HIP$AND$PELVIS$forms.acsm.org/15TPC/PDFs/15 DeMaio.pdf · HIP$AND$PELVIS$ANATOMY$ Muscles$$...
Transcript of HIP$AND$PELVIS$forms.acsm.org/15TPC/PDFs/15 DeMaio.pdf · HIP$AND$PELVIS$ANATOMY$ Muscles$$...
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