Patients present with pain and swelling 4 cm proximal to the radial side of the wrist. It i s more common with repetitive wrist motion especially in sports, such as rowing and weight lifting. In the majority of cases rest, splinting, and glucocorticoid injection is suf \201 cient. Occasionally, surgical decompres- sion is necessary. Figure 5.24 There is thickening around the tendon and synovitis around the extensor group 1 tendons, but with no \202 uid visualized on ultrasound. Management of tenosynovitis \200 Extensor carpi ulnaris (ECU) tenosynovitis This is reactive tenosynovitis in the ECU tendon and it is often initiated by a twisting injury of the wrist. \200 In those with an infectious cause, debridement and antibiotic therapy is necessary, with no role for conservative management or glucocorticoid injection (see Chapter 16 p. 459) Hand therapy, rest, and splinting are of bene \201 t. Medical management aims to prevent tendon rupture. Targeted glucocorticoid injections for non-infectious tenosynovitis. Surgical ste ps include synovectomy and trigger \201 nger release with carpal tunnel decompression. Do rsal synovectomy involves a long incision on the back of the hand, followed by bandage or p laster immobilization for 2 weeks. After this period, removal of sutures and hand therapy c an begin. Scar massage and occasionally desensitization may be needed. It is associated with nocturnal ulna-sided wrist pain and swelling. Pain in the sensory bra nch of the ulna nerve is common. Pain in all motions of the wrist is noted although it is w orse in an extensor and ulna deviated position. The diagnosis is con \201 rmed when pain i s obliterated by injecting local anesthetic into the ECU sheath. Management is the same as intersection syndrome. \200 \200 Kienb cks disease This encompasses avascular necrosis of the lunate bone. It involves a de gree of wrist degeneration. Reasonable func- tion, however, is maintained. The cause of thi s condition is uncertain, but is not thought to be related to trauma. Speci \201 c examples of tenosynovitis Trigger \201 nger Trigger \201 nger and thumb a re common, and can be primary or associated with diabetes, gout, renal disease, and other r heumatic diseases. The flexor tendon is unable to smoothly slide up and down its sheath, an d as a result the \201 nger locks/clicks into a \202 exed position. It can be very pain ful to straighten it up. \200 History \200 \200 \200 \200 Pain particularly on the dorsum of the wrist. Stiffness with subsequent loss of motion. Wea kness of the wrist with diminished grip strength. There is rarely a history of trauma. Examination \200 \200 On clinical examination the triggering can be elicited and a nodule is often palpated at th e distal palmar crease. Treatment includes glucocorticoid injection with an approximately 5 0% success rate. If the glucocorticoid injection does not work then surgical release of the trigger \201 nger is performed, usually under local anesthetic. Tenderness to palpation with occasional dorsal swelling. Decreased range of wrist motion. Investigations \200 Radiographs show characteristic increased density of the lunate bone, as well as fragmentat ion with collapse of the lunate. See Figure 5.25. MR may be useful and can help in planning treatment. HAND AND WRIST: REGIONAL MUSCULOSKELETAL CONDITIONS 160 diabetes, connective tissue diseases, pregnancy, and previ- ous wrist fracture. It occurs m ost commonly in women in the 30 \200\22360-year age groups. The differential diagnosis for this condition includes a cervical radiculopathy, as well as spinal cord lesions and periph eral neuropathies, such as alcoholic and diabetic neuropathies. History \200 Patients often present with a typical history of numbness in the median nerve distribution, particularly in the morning, with pins and needles in a similar distribution. They often r eport that shaking the hand in the morning makes it better. Patients initially have pins an d needles, and pain in the above mentioned distribution and as time progresses they may wel l go on to having diminished sensation. Patients often present with odd pain shooting up th e arms. Figure 5.25 On this plain radiograph of a patient with Keinbock \200\231s disease, sclerosi s of the lunate bone can be seen on both views. The disease is staged according to the degree of degen- eration, with subsequent secondary changes to the car- pal structure and scaphoid bone. Examination \200 Examination should include the cervical spine, as well as a neurological examination of the hand. There may be diminished sensation in the median nerve distribution with wasting of t he thenar muscles. Gentle tapping over the median nerve at the wrist in a neutral position often produces paraesthesia in the dis- tribution of the median nerve. (Tinel \200\231s tes t) Holding the wrist in a \202 exed position will often bring on similar symptoms of ting ling (Phalens \200\231 test). The disease can be divided into mild (sensory de \201 cit on ly), moderate (sensory and motor de \201 cit), and severe (sensory de \201 cit with motor absence) The diagnosis of this disease is generally clinical. However, nerve condition stu dies may be used as an adjunct. Management \200 A short period of physiotherapy with casting or bracing can be attempted, but it is not rec ommended unless there is quick resolution of symptoms. Arthroscopic evaluation may help wit h diagnosis and can provide pain relief. Surgery can be complex and may involve prolonged p eriods of immobilization after osteotomy. Advanced disease can be treated with proximal row carpectomy or arthrodesis. Recovery can often take up to 6 months. Preisser \200\231s disease \200 This is a similar condition to Kienb ck \200\231s, but affects the scaphoid bone. It prese nts with radial and dorsal sided wrist pain. There may be an association with previous non- speci \201 c wrist trauma but this disease is differentiated from scaphoid fracture and no n-union. Management is also complex and beyond the scope of this text. Management \200 \200 Conservative management, such as a Futuro splint and non-steroidal anti-in \202 ammatory d rugs often help. Injection of local anesthetic and glucocorticoid into the carpal tunnel ha ve been shown to keep patients symptom-free for at least 1 year in over 50% of cases. Injec tion is best provided by a hand surgeon or rheuma- tologist as the median nerve is at risk during the injection. If conservative treatment has not worked then early referral to a han d surgeon would be recommended. The treatment would include surgical decompression of the c arpal tunnel, which can usually be performed under local anesthetic. Upper limb nerve entrapment syndromes The radial, ulna, and median nerves may all be compre ssed predominantly from the elbow to the wrist. Patients present with a wide range of sympt oms starting with occasional paraesthesia, and may progress to sensory loss, muscle weaknes s, and pain. Severity depends on the degree of compression, as well as duration of compress ion. It is imperative that the whole limb, as well as the cervical spine is examined when e valuating these patients. Double crush syndrome, as described by Upton and Acoma, is the co mpression of a nerve at one level, which will make it susceptible to damage at another leve l. For example, cervical nerve route compression predisposes a patient to carpal tunnel dis ease. Median nerve compression in the forearm \200 The proximal median nerve can be trapped between the ligaments and muscles at the elbow, an d proximal fore- arm, e.g. between the bellies of the pronator teres muscle. The anterior i nterosseous nerve can be trapped in the forearm resulting in diminished thumb \202 exion and weakness in pronation at 90 of \202 exion. History \200 \200 Median nerve compression Median nerve compression at the wrist: carpal tunnel syndrome This is the most common compressive neuropathy in the upper limb and is a term used to describe a broad group of symptoms associated with compression of the median nerve at the wrist. It is generally idiopathic in origin; however, there is an association with rheumatoid arthri tis, Aching pain in the forearm. Decreased sensation in the radial three-and-a-half \201 ngers . Reduced power in the hand. Examination \200 \200 Sensory de \201 cit in the above-mentioned distribution. Negative Tinel \200\231s and Phal en \200\231s tests. CHAPTER 5 Regional musculoskeletal anatomy and conditions 161 Symptoms of PIN compression can be elicited by resisted supination with an extended elbow. Pressure over the junction of the brachioradialis/extensor carpi radialis tendons, with the forearm in pronation and the wrist in ulna \202 exion, elicits the pain associated with entrapment of the sensory branch. This entrapment is known as Wartenburg \200\231s syndrome . The speci \201 c provocation test involves \202 exion of the elbow to 90 with resistan ce of pronation and supination. Nerve conduction studies are often normal. Management \200 This may involve a hand therapist with splinting and strategies to avoid positions that irr itate the nerve. NSAIDS may help control pain. Surgical release will result in a scar that may be promi- nent and nerve recovery can take up to 6 months. \200 Management Management is as for previous entrapment neuropathies. Thoracic outlet syndrome This is a diagnosis of exclusion and is not an easy diagnosis to m ake. The clinical criteria are far more important than special investigations. Etiology can be subdivided into: \200 Ulnar nerve compression The nerve can be compressed at the elbow (cubital tunnel), usually at an anatomically narrow location. At the wrist (Guyon \200\231s canal) there is usually a cause for the compres- sion, such as a ganglion, hamate fracture, direct trauma, or anomal ous muscles. Arterial: this accounts for 1 \200\2232% of cases and is usually secondary to a bony protub erance from a cervical rib of other anomaly. The occlusion can be acute or chronic with the development of a collateral circulation. This results in either acute ischaemia or a Rayna ud \200\231s type phenomenon. Venous: this accounts for 2 \200\2233% of cases and usually o ccurs in young muscular males, particularly after vigorous exercise. True compression: this is quite rare and is the result of nerve compression at the C8T1 level, and is always a re sult of a bony abnormality. Disputed: this makes up 97% of cases and presents with a variet y of symptoms that are often ambiguous. Provocation testing is positive however Doppler, EM G, and radiographs are normal. History \200 A loss of feeling on the little and ring \201 nger, particularly on the palmar surface an d ulna border is typical. With involvement at the elbow there can be diminished dorsal sens ation. Patients often complain of a dull ache down the arm and occasionally above the elbow . Examination \200 Diminished sensation of the above distribution with a positive Tinel \200\231s test at the elbow. There is intrinsic muscle wasting and weakness with a positive Fromen \200\231s test . (Instead of grabbing a piece of paper with a \202 at thumb, the thumb is bent to grab t he paper. This illustrates use of the FPL tendon which is supplied by the median nerve.) Th e provocation test involves persistent \202 exion at the elbow and recreates the paraesth esiae (Wadsworth test). The severity of the disease is graded using the Dellon or modi \201 ed Bishop system. Nerve conduction studies are recommended if there is any doubt regar ding the diagnosis. History \200 \200 \200 Paresthesia usually in the ring and small \201 ngers is classical. Shoulder pain, but not upper back pain is experienced. Driving, grooming, and lying in bed can all worsen the pai n. There is an association with depression and anger at a later stage. Examination \200 Management \200 It is essential to examine the patient fully unclothed to truly appreciate muscle asymmetry and postural abnor- mality. Masses and fullness in the cervical spine and neck region must be looked for, and a thorough neurological exami- nation is important. The peripheral nerv es must all be evaluated for evidence of compression. There are numerous special provocatio n tests, but the Roos is thought to be the most sensitive and reproducible. The Adson and H alstead maneuvers can also be per- formed. The Roos maneuver entails 90 of shoulder abduc tion with external rotation and 3 minute opening and closing (pumping) the hand. This shoul d reproduce symptoms. Patients should have plain radiographs and usually have CT/MR and EMG studies, which are often normal. Surgical decompression is indicated if conservative treat- ment fails. It is important to t ell the patients that there may be a degree of elbow stiffness with a possibility of weak \202 exor muscles if a sub muscular transposition has been performed. Radial nerve compression The nerve is divided into the posterior interosseous nerve (PIN), which is positioned in the proximal third of the fore- arm, and the super \201 cial branch of the radial nerve, which is predominantly in the distal third, radial aspect of the fore arm. The condition must be differentiated from lateral epicondylitis (tennis elbow). History \200 Dull ache in the proximal forearm with extension up the arm at times. Entrapment of the sen sory branch often causes a sensation of painful water \202 owing down the arm. Complaints of weakness of the hand and wrist. Management \200 Non-operative treatment is the mainstay. It involves postural retraining, as well as physio therapy. A team approach with a social worker, psychiatrist, and pain specialist is essenti al. Surgery should be performed in specialized centers, but it is not always guaranteed to cure the patient. Clinical examination \200 \200 \200 Decreased sensation is not typical. A positive Tinels \200\231 sign over the course of the nerve. Tenderness along the course of the nerve, but not at the common extensor origin at t he elbow. HAND AND WRIST: REGIONAL MUSCULOSKELETAL CONDITIONS 162 Diabetic cheirarthropathy This condition of the hand is not well understood. It is thought to be as a result of a muscular/tendon imbalance with soft tissue disruption. There is a mi cro-angiopathy of the dermal and subcutaneous blood vessels. It is more common in Type 1 di abetics (16 \200\22342%), and can affect 8 \200\22350% of the population. \200 with an imbalance of matrix metalloproteinase inhibitors. It is commonly bilateral and is o ften precipitated by trauma. It is more common in males and usually affects patients over t he age of 40, but only presents much later on. There is a hereditary predisposition and an association with diabetes and epilepsy. There is a very small group of people who have what is known as a Dupuytren \200\231s diathesis in which the disease progresses rapidly; the p atients are usu- ally male. The diathesis is associated with a similar condi- tion on the s oles of the feet, as well as Peyronie \200\231s disease. \200 Patients present with pitti ng and nodules with thickening of the fascia in the hand. Later on this progresses to defor mity at both the metacarpophalangeal and proxi- mal inter-phalangeal joints. Patients repor ts trouble with washing and hygiene of the hands, as well as the \201 nger getting in the way. It is a progressive disease. On clinical examination there are bands and nodules on t he palmar aspect of the hands with deformity of the joints. Occasionally, there may be pads (Garrods \200\231) on the dorsal aspects of the MCPJs and PIPJs. The patient is unable to lay the hand \202 at on the table (a positive Hueston table top test). It is worth having a watchful policy at an early presenta- tion as surgery performed at an immature stage of the disease can worsen it. Referral is recommended when deformity occurs. It must be noted that surgery does not prevent a recurrence of the disease. Patients will complain of a painless loss of function in the hands. On examination there is swelling of the \201 ngers with thick tight and waxy skin. There is initial loss of MCPJ and PIPJ movement but this eventually progresses to DIPJ movement. The pathognomonic sign for the disease is the Prayer sign, which is an inability to oppose palmar surfaces. Differ ential diagnosis should include carpal tunnel and Dupuytren \200\231s disease, as well as s cleroderma. Management includes physical therapy with good diabetic control with judicious use of glucocorticoids. Aldose reductase inhibitors have been tried to decrease the effects of this disease. Soft tissues lesions in the hand and wrist Small tumors in the hand are common and are usua lly benign. Their size and possible interference with function should be monitored, and if a proper diagnosis cannot be made then referral is recommended. Tumors include ganglia, imp lantation dermoid cysts (found along the volar surfaces of the \201 ngers and palms). Mal ignant tumors such as basal or squamous cell carcinoma, and melanoma are less common. Promp t referral must take place. It is not uncommon for the rheumatologist to diagnose skin canc er. Further reading Clayton ML. Historical perspectives on surgery of the rheumatoid hand. Hand Clin 1989; 5: 111 \200\22314. Finkelstein H. Stenosing tendovaginitis at the radial styloid process. J Bone Jt Surg Am 1930; 12: 509 \200\22340. Ganglion A ganglion is a cystic myxomatous degeneration of \201 brous tissue. Ganglia are extremely common around the wrist joint and often originate from the carpus itself. Gangli a in the proximity of peripheral nerves may cause local irrita- tion. Ganglia generally are not painful, but can be irritating. Large ganglia can interfere with movement. Ganglia gen er- ally grow slowly and usually present many months after developing. They are rare in chi ldren under 10 years old and often regress in children. \200 Green DP. Green \200\231s Operative Hand Surgery, 5th edn. Philadelphia: Elsevier, 2005. Hueston JT, Wilson WF. The etiology of trigger \201 nger. Hand 1972; 4: 257 \200\22360. Jebson PJ, Kasdan ML. Hand Secrets, 3rd edn. Philadelphia: Hanley and Balfus, 2006. Kapoor A, Sibbitt WL Jr. Contractures in diabetes mellitus: the syndrome of limited joint m obility. Semin Arthritis Rheum 1989; 18(3): 168 \200\22380. Kienbock R. Peltier L. Concerning traumatic malacia of the lunate and its consequences: deg eneration and compression fractures. Clin Orthopaed 1980; 149: 4 \200\2238. Dorsal wrist ganglia occur over the scaphoid interval on the dorsal aspect of the wrist. Vo lar ganglia occur over the radial artery and are often quite large. On palpation they are c ystic and occasionally feel hard. They move underneath the skin and are usually not tender. Conservative measures include reassurance, and a watch and wait policy. Ganglia can be asp irated and injected with glucocorticoid, but this does not guarantee removal. If the gangli on is signi \201 cantly painful or interfering with activities of daily living the patient can be referred to a surgeon. It is important to let the patient know that even if the gan glion is excised there is a 20% risk of a recurrence. Mackinnon SE. Pathophysiology of nerve compression. Hand Clin 2002; 18: 231 \200\22341. McRae R. Orthopedics and Fractures, 2nd edn. London: Churchill Livingstone, 2006. Miller MD. Review of Orthopedics, 4th edn. Philadelphia: Elsevier, 2004. Nagle D J. Evaluation of chronic wrist pain. J Am Acad Orth Surg 2000; 8: 45 \200\22355. Stanley J. Mini-symposium: Rheumatoid Disease of the Hand and Wrist, the rheumatoid wrist. Curr Orthopaed 2001; 15(5): 329 \200\22337. Stanley J. Mini-symposium: Rheumatoid Disease of the Hand and Wrist, degenerative arthritis of the wrist. Curr Orthopaed 1999; 13(4): 290 \200\2236. Upton ARM, McComas AJ. The double crush in nerve entrapment syndromes. Lancet 1973; 2: 359 \200\22362. Dupuytren \200\231s disease This is a condition of nodular hypertrophy and contracture of t he super \201 cial palmar fascia. It is thought be associated This page intentionally left blank PELVIS, HIP, AND GROIN 164 Pelvis, hip, and groin \200 There are a wide range of musculoskeletal and soft-tissue lesions in and around the hip reg ion. However, to under- stand and appropriately diagnose these conditions, it is important to appreciate the complexity of the anatomy of the hip. Ligaments. Muscles. Hip joint capsule This strong \201 brous capsule attaches proximally to the acetabular ri m and transverse acetabular ligament. Distally, it attaches to the anterior intertrochanter ic line and proximal to the intertrochanteric line posteriorly. These capsular \201 bres take a spiral course from the acetabulum to the intertrochanteric line. Regional anatomy Bones (See Figure 5.26) The pelvic girdle is a ring structure consisting o f two paired innominate bones, the sacrum and the coccyx. Each bone is made of three fundam ental parts \200\223 the ileum, ischium, and the pubis, and each contributes to part of th e hip acetabulum. The articulations of the pelvis include the sacroiliac joints and the sym physis pubis anteriorly (secondary cartilaginous joint). The sacroiliac joints are further stabilized by strong posterior and dorsal sacroiliac ligaments, the sacrotuberous and sacro spinous ligaments. The symphysis pubis is reinforced by the suprapubic and arcuate infrapub ic ligament. Movement across the joints in the pelvis is minimal, but the essential functio n of the pelvis is force transmission from lower limb to the trunk. Ligaments of hip joint (See Figure 5.27a) Hip joint stability is reinforced by ligaments. Iliofemoral ligament Reinforces the \201 brous capsule anteriorly. It is Y-shaped, and at taches to the anterior inferior iliac spine proximally and the intertrochanteric line dista lly. Pubofemoral ligament It reinforces the inferior and anterior aspect of the \201 brous cap sule, arises from the obturator foramen margin and passes laterally to insert onto the inte rtrochanteric line and merges with the medial part of the iliofemoral ligament at its inser tion. The hip joint is a multi-axial ball-and-socket synovial joint designed for stability and a wide range of movement. The ileum forms the superior, pubis the anterior and ischium the po steroinferior part of the acetabulum. The femoral head projects superomedially and anterior ly, and forms an angle of inclination with the shaft of the femur (via the neck) at 125 \200\223130 . Coxa vara describes an inclination angle less than 100 resulting in shorte ning of the affected limb, while coxa valga describes an angle greater than 130 resulting in limb lengthening of the affected side. Ischiofemoral ligament It reinforces the posterior part of capsule, arises from ischial par t of acetabular rim and attaches medial to the base of greater trochanter. Muscles (see table for insertion and origins) Gluteal region \200 \200 \200 \200 Gluteus maximus (inferior gluteal nerve). Gluteus medius (superior gluteal nerve). Gluteus minimus (superior gluteal nerve). Short external rotators: \200 \200 Stability of the hip joint is afforded by a multitude of factors: \200 A substantial bony cup (acetabulum), which is deepened by a \201 brocartilaginous labrum and transverse acetabular ligament. A \201 brous capsule. piriformis (nerve to piriformis; anterior rami of S1); obturator internus (nerve to obturat or internus); iliac crest gluteal surface tuber cule of cr est anterior posterior inferior M U gluteal lines I L acetabulum I iliopubic eminence gr eater sciatic notch ischial spine lesser sciatic notch superior pubic ramus M S I ischial tuber osity U B pubic tubercle I H U obturator foramen C S I P (a) (b) ischiopubic ramus Figure 5.26 (a) diagram of pelvis (lateral view) showin fusion lines wher the three constit uent bones (ilumium, ischium, pubis) meet. (b) Lateral aspect of adult pelvis. CHAPTER 5 Regional musculoskeletal anatomy and conditions 165 pubofemoral ligament iliofemoral ligament ischiofemoral ligament capsule Figure 5.27 Inrinsic ligaments of hip joint. superior gemelli (nerve to obturator internus); inferior gemelli (nerve to quadratus femori s); quadratus femoris (nerve to quadratus femoris). \200 \200 Cruciate anastomosis: this is a collateral supply posterior to hip joint, and has minimal c ontribution to arterial supply to the femoral head. From Inferior gluteal artery and 1st pr ofunda femoral perforating artery. Anterior compartment of thigh \200 Artery of round ligament of femoral head Iliopsoas (femoral nerve and anterior rami of lumbar plexus). Pectineus (femoral nerve). Te nsor of fascia lata (superior gluteal nerve). Sartorius (femoral nerve). Quadriceps femoris (all femoral nerve): \200 \200 \200 \200 \200 \200 \200 Anastomosis rectus femoris; vastus lateralis; vastus medialis; vastus intermedius. Medial compartment of thigh \200 \200 \200 \200 \200 Adductor longus (obturator nerve). Adductor brevis (obturator nerve). Adductormagnus (obtur ator and sciatic nerve). Gracilis (obturator nerve). Obturator externus (obturator nerve). Medial Lateral Circumflex femoral arteries Posterior compartment of thigh Hamstrings: \200 \200 \200 Semitendinosus (tibial division of sciatic nerve); Semimembranosus (tibial division of scia tic nerve); Biceps femoris (both tibial and common \201 bular division of sciatic nerve). Figure 5.28 Blood supply of the femoral head. Blood supply to femoral head (See Figure 5.298) \200 Functional anatomy Locking of the hip joint In the extended position, the hip joint locks. The functional advantage is then the joint can remain in extension (in upright position) wi thout needing muscle contraction. \200 \200 Intra-capsular: branches of obturator artery to head of femur is conveyed via the ligamentu m teres femori. Retinacula: convey branches of the medial and lateral circum \202 ex femor al arteries \200\223 the main blood supply to the femoral head. Nutrient arteries: from br anches of the upper perforating arteries of the profunda femoris, conveyed through the marr ow cavity. Process: In an upright position, the body \200\231s center of mass falls behind the hip joi nt. Gravity shifts the hip posteriorly into extension. PELVIS, HIP, AND GROIN 166 The \201 brous capsule (with its spiraling \201 bres) draws the femoral head into aceta bulum with hip extension. The iliofemoral ligament tightens and screws the femoral head int o the acetabulum with extension. The ischiofemoral ligament acts similarly to the iliofemor al ligament, but has a much weaker effect. During slow walking, the maximum force transmitted across the hip joint is approximately 2. 5 times the body weight, and in running this force increases to about 5.2 times the bodywei ght during toe-off phase. (van den Bogert et al. 1999) Stance phase \200 As a result, the head of the femur and the acetabulum are tightly engaged, preventing dislo cation, and hyperextension of the hip joint. Heel strike: eccentric contractions of hamstring and gluteus maximus restrains further forw ard movement of limb, thus allowing heel strike. Loading: gluteus medius and minimus contra ct to cause abduction of weight-bearing limb. This prevents pelvic tilt (trendelenburg gait ) to the contra-lateral side thus allowing it to swing and maintain center of gravity. Mid- stance: during mid and terminal stance, abductors maintain pelvic stability. At the same ti me, the hip joint moves from a neutral to extended position secondary to the swinging of to rso by the contralateral limb. Terminal stance. Pre-swing: elastic re-coil of intrinsic foo t muscle prepares for toe-off Range of motion The motion is in three planes: sagittal, frontal and transverse, with the g reatest motion in the sagittal plane. \200 Flexion: 120 (knee flexed), 90 (knee extended). Iliopsoas and rectus femoris. Smaller c ontribution from sartorius, tensor of fascia lata (TFL), pectineus, adductor longus, adduct or brevis, adductor magnus (anterior part), and gracilis. Extension: gluteus maximus, semit endinosus, semimembranosus, long head of biceps femoris, and adductor magnus (hamstring por tion). Abduction: normal 45 . TFL, gluteus medius/minimus. Adduction: normally up to 30 . Adductor longus, brevis and magnus, gracilis and pectineus. Internal rotation: usually 40 . Gluteus medius and minimus and TFL. External rotation: up to 45 . Short external rotato rs (obturator internus and externus, gemelli, piriformis, and quadratus femoris) assisted b y gluteus maximus. \200 \200 Swing phase \200 Limb goes from weight bearing to non-weight bearing position. Quadriceps contract to limit the degree of knee \202 exion toe-off. Contraction of hip \202 exors (especially iliops oas) brings the hip into \202 exion. Adductors play a role in swinging the limb inward, k eeping the foot under the pelvis, ready for the next stance phase. In late swing/before hee l strike, hamstrings contract to decelerate forward swing. Movement limitation of hip joint (Clarkson 2000) The \201 brous capsule and the bony join t con \201 guration itself play a role in limiting hip joint movements. However, in additi on to this, the following have additional function in limiting range of motion: \200 Further reading Clarkson HM. Musculoskeletal assessment. Joint range of motion and manual o f muscle strength, 2nd edn. Baltimore; Lippincott Williams & Wilkins 2000. Flexion: by soft tissue apposition, tension of gluteus maximus. Extension: by iliofemoral a nd ischiofemoral ligaments, tension of psoas. Abduction: by pubofemoral ligament and tensio n of hip adductors. Adduction: by soft tissue apposition, the lateral band of iliofemoral l igament, tension of iliotibial band and hip abductors. Internal rotation: Ischiofemoral lig ament and tension of external rotators. External rotation: Iliofemoral and pubofemoral liga ment and tension of internal rotators. Gottschalk F, Kourosh S, et al. The functional anatomy of tensor fascia latae and gluteus m edius and minimus. J Anat 1989; 166: 179 \200\22389. McCarthy J, Noble P, et al. Anatomy, pathologic features, and treat- ment of acetabular lab ral tears. Clin Orthopaed Relat Res 2003; 406: 38 \200\22347. Moore KL, Agur AMR. Essential clinical anatomy, 2nd edn Baltimore; Lippincott Williams & Wilkins, 2002. van den Bogert AJ, Read L, Nigg BM. An analysis of hip joint loading during walking, runnin g, and skiing. Med Sci Sports Exerc 1999; 31: 131 \200\22342. Gait Normal gait consists of two cycles, and the duration of each phase is the same for bot h limbs thus conferring symmetrical rhythm. By means of pelvic rotation, tilt, and lateral displacement, the displacement of center of gravity is minimized during normal gait. This page intentionally left blank PELVIS, HIP AND GROIN: REGIONAL MUSCULOSKELETAL CONDITIONS 168 Pelvis, hip and groin: regional musculoskeletal conditions Diagnosis Bursitis (especially deep iliopsoas bursitis) is commonly under diagnosed (Johnst on et al. 1998). Imaging with US and MR may show \202 uid collections. Main differential diagnosis of hip pain Anterior hip pain \200 \200 \200 \200 \200 \200 \200 \200 Osteoarthritis of hip. In \202 ammatory arthritis. Femoral fracture. Iliopsoas bursitis. O steitis pubis. Tendonitis (commonly adductor). Avascular necrosis of femoral head (see also p. 433). Intra-articular pathology (including labral tears, acetabular rim syndrome and fe mora-acetabular impingement). Hernia (inguinal or femoral most commonly). Management Infection must be excluded. Treatment is usually conservative and consists of re st, NSAIDs, and stretching of the relevant muscles. Glucocorticoid and local anesthetic inj ection under imaging guidance can be very useful. Osteonecrosis (ischaemic necrosis/avascular necrosis) of the femoral head See also p. 433. History \200 \200 Lateral hip pain \200 \200 \200 Common in 30 \200\22350-year-olds. Need to identify the child with Legg \200\223Calve \200 \223Perthes syndrome (idiopathic avascular osteonecrosis of the capital femoral epiphysis o f the femoral head). Identify possible causes \200\223 see Table on p. 433. Hip/groin pain with possible radiation to knee. Trochanteric bursitis. Guteus medius insertional tendonitis/tear. Nerve compression (common ly lateral femoral cuta- neous nerve). Referred pain from lumbar spine. \200 Posterior hip pain \200 \200 \200 \200 Examination \200 \200 Sacroiliitis. Ischiogluteal bursitis. Referred pain from lumbar spine. Vascular insuf \201 ciency (Leriche \200\231s syndrome). May be unremarkable if early stages. Antalgic gait with restricted range of motion (especia lly internal rotation). In late stages, signi \201 cant limb length discrepancy with restr icted movement and muscle wasting. Imaging and diagnosis \200 Bursitis There are multiple bursae located around the hip, in and around areas subject to f riction (between muscle and a bony prominence). Bursitis is commonly an over-use friction p henomenon, but a history of trauma (traumatic bursitis) and infection must be excluded. Radiographs: degenerative changes, sclerosis, subchondral lucency, collapse of femoral head . See Figure 5.29. MR: highly sensitive in showing subchondral oedema. Bone scintigraphy: l ess sensitive than MR in early stages, phase of disease associated with patterns of photopa enia and excess tracer localization. \200 Trochanteric bursitis A common condition in athletes, but also associated with the spondyla rthropathies and obesity. It will cause a well localized tenderness to the superolateral as pect of the greater trochanter. Sometimes there may be associated referred pain to the late ral thigh. Hip movement is unaffected except for internal rotation of the hip. Management \200 Conservative measures: limited weight bearing and/or immobilization. Recent studies suggest a role for bisphosphonates in delaying femoral head collapse. Surgical management include core decompression of femoral head or free vascularized \201 bular grafting in early stag es of the disease. Good medium term results have been reported (Urbaniak et al. 1995). Adva nced diseases will inevitably require surgical intervention, in particular hip joint replac ement. Resurfacing hip arthroplasty is gaining increasing popularity in the treatment of pa inful arthropathy in younger patients. In general, there is 70 \200\22380% chance of femora l head collapse in patients with con \201 rmed osteonecrosis. Iliopsoas bursitis This bursa separates the hip joint from the iliopsoas tendon and may com municate with the joint. More common in sports-related injury requiring extensive hip flexi on. Causes deep anterior groin and thigh pain, and may present with large soft tissue swell ing lateral to the femoral triangle. Pain is exacerbated with hip extension and resisted hi p \202 exion. Ischiogluteal bursitis This is commonly traumatic in nature, occurring after blows to the i schial tuberosity. There is localized tenderness, worse with sitting or lying on it. Someti mes it is hard to distinguish from hamstring injuries. CHAPTER 5 Regional musculoskeletal anatomy and conditions 169 MR arthrogram has been reported to be a useful tool with high accuracy diagnostic rates. (C zerny et al. 1996). Hip arthroscopy has become the gold standard for diagnostic and therape utic purposes. It allows a comprehensive evaluation of labral anatomy. Management \200 Conservative bed-rest and period of immobilization may be helpful initially, but there are no long-term outcome studies to support such conservative measures. Arthroscopic debridemen t of the lesion has been shown to be successful. Hip arthroscopy is a technically challengi ng procedure, but in the hands of an experienced surgeon, can produce good outcome. Femoroacetabular impingement (FAI) This is the abutment of femoral neck on to the anterior rim of the acetabulum. It is increasingly recognized as a cause of signi \201 cant hip/gro in pain, and strongly implicated as a cause of secondary OA. FAI can be either cam (aspherical contoured femoral head abutting against acetabular rim) o r pincer (linear abut- ment of femoral head-neck junction and the acetabular rim) impingeme nt. Cam impingement has been associated with conditions causing a decrease in femoral head-neck offset. \200 Slipped capital femoral epiphysis (S CFE). \200 Legg \200\223Calve \200\223Perthes syndrome. \200 Acetabular rim syndrome (a cetabular dysplasia). \200 Malunited femoral neck fractures. Pincer-type impingements are associated with conditions producing over-coverage by anterior acetabular rim: \200 \200 \200 Figure 5.29 Osteonecrosis of the femoral head Ficat stage 3. Ficat stages: Stage 1-2 = anox ia, bone necrosis, microfractures; Stage 3 = segmental collapse; Stage 4 = secondary OA. Acetabular retroversion. Coxa profunda (increased relative acetabular depth). Protrusio ace tabuli. Labral tears Although \201 rst reported in the late 1950s, it is only in recent times tha t acetabular labral tears have become a recognized cause for hip/groin pain. Tears occur mo st commonly in the anterior part of the labrum. History \200 \200 \200 Commonly effects young active adults <50 years old. Anterior groin pain. Labral tears almos t always have co-existing mechanical symptoms (locking, catching, and giving way). Elicit h istory of previous hip disease (SCFE) or surgery. History \200 Mechanical hip pain, with sharp and catching sensation on certain movements, and locking. U sually groin pain, but may be trochanteric. Commonly associated with degenerative disease a nd in athletes. An overwhelming majority of labral tears are associated with structural hip abnormalities. Important to check for acetabular dysplasia and femoroacetabular impingemen t (FAI). Identify history of minor injuries (e.g. twisting, slipping, falling), posterior h ip dislocation or recent trauma. Examination \200 \200 \200 \200 Limp or positive Trendelenburg test maybe present. Restricted motion - \202 exion and int ernal rotation. Anterior impingement test is almost universally positive. Imaging and diagnosis \200 \200 AP and lateral plain radiographs essential. Identify femoral abnormalities (pistol-grip def ormity, coxa vara and valga) and acetabular abnormalities (os acetbaulare, dysplasia, protr usio acetabuli, and inclination and version of actabulum) MRI is now more commonly used, bu t MR arthrography is becoming the standard investigation. Can help to identify associated l abral tears and chondral damage Examination \200 Hip movement may be unaffected, but may be painful at the extremes. Anterior tear: acute hi p \202 exion with internal rotation and adduction. Posterior tear: hyperextension with ex ternal rotation and abduction. Management \200 Conservative: rest, modi \201 cation of activity and avoiding excessive hip movement. Regu lar NSAIDs. This usually provides temporary relief. Open surgery includes hip dislocation a nd relevant excision osteotomy from the head-neck junction, or resection of the excess acet abular rim causing Imaging and diagnosis \200 Radiographs, CT and MR have not been reliable tools for diagnosis. They are useful for excl uding other hip pathologies. PELVIS, HIP AND GROIN: REGIONAL MUSCULOSKELETAL CONDITIONS 170