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Common Conditions of the Hip
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trochanteric bursitis
The trochanteric bursa is a fluid filled sac that overlies the bony prominence on the thigh bone near the hip joint. The sac provides a cushion for tendons and other structures that glide over the bony prominence called the greater trochanter. Sometimes this sac can become irritated and inflamed or enlarged, causing pain on the side of the hip region. This can occur for no apparent reason, although usually there is some kind of condition that causes the bursa to be rubbed. Bone spurs over the greater trochanter, a tight tendon that runs over the greater trochanter (called the ilio-tibial band), or larger persons getting in and out of chairs can all create rubbing on the trochanteric bursa. Below is a diagram of the location of the bursa sac in relation to other structures in the hip.
In addition, certain movements such as lifting the leg out to the side of the body or doing a similar motion while turning the knee inward can cause pain because the bursa is rubbed between the bone and the structures on top of it.
Trochanteric bursitis can usually be diagnosed with a careful history and physical, but x-rays are often taken to make sure there are no bony abnormalities or problems with the hip joint that could cause similar symptoms. Additional testing such as an MRI or CT scan are not usually necessary unless there is concern about a more involved problem with the hip.
Trochanteric bursitis is usually treated conservatively with anti-inflammatory medications and/ or a cortisone injection. Conservative treatment usually settles down the problem for about 80% of patients. Surgery is uncommon for trochanteric bursitis and reserved for only severe cases. Surgical options might include removing part of the bursa, trimming down bone spurs, or lengthening the ilio-tibial band if it is too taught.
The hip is normally a very stable joint. The head of the femur (thigh bone) is like a ball that fits deeply into the hip socket, called the acetabulum. Also a very strong soft tissue capsule that surrounds the joint and makes it very stable. Hip dislocation occurs when the ball part of the femur comes out of the socket. This is uncommon without significant trauma, such as a car accident, a fall from a height, or a fall onto a bent knee that pushes the hip out of place. Sometimes a person with a history of multiple dislocations might be more prone to re-dislocate because the joint capsule is more loose and prone to instability.
When dislocations occur, they almost always occur with the ball part of the joint being pushed out towards the buttocks region (posterior) versus coming through the groin area (anterior). Depending on which direction the joint comes out of the socket, the affected leg might be trapped in different positions. Posterior dislocations usually leave the injured leg bent and rotated inward, sometimes even shorter appearing than the opposite leg. Anterior dislocations usually are opposite, leaving the injured leg bent but rotated away from the body. With both kinds of dislocations, the injured leg may be numb and unable to move. Because of the traumatic setting that often produces hip dislocations, multiple injuries may be involved to both the blood supply and nerves in the area or to other body sites.
Hip dislocations are often suspected after hearing the report of injury and seeing the patient’s position. A careful history and physical examination will help determine if there are other associated injuries involved, especially injuries to vessels, nerves, or the possibility of other fractures. X-rays of the pelvis, hip, thigh, and knee are often obtained to look for additional fractures. A CT scan might be useful in determining if there are any bony fragments in the joint and to confirm the position of the hip.
Treatment of hip dislocations is an emergency, because the hip can loose its blood supply if the vessels have been damaged. In fact, this can be a process that can develop up to a couple years after the injury and needs to be followed periodically. If there are no hindrances to safely putting the hip back into the joint, such as bony fragments or other fractures that might cause further damage if manipulated, the hip should be reduced (manipulated back into place) as soon as possible. Confirmation that the hip has successfully been reduced might be obtained after the procedure by taking new pictures with an x-ray or CT scan. Your injured leg may be put into a knee immobilizer in effort to prevent you from bending your knee, and putting your hip through any further instability. Your physician will determine when weight can be put on your leg with the use of crutches, and eventually a cane. Physical therapy is often recommended after the injury has stabilized and there is no pain with putting weight on the leg to help strengthen certain muscles around the hip.
developmental dysplasia of the hip
Developmental dysplasia of the hip (DDH) refers to instability of the hip joint in the pediatric population. This occurs when the ball-and-socket hip joint is shallow and leads to instability. DDH can be congenital (a condition present at birth) or developmental (a condition arising during development) and involves problems ranging from laxity of hip ligaments making it easy to dislocate to actual partial or complete dislocation.
Usually, DDH can be detected at birth, but it may develop later in children who have a neuromuscular disorder, such as cerebral palsy. It is five times more common in females than males, and babies delivered from a breech presentation are associated with DDH. In addition, DDH is more prevalent in Caucasians, American Indians, and in families with a history of the disorder.
Early detection of DDH is very important. The condition is painless in a newborn, so there should be a high level of suspicion for the disorder. Several physical examination maneuvers are helpful in detecting instability or dislocation in a newborn. These should be performed by a pediatrician in an initial newborn examination and subsequent, regular, well-child examinations until it is established that the child is walking normally. If instability is not detected as a newborn, it may not be noticed until the infant starts walking. At this time, the infant may limp, walk with a “waddle”, or there may be noticeably unequal leg lengths.
X-rays are usually taken to determine if the hip is partially or completely dislocated, but x-rays are not always helpful in infants less than eight months old if the condition is more that of laxity and propensity to dislocate because at that time, the hip joint is largely made up of cartilage that has not yet fully formed hard bone. Sometimes, an ultrasound can be useful in these patients if there is a question of the diagnosis.
Treatment of DDH depends on the child’s age at detection of the disorder. The goal of treatment is to keep the hip in place while the joint continues to deepen and stabilize. This becomes harder to do the longer the condition has been present undetected and the joint and the surrounding structures have been allowed to develop trapping the hip in an improper position for function. If DDH is detected early within six months of age, a full-time use of a splint that keeps the infant in a frog-legged position for about six weeks (or until stability has been obtained) is usually sufficient. Children older than six months are often referred to a specialist in pediatric orthopedics as they may require more involved treatments including surgery and extensive casting. Delayed treatment of DDH can lead to improper development and limited function of the hip, an extensive course of treatment, and earlier-than-normal development of arthritis in the hip.
The hip is very deep, stable, ball-and-socket joint that allows for a wide range of movements. Wear-and-tear arthritis in the hip occurs when there is a loss of the normal cartilage in this ball-and-socket joint that causes increased friction and pain. Like osteo-arthritis in other joints, it can develop as a result of any previous injury or problems with the hip, such as hip problems as a child, fracture or trauma, previous infections, or lost blood supply to the ball part of the joint.
Patients often describe hip pain as thigh or groin pain. Occasionally, it may be felt on the side of the thigh or in the buttocks. Also, pain caused by a problem hip can be felt primarily in the knee. Stiffness, limited motion (especially with turning the leg inward, or lifting the knee up), and abnormal walking to compensate for the pain may also be noted. Severe arthritis usually causes pain even at night and at rest. Diagnosis of osteo-arthritis in the hip involves a careful history and physical examination to evaluate for these findings as well as looking for classic signs of arthritis on x-ray.
Treatment of osteoarthritis attempts to manage the pain and subsequent limited activity. Conservative treatment may initially begin with regular anti-inflammatory medication or physical therapy. However, osteo-arthritis in the hip is progressive and has no cure once the process has begun. The disease will progress in different individuals at different rates. In younger patients with congenital reasons for osteo-arthritis development, surgery to realign or fuse the hip may help slow the progress of arthritis formation. Eventually, if the hip pain is severe enough, patients may elect to have total hip replacement surgery.
Click here fore more information on the general process, diagnosis, and treatment of arthritis conditions.
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