HIP and PELVIS ISSUESKari M Komlofske, BSN, FNP-C

∗ To understand the anatomy of the pelvis and hip. ∗ To become familiar with common causes of hip pain. ∗ To gain understanding in regards to the diagnostics of

common hip pain. ∗ Treatment options pertaining to hip pain.

Objectives:

• Bone Structure • Iliac crest• Ilium• Sacrum and Sacroiliac joint• Anterior/superior iliac spine• Coccyx• Ischium • Pubis – Pubic Symphysis

Anatomy of the Pelvis

Pelvis and lateral (www.pelvis+anatomy.com)

Anatomy and MUSCLES

• Pectoris Major • Pectoris Minor • Piriformis Muscle • Sciatic Nerve • Inferior gluteal nerve and artery • Inferior pudendal nerve, artery, and vein • Nerve to quadratus Femoris• Nerve that supplies the Obturator Internus Muscle

Anatomy and muscles of the Pelvis

Images for hip anatomy

∗ Adductor muscles (inside thigh)

∗ Iliopsoas muscle (hip flexor muscle that attaches to the upper thigh bone

∗ Rectus femoris muscle (quadriceps muscle on front of your thigh)

∗ Ball and Socket joint

Hip Anatomy – Muscles and Tendons

• Muscle strain • Fracture • Tendonitis • Arthritis • Infection

Pediatrics:• SCFE (Slipped Capital Femoral Epiphysis)• Avulsion of the Femoral Rectus • Congenital hip dysplasia • Septic arthritis

CAUSES OF HIP PAIN:

Pediatrics

SCFE∗ Slipped capital femoral epiphysis∗ Condition happens in teens and pre-

teens∗ Causes: Obesity, increased pressure

on growth plates, diabetes, thyroid disease, kidney disease

∗ Ball at the head of the femur “slips” off the neck of the bone posteriorly

∗ Surgical fixation indicated

Pediatrics continued…

Avulsion of femoris rectus • Sprinting exercises • Sudden intense pain • Inability to lift leg • Operative and non operative • Crutches for comfort • Time – usually 6-10 weeks recovery

Pediatrics:

Congenital hip dysplasia ∗ Hip socket doesn’t full cover the

femoral head ∗ Birth to 1 year – sooner it is diagnosed

(prior to 6 months) better non op treatment

∗ Often treated in Pavlik device∗ Can lead to chronic issues if untreated

or undiagnosed.

Adult and Child Septic arthritis HIP

Adult/Child∗ Infection of the hip joint fluid

(synovium) and joint tissues. ∗ Pt is often septic or ill with fever, +/-

blood cultures∗ Diagnostic is joint fluid aspiration- IR ∗ Treatment formal irrigation and

debridement with IV antibiotics

∗ Causes can be native joint, traumatic injury, prosthetic joint, previous surgery

∗ Underlying cause ∗ Infections may include:

- Staphylcocci – skin - Haemophilus influenzae- Gram-negative Bacilli

(E.Coli)- Streptococci

Muscle Strain/Hip flexor can include: ∗ Sudden, sharp pain in the hip or pelvis after trauma to the area.∗ A cramping or clenching sensation in the muscles of the upper leg area.∗ The upper leg feeling tender and sore.∗ Loss of strength in the front of the groin along with a tugging sensation.∗ Muscle spasms in the hip or thighs

Tendonitis: ∗ The iliopsoas muscle flexes your hip, bends your trunk towards your thigh

and rotates your thigh bone. This tendon can get irritated from overuse, muscle weakness and muscle tightness, resulting in tenderness and pain.

ADULT

1. REST 2. Muscle strain and tendonitis can take up to 6 weeks

depending on the severity 3. Patience 4. Begin with stretching exercises around week 2 when

pain is improved 5. Slowly increase activity as tolerated 6.Around six weeks increase strength training and

endurance

Treatment

∗ A fracture is a break. It is broken (no such thing as a little broken). ∗ If a patient is having pain that isn’t getting better further investigation needs to happen

– possibly a CT scan ∗ Pelvis fractures

– generally non operative in older people -- rami fracture

– non op, WBAT, advance activities as tolerated--Acetabulum fracture

– need orthopedics – generally non WB x 10 weeks; surgical or non surgical

∗ HIP – Almost always surgical

-- Femoral neck– non displaced percutaneous pinning --displaced – hemiarthroplasty (1/2 hip replacement)

-- Intertrochanteric/subtrochanteric: intramedullary rod -- Femur

– shaft: ORIF

-- Distal femur: Retrograde nail

FRACTURE

Hip Fractures – 20 percent mortality age over 80 years • 1:5 will die within one year of fracture • Return to baseline is goal • Fixation within 24 hours is goal • Peripheral nerve block pre-operatively helps decrease

narcotic use• High risk post operative delirium

Just a few Facts…

∗ Arthritis is the most common cause of hip pain leading to replacement

∗ TREATMENT - NSAIDS- Injections - Activity modifications - Physical therapy

∗ Treatment for arthritis is based on PAIN. It is based on pain that is daily and interferes with the patient's ADL’s.

∗ Replacement is an elective surgery anterior vs posterior approach

Arthritis of Hip

INJECTIONS

• Consider injection to manage chronic pain issues

• Kenalog 40 mg/ml (one ml) Lidocaine 1% 4 ml Marcaine 0.25% 4ml total of 8-9 ml will take a full week for the steroid (7 days) up to three to four times per year.

• End stage arthritis as much as they want (Injection limit three per site)

∗ Bates' Guide to Physical Examination and History Taking, 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins

∗ Netter, Frank H. M.D. (2006). Atlas of Human Anatomy, 4th ed. Philadelphia, PA: Elsevier Health Sciences.

∗ Sarwark, John, F. (2010). Essentials of Musculoskeletal Care 4. Rosemont, IL: American Academy of Orthopaedic Surgeons.

∗ Stoller, David, W. (2008). Stoller's Atlas of Orthopaedics and Sports Medicine. Baltimore, MD: Lippincott Williams & Wilkins, a Wolters Kluwer business. Bickley, Lynn, S. (2007).

∗ www.pelvis+anatomy.com; August 2018.∗ www.wheelessonline.com/; August-September 2018.

REFERENCES