Pelvic, Thigh and Hip Injuries - MSK Flashcards
Pelvic Fracture Presentation
-Groin pain
-Proximal femur pain
-Pain with weight bearing—lateral hip, groin, or buttocks
-In trauma most pelvic injuries associated with other major injuries (head, chest, abdomen)
-Three types:
A: Stable
B: Rotationally unstable
C: Completely unstable (rotationally, posteriorly and vertically)
-Type A fracture: avulsion (chip) fractures not involving the ring of the pelvis
-Treated symptomatically
-Can occur in elderly and in young, athletic patients
-Patient may ambulate as tolerated with a walker initially then crutches
-Excellent healing expected within 8 weeks
-Type B fracture: rotationally unstable (example: open book)
-More widely displaced injuries treated with ORIF with plate
-These patient minimally weight bearing (bed to chair) for 6-8 weeks followed by crutches, slow progression to full WB
-Type C fracture: Completely unstable (rotationally, vertically and posteriorly)
-Treatment: depending on extend of displacement ORIF may be indicated, if not closed surgically, need close follow-up with repeat x-rays, patients with these fractures need to be seen by a surgeon who has specialized in pelvic and acetabular surgery
Femur fractures
-Femoral Shaft Fracture: fracture located below the lesser trochanter and above the condylar region
-Mechanism: high energy trauma such as MVA, pathologic fractures in cancer
-Presentation: pain along the thigh with obvious deformity, inability to bear weight
Treatment:
-Immediate splinting for comfort
-Traction until ORIF
-Open fractures are surgical emergency
Hip injuries: Dislocation Anterior
- Anterior hip dislocation: far less common than posterior dislocation, account for about 10% of dislocations
- Mechanism : High impact injury, usually MVA or severe fall, Mechanism is forced abduction
- Presentation is typically abducted/ER/flexed
- In many cases, femoral head injury occurs with forceful dislocation
- Early closed reduction is treatment of choice (under anesthesia)
- Different reduction techniques depending on location of dislocation, traction along line of femur
- Anterior dislocations associated with fractures require surgical consult
Hip injuries: Dislocation Posterior
- Posterior hip dislocations: most common type of dislocation, occurs in 90% of hip dislocations
- Usually mechanism is force applied to flexed knee when hip is flexed (dashboard injury)
- Can be associated with posterior acetabular fractures
- On exam lower extremity is shortened, flexed/IR/adducted
- Imaging is same for anterior dislocation
- Should be reduced within 8-12 hours, considerable traction necessary followed by flexion, IR/ER
- Fractures associated with dislocations require surgical consult
Complications of hip dislocations:
- Avascular necrosis due to disruption of blood supply
- Sciatic or femoral nerve damage
- Traumatic arthritis
Avascular necrosis of femoral head
-Disruption of blood supply to the femoral head results in necrosis of bone and femoral head collapse
-Associated with femoral neck injuries, posterior dislocations (timely reduction imperative)
-risk factors: Alcohol abuse, Steroid use, Sickle cell disease, RA, SLE, Trauma
-presentation: Dull/achey pain in groin, lateral hip or buttocks that progresses slowly, Limited range of motion, Limp
-Imaging: Radiographs may be normal in early phase (MRI if high suspicion) , Later patchy areas of sclerosis and lucency, “Crescent sign”
treatment:
-Without femoral head collapse: Protected weight bearing, Bone graft, Controversial
-With femoral head collapse: Total hip arthroplasty
-adverse outcomes: Femoral collapse, Degenerative arthritis, Chronic pain, Decreased ROM, Limp
Hip fractures (proximal femur fractures)
-Common in elderly with osteoporosis
-Frequency doubles with every decade beyond age 50 years
-Generally involve femoral neck or intertrochanteric regions, can involve femoral head
-Presentation: Usually fall history, Groin pain, Inability to bear weight, Elderly patient with hip pain after fall is fracture until proven otherwise
Exam: Inspection- ER, abduction, shortening in femoral neck or intertrochanteric fractures, skin changes, bruising, Pain with passive range of motion (often not able to tolerate any ROM), Inability to perform straight leg raise, Neurovascular exam
-Generally occur with dislocations which can cause indentations, abrasion of the bone
-Occasionally seen with severe trauma
-Treatment non-operative acceptable for small injuries, operative repair if large or if bone fragment precludes complete reduction
Femoral Neck Fractures
- Account for ½ of all proximal femur fractures
- 95% occur in elderly (osteoporosis, increased risk of fall)
- Femoral neck fractures in young associated with high-energy trauma
- Non-displaced, displaced and impacted
- May give history of trauma or increased activity level
- Complain of groin pain
- Pain with internal rotation
- Displaced: treatment with ORIF, timely due to risk of AVN
- Impacted fractures: can be treated operatively or non-operatively, period of bed rest then careful WB
- Surgical intervention >48 hours after fracture associated with increased mortality
- In patients <60 years old, surgical emergency due to risk of osteonecrosis
Intertrochanteric fractures
- Occur between greater and lesser trochanters
- Primarily in the elderly after a fall
- Women>men
- Operative treatment is best
- In old, non-operative patients, traction for 8 weeks then very partial WB/physical therapy
Trochanteric Bursitis
- Inflammation/hypertrophy of the greater trochanteric bursa
- May develop with inflammatory arthritis, leg length discrepancy
- Pain/tenderness over greater trochanter
- Pain may radiate to knee
- Patients may be unable to lie on the affected side
- Point tenderness over greater trochanter
- Pain exacerbated by hip abduction
- Diagnostic Tests: AP pelvis and lateral hip x-rays to rule out bony abnormalities
- Treatment: NSAIDS, IT band stretching, ice, steroid injections
Lateral Femoral Cutaneous Nerve Entrapment
-Compression or entrapment of the lateral femoral cutaneous nerve
-LFCN is sensory therefore no motor dysfunction
-LFCN most susceptible to compression where it exits pelvis just medial to ASIS (tight belt, obesity, scar tissue, rarely intra-abdominal process)
-Pain, burning or decreased sensation over nerve distribution (lateral thigh)
-Aching in groin area
-Pain radiating to SI joint
-Runners may feel sharp “electric shock” pain with each hip extension
-Decreased sensation over distribution of nerve
-Pressure or tapping over or medial to ASIS reproduces paresthesias or tenderness
-Radiographs: AP pelvis and lateral hip to rule out bony abnormality, abdominal imaging if mass suspected
-TX: Remove source of compression, Weight loss, Corticosteroid infiltration where nerve exits, Neurontin
Surgical release rarely required
Iliotibial band snapping of the hip
- IT band thick group of fibers that starts at iliac crest and extends across lateral portion of thigh and attaches at tibia
- Coordinates muscle function and stabilizes knee
- Snapping or popping sensation may occur as ilotibial band moves over the great trochanter
- Snapping (IT band suluxation) with walking or running
- Pain over greater trochanter
- In some cases, trochanteric bursitis develops
- Recreate snapping by having patient stand and rotate hip while adducted
- Snap can be palpated over greater trochanter
- AP pelvis and lateral hip to exclude bony abnormalities
- CT arthrogram or MRI if intraarticular pathology suspected
- TX: Reassurance, Exercise for strengthening and stretching IT band, abductors and adductors, NSAIDS, Treatment of bursitis if present
Osteomyelitis
- Infection in the bone
- In adults infection usually secondary to open fracture after surgical fixation
- In children infection due to hematogenous spread
- Clinical presentation, Local swelling, Fever, Pain, Drainage, Delayed fracture healing, Excessive crying in infants, Inability to bear weight on affected limb
- History: Recent open fracture, Recent ORIF, Immunocompromise, Recent systemic illness, Immunization status
- Work-up: CBC, ESR, CRP, X-ray, CT better than x-ray and should be used if highly suspicious and x-ray negative, Gold standard is biopsy or aspiration
- Treatment, Surgical debridement, IV antibiotics, Local antibiotic therapy via antibiotic-impregnated beads
- Adverse Outcomes, Amputation, Refractory osteomyelitis requiring long term antibiotic therapy, Rarely metaplasia in chronic lesion leading to SCC
