The hip

8,816 views

Published on

0 Comments
13 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
8,816
On SlideShare
0
From Embeds
0
Number of Embeds
45
Actions
Shares
0
Downloads
654
Comments
0
Likes
13
Embeds 0
No embeds

No notes for slide

The hip

  1. 1. OS COXA (HIP BONE) COMPOSED OFIlium• Largest component; it is a fan like wing and an inferiorly positioned body it forms 2/5 of the hip bone; the wing serves as the insertion for the gluteal muscles while the anterior portion of the wing serves as the proximal attachment of the iliacusIschium• Composed of the ischium and the ramus collectively forming the ischial tuberosity• Serves as an attachment to several muscles and the sacrotuberous ligament; the spine serves as the attachment for the sacrospinous ligamentPubis• Smallest bone consists of a body, inferior and superior rami
  2. 2. THE OS COXA
  3. 3. ACETABULUM• Deep seated depression in the lateral pelvis which allows for the proximal transmission of weight from the axial skeleton to the lower extremity• It faces laterally, inferiorly & anteriorly; acetabular development is determined by the age of 8 years, the depth of the acetabulum increases additionally at puberty due to the development of three secondary centers of ossification• Inverted horseshoe-shaped area covering the anterior superior and posterior margins,• Forms the acetabular notch that is occupied by the ligamentum teres and obturator artery• Diameter of the acetabulum is slightly less than that of the femoral head resulting in an incongruous fit of the joint surfaces.The purpose of this incongruity unloads the joint during partial weight bearing, by allowing the femoral head to sublux laterally out of the cup while in full weight bearing the femoral head is forced into the acetabulum.
  4. 4. ACETABULUM
  5. 5. FEMUR• The longest bone in the body and consists of a head, neck and greater and lesser trochanter• The fovea capitis, serves as the attachment of the ligamentum teres• The femoral neck serves to extend the weight bearing forces lateral and inferior to the joint fulcrum• The head of the femur is angled anteriorly, superiorly and medially. The femoral neck is externally rotated with respect to the shaft also the neck forms the angle of anteversion/declination (in a normal adult, forms an angle of about 125 degrees with respect to the shaft; in children, 160 degrees)• Trabecular bone core encased in a thin cortical bone shell• Trabecular bone in the femoral neck and head is specially designed to withstand high loadsThis however has a point of weakness called the ward triangle which is a common site of osteoporotic change
  6. 6. FEMUR
  7. 7. ANGLE OF INCLINATIONAngle within the frontal plane between the femoral neck and the medial side of the femoral shaftAdult: 125 degreesAcquired or congenital changes Coxa vara: < 105 degrees Coxa valga: >140 degrees
  8. 8. TORSION ANGLE• Relative rotation in the transverse plane existing between the shaft and neck of the femur• Normal is 10-15 degrees anterior to the medial/lateral axis through the femoral condyles, termed “normal anteversion”• Torsion angle and inclination angle creates maximal congruency between femur and acetabulum • Anteversion: > 15 degrees • Retroversion: < 10 degrees
  9. 9. JOINT CAPSULE• A cylindrical Sleeve• Proximally : Pelvis• Laterally : Acetabular labrum and extends laterally to the femoral head• Anteriorly : Intertrochanteric fossa• Both the capsule and the articular cartilage are thicker anterosuperiorly consequently thinner posteroinferiorly• Supported by muscles and by intra/extra articular ligaments
  10. 10. • Coxa valga: increase in the neck-shaft angle• Coxa vara: decrease in the neck-shaft angle• Greater and lesser trochanters are large eminences situated at the junction of the neck & the shaft• Trochanters are connected anteriorly by the intertrochanteric line• Trochanters are connected posteriorly by the intertrochanteric crest• Linea aspera is where the muscles and intermuscular septa attach• Lateral and medial femoral condyles are separated posteriorly by the intercondylar notch• Medial and lateral femoral epicondyles are situated above the condyles• Adductor tubercle is continuous with the medial epicondyle
  11. 11. JOINT CAPSULE
  12. 12. LIGAMENTUM TERES/CAPITIS FEMORAL LIGAMENT• Runs from the acetabular notch to the fovis capitis of the femur attaching the femoral head to the inferior acetabular rim• Tightens during: Adduction, flexion and external rotation• Assists in the stabilization of the hip joint in functional ROM by preventing subluxation of the femoral head superiorly and laterally and by checking the extremes of hip rotation and adduction
  13. 13. TRANSVERSE ACETABULAR LIGAMENT• Fibrous link from the inferior acetabular notch that connects the anteroinferior and posteroinferior horns of the semilunar surface of the acetabulum• Posterior aspect: bone beneath the lunate surface• Anterior aspect: labrum
  14. 14. TRANSVERSE ACETABULAR LIGAMENT
  15. 15. ACETABULAR LABRUM• A ring consisting of fibrocartilage and dense connective tissue• Encases the femoral head and is attached to the acetabular margin• Enhances joint stability decreases force transmitted to the articular cartilage and provides proprioceptive feedback• Substantial static stability to the hip joint is provided by deepening of the socket that is provided by the labrum• Enhances stability by providing negative intra-articular pressure in the hip joint• Also known to improve mobility of the hip by providing an elastic alternative to the bony rim• Composed of: traingular cross section, internal & external articular surface, basal surface mostly made up of type I collagen fibers
  16. 16. ACETABULAR LABRUM
  17. 17. • Iliofemoral ligament • Consists of 2 parts: inferior (medial) & superior (lateral); strongest ligament of the body and is oriented superior laterally and blends with the iliopsoas muscle; limits the range of hip extension and allows the maintenance of the upright posture and reduces the need for contraction of the hip extensors in balanced stance; tightened through hip adduction• Pubofemoral ligament • Blends with the inferior band of the iliofemoral and the pectineus muscle; orientation of the pubofemoral ligament is more inferior medial; fibers tighten in extension and abduction and reinforce the joint capsule along the medial surface• Ischiofemoral ligament • Winds posteriorly around the femur and attaches anteriorly, strengthening the capsule; tightens with internal rotation of the hip and is more commonly injured than other hip ligaments
  18. 18. EXTRA-ARTICULAR LIGAMENTS OF THE HIP
  19. 19. HIP JOINT (CLOSED)
  20. 20. HIP JOINT (OPEN)
  21. 21. MUSCLES• Iliopsoas • Made of the psoas and iliacus; most powerful hip flexor, weak adductor and external rotator of the hip• Pectineus • Adductor, flexor internal rotator of the hip• Rectus Femoris • Injury can cause capsular adhesion of the hip; flexion of the hip & extension at the knee• Tensor Fascia Latae • Counteracts the backward pull of the G.Max on the iliotibial band; assists in flexing, abducting and internally rotating the hip• Sartorius • Longest muscle in the body; flexion abduction and external rotation of the hip; some degree of hip flexion• Gluteus Maximus • Largest and most important hip extensor and external rotator; usually active only when the hip is in flexion like in stair climbing or when extension of the hip is resisted
  22. 22. MUSCLES
  23. 23. MUSCLES• Gluteus Medius • Main abductor of the hip and primary stabilizer of the hip and pelvis; deltoid of the hip; anterior portion flexes, abducts and internally rotate the hip; posterior portion extends and externally rotates the hip; provides pelvic support during one legged stance; decelerator of hip adduction• Gluteus Minimus • Major internal rotator of the femur and abducts the thigh and helps with pelvic support• Piriformis • Most superior of the external rotators of the hip; at 60deg of hip flexion = ER; at 90deg of hip flexion reverses its muscle action = IR and abductor of the hip• Obturator Internus • Normally an External rotator and internal rotator of the ilium but becomes an abductor of the hip at 90deg of hip flexion• Obturator Externus • Adductor and external rotator of the hip• Gemelli • Has superior and inferior parts both function as a minor external rotator• Quadratus Femoris • External rotator of the hip
  24. 24. MUSCLES G.Med Piriformis Gemellus& Obturator
  25. 25. HAMSTRINGS• Biceps Femoris • Long head: decelerating the limb at the end of swing phase and forceful hip extension; extends hip flexes knee and externally rotates the tibia• Semimembranosus & Semitendinosus • Assist with internal rotation of the thigh and leg All three muscles of the hamstring complex (except the short head of the biceps) work with the posterior adductor magnus and the gluteus maximus to extend the hip Also a knee flexor and a weak hip adductor, long head of biceps femoris: external rotation of the thigh and leg• 3 Main functions of the hamstrings while running 1. Decelerate knee extension at the end of forward swing phase, helps provide dynamic stabilization 2. At foot strike: elongates to facilitate hip extension through an eccentric contraction further stabilizing the leg 3. Assist the gastrocnemius in extending the knee during takeoff phase of the running cycle
  26. 26. HAMSTRINGS
  27. 27. HIP ADDUCTORS• Adductor Magnus • Most powerful adductor and is active to varying degrees in all hip motions except abduction; posterior portion is sometimes considered functionally as a hamstring due to anatomic alignment• Adductor Longus • During resisted adduction this is the most prominent muscle and forms the medial border of the femoral triangle; assists with external rotation, extension and internal rotation; commonly strained• Gracilis • Most superficial and medial also the longest; adducts and flexes the thigh and internally rotates the leg Other adductors of the leg include the adductor brevis and pectineus muscles
  28. 28. HIP ADDUCTORS
  29. 29. HIP FLEXORS SUMMARYPRIMARY SECONDARY Iliopsoas  Adductor brevis Sartorius  Gracilis Tensor fascia latae  Gluteus minimus Rectus femoris Pectineus Adductor longus
  30. 30. HIP ADDUCTORSPRIMARY SECONDARY Adductor longus  Biceps femoris Adductor brevis  Quadratus femoris Pectineus  Gluteus maximus Gracilis Adductor magnus
  31. 31. HIP EXTERNAL ROTATORSPRIMARY SECONDARY Gluteus maximus  Gluteus medius Piriformis  Gluteus minimus Obturator internus  Obturator externus Gemellus superior  Biceps femoris Gemellus inferior Quadratus femoris Sartorius
  32. 32. HIP INTERNAL ROTATORS• Gluteus minimus• Gluteus medius• Tensor fascia latae• Adductor longus• Adductor brevis• Pectineus• Semitendinosus• Semimembranosus
  33. 33. HIP EXTENSORSPRIMARY SECONDARY Gluteus maximus  Gluteus medius Biceps femoris Semitendinosis Semimembranosis Adductor magnus
  34. 34. HIP ABDUCTORSPRIMARY SECONDARY Gluteus medius  Piriformis Gluteus minimus  Sartorius Tensor fascia latae
  35. 35. THIGH MOVEMENTS BY COMPARTMENT
  36. 36. BURSAE• Iliopsoas bursa • Largest and most constant bursa about the hip present in 98% of adult individuals • Situated deep to the iliopsoas tendon and serves to cushion the tendon from the structures on the anterior aspect of the hip joint • Can become inflamed and distendend MC: RA; can also be associated with athletic activity; overuse and impingement syndromes; OA; pigmented villonodular synovitis; villonodular synovitis, synovial chndromatosis, infection, pseudogout, metastatic bone disease and in rare cases after total hip athroplasty
  37. 37. BURSAE• Trochanteric bursa • 2 clinical significant trochanteric bursae: one between the gluteus medius and minimus and a superficial one located between the greater trochanter and the TFL; compression and friction of the bursa from an adaptively shortened TFL can result in trochanteric bursitis• Ischiogluteal bursa • Located between the ischium and the gluteus maximus; can be painfully squeezed between the ischial tuberosity and the hard surface of a chair during sitting, producing an ischial bursitis (weaver’s bottom)
  38. 38. FEMORAL TRIANGLE• Superior border : Inguinal Ligament• Lateral border: Sartorius Muscle• Medial border: Adductor longus Muscle
  39. 39. FEMORAL TRIANGLE
  40. 40. NEUROLOGY• Posterior Gluteal Region (Cutaneous) • Subcostal nerve • Iliohypogastric nerve • Posterior Rami of L1-L3 • Posterior Primary Rami of S1-S3• Anterior Region (Cutaneous) • Iliohypogastric nerve (superior to the inguinal ligament) • Subcostal nerve (inferior to the inguinal ligament) • Fermal branch of the genitofemoral nerve • Ilioinguinal nerve Pain referred from the hip joint may be felt anywhere in the thigh leg or foot
  41. 41. VASCULAR SUPPLY• Medial and lateral femoral circumflex supplies proximal femur• Femoral head is supplied by a small branch off obturator artery• Acetabulum is supplied by branches from superior and inferior gluteal arteries
  42. 42. HIP MOBILIZATION• Flexion: Femur rolls superior and glides inferior on pelvis• Abduction: Femur rolls lateral/superior & glides inferior on pelvis• IR: Femur rolls medial & glides lateral on pelvis• Extension: Femur rolls inferior & glides superior on pelvis• Adduction: Femur rolls medial/inferior & glides superior on pelvis• ER: Femur rolls lateral & glides medial on pelvis
  43. 43. OSTEOKINEMATICS AND ARTHROKINEMATICS• Resting position: 30deg flexion, 30deg abduction, slight lateral rotation for OPP (slight ER)• Convex: Femur• Concave: Acetabulum• Motion: Opposite direction• CPP: Max, ER, ABd• Capsular Pattern : Flexion, abduction, medial rotation
  44. 44. NORMAL RANGES AND END FEELS AT THE HIP MOTION ROM (DEGREES) END FEEL FLEXION 110-120 TISSUE APPROXIMATION/ TISSUE STRETCH EXTENSION 10-15 TISSUE STRETCH ABDUCTION 30-50 TIISUE STRETCH ADDUCTION 25-30 TISSUE APPROXIMATION/TISSUE STRETCHEXTERNAL ROT. 40-60 TISSUE STRETCHINTERNAL ROT. 30-40 TISSUE STRETCH
  45. 45. PELVIC MOTIONS• Hip flexors cause an anterior pelvic tilt• Hip extensors a posterior pelvic tilt• Abductors and adductors a lateral pelvic tilt• Rotators of the hip cause rotation To prevent excessive pelvic motion when moving the femur at the hip joint, the pelvis must be stabilized by the abdominals, erector spinae, multifidus and quadratus lumborum muscles
  46. 46. ANTERIOR PELVIC TILT• Results in hip flexion and increased lumbar spine extension• Caused by hip flexors and back extensors• Line of gravity falls anterior to the axis of the hip joint, stability is provided by the abdominals and hip extensors
  47. 47. POSTERIOR PELVIC TILT• Results in hip extension and lumber spine flexion• Caused by hip extensors and trunk flexors• Line of gravity of the tunk falls posterior to the axis of the hip joints, dynamic stability is provided by the hip flexors and back extensors and passively by the iliofemoral ligament
  48. 48. * The pelviccrossed syndromeis exhibited byadaptivelyshortened hipflexors andhamstrings andinhibited gluteimuscles andlumbar errectorspinae
  49. 49. NORMAL GAIT (SWING PHASE 40%)Initial swing Midswing Terminal swingFlexion 20deg Flexion 20- Flexion 30deg 30deg *Requirements for Normal Gait (ROM) • Hip extension 0-10 deg • Hip flexion 0-30 deg
  50. 50. NORMAL GAIT (STANCE PHASE 60%)Initial Loading Midstance Terminal Pre-swingContact Response StanceFlexion Flexion Extending Apparent Neutral30deg 30deg to Neutral Hyperextension Extension
  51. 51. GAIT DEVIATIONSInsufficient Insufficient Circumduction Hip hiking ExaggeratedHip flexion at hip extension during swing during swing hip flexioninitial contact at stance during swing Weak hip  Insufficient  Compensation  Compensation  Lower flexors hip for weak hip for weak extremity Hip flexor extension flexors dorsiflexors flexor paralysis ROM  Compensation  Compensation synergy Hip extensor  Hip flexion for weak for weak knee  Compensati Spasticity contracture dorsiflexors flexors on for Insufficient  LE flexor  Compenssatio  Compensation insufficient hip flexion synergy n for weak for externsor hip flexion or ROM hamstrings synergy dorsiflexion pattern
  52. 52. FLEXION• Axis: over the lateral aspect of the hip joint using the greater trochanter of the femur for reference• Stationary arm: lateral midline of the pelvis• Moveable arm: lateral midline of the femur using the lateral epicondyle
  53. 53. EXTENSION• Axis: over the lateral aspect of the hip joint using the greater trochanter of the femur for reference• Stationary arm: lateral midline of the pelvis• Moveable arm: lateral midline of the femur using the lateral epicondyle for reference
  54. 54. ABDUCTION• Axis: over the ASIS of the extremity being measured• Stationary arm: align with imaginary horizontal line extending from one ASIS to the opposite• Moveable arm: anterior midline of the femur using the midline of the patella for reference
  55. 55. ADDUCTION• Axis: over the ASIS of the extremity being measured• Stationary arm: align with imaginary horizontal line extending from one ASIS to the opposite• Moveable arm: anterior midline of the femur using the midline of the patella for reference
  56. 56. MEDIAL ROTATION• Axis: Anterior aspect of the patella• Stationary arm: perpendicular to the floor or parallel to the supporting surface• Moveable arm: anterior midline of the lower leg using the crest of the tibia and a point midway between the two malleoli for reference
  57. 57. LATERAL ROTATION• Axis: Anterior aspect of the patella• Stationary arm: perpendicular to the floor or parallel to the supporting surface• Moveable arm: anterior midline of the lower leg using the crest of the tibia and a point midway between the two malleoli for reference
  58. 58. DIAGNOSIS Physical Findings INTERVENTIONLegg-Calve-Perthes dse. Limited hip abduction, Maintain ROM follow flexion and internal position of femoral head in rotation relation to acetabulumSlipped capital femoral Pain and limited internal NWB and surgical pinning epiphysis rotation, leg more comfortable in external rot; LLD Avulsion Fracture Pain on passive stretch, ROM & Strengthening Ex active contraction and palpation Hip Pointer Tenderness over iliac Rest, ice, NSAID, local crest pain on ambulation steroid & anesthesia and active abduction Contusion Pain on palpation and Rest, ice, compression, motion and ecchymosis static stretch and NSAIDs
  59. 59. DIAGNOSIS PHYSICAL FINDINGS INTERVENTIONMyositis Ossificans Pain on palpation; firm Ice, stretching, NSAIDs, surgical mass may be palpable resection after 1 year if conservative treatment fails Femoral Neck ROM may be painful, No weight bearing until evidence of Stress Fx pain on palpation of healing with gradual return to greater trochanter activities; superior surface fx: ORIFOsteoid Osteoma Restricted motion and Surgical removal; Aspirin NSAIDs quadriceps atrophy Iliotibial band Positive Ober’s Test Modified activity, footwear, stretching syndrome program, ice, NSAIDs Trochanteric Pain on palpation Ice, NSAIDs, stretching and Bursitis protection from trauma, steroid injectionAvascular Necrosis Pain on ambulation, Protected weight bearing, of the Femoral abduction IR ER strengthening, THA Head Piriformis Pain on active ER; Stretching, NSAIDs, relative rest and syndrome passive IR and correction of offending cavity
  60. 60. COMMON CAUSES OF HIP AND THIGH PAINCONDITION DESCRIPTION OF FINDINGSOA of the hip Tenderness over ant. hip capsule; pain by passive rotation; restricted ROM; +Stinchfield test; abductor limp, Functional LLD Hip fx Tenderness over the ant. hip capsule or intertrochanteric region; Limb ER and shortened; +Stinchfield test Meralgia Altered Sensation over anterolateral thigh; symptom reproduced byParasthetica pressure or percussion just medial to the anterior-superior iliac spine Piriformis Tenderness to deep palpation near the hook of the greater trochanter; Tendinitis Pain reproduced by piriformis stretch G.Max Tenderness near the gluteal fold at the inferior aspect of the gluteus Tendinitis max; +Yeoman’s test
  61. 61. COMMON CAUSES OF HIP AND THIGH PAINCONDITION DESCRIPTION OF FINDINGS G.Med Tenderness just proximal to the greater trochanter; Pain by resisted tendinitis abduction of the hipTrochanteric Tenderness over the lateral aspect of the greater trochanter; +Popping bursitis and Crepitation with flexion-extension of hip; tight ITB +Ober’s testQuads strain Tenderness and swelling of the involved area; weakness; restriction ofor contusion knee flexion esp with hip extended; warmth and firmness Hamstring Localized tenderness and swelling; ecchymosis; restricted knee strain flexion and straight leg raising; abnormal tripod signPelvis fx or Tenderness of the pubic symphysis, iliac crest, sacroiliac jts; paindisruption +lateral pelvic compression test, anteroposterior pelvic compression test, pubic symphysis test, Patrick’s test or Gaenslen’s test
  62. 62. POTENTIAL CAUSES OF HIP PAIN Type of Pain/Structure Cause Articular cartilage Chondral lesion; OA Childhood d/o Congenital Dysplasia; Legg-Calve- Perthes; Slipped capital femoral epiphysis Inflammation Trochanteric bursitis; Psoas bursitis; Tendinitis; Toxic Synovitis Infection Septic arthritis; Osteomyelitis Labra tear None specified Neoplasm None specified Neurologic Local Nerve entrapment
  63. 63. POTENTIAL CAUSES OF HIP PAIN Type of Pain/Structure Cause Overuse Stress fx of femur; strains; inguinal hernia; femoral hernia Referred Lumbar disk pathology; lumbar spine DJD; athletic pubalgia; radiculopathy; piriformis syndrome; SI jt pathology; GUT pathology; Abdominal wall pathology Systemic RA; Crohn’s dse; Psoriasis; Reiter’s Syndrome; SLE Trauma Soft tse contusion; fx of femoral head; dislocation of femoral head; avulsion injury; Myosistis ossificans Vascular Avascular Necrosis; Osteonecrosis
  64. 64. MEDICAL RED FLAGS• Pain at McBurney’s point: 1/3 the distance from R ASIS to umbilicus = appendicitis• Blumberg’s Sign: rebound tenderness in supine select a site away from the painful area, place your hand perpendicular to the abdomen and pushdown deep and slow lift up quickly = (+) peritonitis• Psoas test: supine, SLR to 30deg & resist hip flexion = (+) pelvic inflammation or infection in lower quad abdominal pain; hip or back pain if (-)• Enlarged inguinal lymph nodes• Hip pain 18-24 screen for testicular cancer• Systemic causes of hip pain Bone tumors Crohn’s Disease Inflammatory bowel Pelvic inflammatory disease Ankylosing spondylitis Sickle Cell anemia Hemophilia
  65. 65. SYNERGY PATTERNS OF THE HIPFLEXOR SYNERGY EXTENSOR SYNERGY• Abduction and • Extension and lateral rotation medial rotation and adduction
  66. 66. ASSESSMENT OF THE HIP
  67. 67. THOMAS TEST• Asses for tight hip flexors• Supine with lumbar spine stabilized & involved LE extended• Flex contralateral hip to the abdomen
  68. 68. ELY’S TEST• Assess for tight rectus femoris• Sidelying to prone, hip extension• Flex knee• Inability to maintain hip extension when knee is flexed
  69. 69. OBER’S TEST• Assess for tight ITB• Sidelying with involved hip up• Extend involved hip & allow LE to drop into adduction• (+) if LE fails to drop
  70. 70. SCOUR TEST• Assess for labral tear• Supine flex hip to 90• IR/ER hip with abd/add while applying a compressive force down femur• (+) clicking, grinding or pain due to arthritis, labral tear, avascular necrosis, osteochondral defect
  71. 71. ANTERIOR AND POSTERIOR LABRAL TESTS• Assess for labral tear•Ant: Supine in PNF D2 flexion (flex, ER & Abd)•Post: Supine in PNF D1 flexion (flex, IR & Add)•To test Ant: Resist D2 extension (ext, IR &Add) Post: Resist D1 extension (ext, ER & Abd)• (+) reproduction of pain or click
  72. 72. FABER (PATRICK’S) TEST• Assess SI jt pathology• Supine – passiely flex, abd & ER so that the lateral malleolus of the involved LE is on the other knee• Apply overpressure to flexed knee• (+) pain 2dary to OA, osteophytes, intracapsular FX or LBP 2dary to SI Px: tightness without pain is (-) may indicate problem with sartorius muscle
  73. 73. TRENDELENBURG’S TEST• Weakness of G.Med• Standing• Flex the contralateral LE: iliac crest on WB side should be lower than the NWB side• (+) dropping of the NWB limb is 2dary to abductor weakness
  74. 74. PIRIFORMIS TEST• Assess for tight piriformis• Supine or contralateral sidelying• Flex hip to 70-80 with knee flexed & maximally adduct LE (apply downward force to the knee)• (+) pain in buttock & sciatica; IR stresses superior fibers; ER stresses inferior fibers
  75. 75. ORTOLANI’S AND BARLOW’S TESTSORTOLANI’S TEST BARLOW’S TEST• Asses for congenital hip • Assess for hip dysplasia dislocation • Supine 90/90; clinician’s• Supine knees and hip flexed thumbs are on the infant’s to 90; clinician’s thumbs are medial thigh & fingers on on the medial thigh and the lateral thigh fingers on the lateral thigh • Apply a posterior force• Firmly traction the thigh while thru the femur as the thigh gently abducting the leg so that the femoral head is Is gently adducted translated anterior into the • (+) examiner’s finger that acetabulum is on the greater• (+) reduction of the hip and trochanter will detect a audible clunk palpable dislocation
  76. 76. AVASCULAR NECROSIS OF THE HIP• Medications Acetamenophen for pain NSAIDs for pain/inflammation Corticosteroids contraindicated since they may be causative factor Steroid dose for other pathology should be decreased• PT goals, outcomes and intervention Joint and bone protection Maintain/Improve joint mechanics and connective tissue functions Implementation of aerobic capacity/endurance conditioning or reconditioning such as aquatic programs Postsurgical Intervention: regaining functional flexibility, improving strength/endurance/coordination and gait training
  77. 77. LEGG-CALVE-PERTHES DISEASE• Medications Acetaminophen for pain NSAIDs for pain and inflammation• PT goals, outcomes and intervention Joint/bone protection strategies Maintain/Improve joint mechanics and connective tissue functions Implementation of aerobic capacity/endurance conditioning or reconditioning such as aquatic programs Post surgical intervention: regaining functional flexibility, improving strength/endurance/coordination and gait training
  78. 78. OSTEOCHONDROSIS
  79. 79. SLIPPED CAPITAL FEMORAL EPIPHYSIS• Medications Acetaminophen for pain NSAIDs for pain and inflammation• PT goals, outcomes and intervention Joint/bone protection strategies Maintain/Improve joint mechanics and connective tissue functions Implementation of aerobic capacity/endurance conditioning or reconditioning such as aquatic programs Post surgical intervention: regaining functional flexibility, improving strength/endurance/coordination and gait training
  80. 80. SLIPPED CAPITAL FEMORAL EPIPHYSIS
  81. 81. FEMORAL ANTEVERSION AND ANTETORSION• PT goals, outcomes and intervention • Maintain/Improve joint mechanics and connective tissue functions
  82. 82. COXA VARA AND COXA VALGA• PT goals, outcomes and intervention • Maintain/Improve joint mechanics and connective tissue functions
  83. 83. TROCHANTERIC BURSITIS• Medications Acetaminophen for pain NSAIDs for pain and inflammation• PT goals, outcomes and interventions Implementation of flexibility exercises Manual therapy for joint mechanics oSoft tissue massage techniques and joint oscillations to reduce pain or muscle guarding oBiomechanical causes corrected with joint mobilization Implementation of aerobic capacity/endurance conditioning exercises Application of thermal agents for pain reduction, edema reduction and muscle performance Patient education and training for instrumental activities (IADL)
  84. 84. TROCHANTERIC BURSITIS
  85. 85. ITB TIGHTNESS/FRICTION DISORDER• Medications Acetaminophen for pain NSAIDs for pain and inflammation• PT goals, outcomes and interventions Reduction of pain and inflammation using modalities, soft tissue techniques and manual therapy techniques (PJM/massage) Correction of muscle imbalances and biomechanical faults using strengthening, endurance, coordination and flexibility on ITB, hamstrings, quads, hip flexors Gait training and patient education regarding the selection of running shoes and running surfaces Orthoses may be fabricated
  86. 86. ITB TIGHTNESS/FRICTION DISORDER
  87. 87. PIRIFORMIS SYNDROME• Medications Acetaminophen for pain NSAIDs for pain and inflammation• PT goals, outcomes and interventions Reduction of pain and inflammation using modalities, soft tissue techniques and manual therapy techniques (PJM/massage) Correction of muscle imbalances and biomechanical faults using strengthening, endurance, coordination and flexibility exercises Restore muscle balance and patient education regarding protection of the sacroiliac joint (instruction not to step off a curb into dysfunctional lower extremity) Correction of biomechanical faults may include orthoses or orthotic devices for feet
  88. 88. PIRIFORMIS SYNDROME
  89. 89. TOTAL HIP REPLACEMENT• PT goals, outcomes, interventions Patient should avoid the position of hip flexion >90deg with adduction and internal rotation, partial weight bearing to tolerance is initiated on the second postsurgery day using crutches or a walker with typical surgical procedures Focus on mobility, transitional movements, ambulation and return to premorbid ADL
  90. 90. TOTAL HIP REPLACEMENT
  91. 91. BURN PROFILE OF THE HIP• Anticipated deformity: Flexion and adduction• Splinting type: Anterior hip spica, abduction splint• PT intervention and goals Positioning Splinting Edema control Scar management PROM Massage Conditioning and Endurance training PJM, electrotherapeutic modalities, compression devices, hydrotherapy, physical agents
  92. 92. References:Orthopaedicexamination, evaluation,intervention – MarkDuttonTherapeutic Exercise –Kisner & ColbyNPTE Review andStudy guide 2011 –Susan B. O’Sullivan &Raymond P. SiegelmanOrthoNotes – DawnGuilickPT EXAM The CompleteStudy guide – Scott M.GillesOrthopedic PhysicalAssessment – Magee

×