Hip and Femur

Hip and Femur

Overview

·        Primary concerns:

o   Range of motion

o   Gait

·        Also need to examine

o   The lower back and sacro-iliac joints

o   Vasculature of the leg: pulses, temperature, capillary refill

o   Peripheral nerves: eg sensory

·        Problems arising with the hip:

o   Fracture

o   Arthritis

o   Dislocation: trauma, also in congential abnormalities, infection, Cerebral Palsy

o   Epiphyseal dislocation (typically a chubby 11 year old boy with a slipped femoral epiphysis)

o   Infection: septic arthritis

 History

·        Impact on daily activities

·        Walking distance

·        Climbing stairs

·        Getting out of low chairs

·        Location:

o   Anterior/groin pain: ?hip

o   Lateral: ?trochanteric bursitis, referred from spine

o   Posterior: referred from spine, gluteus medius tendonitis

Hip Exam

·        Inspection

o   While standing:

§  Observe gait

§  Walking:  on toes (tests S1), on heels (test L5) 

§  Observe from front and do Trendelenberg‟s test: thumb on each ASIS while they alternate standing on one leg. Sagging to contra-lateral side is Trendelenburg positive (ie lack sufficient abductor strength to stabilise pelvis) 

§  Observe from back: wasting of gluteals, posterior surgical scars, etc 

§  Test the joint above (sacro-iliac joints and lumbar spine): Bend over (measure how far they do down – eg fingers to floor, toes, mid-calf, etc). Extend back

§  Test the joint below: crouch down to test knees

§  Palpate sacro-iliac joints and lumbar spine for tenderness

o   On bed, look especially for:

§  Scars, hernia, bruising, inflammation

§  Muscle wasting: gluteals, quads, biceps and adductors

§  Leg length (check they‟re lying straight and pelvis is straight):

·        Real leg length discrepancy: Measure ASIS to medial melleolus on each side. If there is a discrepancy then flex both knees to isolate the discrepancy to above or below the knee

·        Apparent leg length discrepancy: measure umbilicus to medial melleolus. If discrepancy but no real leg length discrepancy then postural cause

·        Palpation:

o   Groin: lumps: hernias, lymph nodes, femoral artery aneurysm Þ pain is not hip pain

o   Check for ilio-tibial band pain over the greater trochanter Þ pain is not hip pain

·        Range of motion: always state start and end: from X to Y degrees (eg adduction from 0 to 30 degrees)

o   Compare sides 

o   Thomas test for fixed flexion deformity (ie not full extension): Bring up good leg with hand under the spine. When pelvis starts to flex the bad leg won‟t be able to remain straight if there is fixed flexion deformity. Quantify by measuring the degrees that the bad leg has risen from lying flat 

o   Test flexion 

o   To test adduction (0 - 20º) and abduction (0 - 50º), stabilise hip by holding hand across both ASIS or abduction the opposite leg

o  Internal (0 - 45º) and external rotation (0 - 45º): flex hip and knee and lever hip using lower leg

o  Don‟t test extension

·        Finally check: 

o  Leg pulses ® relevant to operative risks

o  Joint above: did this while standing

o  Joint below: check knee

·        X-ray

Injury

·        Fracture of Femoral Neck:

o  Commonest site in elderly, associated with osteoporosis

o  Types: subcapital, transcervical, basicervical, intertrochanteric

o  Clinical: History of fall, pain in hip. Patient lies with limb in lateral rotation and leg looks short 

o  Location: key issue is disruption of blood flow to the femoral head. Most blood flow is via the attachment of the capsule. If disrupted (via a fracture at or above a basicervical fracture) ® avascular necrosis 

o  Treatment: Operative mostly. Displaced fractures will not unite without internal fixation.

o   Richardson‟s screw often used, otherwise hip replacement

o  Complications include: dementia, pressure sores, pneumonia, urinary infection, not liver failure

o  Clinical difference between a dislocated femur and a fractured neck of femur: both are shortened. 

o   Neck of femur: leg externally rotated, dislocation: leg internally rotated („in points out and out point in‟)

·        Femoral shaft Fracture: 

o  Clinical: Mostly young adults. Shock is severe and with closed fracture fat embolism common. Leg is rotated externally may be short and deformed. Thigh swollen and bruised. Shock MUST be treated, ABG should also be done 

o  Risk of fat embolism: do CXR (?pleural effusion, congested pulmonary veins etc)

o  Treatment: Intramedullary nailing

·        Comminuted fractures of the femur:

o  Mechanism: violent trauma (eg motor bike accident)

o  Traction or external fixation +/- grafting to fill the gaps

·        Supracondylar fracture of the distal femur:

o  Mechanism: Forceful flexion/hyperextension in osteoporotic bone

o  Gastrocnemius then pulls the femur forward

o  Internally fixate with long blade plate

·        Condylar fracture of the femur: 

o  Mechanism: Fractures entering the intercondylar notch can divide a condyle from the femur (eg knee hitting the dash board) 

o  Management:

§  Undisplaced: aspirate + traction for 4 weeks then cast

§  Displaced: open reduction and internal fixation

o  Complications: avascular necrosis, collapse, varus or valgus deformity