Osteitis pubis

1. What is the cause of osteitis pubis?
2. How does osteitis pubis present?
3. What is seen on CT/X-rays?
4. What is the treatment of osteitis pubis?

Answers:
1. This is an inflammatory condition of the pubic rami, caused by adductor overuse.
2. Pubic symphysis or groin pain radiating into the thigh, causing popping with ambulation and pain with resisted adduction.
3. Periosteal thickening.
4. Rest, NSAIDs, steroid injection, physical therapy. Surgery for severe cases.

Avulsion fractures in the hip

1. How do ischial tuberosity avulsion fractures usually occur? What is the presentation? How is it distinguished from ischial tuberosity bursitis?
2. How are ischial tuberosity avulsion fractures treated?
3. How are ASIS avulsion fractures caused? What is the presentation?
4. What is the treatment of ASIS avulsion fractures?
5. What is the cause of AIIS avulsion fractures? What is the presentation?
6. What is the treatment of AIIS avulsion fractures?

Answers:
1. They are caused by forceful hamstring contracture with knee in extension and hip in flexion. The presentation is of sudden pain and tenderness over the ischial tuberosity, whereas ischial is of insidious onset.
2. Rest, ice, weight bearing as tolerated. Resistance exercises can be started after achieving a full ROM.
3. ASIS avulsion is caused by forceful contraction with hip extended and knee flexed. The lateral femoral cutaneous nerve may be involved and there is acute pain and tenderness over the ASIS, with hip flexion pain.
4. Rest, ice, weight bearing as tol. May require knee splinting in flexion.
5. AIIS avulsion is caused by forceful kicking and quad contraction. Presentation is as pain over AIIS or acute groin pain.
6. Treatment is with rest and ice, weightbearing as tolerated.

Slipped capital femoral epiphysis (SCFE)

1. What is SCFE?
2. What is the most common age for SCFE?
3. What is the presentation of SCFE?
4. What will radiographs show?
5. What is the treatment of SCFE?

Answers:
1. Injury to epiphyseal growth plate at the head of the femur --> displacement of plate.
2. 11-16 yrs.
3. Usually presents as groin pain, but may present as thigh or knee pain. Antalgic gait, with limited int hip rotation.
4. Medial and posterior displacement of epiphysis.
5. NWB, surgery. Endocrine testing for growth hormone, thyroid, panhypopituitarism, MEN.

Femoral neck stress fractures

1. What are the two types of femoral stress fractures? Which is more stable?
2. What is the presentation of a femoral stress fracture?
3. How long does it take for bone scan to turn positive after onset of symptoms?
4. What is the treatment for the two types of fracture?

Answers:
1. Compression and transverse fractures. Compression fx are more stable and occur at the inferior neck of the femur. Transverse fx is unstable and occurs in superior femur.
2. Groin pain worse with ADLs, pain with int/ext rotation.
3. 2-8 days.
4. Compression-type fracture should be treated with bed rest, then weightbearing with pain free. Transverse fractures should be treated with internal fixation.

Intertrochanteric and subtrochanteric hip fractures

1. What is the most common type of hip fracture?
2. What is the general presentation of hip fracture?
3. What type of hip fracture is the most difficult to stabilize surgically? Why?
4. When does rehab start after subtrochanteric hip fracture?

Answers:
1. Intertrochanteric.
2. Hip pain, externally rotated and shortened limb.
3. Subtrochanteric is most difficult to stabilize due to high mechanical stresses.
4. Start rehab after healing is evident.

Femoral neck fractures

1. What are modifiable risk factors for hip fracture?
2. What are complications of a femoral neck fracture? What are complications of surgery for femoral neck fx?
3. What is the presentation for hip fracture?
4. What are the four stages of femoral neck fx?
5. What are the treatments of femoral neck fx?

Answers:
1. Alcohol, caffeine, smoking, antipsychotics, benzos, malnutrition, low body weight.
2. Morbidity from disruption of blood vessels to femoral head, causing necrosis. Postop, can have nonunion or osteonecrosis.
3. Hip pain, limb ext rotation, and apparent shortened limb.
4. Garden stages: I is incomplete, nondisplaced. II is complete, nondisplaced. III is displaced with hip joint capsule partially intact. IV is displaced with hip joint capsule completely disrupted.
5. For stages I and II, pins across fx site, early rehab. For stages III and IV, replacement of femoral head, followed by rehab with hip precautions (no flexion >90, no adduction or internal rotation).

Avascular necrosis of the femoral head

1. What is the definition of avascular necrosis? What are the most common causes?
2. What is avascular necrosis of the hip called in children aged 2-12?
3. What are the symptoms of avascular necrosis of the hip?
4. What is seen on MRI in avascular necrosis?
5. What is the treatment?

Answers:
1. Death of femoral head without sepsis, commonly caused by steroid use or alcohol abuse.
2. Legg-Calve-Perthes disease.
3. Insidious onset of groin, anterior thigh, or knee pain, with short swing and stance phase, and loss of hip rotation.
4. MRI shows irregular or mottled femoral head.
5. Bracing or casting in peds population. In adults, osteotomy of femoral head if disease not advance, but may require THA.

Posterior hip dislocation

1. What is the most common type of hip dislocation?
2. How does posterior hip dislocation often occur?
3. What nerve is often damaged in posterior hip dislocation?
4. What is the appearance of a posterior hip dislocation?
5. How is posterior hip dislocation treated?

Answers:
1. Posterior (90%).
2. MVA in which knee strikes dashboard.
3. Sciatic nerve.
4. Flexed, adducted, and internally rotated. It may appear shorter.
5. Surgery (emergent).

Greater trochanteric bursitis

1. Where is the trochanteric bursa located?
2. What conditions is trochanteric bursitis associated with?
3. What are the symptoms?
4. What is the provocative test?
5. What is the treatment?

Answers:
1. Located over greater trochanter and deep to gluteus medius, gluteus minimus, and TFL.
2. Hip OA, obesity, leg length discrepancy, direct trauma, overuse, herniated lumbar disc, and hemiparesis.
3. Night pain, inability to like on affected side, hip snapping.
4. Pain over greater troch during movement from full extension to flexion.
5. IT band stretching, NSAIDs, hip adductor strengthening, local cortisone injection.

Groin strain

1. How does groin strain (hip adductor strain) usually occur?
2. What are the symptoms of groin strain?
3. What is the provocative test?
4. What imaging should be ordered?
5. What is the treatment?

Answers:
1. Resisted forced abduction of the hip.
2. Pain in the adductors distal to their origin.
3. Pain with resisted hip adduction.
4. X-rays of hip including adductor tubercle to rule out avulsion.
5. Rest, ice, NSAIDs, advance to stretching and strengthening.

Iliopsoas bursitis and tendonitis

1. What are the symptoms of iliopsoas tendonitis or bursitis?
2. What is the provocative test?
3. What is the treatment?

Answers:
1. Hip snapping with flexion due to IT band snapping over greater trochanter or iliopsoas tendon subluxing, tenderness over iliopsoas muscle.
2. Pain on hip flexion.
3. Ice, NSAIDs, stretching and strengthening, cortisone injections.

Piriformis syndrome

1. How is the piriformis usually injured?
2. What are the clinical symptoms of piriformis syndrome?
3. What is the provocative test for piriformis syndrome?
4. What is the treatment?

Answers:
1. Poor body mechanics, forceful hip internal rotation. (Sciatic nerve may be involved.)
2. Pain in lateral buttock, posterior hip and prox posterior thigh, SI joint, with tenderness over the muscle belly going from the sacrum to the greater trochanter. It is exacerbated by walking up stairs.
3. Pain with internal hip rotation, adduction, and flexion.
4. Stretching, NSAIDs, US, local cortisone injection.

Hamstring strain

1. What are predisposing factors to hamstring strain?
2. What is the strength ratio of hamstrings to quads?
3. What are the grades of hamstring strain?
4. What is the provocative test for hamstring strain?
5. what is the treatment of hamstring strain?

Answers:
1. Inadequate warmup, poor flexibility, exercise fatigue, poor conditioning, and muscle imbalance.
2. 3:5.
3. Grades I (strain) to III (complete tear).
4. Pain in ischial region with knee flexion.
5. Ice, compression, weight bearing reduction, NSAIDs, gentle stretch.

Leg length discrepancy

1. How is a true leg length discrepancy assessed?
2. How do you measure for discrepancy in the femur?
3. How do you measure an apparent leg length discrepancy?
4. What are the causes of an apparent leg length discrepancy?

Answers:
1. Measure from ASIS to the medial malleoli.
2. Patient lies supine and flexes knees to 90 degrees, assess if one knee is higher than the other.
3. Measure from umbilicus to medial malleoli.
4. Pelvic obliquities or flexion/adduction deformities of the hip.

Tests of the hip joint

1. What is FABER (Patrick) test used to assess?
2. What is Thomas test used to assess?
3. What is Ober's test used to assess?
4. What conditions are associated with a positive Trendelenberg?

Answers:
1. Inguinal pain in flexion, abduction, and external rotation is an indication of hip joint pathology.
2. Hip flexion contractures.
3. Iliotibial band and TFL contractures.
4. Trendelenberg indicates gluteus medius weakness, associated with radiculopathy, polio, meningomyelocele, fractures of greater trochanter, SCFE, congenital hip dislocation.
6.

Ligaments of the hip

1. What is the purpose of the acetabular labrum?
2. What is the iliofemoral ligament?
3. What ligament checks medial rotation? Abduction?
4. What is the first ROM to be limited in OA?

Answers:
1. Deepens acetabulum and holds femoral head in place.
2. The iliofemoral ligament (Y-ligament of Bigelow) is the strongest ligament in the body, going from the AIIS to the intertrochanteric line.
3. The ischiofemoral ligament checks medial rotation. The pubofemoral ligament checks abduction.
4. Internal rotation.

Hip muscles

1. What are the hip flexors?
2. What are the hip adductors?
3. What are the hip abductors?
4. What are the hip extensors?
5. What are the lateral rotators of the hip?
6. What are the medial rotators of the hip?

Answers:
1. Flexors: iliopsoas, sartorius, rectus femoris, gracilis, adductor longus, adductor brevis, adductor magnus, pectineus, TFL.
2. Anterior: gracilis, adductor magnus, adductor brevis, adductor longus, pectineus. Posterior: gluteus maximus, obturator externus, gracilils, biceps long head, medial hamstrings.
3. Gluteus medius, gluteus minimus, TFL, sartorius, piriformis, gluteus maximus.
4. Gluteus maximus, gluteus minimus, gluteus medius, piriformis, adductor magnus, hamstrings.
5. Piriformis, obturator internus, gemelli, obturator externus, quadratus femoris, gluteus muscles.
6. TAGGGSS: tFL, adductors (magnus, longus, brevis), gluteus medius, gluteus minimus, gracilis, semitendinosus, semimembranosus.