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Congenital Hip Dislocation
Pathological Dislocation
Avascular Necrosis
Legg - Calve Perthes Disease
Slipped Capital Femoral Epiphysis
Coxa Vara
Coxa Valga
Transient Synovitis
Snapping Hip
Piriformis Syndrome
Tensor Fascia Latae Tightness
Deeper Acetabulum
Hip Fracture
Total Hip Replacement

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· Different manifestations and approaches tp patient depending on the
      patient’s age
· Common in or among: female (2-3x common)
        Left side (5x common)
        Italy or Japan – the way they carry their babies
        Breech delivery
· Associated with other congenital  conditions like Torticollis, Metatarsus
      Varus, Ligamentous Laxity

· NEWBORN/NEONATAL STAGE (birth less than 6 mos)
-  dislocation of femoral head – is upward and posteriorly
-  positive in PROVOCATIVE TESTS because the hip is still lax (ligaments)

A. Barlow’s Test – move the hip from normal to dislocated; if you want to
      dislocate thehip
        	  - palpable or audible click of DISLOCATION 

B. Ortolani’s Test – to reduce the dislocation, opposite the Barlows
        	  - palpable or audible click of REDUCTION

· As the baby grows old, the provocative tests become negative because of
      the development of some strength of the ligaments and muscles
· Other signs of dislocation: asymmetry of the thigh and inguinal
      crease/folds limitad abduction on the affected side

· GALLEAZI’S test – measures the length of the leg with the knees and hip

* the affected is shorter and there’s TELESCOPING or a sensation or pull
* 1st 3 mos- femoral head is not yet visible thru x-ray (confirmatory test)

· INFANCY STAGE up to 2y/o
* px is already sitting
* if bilateral, there’s WADDLING GAIT
* if unilateral – weakness of gluteus medius ( stabilizes the pelvis)

- Shortened length of ms – (+) weak ms, so in standing there’s broadening
      of the buttocks
- (+) weak ms hyperlordosis of the lumbar spine since hip ms also acts on
      the spine
- in walking – (+) lurching, which is a method to decrease the lever arm,
      thereby decreasing the force needed by the gluteus medius to
      prvent tilting
* Negative provocative tests but the other signs ( thigh & inguinal crease
      & limitad abduction ) can still be seen
* (+) galleazi & there’s minimal telescoping 

· 6 y/o & beyond: Limping
* LOM of hip
* Weakness of the gluteus medius
* Negative provocative tests
* Trendelenburg & lurching

· Treatment
* Initial Stage (px is still a baby)
- reduce the femoral head back to the acetabulum through TRACTION
- allow the femoral head to maintain that position until the supporting
      structures develop some strength & the jointr stabilizes thru/by:
- putting the patient in a non-rigid splint
- even if only one side is affected, the splint should still be bilateral
      to stabilized the pelvis which moves in unison
- the position should be 90 deg of flexion and abduction beyond 60 deg
      ( frog leg position )
- ex: Von Rosen, Pavlik Harness ( 6mos ), Ilfeld ( 12-13mos )
- at 9 mos, the patient can now walk but with crutches to decrease wt

·Late Stage ( 2-6y/o )
- non-rigid orthosis-can still be tried but usually is not enough
- Surgery
- done after putting  the patient in a flexed and abducted position to
      contain the head
- to improve the fit of the acetabulum and the femoral head

1.Varus Osteotomy – cut a wedge of bone either in the trochanter or the
      femoral neck, then, fuse it. Decreases the neck-shaft angle
2.Salter Innominate Osteotomy – same procedure: surgery done on the pelvis
      if the acetabulum is too shallow to increase the coverage
3.Pemberton – cut the acetabulum at the middle then advance the upper
      segment producing a deeper acetabulum

·Femoral Anteversion or Angle of Torsion of the Femoral Shaft
- since the orientation of the acetabulum is forward, downward and outward,
      the femoral head undergoes torsion in the upper part to fit in the
- in CHD, (+) excessive anteversion. Treatment: Varus or Salter Osteotomy
      Derotation of the femoral head and neck

            Special Test   
            Gait Analysis     
            US -whil;e doing Ortolani, (+) dislocation of the femoral head

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·Loosening, subluxation, dislocation of the femoral head from the
·Reasons 1. Erosion in the femoral head and acetabulum
         2.Weakness and paralysis of the hip ms
- adduction contracture of the hip
- paralysis of the hip abductors

·Dislocating forces – adduction and extension of the hip

·causes: CP, Spina Bifida, Poliomyelitis,  Malignancy, Fracture, TB of the
         hip, Arthritis, Pyogenic Infection ® increase pus® destroy ms,
         ligaments, bones & capsule, Neuropathatic Joint – destroyed
         nerve supply
.Treatment:     1. Traction
  	         2. Bracing –in flexed and abducted position
          	 3. Surgery: as that of CHD     

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· Disruption of the blood supply to the femoral head ( Posterior
      Retinacular Arteries )
· Most common cause:  fracture of the femoral neck, ( in close proximity
      with the PRA)

· Other causes:
1.Forceful manipulation of the hip ( ex. If beyond  60 deg of abduction,
      in CHD extreme rotation )
2.Forceful reduction of the Slipped Capital Femoral Epiphysis (SCFE)
3.Any abnormality in the blood
a.Sickle-cell anemia – RBC can’t pass thru the small vessels easily because
      they are no longer deformable, if several RBC grouped together ® a
      clot is formed blocking small blood vessels ® prolonged ischemia
b.Decompression Disease ( Caisson’s Dse ) – occurs among deep sea divers 
- sudden formation of nitrogen bubble follwing sudden ascend which cannot
      be removed ® will impede blood flow.
- can also cause SCI, if nitrogen bubbles formed in the artery supplying
      the spinal cord.

· Idiopathic Causes:		
1. Legg-Calve Perthes Dse – in children
2.Idiopathic Osteonecrosis of the femoral head in adults = 30-60; bilateral
      clotting chronic alcoholism

1.Necrosis – will last for 5 mos
           - bone cells and bone marrow die
           - migration of undifferentiated mesenchymal cells
           - angiogenesis (formation of new blood vessels)

2.Fragmentation – aka Stage of Bone Resorption
           - crescent sign – presence of radioluscent area immediately at
                the subchondral bone, represents a fracture
           - will last 5-7 mos       

3. Re- ossification or Regeneration – new bone cells replace the dead cells
           - called Creeping Substitution – 2-4 years
           - dead cells are resorbed by inflammatory cells
 4.   Remodelling – new femoral head establishes
           - if the femoral head involvement is severe, establishment of
                a Normal Head should not be expected 7 a deformed head
                will lead to degenerative arthritis and pain.         

· Symptoms: 
          - Limps and slight spasm at hip, pain on weight bearing referred
              to the thigh and knee
          - Pain on groin, restricted abduction and Internal rotation 

· Treatment    
1. Remove weight bearing – crutches and pool therapy (1st line of tx )
2. Traction – to relax muscle and decompress the hip
      			       - for inflammation and spasm
3. Positioning of the femoral head in Abduction & Internal Rotation
       - to allow the hip to remodel thru full containment in acetabulum
       - Scottish Rite, Toronto, Trilateral, Petricast, Boomstick and brace
4. Surgery – same with CHD
       - indicated if – it is in the late stage
       - patient didn’t unweight the limb ? femoral head was deformed
         ( poor  prognosis )
A. Varus Deterioration Osteotomy – to position the head in acetabulum
B. Salter/Pemberton – to change the contour of the acetabulum to
         adequately cover the femoral head.

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· ( less than 7y/o ) boys, 
· unilateral
· short stature 
· not inheritable, 
· rare in black

· Classification by Catteral
     - provides information about the severity of the head involvement

Grade 1 – involvement of the anterolateral portion of the femoral head;
     best progression
Grade 2 – involvement of head, less than 50%
Grade 3 – greater than 50%, not complete; near complete involvement
Grade 4 – 100%, most severe; complete total involvement

· HEAD AT RISK ( as seen in x-ray )
1. Diffuse metaphyseal resorption – there would be a substance to support
      the epiphysis ( most distal part of the femoral head ),
      metaphysic –below the epiphysis
2. (+) Lytic area or a defect in the lateral border of the epiphyseal
      plate ( Gage Sign ) w/ underlying metaphysic resorption
3. (+) Calcification lateral to epiphysis, indicates that there was a
      preceding lytic area
4. (+) Horizontal physis, which is below the epiphysis
5. (+) Lateral Subluxation – there would be no head for the acetabulum
      to cover

· GOOD prognosis – if px is: younger, thinner, male, min/absent sign of
      the HAR

· POOR prognosis – if the px is: older, obese, female, (+) signs of the
      fem. HAR

· PROBLEM: the DX is usually delayed, because the complaint of the patient
      is knee pain or discomfort and not hip pain, so if the patient
      complains of knee pain and there is no knee pathology, check
      the hip for the Legg-Calve Perthes Dse
· LIMP – most common symptom, aggravated by weight bearing
· DX: MRI, Bone Scan

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· Immature individuals only
· Young patients – 10-16y/o; boys
· Direction of slipping: downward and backward ( head )
· High frequency in or among: obese, black and in children

· Etiology:
1. rapid increase in weight – increase weight bearing by the hip
2. obliquity of the epiphysis
3. minor trauma ( most often it is not remembered by the patient )

· Onset:
1. Acute – the patient is apparently well
         - (+) sudden trauma
         - acute onset of pain and LOM

2. Acute onset superimposed on a chronic slipping
    - patient is initially complaining of hip discomfort, LOM and limping
    - occurrence of a minor trauma ( stumbling, slipping ) leads to severe

3. Slowly progressive chronic hip pain and LOM

· LIMP – most common manifestation

· Other signs and manifestations: 
adult – pain
Children – pain that is referred to the knee or the inner thigh
         - LOM in abduction and Internal Rotation

. DX: X-ray – slipping can be seen ( downward and backward ) lateral view

1. Traction and immobilization – pain on weight bearing and muscle spasm
2. Crutches – to immo0bilize the hip when pain and swelling subsides
     ( minor slipping )
3. Surgery – to contain the head in the acetabulum ( severe slipping )
 - ex. Osteotomy, innominate ( pelvis and hip ) 

· Complications:
        1. Osteonecrosis
        2. Chondrolysis
        3. Degenerative Osteoarthritis 

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· Neck shaft angle is less than 135 degrees

· ACQUIRED – 2 degrees interttrochanteric fracture; complications of SCPE,
      Legg-Calve, CHD, femoral neck, fracture, Paget’s, Rickets and
      osteomalacia ( softening of the bone )
· CONGENITAL – or developmental 
       -2 degrees abnormality in the anatomy of the femoral neck evident
        once the patient starts to walk

· (+) Shortening of the limb – weakness of the gluteus medius, limited
· Shortened stride length , trendelenburg, limping
· DX: X-ray – decrease angle
· Treatment: surgery—wedge osteotomy to increase the neck-shaft angle
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· Neck shaft angle is more than 135 degrees

· PHYSIOLOGIC – seen in people who cannot stand 
· Disappears when the baby starts to walk

· PATHOLOGIC when – it is still persistent beyond ambulation

· Treatment: if unilateral – stretching
· Severe – decrease the neck-shaft angle thru osteomy

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· Synovisis- inflammation of the joint
· Minor trauma or low grade inflammation
· Last only for 1 to 2 weeks, disappears spontaneously, px can resume to
       Normal activies
· If persistent- r/o legg-calve (stage is exemplified by synovitis)

· S/sx : hip pain , LOM, spam , limpimg

· May lead to Legg- Calve
· DX : X-ray- normal

· TX :	1. Bed rest, immobilization
        2. Traction
        3. Pain meds/pain relief
        4. Dec. wt, Bearing , BAC

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· More annoying than pain , common in female
· CAUSES : Slipping of the ITB (iliotibial band) over the greater
      trochanter, 2deg. Ostreochondritis dissecans, loose bodies,
      hypertrophy of the iliopsoas ms/tendon slipping over ht
      iliopectineal eminence
· May or may not be treated

· Treatment : for comfort-strectching of the ITB, iliopsoas ms, heating

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· PIRIFORMIS MS : a ms in the butt that  crosses the greater sciatic 
      foramen: Sciaitc nerve and other vessels pas underneath this ms
· If the piriformis ms is swollen/ inflamed /hypertrophied/spastic-
      can compress the sciatic nerve & other vesels- SCIATIC PAIN
      which radiates down the butt, hamstring & up to the foot
· ER : action of the piriformis ms; Since periformis ms is swollen is
      tight/shortened/spastic there’s LOM of IR
· Stride length decrease, because normally a person walks with ER leg

· Treatment : pain meds & PT – decrease pain

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· In the hip, there are more than 15 bursae, but only 4 produces or are
      significant in the clinical conditions 

        -  located under the ilipsoas ms, between and ilipectineal eminence
        -  SX:  pain and tenderness on the ant portion of the hip/ on the
           inguinal area extension – painful because it stretches the bursa
        -  should be different with hernia, lymphadenopathy, abscess
        -  Treatment: pain relief, heating modalities, anti-inflammatory
           drugs, stretching

        -  Located above and behind the greater trochanter, below the
           tendon of g. meduis
        -  Sx: if mov’t stresses the bursa pain (adduction)
        -  disappearance of the normal depression on the butt
        -  Treatment: same

        -  between the greater trochanter and subcutaneous tissue (bet.
           Bone and tissue)
        -  Sx: painful on the palpation, px can’t lie on the affected side,
           px can’t adduct the hip (stresses the bursa)
        -  Tx: intrabursal injection of the lidocaine; bursectomy

        -  Located superfiscial to ischial tuberosity
        -  Tailor’s or Weaver’s bottom
        -  Common among paraplegics, students, boatmen, tailors
        -  too much/ prolonged seating on hard surface
        -  Sx: pain upon hamstring activation (ex.  Climbing)
        -  Tx: Avoid sitting on hard surfaces/ use seat cushions; do wt
           transfers; PT/Med

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· (+) OBER’S  sign
· TFL – crucial ms that should be prevented from having tightness if the px
      has CP, muscular dystrophy, polio
· Treatment: Stretch the ms, put the patient in kneeling position & ask to
      bend on the opposite side
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· Degeneration of cartilage which lead to ankylosis causing the narrowing
      of the Hip joint
· CAUSES: complication of infection; results of SCFL, idiopathic
· Treatment: Bed rest & traction ( dec wt bearing ) ; Hip replacement - if
      ankylosis cant be treated

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· CAUSES: can be a consequence of tuberculosis of the hip, osteomyelitis,
      RA & hip pathology
· Treatment: decompress the hip joint, decrease weight bearing, tract

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FRACTURE – femoral neck fracture

- poor prognosis; most common cause is AVASCULAR NECROSIS
A. Subcapital
B. Transcervical
C. Basicervical

· EXTRACAPSULAR FRACTURE – prone to develop comminuted fracture, but still
      have a better healing because of adequate blood supply

A. Intertrochanteric
B. Pertrochanteric
C. Subtrochanteric

· Treatment: medical/surgical
1. Immobilization with traction in INTERTROCHANTERIC FRACTURE, if not
2. In ELDERLY, replace with the prosthesis & ambulate 1 day post-operation
3. In CHILDREN, close reduction
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- Post operation program: started one day 
- Rationale of procedure: replace only 1 component entails 
                                        greater risk of developing OS of 
                                        the unreplaced part
- Removal of the femoral head – metallic alloy
        Acetabulum – polyethylene substance ( hard plastic )

- PARTIAL hip replacement – only 1 part is replaced

- JOINT REPLACEMENT in general: 
 1. Resectional
 2. Interpositional
 3. Replacement

- Indications:  

1. Any hip pathology that may results in 
    ankylosis such as ankylosis spondylitis, 
    severe degenerative OA Contraindication 

1. Infection in the area
2. Paralysis of the ms that is supposed 
    to stabilized the prosthesis
3. If the patient can’t follow commands 
    ( unconscious/psychiatric px )
4. Severe osteoporosis
5. Extensive malignancy
6. If the patient is young, maximize other 
    form of treatment to prevebt repeated
    joint replacement, since thjay are prone 
    to have dislocation 2º active lifestyle 
    ( relative CI )

-	5-15 years- lifespan of a prosthesis 
                ( with all the given precautions being 
                followed )

-	TYPES: 1. Cemented – the bone cement that 
                                is used is methylmetacrylate
                                - PWD immediately, day 1 
                                with assistive device
               2. Non-cemented – no bone cement; 
                                 the bone tissues are allowed to 
                                 grow into the prosthesis
	- If it is cemented, but OSTEOTOMY was done, 
                  delay weight bearing for 6 weeks
	- SURGERY – lateral approach, posterior approach
                - ( given before and after the surgery )
                       1.  hip flex not beyond 90º
                       2.  hip adducted not beyond midline, 
                            use adduction pillows
                       3.  no hip abduction beyond 45º
                       4.  no excessive IR & ER
                       5.  avoid sitting in low chairs
                       6.  avoid crossing legs
                       7.  in climbing stairs, the GOOD leg first
                       8.  in standing, look at the ceiling & SCOOT 
                            1st to the edge of the chair
                       9.  turn to the GOOD side
                       10. in sleeping, the GOOD side faces 
                             the door, the BAD faces the wall
                       11. in driving ( after 6 weeks ) the seat 
                             should be slightly reclined and 1-2 pillows

	- To increase the seat ht; enter with the Bad side 

                 1. Isometrics
                 2. Gluteal setting – squeeze butt
                 3. Quads setting
                 4 Abduction exercises – thera band
                 5. Strenghthen the weight bearing muscles

DAY 2-3
                 1. AROM exercise
                 2. CANE on opposite side until the 
                     gluteus medius is weak

PRONE: stretch  the anterior hip structures 
                 ( capsule and ligament )

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