Chapter 11 - Injuries -The Hip, Thigh, and Pelvis

8/14/2019 Chapter 11 - Injuries -The Hip, Thigh, and Pelvis

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Chapte

r 11 -

Injuries

-The Hip,

Thigh,

and

Pelvis

Introduction

Biomechanics

Contusion of quadriceps

Myositis ossificans traumatica

Quadriceps strain and ruptures

Avulsions of the iliac spines

Hamstring strains

Ischial apophysitis

Groin strains

Hip pointer and fracture iliac crest

Iliac crest apophysitis and avulsion

Trochanteric bursitis and snapping hip

Hip strain

Conjoint tendon strain

Osteitis pubis

Nerve entrapment

Labral tears

Stress fractures

Fractured hip; acute slip of the upper femoral epiphysis (SUFE)

Dislocation of the hip

Fractured femur and pelvis

Hip arthroscopy

Avascular necrosis femoral head

Osteoarthritis


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1 Ireland J The Hip, Thigh and Pelvis in Sherry E and Bokor D (eds). Manual of Sports Medicine, Chapter 13.

GMM, London, 1997.

Introduction

Injuries of the hip, thigh and pelvis are not that common from sport. They may be subtle in

presentation and diagnosis is difficult or catastrophic with serious immediate and long -term

consequences (e.g. hip fracture or pelvic fracture with shock).

Biomechanics of the hip

The hip is a ball and socket joint with simultaneous motion in all 3 planes (up to 120 of flexion,

20 of abduction and 20 of external rotation). The joint reactive forces are 3 to 6 times body

weight due to contraction of the large muscle groups about it; this is increased to with jumping or

running.

The acetabulum has a fibrocartilaginous rim (labrum) to deepen it and so add further stability.

The postero-superior surface of the acetabulum is thickest to accommodate weight-bearing. the

neck forms an angle of about 125 with the shaft and is 20 anteverted. The hip capsule drops

down across the front of the neck but only part-way at the back. It is reinforced by three

ligaments (the ilio-femoral ligament of Bigelow is the strongest). The major blood supply to the

head is from the medial circumflex branch (of the profunda femoris) which is at risk from

fractures of the neck of femur and dislocations.

Contusion of quadriceps (cork thigh, Charley Horse)

The result of a direct blow during contact which varies from mild to severe. Often worse when

the muscle is relaxed and occurs in the musculotendinous junction of the Rectus femoris

(central position of the quadriceps).

Clinical features There is pain, stiffness, a limp, and progressive swelling with bruising. The pain

is increased by resisted knee extension and hip flexion. Due to bleeding into the soft tissues

symptoms becomes worse over the subsequent 48 hours.

Classified according to that of Jackson and Feagin

Table 1. Classification of contusion quadriceps

Mild Localized tenderness in the quadriceps, kneemotion of 90 degrees or more, no alteration of gait.

The athlete is able to do a deep knee bend.

Moderate Swollen tender muscle mass, less than 90 degrees


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a hard mass at the two to four weeks. (May resolve after six months if the injury is low grade and

in the musculotendinous region).

Treatment as for contusion of the quadriceps. Aspiration or open drainage of the haematoma

may be necessary. Femoral nerve blocks, NSAIDs and radiotherapy have been used.

Quadriceps strain and ruptures1

The result of a severe contraction when either accelerating or kicking (usually the rectus femoris

and distal in the thigh).

Clinical features are localized tenderness or a palpable defect (Fig 1). The pain is exacerbated

by resistance of hip flexion in extension and full knee flexion in a prone position. MRIs show a

high signal on a T2 weighted image.

Differentiate from an L3 nerve root lesion (pain is in both mid-lumbar back and leg); made worse

by straight leg raising).

Treatment as for quadriceps contusions.

1. J B Ryan, J H Wheeler, W J Hopkinson et al. 1991 Quadriceps contusions west point update Am J Sports Med

19, 299-304.

Avulsions of the iliac spines

The mechanism of injury is a sudden violent contracture of the rectus femoris muscle,(occasionally the sartorius muscle seen in soccer players. Players tend to be in their mid teens.

Clinical features - include severe pain point tenderness and bruising (sometimes dramatic)

diagnostic. Treatment includes rest, ice, compression and elevation. If there is persisting

functional impairment then surgery may be necessary to fix the apophysis or avulsed fragment.

Sometimes the bone fragment needs to be excised (at later date).

Hamstring strains

In the late swing phase of the gait cycle, hamstrings decelerate the limb. with sudden

acceleration from the stabilizing flexion to active extension, strain is put on the hamstring

muscles. This injury is most likely to occur with sudden hamstring contraction in athletes when

they are cold or have not done adequate stretching. Common situations are at the starting

blocks, sprinters at take off, (or high jumpers and long jumpers) an sudden acceleration or

resisted extension by football players(Fig 2).

The short head of the biceps femoris is most commonly affected. Occasionally dystrophic


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calcification is seen.

The patient may describe a twinge or a snap and localize an area, (such as the short head of

the biceps). Swelling and a palpable defect are common.

Treatment includes rest, ice, compression, elevation and physiotherapy (local cryotherapy and

ultrasound). A stretching programme is commenced once pain has subsided.

Recovery is from days to week (depending upon the severity).

The key to treatment is to remedy poor training techniques and improve flexibility. The athlete

must carry out an adequate warm-up and stretching programme prior to a return to sporting

activities. The significant imbalance between quadriceps and hamstrings needs to be overcome,

and adequate return hamstring strength before returning to sport. A firm elasticized support is

useful.

Re-injury may occur with longer recovery; therefore exercise good judgement about when to

return to sport.

Ischial apophysitis (Weavers bottom, ischial bursitis) and avulsions

The result of excessive running, (especially in adolescents). Repetitive strain is put upon the

apophysis; worsened by tight hamstrings. Severe contracture of the hamstrings musculature

may avulse the tuberosity.

There is a dull ache and tenderness in the area and associated tightness of the hamstrings.

Ecchymosis and a palpable defect are present.

X-ray will show fragmentation or avulsion of the apophysis.

Treatment includes rest, ice, compression, elevation and physiotherapy and a flexibility

programme as per a hamstring strain. Significant displacement or functional disability may

necessitate surgical fixation.

Groin strains (adductor strain)

The groin is an ill-defined area and most part injuries here involve the adductor muscles.

Important: Exclude fractures, avulsions, hip joint injuries, inflammation of the pelvic joints,

bursitis about the hip, snapping hip, nerve entrapment and various forms of referred groin pain

from hernias, prostatitis, urinary infections, gynaecological disorders, rheumatological diseases,

bone infections and tumours.

Occurs in sports where cutting, side stepping or pivoting are required (as in soccer and rugby).


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Treatment includes rest, ice packs, compression and elevation (first 24 hours). Occasionally

aspiration and injection of local anaesthetic needed. After bleeding has ceased, ultrasound and

other physical therapy modalities useful. Protective padding when return to contact sports.

Rarely is surgical fixation required for displaced iliac crest fractures (where skin tenting).

Iliac crest apophysitis and avulsion

May result from repetitive stress in adolescents especially running with a cross-over style of arm

swing. Severe contraction or a direct blow may also avulse the iliac crest.

Clinical features are tenderness (anteriorly or posteriorly) on the iliac crest depending upon

whether tensor fascia lata, gluteus medius or oblique abdominal muscles are involved typically.

Resistance to abduction and contralateral flexion of the trunk frequently exacerbates the pain.

X-rays are needed to exclude avulsion of the iliac apophysis.

Treatment includes rest, ice, compression and elevation and physical therapy. It may be

necessary to change the athletes running style and gradually re-introduce activities.

Occasionally surgery is necessary to reduce the avulsed iliac crest.

Trochanteric bursitis and snapping hip

An inflammation of the bursa over the greater trochanter region as a result of increased shear

stress caused by the ilio-tibial band over the trochanter. Often a broad pelvis and large

quadriceps angle (Q-angle). Leg length discrepancies, pelvic tilt or cross over type running style

may be present. A snapping hip is due to thickening of the posterior part of ilio-tibial band which

produces a painless snapping sensation (snapping ilio-tibial band syndrome).

Clinical features are pain over the lateral aspect of the thigh when lying on the affected side (in

the posterior and lateral aspect of the trochanter). Abducting against resistance in an internally

rotated position will exacerbate the pain. A snapping sensation may be noted with the patient

standing on the extended knee and pushing the hip into an adducted and flexed position.

Other snapping hip is seen with repetitive rubbing of the capsule in running or ballet (involves

the iliopsoas tendon) so called Iliopsoas Bursitis.1

Clinical features include pain around the medial aspect of the groin which occurs with rotation of

the hip. Resistance to flexion of the hip from 90 degrees of flexion leads to increased pain and

tenderness in the groin. Clicking is reproducible to note that pain may be referred from the

lumbo-sacral spine or sacroiliac joint.

1. M. Jacob, B. Young 1973 Snapping hip phenomenon among dancers Am Correct Ther J 32, 92.


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Treatment includes rest, ice, compression, and elevation followed by ultrasound (low frequency

pulsed) and stretching of the ilio-tibial band and iliopsoas to overcome contractures. Correct any

leg length discrepancy or abnormal running style, Orthotics can help. Steroid injections and anti

inflammatories may be useful in an acute bursitis. Surgery has a limited place and only after aprolonged period of conservative management ( technique involves Z-plasty of the ilio-tibial

band or lengthening of iliopsoas in iliopsoas bursitis). Other bursitis iliopectioneal - pain over

anterior hip with antalgic gait. R.I.C.E, NSAIDs, stretching, flexibility.

Hip strain (pericapsulitis, synovitis, irritable hip)

The result of a direct blow, twisting injury, or from overuse of the hip. Inflammation of the lining

or a strain of capsular ligaments occurs may be cause of hip pain in young athletes.

There is pain in the groin, radiating into the thigh. Athlete comfortable in flexion, abduction and

external rotation (increases volume of joint capsule so decompressing). Pain is worsened by

extension and internal rotation. Antalgic gain may be noted.

Exclude infection (especially in children and SUFE). X-rays may show joint widening. Bone scan

is often useful (positive).

Treatment includes R.I.C.E. and non-weightbearing. Bed rest (with springs and slings) in

children, until complete resolution of symptoms. If capsular tightening occurs then a flexibility

programme is required. Rarely is his arthroscopy necessary.

Conjoint tendon strain

Results from stress on the abdominal musculature (from a mark in football or heading in

soccer).

Pain and tenderness over the superior pubic ramus. Hip movements are full. X-rays are normal.

The bone scan is occasionally positive.

Treatment R.I.C.E., physical therapy and a flexibility programme. Only occasionally surgery.

Osteitis pubis

A self limiting necrosis in the bone of the pubis and synchondrosis.1

Results from repetitive shear stress across the symphysis in running and kicking sports

(subacute periostitis).

Clinical features are a gradual onset of groin pain worsened by activity. Severe pain when


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jumping. Tenderness is maximal over the symphysis, the body and rami of the pubis;

aggravated by pelvic compression, full flexion, wide abduction of the hips and even sit ups.

Exclude hernias, groin strains and prostatitis in males. X-rays changes are delayed for at least a

month but show a periosteal reaction and demineralization of the subchondral bone leading to a

moth eaten appearance around the symphysis. (In severe cases erosion can lead to instability;

detected in single leg weight bearing views of the pelvis).

1 J M Cochrand 1971 Osteitis Pubis in athletes Br J Sports Med 5, 233.

Bone scans are often positive in the early stages (Gallium scans to exclude an infection).

Treatment includes rest, NSAIDs and occasionally steroid injections. Then gradual re-

introduction of a flexibility programme and increased weight bearing. May take up to 12 months

to recover.

Nerve entrapment

The nerves usually involved are the ilio-inguinal nerve, obturator nerve, genito-femoral nerve

and lateral cutaneous nerve of the thigh. Hypertrophy of muscles (hypertrophied abdominal

muscles may entrap theilio-inguinal nerve; enlarged hip adductors in skaters may entrap the

obturator nerve) or scarring are the most likely causes. Meralgia paraesthetica is caused by

compression of the lateral femoral cutaneous nerve. A knowledge of the distribution of the

nerves will help to make a diagnosis. These areas are likely to exhibit pain and paraesthesia.

Tenderness may be experienced over the sub cutaneous emergence of the nerve Tineb positive

EMG.

Treatment: NSAIDs, stretches and local steroid injections are the first tried, but if symptoms

persist then surgical release is necessary. Make sure athlete is not wearing tight braces, pads

etc nor using long periods of hip flexion.

Labral tears

Typically seen in dysplastic hips where there are abnormal loads (shear and strain) on the

labrum. Also from excessive twisting action.

A sharp pain or a catching sensation on a background of a dull ache. (Aggravated by flexion and

internal rotation of the hip). X-rays may show acetabular dysplasia. Tears are confirmed by

arthrography or arthroscopy (usually in the posterior aspect of the hip joint).

Treatment is rest and surgical excision / repair (difficult).

Stress fractures

First described by Briethaupt in 1855 in German soldiers (Stechow noted on x-rays in 1897).


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Stress fractures of the neck of femur were described by Blecher in 1905. Much of the early

literature in regard to stress fractures was from the military. Nowadays stress fractures seen in

athletes; the highly motivated athletes in peak condition and at maximal performance. Risk

factors are endocrine disorders especially in amenorrhoeic female athletes (see Chapter 23)

clearly on overuse injury.

The mechanism is a partial or complete fracture of bone due to an inability to withstand non

violent stress applied in a rhythmic/repeated sub maximal mode.

Controversy exists as to whether they are due to fatigue of muscles leading to increased load or

(as Stanitski believes)1 an increased muscular force plus increased rate of remodeling leading

to resorption and rarefaction and ultimately to stress fractures. This will manifest as a periosteal

or endosteal response giving an appearance of a stress fracture which may ultimately progress

to a linear fracture and in time displace.

1. C.L. Stanitski, J H McMaster, P.E. Scranton. 1978. On the nature of stress fractures. Am J Sports Med. 6, 391.

The clinical and x-ray criteria for diagnosis of a stress fracture are:

Premorbid normal bone

No direct trauma/inciting activity

Pain and tenderness (on percussion and antalgic limp) prior to x-ray changes - useful

clinical sign.

Subsequent x-rays show resolution and modeling

Positive bone scan

Assess the opposite limb clinically and by x-ray to exclude a stress fracture (as not always

symptomatic). Differential diagnosis includes tumour (particularly osteosarcoma and Ewings

tumour), osteomyelitis or periostitis from TB or syphilis. Jumping sports have a strong often

injure the femur and pelvis but stress fractures have been noticed amongst hikers and fencers

(especially in the pelvis).

Typically classified into those of the femoral neck or shaft.

Femoral neck (Hajeck)1

Compressive of inferior cortex - young patients/early internal callus/sclerosis may

complete non-weight bear/modify training.

Transverse of superior cortex - older patients/initial crack in superior cortex may

displace.

Femoral shaft (Blickenstaff)2


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medial proximal femur

displaced spiral oblique

transverse distal

crutches (4 to 8 weeks), may complete, often need to operate.

Treatment involves decreased weight bearing and modified training. May be all that is required

early femoral shaft stress fractures and compressive type of femoral neck fractures. In the older

patient it is wise to pin at an early stage (as a risk of progression). Be aware: to ensure that both

elite athletes and amateurs do not suffer significant stress fractures. Finite element analysis

evidence suggests that a maximum 100 miles over a three month period is the limit for a first

time jogger.

1 MR Haje K, HB Noble. 1982 Stress fractures of the femoral neck in joggers. Am J Sports Med 10, 112.

2 LD Blicken Staff, JM Morris 1966. Fatigue fracture of the femoral neck. JBJS 48A, 1031.

Fractured hip; acute slip of the upper femoral epiphysis (SUFE)

These occur from a sever force applied while the foot is planted and the hip twisted. (Seen in

cross country and downhill skiers from a low velocity fall Skiers HIP). Hip fracture may occur or

SUFE in child (Fig 3).

There is severe pain and an inability to weightbear, with shortening and external rotation in the

hip. Exclude a past history of ache or an antalgic gait with an acute or chronic slipped upper

femoral epiphysis.

Treatment is immediate immobilisation and then immediate operative stabilization and drainage

of the capsular haematoma.

Dislocation of the hip

Dislocations result from a direct impact to the flexed knee and hip (anterior or posterior)(Fig 4).

There is severe pain and typical deformity with the leg in a flexed and internally rotated position

(posterior dislocation) or externally rotated (anterior dislocation). The sciatic nerve may be

involved.

Immobilize the athlete give analgesia and plan immediate reduction (open if necessary) of the

hip to reduce the likely development of AVN and later OA. This is a surgical emergency with

serious long term consequences for a young athlete.

Fractured femur and pelvis


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High velocity injuries. Significant pain and deformity occurs. Exclude neurological or vascular

compromise. There often are associated head, neck, chest (pneumothorax) and abdominal life

(splenic/hepatic/renal/bladder/urethral rupture) threatening injuries which must be found and

treated urgently.

Apply MAST suit immediately. Note blood at tip penis (indicates urethral rupture)1. Resuscitate

the athlete with special attention to head injury, immobilize the neck, exclude need for chest

tube peritoneal lavage/exploratory laparotomy. Optimize volume replacement (up to 40 units of

blood can disappear into a fractured pelvis) and give adequate analgesia. Surgery is almost

always required to reduce and hold fractures of the femur (neck/shaft) and quite often for the

pelvis (external fixateur to tamponade bleeding in displaced and unstable pelvic fracture.

Consider applying pelvic clamp in ER (if >10 minutes to get to OR and BP is low). Such athletes

have high chance of long term back pain, leg length discrepancy, pelvic pain and impotence.

Hip arthroscopy -Bowman first reported hip arthroscopy in 1937. It has recently become morewidely used but the uses, apart from diagnostic, are fairly limited. It is a difficult, technique

dependant procedure.

1 E Sherry 1993 Skiing Trauma in Australia. MD thesis UNSW.

Possibly useful where there is unexplained hip pain, where of synovitis or early osteoarthrosis

can be used for lavage in early osteoarthrosis and for treatment of labral tears, removal of loose

bodies (from fractures, osteochondromatosis and villonodular synovitis). Several techniques

have been described.

Avascular necrosis femoral head

A partial or complete disruption of the blood supply to the femoral head resulting in necrosis of a

segment which may then under go collapse before revascularization has occurred. A

catastrophe for a young athlete.

Most commonly follows a fracture of the head or femoral neck or dislocation/subluxation

(especially if associated with delay in reduction; Posterior dislocations in particular disrupt the

superior retinacular vessels). Perthes Disease, results from an increased intracapsular pressure

following a synovitis which compromises the vascular supply to the femoral head. AVN is

classified according to that of Ficat1 with diagnostic and surgical intervention noted. (Table 2)

Table 2. Ficats classification of AVN

Stage Pain Exam XR Bone Scan MRI Treatment0 None Normal Normal Normal Normal Normal

1 Minimal I.Rot Normal No help Some

changes

?core

decompression

2 Moderate ROM Positive Positive Graft


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Porosis/ sclerosis

3 Advanced ROM Flat,

crescent

sign

Positive Positive Joint

replacement

4 Severe Pain

Acetabular

changes

Positive

Positive Joint

replacement

Osteoarthritis

High correlation with high impact sports especially track and field and racquet sports. Work

performed by Radin shows that compression of the joint with oscillating repetitive high impact

loads leads to microfractures. Conditions associated with avascular necrosis will advance the

onset of osteoarthrosis. Athletes with extensive sports participation have a 4 to 5 fold increased

incidence of OA2 (up to 8.5 if also involved in an occupation risk of OA. Patients who have had

hip replacements should not play impact.

1 RP Ficat, J Arlet. 1980 Ischaemia and Necrosis of Bone. Baltimore. Williams and Williams.

2 E Vingard, L Alfredsson, I Goldi, C Hogstedt. 1993. Sports and osteoarthrosis of the hip. Am JSports Med 21,

195-200.

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Chapter 11 - Injuries -The Hip, Thigh, and Pelvis