Pelvis and Hip

ANATOMY

Images


Joints

Sacro-Iliac Joint

Type

Congruency

Degrees of Freedom

Ligamentous Support

 


Pubic Symphysis

Type

Degrees of Freedom


Hip Joint

Type

  • Ball and socket

Congruency

Degrees of Freedom

  • Flexion / Extension, Abduction / Adduction, Internal Rotation / External Rotation

 


Kinesiology


ASSESSMENT

Subjective Assessment

  • Mechanism of Injury
    • Position of Foot / Knee
    • Direction of force
  • Initial Symptoms and Progression
    • Degree and location of pain
    • Giving way – due to pain or just gave way
    • Locking
    • Clicks, cracks or pops
    • Ability to WB
    • Aggravations and Eases – ie pain behaviour
  • Past Hip History
    • Both that knee and other side, including operations.

Objective Assessment

General Considerations

  • In an acute injury:
    • Often everything hurts
    • Weightbearing is usually difficult
    • Active and passive movement is often painful
    • The patient will probably use extensive muscle guarding to prevent further pain
  • This makes assessment difficult and patients should be referred on for followup assessment and treatment advice

OBSERVATION

  • OBS – HR, BP, TEMP (IF INDICATED)
  • Distal Neurovascular function (pedal pulse, capillary return, sensation, movement, warmth)
  • Swelling
  • Color – is it red?
  • Any Bruising / deformity

FUNCTIONAL TESTS

  • Ability to WB
  • Squat – Bilateral and Unilateral
  • Duckwalk (if able to deep squat without significant pain

GENERAL TESTS

  • Range of motion (Active vs Passive)
  • Flexion / Extension, Abduction / Adduction, Internal Rotation / External Rotation
  • Squat – Bilateral / Unilateral
  • Active Straight Leg Raise

SPECIAL TESTS

  • FABER
    • Passive Flexion, ABduction and External Rotation
  • FADIR
    • Passive Flexion, ADduction and Internal Rotations

 

  • Quadrant
  • Muscle Length Tests
    • Ober’s Test
    • Hamstrings
    • Quadriceps

Impingement Tests

FABER

Technique

 

Interpretation

  • Pain

 

 

 

 

 

 

 

 

 

 

 

 

 


 

 

 

 

 

 

 

 

 

 

 

 

Active Straight Leg Raise Test

 

 

 

 

 

 

 

 

 

 

 

 

 


MANAGEMENT

Overview

  • Always follow general principles:
    • Rest, Ice, Compression, Elevation (first 48-72 hours)
    • Avoid Heat, Alcohol, Reinjury and Massage (for first 48-72 hours)
    • Most injuries allow weight bearing as tolerated (consider crutches)
    • Arrange followup for reassessment once the acute symptoms have subsided
  • Consider more significant injury if:
    • Noise / feeling = “pop” or “crack” –
    • High force injury (dashboard injury or fall from height) – acetabular fracture
    • Locking
      • Inability to flex or extend the hip (labral or loose body)

Labral Tear

Injury

Findings

Grading

Management

 


Tendinopathy

Injury

  • Tendinopathy involves a process of mucoid degeneration with neovessels (presence of neurovascular structures within the tendon) which is also known as “tendinosis” (tendon degeneration without inflammation).
  • Tendinopathy is usually the result of an inability to recover adequately from the load placed on the structure, which may be caused by or excessive activity (especially if a sudden increased in load) or biomechanical error such as:
    • Inappropriate footwear (poor shock attenuation)
    • Unforgiving running surfaces
    • Poor lower limb mechanics (eg increased force  required to supinate the foot)
    • Tight quadriceps / ITB
    • Poorly tracking patella
  • Tendiopathies around the hip:
    • Hamstring tendinopathy
    • Psoas tendinopathy
    • ITBFS
    • Snapping Hip

Findings

  • Clinically, the patient usually has tenderness over
  • Ultrasound can show extent of damage, however does not really change management

Grading

  • Tendinopathy is categorised into stages:
  • Stage 1 – Pain only after activity
  • Stage 2 – Mild symptoms until warmed up, then  pain after activity
  • Stage 3 – Pain that doesn’t warm up –  continually sore

Management

  • Correction of biomechanical irregularities
  • Eccentric exercise program
  • Relative rest
  • Recalcitrant cases may need additional Mx options – NO patches, sclerosing agents, autologous blood have all been used with additional effect; surgery is reserved for cases not responding to conservative Mx

Paediatric Injuries

Transient Synovitis

SUFE

Perthes

Avulsion Fractures

  • ASIS (Sartorius)
  • AIIS (Rectus Femoris)
  • Ischial Tuberosity (Hamstrings)
  • Iliac Crest (Erector Spinae)

Injury

Findings

Grading

Management


PELVIS AND HIP IMAGING

Deciding to Image

  • The

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 

 

 

 

 

 

 

 

 

 

 

 

Pelvis and Hip X-rays

  • If you request Pelvic and Hip x-rays, you will usually be presented with an AP and a lateral
  • Note that standard hip films will not show the mid to distal femur

Views

AP, Lateral, Dunn views

Imaging for Femoro-Acetabular Impingement

  • Plain x-rays will not show damage to ligaments or cartilage, but can be useful in diagnosis of impingement. A standard pelvic and hip view can be complemented with a Dunn view.
  • Internal derangement is best imaged using MRI
  • CT scans are useful for further examining the bony component of the hip joint.

 

 

 

 

 

 

 

 


 

 

 

 

 

 

 

 

Abnormal X-rays