Presenter: PGY 1 王執雋

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Part I: Disorders of the Hip and Groin
• 所有年齡層都很常見
• 很難 DDx ( 有很多不同結構 )
• 疼痛形態廣泛

groin
buttock
lateral hip
greater trochanteric region
low back
thigh
myofascial pain syndrome
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Avascular Necrosis

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 Avascular Necrosis
I. Introduction

Avascular necrosis (osteonecrosis) of the femoral head (AVNFH)

好發年齡 : 取決於病因，全年齡都有可能

病生理 :
創傷 非創傷

阻斷 femoral head 血液供應循環

骨頭缺血性壞死和細胞死亡
If untreated

collapse of the femoral head with significant pain and disability

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 Avascular Necrosis
II. Pathogenesis
• Traumatic:
– 骨折或髖關節脫位對血管系統的直接損傷
– 通常很明顯，治療選擇有限
• Non-traumatic
– 難以診斷（早期、無症狀、輕微症狀、模仿其他髖關節疾病）
– 早期治療選擇至關重要

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 Avascular Necrosis
II. Pathogenesis
• Non-traumatic
– 主要致病因素 : steroids and alcohol use
• 代謝或血液學疾病
– 狼瘡、鐮狀細胞病、器官移植、凝血病。
• 與每日、最大、累積劑量和給藥途徑有關
• 目前沒有關於安全劑量的 guideline
• 成因 : 脂肪栓塞（高血脂症）引起的骨內高壓

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 Avascular Necrosis
III. Symptoms and Diagnosis

• Hip, groin, and buttock pain

• 隨著負重增加
• Hip ROM
– 內旋、屈曲、外展減少

• Plain anteroposterior (AP) and frog-leg lateral

radiographs
– cystic and sclerotic changes or flattening of the femoral
head
– 早期或輕度病例中可能是正常的
– MRI 和 CT 可以更早期發現病灶
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Fig. 36.1 Anteroposterior radiograph of the pelvis, showing advanced avascular
necrosis of both femoral heads.

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 Avascular Necrosis
IV. Treatment Options

• 取決於確診時間
• 保守治療：促進早期骨缺損的癒合
– 減輕受影響關節的重量
– NSAIDs
– 雙膦酸鹽可能可以減緩骨塌陷的進程
– Statin 可能有助於皮質類固醇導致的 AVN
• 體外衝擊波治療
– 可減輕疼痛、改善髖關節功能並使 AVN 消退。 9
 Avascular Necrosis
IV. Treatment Options
• 手術治療
– 早期階段：保留髖關節的手術
• 股骨頭減壓
• 注射濃縮骨髓
– 自體幹細胞等生物因子
• 減緩 / 停止 AVNFH 的進展
• 有些病患在 MRI 上看到改善
– 股骨頭塌陷伴髖關節退行性改變
• 全髖關節置換術

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 Legg-Calvé-Perthes Disease and
Slipped Capital Femoral Epiphysis

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 Legg-Calvé-Perthes Disease and Slipped
Capital Femoral Epiphysis
I. Introduction of LCPD

sickle cell disease, lupus erythematosus,

chemotherapy, long-term corticosteroid use

idiopathic osteonecrosis of the femoral epiphysis

永久性股骨頭畸形和早發性骨關節炎 (OA)

• DDx:
– Hypothyroidism, septic arthritis, and transient synovitis
• 可能在晚期會發生心血管疾病
• 可能與懷孕期間吸煙有關 12
 LCPD and SCFE
I. Introduction of SCFE

急性創傷或重複性微創傷

由於生長板（ physis ）無力，

近端股骨的股骨頭（ epiphysis ）在股骨頸上移位

• 18-63% 病人發生在雙側
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white ,least in Asian

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 LCPD and SCFE
II. Symptoms and Physical Exam
• LCPD: antalgic gait
– hip, knee, groin, or thigh pain.
– 腿長差異
– ROM: 外展、內旋在屈曲 / 伸展時皆受限
• SCFE: 根據滑動的嚴重程度和穩定性而不同
– 急性 / 慢性 腹股溝 / 髖 / 膝疼痛，行走困難
– 可能會出現無痛性跛行伴隨患肢外旋
– 髖關節內旋受限
– obligatory external rotation
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 LCPD and SCFE
II. Symptoms and Physical Exam

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 LCPD and SCFE
III. Diagnostic Tests

• AP and frog-lateral of the pelvis

– 生理變化和 X 光片變化之間有一段 delay
• Dynamic gadolinium-enhanced subtraction MRI
– 對兒童安全、有效
– 對早期缺血、壞死和血管重建更敏感
• 雙側都要看
• Referred pain to the knee is common
– 年紀輕的患者常以膝蓋疼痛為主訴
– MRI is not typically indicated unless the radiographs are
unrevealing. 17
LCPD and SCFE
III. Diagnostic Tests

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Fig. 36.2 Anteroposterior
radiograph of a severe, acute
slipped capital femoral
epiphysis.

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 LCPD and SCFE
IV. Treatment of LCPD
• 早期：保守治療
– NSAIDs
– 受保護的負重，有限的體力活動
– 物理治療 for ROM.
• 早期：手術治療
– optimize positioning of the femoral head in the acetabulum
– 建議 6 歲或以上
– 在某些情況下，在年輕時就開始崩塌或發展為嚴重的關節炎
• 後期：手術
– total hip resurfacing or a total hip arthroplasty.
• Abduction bracing once as a conservative plan
– But no evidence sufficient 20
 LCPD and SCFE
IV. Treatment of SCFE
• 未經處理的 SCFE
– 增加患關節炎的風險
– 45% 的兒童在 50 年後需要進行 THA
• 穩定 physis 以防止滑脫惡化
– percutaneous in situ fixation.
– closed reduction increase the risk of osteonecrosis, avoided
• 骨科急症
– immediate internal fixation.
– gentle ROM within a few days
– protected weight bearing for 6 to 8 weeks
– progressive strengthening and functional exercises
– return to advanced activities (i.e., sports) once patients have
regained full strength and can participate without pain.
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 Greater Trochanteric Pain Syndrome
I. Introduction
• muscle converge on trochanter of the femur: the gluteus medius and minimus,
piriformis, obturator externus, obturator internus, iliotibial tract, and multiple bursae.

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 Greater Trochanteric Pain Syndrome
I. Introduction
• Greater trochanteric pain syndrome (GTPS)
– 轉子周圍髖關節疼痛和壓痛
– mimics myofascial pain, infection, degenerative joint disease, heterotopic
ossification, and lumbosacral spinal pathology.
– 10-25% population, 女性居多
– 運動和久坐的患者
– DDx: low back pain, leg-length discrepancies, OA, and iliotibial band (ITB)
thickening
• 主要成因： Gluteal tendinopathy, ITB thickening, abductor tendon tears.
not bursitis
• Pathophysiology:
→ 運動活動的突然變化 / 增加
→ 異常力矢量
→ 髖關節生物力學改變
→ 髖關節炎或膝關節炎或腰痛引起的代償性步態模式 23
 Greater Trochanteric Pain Syndrome
II. Complaints and Presentation

• 患側臥位疼痛
• reproducible tenderness in the region of the greater
trochanter, buttock, lateral or posterolateral thigh.
• 轉移痛
– the groin, low back, knee
• often confused with lumbar spinal pathology
• 50% of GTPS in patients underwent lumbar surgical evaluation
• improve after trochanteric injection
• 大腿主動外展或被動內收也可重現疼痛

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 Greater Trochanteric Pain Syndrome
III. Diagnosis
• 基於病史和 PE
– 外側髖部壓痛點
– 觸發性測試，例如 Ober’s 和 Thomas 測試
– 神經系統檢查陰性
– 與疼痛相關的臀中肌無力應與真正的神經系統無力相鑑別

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 Greater Trochanteric Pain Syndrome
III. Diagnosis
• Plain radiography
– greater trochanteric surface irregularities and enthesophytes
– 代表 abductor tendon pathology, tendon or bursal calcifications,
– can differentiate from OA or fractures.

• MRI
– GTPS 具有轉子周圍水腫
– 臀小肌或臀中肌病變，通常是肌腱變性而不是撕裂。 26
 Greater Trochanteric Pain Syndrome
III. Diagnosis
• Ultrasound
– 患者舒適度、低成本、實時成像
– 在檢查時將超音波發現與壓痛進行比較。
– 肌腱變性：
• 增厚的 hypoechoic 結構伴有正常纖維束狀的喪失。
• 鈣化：常見於臀中肌和臀小肌腱。

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 Greater Trochanteric Pain Syndrome
IV. Treatment

• 保守治療
– physical therapy, weight loss, NSAIDs, topical agents, and
behavior modification.
– trochanteric bursal injections
• local anesthesia and corticosteroid
– repetitive low-energy shock-wave therapy and targeted,
home-based exercise programs
• 在實施 15 個月內，兩者均優於皮質類固醇注射
• 手術治療
– 嚴重病例
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 Coxa Saltans Externa/Interna
I. Introduction of externa

• Coxa saltans 又叫 snapping hip

• 三個主要成因 , extra-articular (either external or internal)
or intra-articular.
• external extra-articular
– 最常見的
– ITB 後側或臀大肌的前部，在髖關節屈曲和伸展或內外旋轉
時彈過大轉子。
• 可能是 GTPS 的原因之一
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Coxa Saltans Externa/Interna
I. Introduction of externa

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 Coxa Saltans Externa/Interna
I. Introduction of interna

• 髂腰肌腱彈過 femoral head ， prominent iliopectineal

ridge ， exostoses of lesser trochanter ， iliopsoas bursa
• 見於反復進行髖關節屈曲或股骨外旋的患者，如芭蕾舞、阻力訓
練、深蹲、划船、跑步、足球和體操等。

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 Coxa Saltans Externa/Interna
II. Complaints and Presentation

• catching or “giving way” sensation

• 轉子滑囊發炎，引起疼痛
• 許多不會引起疼痛

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 Coxa Saltans Externa/Interna
III. Diagnosis

• 容易診斷
– 獨特的解剖位置
– 經常可見的啪啪聲

• Ober’s 對 ITB tightness 的測試呈陽性。

• 超音波可以診斷外部和內部的 coxa saltans

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 Coxa Saltans Externa/Interna
IV. Treatment

• 這兩種情況也可以通過保守治療

– 類似於 GTPS 。

• 對於保守治療無效的患者，可以考慮手術。

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Hip Impingement and Acetabular Labral
Tears
I. Introduction

• 股骨頭頸交界處撞擊髖臼緣
• 盂唇改變和軟骨損傷
• 唇裂的最常見原因 (79%)

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 Hip Impingement and ALT
I. Introduction
• Cam-type
→股骨頭的非球面性，股骨頭頸交界處的 offset 變短。
→不能在髖臼內平穩旋轉
→在軟骨唇交界處引起剪切力
→導致盂唇撕裂主要位於外圍（外部）位置。

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 Hip Impingement and ALT
I. Introduction
• Pincer-type
– 常見中年女性，並且不如 cam-type 常見
– 髖臼對股骨頭前部或後部的覆蓋增加
– 在屈曲和內旋過程中，突出的髖臼邊緣和股骨頸之間的重複接觸導致盂
唇受壓，多出的後下髖臼上出現軟骨磨損。
• 治愈率：
– cam-type > pincer-type
– 損傷的位置較周邊， capsule 血液供應較好

大多數患者俱有兩種類型的形態
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 Hip Impingement and ALT
II. Complaints and Presentation

• 隱匿性發作的腹股溝疼痛，隨著活動而惡化
• pain with end ROM, particularly hip flexion and internal
rotation
• limitations in activities
– 深蹲或是準備蹲下
• PE:
– positive (painful) flexion, adduction, and internal rotation (FADIR)
impingement test

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 Hip Impingement and ALT
III. Diagnosis
• AP pelvic and frog-leg lateral, cross-table lateral, false profile, and
Dunn lateral views.
• Clinical correlation is important
– 無症狀患者的影像學異常率很高

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 Hip Impingement and ALT
IV. Treatment

• 保守治療
– activity modification, NSAIDs, and physical therapy.
– PT
• 活動髖關節
• 改善軟組織柔軟度
• 加強臀部肌肉
• 改善本體感覺和從功能控制到髖關節動態控制
– Intra-articular hip injections
– Regenerative medicine techniques, but more research is
needed
• 手術治療
– Hip preservation surgery
– If OA, poor outcome following surgery. 40
 Hip Dislocation
I. Introduction

• 髖臼的深度讓關節很穩定
• 重大創傷引起
– children (skeletal immaturity)
• hip dislocation > hip fracture
– adults
• acetabulum fracture accompany hip dislocation.
• 股骨頭最常發生向後脫位

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 Hip Dislocation
II. Complaints and Presentation

• 嚴重的髖關節疼痛
• 傾向於保持髖關節屈曲、內旋和內收
• 由於疼痛，無法容忍 ROM 或阻力測試
• 應進行完整的神經系統檢查以評估 lumbosacral
plexopathy, sciatic neuropathy, and femoral
neuropathy

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 Hip Dislocation
III. Diagnosis

• AP pelvic and a 15-degree oblique lateral views

• CT or MRI can be obtained if further characterization
of associated injuries is needed.

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 Hip Dislocation
IV. Treatment

• 骨科急症
– immediate closed reduction
– Post reduction radiographs
– Surgery
• 修復移位或粉碎性骨折並清除關節內雜質
• non–weight bearing for 3 to 4 weeks
• protected weight bearing for an additional 3 weeks
• progressive rehabilitation
– 取決於病人 comfort level, surgery or not
• Complications(10% of patients)
– sciatic nerve injury, posttraumatic OA, and AVN
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Thank you!

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