HIP AND PELVIS Marlene DeMaio, MD Prof, Dept of Orthopaedic Surgery, Marshall University VAMC HunCngton, WV ACMS Team Physician CourseSan AntonioFeb 2015
HIP AND PELVIS
Marlene DeMaio, MD Prof, Dept of Orthopaedic Surgery, Marshall University
VAMC HunCngton, WV
ACMS Team Physician CourseSan AntonioFeb 2015
OBJECTIVES
• Learn the anatomic landmarks of the hip and pelvis • Demonstrate the basic physical exam • Be familiar with the op:ons for diagnos:c imaging of the hip
• Develop a differen:al diagnosis of hip pathology – Athlete – Older individuals
• Iden:fy urgent/emergent hip pathology
HIP AND PELVIS
• Complex anatomy – Bone – SoD Tissue
• Prevalence of disorders probably higher than reported – Discrete condi:ons – Compensatory/secondary disorders
HIP AND PELVIS ANATOMY
• Bone – Pelvis
• Sacrum • 2 innominante bones
– Hip • Femoral head • Acetabulum
HIP AND PELVIS ANATOMY
• Open physes and fusion varies – Pelvis
• Fusion late teens: ilium, ischium, pubis • 3rd decade: Ischial tuberosity, ASIS
– Hip • Late teens: Femoral head
• Important for stress fx and avulsion fx Anderson AJSM 2001 29:521
HIP AND PELVIS ANATOMY Ligaments
• Strongest of en:re body – Anterior iliofemoral ligament (Y ligament of Bigelow) • Prevents hyperextension
– Pubofemoral ligament • Prevents excessive abduc:on
– Ischiofemoral ligament • Tightens in flexion
– Sacroiliac ligaments (anterior and posterior)
– Sacrospinous ligaments – Sacrotuberous ligaments
HIP AND PELVIS ANATOMY Muscles
MUSCLE GROUP SPECIFIC MUSCLES INNERVATION
Hip Flexors Iliac and psoas Pec:neus Rectus Femoris Sartorius
Femoral nerve
Adductors Adductor brevis & longus Adductor magnus Gracilis
Obturator nerve Obturator nerve and :bial branch of the scia:c nerve Obturator nerve
External rotators Gluteus maximus Piriformis Obturator internus & externus Superior & inferior gemellus
Inferior gluteal nerve Lumbosacral plexus
Abductors Gluteus medius & minimus Tensor fascia lata
Superior gluteal nerve
HIP AND PELVIS ANATOMY Hilton’s Law
The same trunks of nerves whose branches supply the groups of muscles moving a joint
furnish also a distribu:on of nerves to the skin over the inser:on of the same muscles and the interior of the joint receives its nerves from the
same source.
HIP AND PELVIS ANATOMY
• Dermatomes • Muscle Groups
HIP AND PELVIS ANATOMY
• Important nerves – L3 – Scia:c – Obturator
• Physical signs – L3 dermatome – Scia:ca – C sign
Hip Pain
• Hip joint pain – most commonly in the
groin and anterior thigh – may radiate to the knee
• Pain over the greater trochanter – trochanteric bursi:s
• BuXock pain – scia:c nerve – lumbar spine referred pain – Piriformis syndrome
COMMON CONDITIONS • Acute
– SoD :ssue • Muscle strain • Contusions • Labral tears • Bursi:s
– Bone & Car:lage • Avulsions & apophyseal
injury • Fracture • Disloca:on • Loose bodies
• Insidious – Sports hernia – Athle:c pubalgia – Ostei:s pubis – Bursi:s – Snapping hip – Stress reac:on and fx – OA
• Referred pain – Lumbar spine – Compression Neuropathies
ADer Anderson AJSM 2001 29:521
History • Mechanism – Acute injury – Overuse – Preceding events
• Loca:on of pain • Onset of pain • Nature/ severity of pain: PQRST • Childhood or previous hip problems
PHYSICAL EXAM
• Lumbar Spine • Pelvis • Hip • Leg • Knee • Alignment
– Hip version – Knee – Foot
• Leg Lengths
• Inspec:on • Palpa:on • ROM • Special Tests
Leg Length Tests
• True Leg Length – Measure ASIS to medial malleolus
– Posi:ve = 1-‐1.5 cm
• Apparent (Func:onal) Leg Length – Umbilicus to Medial malleolus
PHYSICAL EXAMINATION
• Palpa:on – Greater trochanter –
bursi:s – Pubic rami – fractures – Ischium – fractures,
bursi:s, scia:c nerve
• Meralgia Parasthe:ca – Numbness over the lateral
thigh – Compression of the lateral
femoral cutaneous nerve
PHYSICAL EXAM
• Special Tests – Log roll: most specific for intra-‐ar:cular pathology – Impingment test (flexion/adduc:on/IR): sensi:ve but not specific for hip
– Posterior impingment test (extension/abduc:on/ER) • Aka Faber or Patrick test
– Trendelenburg – Thomas – SI Joint Compression and Distrac:on Test – McCarthy
Posterior Impingment Test (Faber or Patrick’s Test)
• Flexion, ABD, ER • Posi:ve = hip or SI joint
Trendelenberg Test
• Stand on one leg • The WB leg is the involved hip
• Posi:ve test pelvis on opposite side drops – From weak gluteus medius
Thomas Test
• Pt Posi:on = supine with both leg on table
• Evalua:on – One hand under lumbar
region – Passively flex one leg to
chest
• Posi:ve = straight leg raises off table – Increased lordo:c curve
SI Joint Compression & DistracCon Test
• Compression =supine • Distrac:on = supine or side lying
• Evalua:on – Compression overpressure to ASIS
– Distrac:on • Down pressure through anterior aspect of ilium
Ober Test
Lateral Decubitus Stabilize pelvis & flex knee Flex hip à abduct hip à extend hip
If hip does not adduct to midline or below then ITB is over :ght
Intra-‐arCcular Tests
• Log Roll
• McCarthy
• Fitzgerald
Other Tests: PalpaCon of Snapping • Snapping hip – Intra-‐ar:cular
• Any cause of labral or chondral injury – Extra-‐ar:cular
• Medial – Iliopsoas “snaps” over the superior ramus, anterior hip or lesser trochanter
• Lateral – ITB and or edge of the gluteus maximus “snaps” over the greater trochanter
• Posterior: ischiofemoral impingement – Unclear cause: lesser trochanter abuts the ischial tuberosity?
Henning, Sports Health 2014 6:122
IMAGING • Plain radiographs – AP pelvis – AP hip – Cross table lateral hip
• US • CT • MRI-‐contrast for labral & hip joint pathology
IMAGING • Plain radiographs – AP pelvis – AP hip – Lateral hip
• Frog lateral-‐proximal femur – Not a true lateral of the
joint
• Cross table lateral-‐of the hip, true lateral – Trauma – Stress fracture
– False profile
Cross Table vs. Frog Leg Lateral
Role of X-‐rays
• Evaluates the bone – Fracture – Bony lesions
• Helps understand the pathology – DDH – FAI
19 yo with right groin pain over several weeks
ADer returning to running…
Femoral Neck “FaCgue Fx”
• 1905: Belcher’s work with German soldiers • Increased incidence in civilian popula:on in last 20 yrs
• Usually associated with running and marathons
• Stress Fracture – Fa:gue fracture: normal bone, abnormal stress – Insufficiency fracture: abnormal bone, normal stress.
Pathogenesis
• Mechanism – Repe::ve submaximal stresses that exceeds the ability of bone to adapt
– Muscle fa:gue à abnormal gait à abnormal stress
OR
– Increased muscle forces àabnormal stress
THE BONE LOSES
Radiographic EvaluaCon
• Plain films: nega:ve 2/3 (ini:ally), changes usually late.
• Nuclear med: sens 93-‐100%, spec76-‐95% compared to plain films
• MRI: dec signal T1, inc signal T2 and STIR – Greater sens, spec, and accuracy when compared to Nuc Med (Shin et al.)
ClassificaCon
Treatment
Shin JAAOS, 1997
Work Up and Treatment
• Plain X-‐ray! • Non-‐weightbearing with crutches • Bone scan or MRI if x-‐ray nega:ve but clinical suspicion is high
• Maintain non-‐weightbearing un:l bone scan is done and read as nega:ve
• Urgent referral for all femoral neck stress fractures
SCFE
• Males > females • 10-‐13 yo • Obese • Pain referred to the Knee
• Maintain high index of suspicion
Other Bony Lesions
• Pelvic stress fractures – About 4% of stress fx – Usually in runners – Pubic rami fx
• Ostei:s Pubis – Assoc with twis:ng, shearing forces – Xray: Subchondral cysts, osteophytes, sclerosis – MRI: edema
Other Bony Lesions
• Apophyseal avulsions – Up to 24% athle:c injuries in children – Most common (in order)
• Ischial tuberosity: hamstrings • AIIS: direct head of rectus femoris • ASIS: sartorius • Pubic symphysis: adductors (brevis, longus) and gracilis
– Usually non-‐opera:ve management • Consider surgery if acute and > 2cm displacement
Kjellin, Sports Health 2010 2:247
MRI
• Get x-‐rays first • Best with a high resolu:on magne:c (1.5T) • Findings – Effusion: intra-‐ar:cular pathology – Paralabral cyst: labral pathology – Subchondral cysts: early OA
• Intra-‐ar:cular gadolinium is necessary to evaluate the joint (labrum)
X-‐rays in FAI
• Pincer – Cross over sign – Posterior wall sign
• Cam – Pistol grip – SCFE – Kissing lesion
MRI and the Labrum
• Arthrogram – 92-‐97% sensi:vity – 95% accuracy – Triangular shape in younger pts, irregular or round in older pts
– Pathology • Labral
– Fraying at ar:ucular jxn – Tear with separta:on from the ar:cular car:lage
• High associa:on of labral pathology and chondral damage
Lischuk, Sports Health 2010 2:252
MRI
CAM Pincer
MRI
Contusion Muscle Strain
Hip Disorders Are O]en a Syndrome
• Use the history to direct the PE and imaging
• Make a differen:al • Prove the differen:al • Look at the en:re pa:ent
• Correct abnormal mechanics