of body weight, fat accelerates rate of cartilage destruction
  135. medications
    • aspirin three pain relievers – Tylenol
    • anti-inflammatory drugs – Aleve
    • cortical steroids
    • sleep meds
    • topical creams
    • supplements
  136. orthotics
    • heel wedges, orthotics, and good shoes crucial for aligning legs and keeping pressure off these
    • rubber shoe inserts can decrease impact loading from knees and hips
  137. vitamins/minerals
    arthritis incidence higher in people with low vitamin C and D
  138. Total Hip Replacements
  139. true or false – hip replacements are done to get rid of pain, not for function
    true
  140. characteristics
    • 750,000 hip arthroplasty's
    • 1/3 to 1/2 are THA
    • $15 billion a year
    • 60% paid by Medicare
  141. etiology
    • rheumatoid arthritis
    • osteoarthritis – pain
    • avascular necrosis
    • alcoholism
    • tumor
    • TB
    • congenital hip deformities
  142. fixation type
    cemented or on cemented
  143. surgical approaches
    • anterior
    • anterior lateral
    • direct lateral
    • posterior lateral
  144. rehab goals
    • education
    • guard against dislocation
    • gain functional strength
    • gain hip and knee strength
    • prevent deep vein thrombosis, pulmonary embolism
    • teach transfers and ambulation
    • obtain pain-free range of motion
  145. recommended long-term activities
    nothing non-impact; bike, dancing, golf, Nordic track, swimming, walk, bowl, double tennis, low-impact aerobics
  146. Sir John Charnley?
    father of temporary THA with a head 22 mm, now used 36 – 44 mm (had stability so decreases dislocation of)
  147. Femoral Stem Fixation - un cemented
    • for young population, less loosening long-term
    • living interface between stem and bone
    • TDWW ( with Walker 6 – 8 weeks post op and PWB - check with MD)
  148. Femoral Stem Fixations – cemented
    • cement will eventually microfracture and loosen
    • WBAT – with Walker immediately after surgery
  149. Basic Surgical Procedure
    open the capsule dislocate the hip , saw the femoral neck and ream of acetabulum,brooch with humor and place trials, once in the right place, pressfit or flue femoral component, place ball to reduce hip
  150. Different Surgical Approaches
  151. anterior
    • extension, adduction, and external rotation (TFL, glut med)
    • muscle sparing – so quicker recovery
    • Meralgia peresthetica - anterlateral femoral cutaneous nerve gets irritated
    • precautions 0 – 3 months: no long strides walking or backwards walking, don't kneel on surgical side, avoid extreme abduction or external rotation, don't. Unplanted could, don't swing surgical leg out of bed, don't crossleg
  152. direct lateral
    avoid hip extension, adduction, external rotation and abduction exercises
  153. posteriolateral
    • avoid hip flexion, adduction, internal rotation ( and external rotation exercises)( TFL, Glut max, ER)
    • most commonly done
    • slightly higher dislocation rate
    • precautions 0 –3 months – don't flex > 90, don't cross legs in chair or bed, don't adduct past midline, avoid low chairs
  154. Rehab Protocol
  155. preop
    instruct on precautions, transfer and ambulation instructions, demo they want to exercises
  156. day 1 - 2
    • Quad sets, hamstrings sets, glut sets, ankle pumps
    • 4 way isometrics
    • straight leg raise, heel slide <90
    • up in chair 2x's a day, transfers, upper extremity exercises, initiate appropriate ambulation ( cemented versus non-cemented
  157. day 3 - 7
    straight leg raises, abduction, adduction, supine – stand, light quad stretch
  158. week 1-2 (discharge criteria)
    • independent transfers, bedroom, home program, and straight leg raise
    • ambulate 50 feet
    • if not met, need extended rehab facility
  159. at discharge
    • install elevated toilet seat
    • home exercise program
    • no driving for six weeks
  160. Components of THA
    • femoral stem = titanium alloy
    • acetabulum = cobalt, chrome, titanium or tantalum component
    • acetabulum liner = polyurethane, ceramic or metal
    • femoral head = general metal or plastic
  161. Bad THA
    metal on metal: durum, depuy ASR, early loosening, metallosis, pseudo-tumors, ALVAL
  162. How Hip Dislocation Looks
  163. posterior dislocation
    foot rotated in and length is shortened
  164. anterior dislocation
    foot rotated out and leg shortens
  165. Hip Resurfacing
  166. indications for <55 550 you with active lifestyle andgoof FH, will have no....?
    Activity restrictions after six months

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