Coxa sultans - External Snapping Hip

COXA SULTANSDr. TARUN KUMAR BADAM

UNDER GUIDANCE OF : PROF A. DEVADOSS Dr. SATHISH

DEVADOSS

COXA SULTANSCase Report : 24yr old male patient, operated case of shaft of femur # for which IMIL Nailing was done , presented for follow-up

Incidentally, Snapping of the IT band over GT was seen , which was asymptomatic

This is External Snapping Hip or External Coxa sultans

COXA SULTANS Coxa sultans, or ‘Snapping Hip’ is characterised by an audible snapping, usually with flexion and extension of the hip during exercise or simply with normal daily activities. Mostly it is asymptomatic, but some patients have pain and discomfort Types of Coxa sultans :

(a) Extra-articular - External - Internal (b) Intra-articular

EXTERNAL COXA SULTANS

EXTERNAL COXA SULTANS

Most common type of Coxa sultans or Snapping Hip

It is mainly due snapping of IT Band,Gluteus maximus and TFL complex over Greater Trochanter of the hip

Seen in Athletes, Ballet dancers, Soccer players

ANATOMYIT BAND takes origin from iliac crestProximally, gives attachment to TFL anteriorly and Gluteus maximus posteriorlyDistally, attached to Linea Aspera of femur and Gerdy’s tubercle on Antero lateral aspect of TibiaComplex origin and Insertion of this structure allows it to be taut in all ranges of motion

In the undersurface of IT Band, GT is present which is separated from it by Trochanteric bursa

ETIOPATHOGENESISAny increase in tension in the already taut IT

Band, with repeated movements of flexion and extension

Increased friction over GT

Trochanteric bursitis and Chronic fibrosis of IT Band Complex

Snapping of IT Band over GT

EXTERNAL COXA SULTANS

CAUSES OF INCREASED TENSION IN IT BAND COMPLEX

Excessive Flexion and Extension of the hip

Femoral anteversion

Femoral retroversion

Internal tibial torsion

Excessive foot pronation

Other CausesWeakness of Hip Abductors

After Total Hip Replacement

- Curved femoral stem

- Placement of femoral component is too far medial

- Angulation in relation to long axis of the femur

CLINICAL FEATURESPatients will c/o Snapping sensation over lateral aspect of hip

Sometimes, associated with discomfort

Confirmation

- Patient should be in Left lateral or Right Lateral position

- Hip is actively flexed by the patient, and examiner palpates over GT for the snapping

- Snapping can be blocked by applying pressure over GT

INVESTIGATIONS

MRI Scan of Hip: Thickening of the Posterior border of IT Band or Anterior border of Gluteus maximus

INTERNAL COXA SULTANS

INTERNAL COXA SULTANSIt is due to Snapping of Iliopsoas musculotendinous unit over Head of the Femur (mainly), followed by Ilio-pectineal ridge and Lesser Trochanter

Seen mainly in Rowers

ANATOMYMusculotendinous unit of Iliopsoas

passes in the osseous groove between AIIS

and Iliopectineal eminence

From it’s lateral position when hip is in flexion, to it’s medial position when hip is in extension, Iliopsoas tendon remains in the osseous groove

It moves back and forth on the Head of the femurIn Rowers, strong Iliopsoas can cause snapping during this movement

ETIOLOGY

Tight Iliopsoas musculotendinous unit

Exostosis of Lesser Trochanter

Exostosis of Iliopectineal ridge

CLINICAL FEATURESPatients will c/o Snapping sensation over anterior aspect of hip

Sometimes, associated with discomfort

Confirmation

- Patient should be in supine position

- Hip is actively flexed by the patient, and examiner palpates over Head of the femur for the snapping

- Snapping can be blocked by applying pressure over Head of the femur

INVESTIGATIONS1. MRI SCAN OF

HIP/PELVIS

- Thick Iliopsoas musculotendinous unit

2. Iliopsoas Bursography

- Snapping of Iliopsoas tendon can be seen

INTRA ARTICULAR COXA SULTANS

INTRA ARTICULAR COXA SULTANS

In this type, Snapping occurs mainly due Intra-articular lesions like Labral tears, Loose bodies, and Synovial Chondromatosis

Pain in the hip is more frequent complaint than Snapping

ETIOPATHOGENESIS

Loose bodies can lodge in foveal area of Acetabulum and can lead to Snapping of hip

CLINICAL FEATURES

Patients mainly give a history of trauma

Pain in the hip is the Chief complaint

Can have snapping sensation intra articulately

Quadrant test will be positive in case of Labral tears

INVESTIGATIONS

MRI SCAN OF HIP

- for Labral tears and Loose bodies

MANAGEMENT OF COXA SULTANS

Majority of the patients with snapping hip are asymptomatic and some are incidentally found. In these patients nothing need to be done as it is asymptomatic

Few patients will be symptomatic with minimal discomfort without disturbing the daily routine activities

Very few have severe snapping even with daily activities and pain during the snapping

CONSERVATIVE MANAGEMENTIn all symptomatic patients, initially conservative management is done with

(a) Rest

(b) Avoiding the activities and movements which cause snapping

(c) NSAIDS

(d) Local Hydrocortisone injection

STRETCHING AND STRENGTHENING EXERCISES

CCT AND BFSTCold Compression therapy ( CCT ) :

In 1st 48hrs, CCT is given which decreases the inflammation and pain

Swelling decreases which promotes more blood supply to the site of inflammation

Limits the cellular breakdown and tissue damage

Limits the amount of healing by fibrosis to occur

BLOOD FLOW STIMULATION THERAPY ( BFST )

Once Inflammation and swelling decreases, BFST increases blood flow and oxygen and nutrient supply to the involved site

Accelerates the process of healing of soft tissue

Decreases the risk of muscle atrophy

SURGICAL MANAGEMENT EXTERNAL COXA SULTANS :

Z-plasty of the Ilio-tibial band with excision of Trochanteric bursa

• Anchoring of the Ilio-tibial band to Greater trochanter

• Elipsoid resection of the tract over GT• Resection of posterior half of the tract at the

Gluteus maximus insertion

INTERNAL COXA SULTANS: Lengthening of the postero-lateral tendinous portion of the iliopsoas tendon

INTRA-ARTICULAR COXA SULTANS: Arthroscopically removal of loose bodies and resection of Labral tears

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