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Young adult hip evaluation + conditions
- 1. Young Adult + AdolescentHips Assessments and Diagnoses David Slattery Orthopaedic Surgeon 0417 034 985 drslattery@vbjs.com.au 1
- 2. About Me David@melbourneboneandjoint.com Graduated MelbourneLaw School Paediatric + Adult Hip, Knee, Pelvic Surgeon Anterior + Posterior Total Hip Replacement Fellowships – Switzerland, UK, Australia Royal Childrens Hospital St Vincent’s Hospital Avenue Hospital Medicolegal Examiner 2
- 3. David@melbourneboneandjoint.com Upper + LowerLimb Trauma Anterior Total Hip Replacement Robotic Knee Replacement Young Adult Hip Surgery Hip Preservation Surgery Pelvic + Acetabular Fracture Surgery 3
- 4. When is ittime to refer? 3 Guidelines: • When the diagnosis is uncertain • Mechanical Instability • When it doesn’t add up • When it isn’t getting better • When the patient (or parent) is concerned • Non-organic illness is uncommon in kids • Red Flags: weight bearing pain, limping, fevers, sweats, weight loss, avoiding activity
- 5. Hip – CommonPathology drslattery@vbjs.com.au • Anterior – FAI – Dysplasia – OA – Microinstability – SUFE* – AVN • Posterior: – SIJ – Radiculopathy – Lx Spine – Ischiofemoral impingment – Subgluteal Syndrome – Cluneal Nerve Entrapment 5 • Lateral: - Troch Bursa - Gluteal tendons - GTPS - Meralgia Parasthetica - Abductor overload • Midline/Medial: • Osteitis Pubis • Adductor tendinitis/tears • Lig Teres
- 6. Hip Clinical Evaluation drslattery@vbjs.com.au •History: – Injury? – Previous pain? – Location – Night pain – Location – What impact having on them – work/sports/school • Associated Symptoms: – Locking/Catching/Clicking – Instability symptoms – Limping – Other Joint problems – Ligament Laxity • Past History: – Paediatric hip problems – Family Hx of THRs 6
- 7. Hip Clinical Examination drslattery@vbjs.com.au •Walking into room – Ease of getting out of seat – Crutches – Pain – Limping – Gait pattern • How sitting in the chair? 7
- 8. Hip Clinical Examination drslattery@vbjs.com.au •Standing: – Pelvic obliquity/LLD – Atrophy – Scoliosis/Spinopelvic alignment – Trendelenburg + modified – Forward Bend test • Walk/Run/Squat/Lunge • Supine – Palpation – Logroll – Thomas Test – Flexion/IR/ER 8
- 9. Hip Clinical Examination drslattery@vbjs.com.au •Standing: – Pelvic obliquity/LLD – Atrophy – Scoliosis/Spinopelvic alignment – Trendelenburg + modified – Forward Bend test • Walk/Run/Squat/Lunge • Supine – Palpation – Log Roll – Adduction/Abduction – Thomas Test – Flexion/IR/ER – FADIR – FABER – Anterior instability – HEER test 9
- 10. Hip Clinical Examination drslattery@vbjs.com.au •Lateral: – Gluteal Strength – Lateral Cycling – Ober’s – Crepitation – ABHEER 10
- 11. Hip Clinical Examination drslattery@vbjs.com.au •Prone: – SIJ – Hamstrings + Origin – Rotational Profile – Hyperextension instability test 11
- 12. Hip Clinical Examination drslattery@vbjs.com.au •Special Tests: – Ligament Laxity – Psoas – Lig Teres – Ischiofemoral impingement – Voluntary ITB snapping – Rectus femoris – Hamstrings – Adductors – Pelvic Instability Tests 12
- 13. Pelvis X RayEvaluation drslattery@vbjs.com.au 13
- 14. Pelvis X RayEvaluation drslattery@vbjs.com.au 14
- 15. Pelvis X RayEvaluation drslattery@vbjs.com.au 15
- 16. Pelvis X RayEvaluation drslattery@vbjs.com.au 16
- 17. Causes of HipOA Hip Dysplasia 43% Perthes Disease 22% Slipped Epiphysis 12% Idiopathic 12% Other 12% Aronsen et al JBJS 17
- 18. Hip Tuning 18 Courtesy MMillis Impingement Instability
- 19. Case 1 • 18yrOld AFL player with stiff, painful right hip – Can’t run – Difficult playing football – Gets stiff at the end of a day – Limps at times – Gets clicking and locking within the hip
- 20. Case 1 • Examination –No internal rotation – Pain to deep palpation over the anterior groin – Irritability with flexion, internal rotation and adduction
- 21. Case 1 • Examination –No internal rotation – Pain to deep palpation over the anterior groin – Irritability with flexion, internal rotation and adduction
- 22. Case 1 • Xray –CAM Morphology – FAI suspected
- 23. Case 1 David@melbourneboneandjoint.com • MRI –‘Labral Tear’ – ‘Paralabral Cyst’
- 24. 4 © David Slattery2018 NORMAL PINCER CAM MIXED
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- 26. LABRAL TEARS +FAI David@melbourneboneandjoint.com Images courtesy Prof Ganz
- 27. Case 2 • 16yrFemale with Right Groin Pain, clicking, giving way – Worse after sports and activity (Gym/Ballet) – Limping • Mum had hip replacement in 50s
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- 29. Case 2: HipDysplasia
- 30. Case 2: HipDysplasia
- 31. Case 2: HipDysplasia
- 32. Case 2: HipDysplasia
- 33. Case 2: HipDysplasia
- 34. Hip Dysplasia David@melbourneboneandjoint.com • Doesn’tjust affect babies + kids • VERY common 1:100 babies • Easily Missed • Low threshold for USS • Adolescents/Young Adults – on average see 5 specialists before a diagnosis of DDH is made
- 35. Case 3 12yr Boywith Right Thigh/Knee Pain Present for 2 weeks, constant, aching Worse with activity, limps after school Doesn’t play much sport Otherwise well No history of other medical problems Thoughts? Differentials?
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- 38. SCFE (SUFE) 3 © DavidSlattery 2019
- 39. Case 3 Videos courtesyL Donnan
- 40. Case 3 40 Causes • Obesity •Endocrinopathies • Hormonal • Trauma Presentation • Acute vs Chronic vs Acute on Chronic • Hip Pain • Knee Pain • Trauma
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- 45. SUFE David@melbourneboneandjoint.com 45 © DavidSlattery 2019
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- 47. SUFE High Index ofSuspicion Groin Sprains/Strains in kids are uncommon Low threshold for investigations/radiology If Unsure – put on crutches and refer!
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