HIP AND PELVIS. Marlene DeMaio, MD. ACMS Team Physician Course San Antonio Feb 2015

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1 ACMS Team Physician Course San Antonio Feb 2015 HIP AND PELVIS Marlene DeMaio, MD Prof, Dept of Orthopaedic Surgery, Marshall University VAMC HunCngton, WV

2 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

3 HIP AND PELVIS Complex anatomy Bone SoD Tissue Prevalence of disorders probably higher than reported Discrete condi:ons Compensatory/secondary disorders

4 HIP AND PELVIS ANATOMY Bone Pelvis Hip Sacrum 2 innominante bones Femoral head Acetabulum

5 HIP AND PELVIS ANATOMY Open physes and fusion varies Pelvis Hip Fusion late teens: ilium, ischium, pubis 3 rd decade: Ischial tuberosity, ASIS Late teens: Femoral head Important for stress fx and avulsion fx Anderson AJSM :521

6 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

7 HIP AND PELVIS ANATOMY Muscles MUSCLE GROUP SPECIFIC MUSCLES INNERVATION Hip Flexors Adductors External rotators Abductors Iliac and psoas Pec:neus Rectus Femoris Sartorius Adductor brevis & longus Adductor magnus Gracilis Gluteus maximus Piriformis Obturator internus & externus Superior & inferior gemellus Gluteus medius & minimus Tensor fascia lata Femoral nerve Obturator nerve Obturator nerve and :bial branch of the scia:c nerve Obturator nerve Inferior gluteal nerve Lumbosacral plexus Superior gluteal nerve

8 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.

9 HIP AND PELVIS ANATOMY Dermatomes Muscle Groups

10 HIP AND PELVIS ANATOMY Important nerves L3 Scia:c Obturator Physical signs L3 dermatome Scia:ca C sign

11 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 Hip Pain

12 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 :521

13 Mechanism Acute injury Overuse Preceding events History Loca:on of pain Onset of pain Nature/ severity of pain: PQRST Childhood or previous hip problems

14 PHYSICAL EXAM Lumbar Spine Pelvis Hip Leg Knee Alignment Hip version Knee Foot Leg Lengths Inspec:on Palpa:on ROM Special Tests

15 Leg Length Tests True Leg Length Measure ASIS to medial malleolus Posi:ve = cm Apparent (Func:onal) Leg Length Umbilicus to Medial malleolus

16 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

17 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

18 Posterior Impingment Test (Faber or Patrick s Test) Flexion, ABD, ER Posi:ve = hip or SI joint

19 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

20 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

21 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

22 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

23 Intra- arccular Tests Log Roll McCarthy Fitzgerald

24 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 :122

25 Plain radiographs AP pelvis AP hip Cross table lateral hip US CT MRI- contrast for labral & hip joint pathology IMAGING

26 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 IMAGING

27 Cross Table vs. Frog Leg Lateral

28 Role of X- rays Evaluates the bone Fracture Bony lesions Helps understand the pathology DDH FAI

29 19 yo with right groin pain over several weeks

30 ADer returning to running

31 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.

32 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 à abnormal stress THE BONE LOSES

33 Radiographic EvaluaCon Plain films: nega:ve 2/3 (ini:ally), changes usually late. Nuclear med: sens %, 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.)

34 ClassificaCon

35 Treatment Shin JAAOS, 1997

36 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

37 SCFE Males > females yo Obese Pain referred to the Knee Maintain high index of suspicion

38 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

39 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 :247

40 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)

41 X- rays in FAI Pincer Cross over sign Posterior wall sign Cam Pistol grip SCFE Kissing lesion

42 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 :252

43 MRI CAM Pincer

44 MRI Contusion Muscle Strain

45 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

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