Hip

Question 1

List four ‘red flags’ of hip symptoms

Answer 1

• Severe nocturnal pain
• Inability to weight bear
• History of malignancy with hip pain
• Rapid deterioration of hip symptoms

Question 2

What is greater trochanteric pain syndrome?

Answer 2

• A regional pain syndrome
• Chronic intermittent pain around the greater trochanter
• Inflammation/trauma in muscles, tendons, fascia or bursa

Question 3

List two clinical features of greater trochanteric pain syndrome

Answer 3

• Lateral hip pain
• Point tenderness adjacent to greater trochanter
• Positive trendelenburg test

Question 4

What is the initial management of greater trochanteric pain syndrome?

Answer 4

• Reassurance condition is usually self-limiting
• Lifestyle
  
  • Activity modification
  • Ice pack applied for 10-20min
  • Weight loss
• Paracetamol and NSAIDs
• Peri-trochanteric corticosteroid injection
• Physiotherapy

Question 5

Outline the types of femoroacetabular impingement (FAI)

Answer 5

• CAM: abnormal femoral head
• Pincer: abnormal extension of acetabulum
• Mixed: both CAM + Pincer types

Question 6

State three clinical features of femoroacetabular impingement

Answer 6

• Activity related groin or hip pain
• Difficulty sitting
• Mechanical symptoms
  
  • locking, giving way, catching
• Reduced hip flexion: esp with internal rotation
• Externally rotated limb

Question 7

What test can be used to diagnose femoroacetabular impingement?

Answer 7

Anterior impingement test

Positive: anterior hip pain present on flexion, adduction, internal rotation.

Question 8

Outline the treatment of femoroacetabular impingement?

Answer 8

• Observation: if minimally symptomatic with no mechanical symptoms
• Arthroscopic hip surgery
• Open surgical hip dislocation + osteotomy
• Periacetabular osteotomy: improves coverage of femoral head
• Total hip arthroplasty: age >60 with end-stage hip degeneration

Question 9

Which artery supplies the majority of blood supply to the femoral head?

Answer 9

Medial femoral circumflex artery

Question 10

Name three risk factors specific for femoral head AVN

Answer 10

• Alcohol
• Steroids
• Trauma
  
  • Femoral neck fracture
  • Posterior hip dislocation
• Transplant surgery
• Liver disease
• Sickle cell disease

Question 11

Describe the illness course of AVN of femoral head

Answer 11

• May initially be asymptomatic
• Symptomatic as femoral head begins to collapse
• Uniform progression if untreated
• Cartilage initially intact as it receives nutrients from the synovial fluid
• Breaks down when underlying bone collapses

Question 12

What features on examination suggest femoral head collapse?

Answer 12

• Pain with internal rotation
• Clicking of the hip
• Reduced range of motion

Question 13

Request one imaging modality for suspected AVN of femoral head

Answer 13

• MRI hip: Gold standard
• AP and lateral x-ray of hip: may be normal
  
  • Always image contralateral hip due to bilateral involvement in 40-80% of cases

Question 14

Outline the treatment options for AVN of femoral head

Answer 14

• Footwear and walking aids
• Education, sitting position
• Treat any underlying factors
• Bisphosphonates
• Stages I-II (before collapse): core decompression
  
  • Reduces intraosseous pressure
  • Promotes new bone formation; angiogenesis
• Stages III-V (collapsed): arthroplasty

Question 15

What is Crescent sign of the femur?

Answer 15

Subchondral lucency at the femoral head

Indicates imminent articular collapse requiring arthroplasty

Defines Stage III AVN of femoral head

Question 16

Describe three clinical features of osteoarthritis of the hip

Answer 16

• Chronic history of groin ache
  
  • Exacerbated by exercise and relieved by rest
  • May radiate to knee
• Stiffness after rest, with later difficulty reaching toes
• Abnormal gait: positive Trendelenburg test
• Leg usually externally rotated and adducted, fixed flexion