COXA SULTANS Dr. TARUN KUMAR BADAM UNDER GUIDANCE OF : PROF A. DEVADOSS Dr. SATHISH DEVADOSS
COXA SULTANSDr. TARUN KUMAR BADAM
UNDER GUIDANCE OF : PROF A. DEVADOSS Dr. SATHISH
DEVADOSS
COXA SULTANSCase Report : 24yr old male patient, operated case of shaft of femur # for which IMIL Nailing was done , presented for follow-up
Incidentally, Snapping of the IT band over GT was seen , which was asymptomatic
This is External Snapping Hip or External Coxa sultans
COXA SULTANS Coxa sultans, or ‘Snapping Hip’ is characterised by an audible snapping, usually with flexion and extension of the hip during exercise or simply with normal daily activities. Mostly it is asymptomatic, but some patients have pain and discomfort Types of Coxa sultans :
(a) Extra-articular - External - Internal (b) Intra-articular
EXTERNAL COXA SULTANS
EXTERNAL COXA SULTANS
Most common type of Coxa sultans or Snapping Hip
It is mainly due snapping of IT Band,Gluteus maximus and TFL complex over Greater Trochanter of the hip
Seen in Athletes, Ballet dancers, Soccer players
ANATOMYIT BAND takes origin from iliac crestProximally, gives attachment to TFL anteriorly and Gluteus maximus posteriorlyDistally, attached to Linea Aspera of femur and Gerdy’s tubercle on Antero lateral aspect of TibiaComplex origin and Insertion of this structure allows it to be taut in all ranges of motion
In the undersurface of IT Band, GT is present which is separated from it by Trochanteric bursa
ETIOPATHOGENESISAny increase in tension in the already taut IT
Band, with repeated movements of flexion and extension
Increased friction over GT
Trochanteric bursitis and Chronic fibrosis of IT Band Complex
Snapping of IT Band over GT
EXTERNAL COXA SULTANS
CAUSES OF INCREASED TENSION IN IT BAND COMPLEX
Excessive Flexion and Extension of the hip
Femoral anteversion
Femoral retroversion
Internal tibial torsion
Excessive foot pronation
Other CausesWeakness of Hip Abductors
After Total Hip Replacement
- Curved femoral stem
- Placement of femoral component is too far medial
- Angulation in relation to long axis of the femur
CLINICAL FEATURESPatients will c/o Snapping sensation over lateral aspect of hip
Sometimes, associated with discomfort
Confirmation
- Patient should be in Left lateral or Right Lateral position
- Hip is actively flexed by the patient, and examiner palpates over GT for the snapping
- Snapping can be blocked by applying pressure over GT
INVESTIGATIONS
MRI Scan of Hip: Thickening of the Posterior border of IT Band or Anterior border of Gluteus maximus
INTERNAL COXA SULTANS
INTERNAL COXA SULTANSIt is due to Snapping of Iliopsoas musculotendinous unit over Head of the Femur (mainly), followed by Ilio-pectineal ridge and Lesser Trochanter
Seen mainly in Rowers
ANATOMYMusculotendinous unit of Iliopsoas
passes in the osseous groove between AIIS
and Iliopectineal eminence
From it’s lateral position when hip is in flexion, to it’s medial position when hip is in extension, Iliopsoas tendon remains in the osseous groove
It moves back and forth on the Head of the femurIn Rowers, strong Iliopsoas can cause snapping during this movement
ETIOLOGY
Tight Iliopsoas musculotendinous unit
Exostosis of Lesser Trochanter
Exostosis of Iliopectineal ridge
CLINICAL FEATURESPatients will c/o Snapping sensation over anterior aspect of hip
Sometimes, associated with discomfort
Confirmation
- Patient should be in supine position
- Hip is actively flexed by the patient, and examiner palpates over Head of the femur for the snapping
- Snapping can be blocked by applying pressure over Head of the femur
INVESTIGATIONS1. MRI SCAN OF
HIP/PELVIS
- Thick Iliopsoas musculotendinous unit
2. Iliopsoas Bursography
- Snapping of Iliopsoas tendon can be seen
INTRA ARTICULAR COXA SULTANS
INTRA ARTICULAR COXA SULTANS
In this type, Snapping occurs mainly due Intra-articular lesions like Labral tears, Loose bodies, and Synovial Chondromatosis
Pain in the hip is more frequent complaint than Snapping
ETIOPATHOGENESIS
Loose bodies can lodge in foveal area of Acetabulum and can lead to Snapping of hip
CLINICAL FEATURES
Patients mainly give a history of trauma
Pain in the hip is the Chief complaint
Can have snapping sensation intra articulately
Quadrant test will be positive in case of Labral tears
INVESTIGATIONS
MRI SCAN OF HIP
- for Labral tears and Loose bodies
MANAGEMENT OF COXA SULTANS
Majority of the patients with snapping hip are asymptomatic and some are incidentally found. In these patients nothing need to be done as it is asymptomatic
Few patients will be symptomatic with minimal discomfort without disturbing the daily routine activities
Very few have severe snapping even with daily activities and pain during the snapping
CONSERVATIVE MANAGEMENTIn all symptomatic patients, initially conservative management is done with
(a) Rest
(b) Avoiding the activities and movements which cause snapping
(c) NSAIDS
(d) Local Hydrocortisone injection
STRETCHING AND STRENGTHENING EXERCISES
CCT AND BFSTCold Compression therapy ( CCT ) :
In 1st 48hrs, CCT is given which decreases the inflammation and pain
Swelling decreases which promotes more blood supply to the site of inflammation
Limits the cellular breakdown and tissue damage
Limits the amount of healing by fibrosis to occur
BLOOD FLOW STIMULATION THERAPY ( BFST )
Once Inflammation and swelling decreases, BFST increases blood flow and oxygen and nutrient supply to the involved site
Accelerates the process of healing of soft tissue
Decreases the risk of muscle atrophy
SURGICAL MANAGEMENT EXTERNAL COXA SULTANS :
Z-plasty of the Ilio-tibial band with excision of Trochanteric bursa
• Anchoring of the Ilio-tibial band to Greater trochanter
• Elipsoid resection of the tract over GT• Resection of posterior half of the tract at the
Gluteus maximus insertion
INTERNAL COXA SULTANS: Lengthening of the postero-lateral tendinous portion of the iliopsoas tendon
INTRA-ARTICULAR COXA SULTANS: Arthroscopically removal of loose bodies and resection of Labral tears
THANK YOU