Emergency Department Evaluation: Hip Injuries
Emergency Department Evaluation: Hip Injuries
The hip is a ball-and-socket joint that consists of the acetabulum and the proximal femur 2-3 inches below the lesser trochanter. There is a strong fibrous capsule surrounding the joint.
Acute hip pain in athletes is almost always the result of a strain or musculotendinous injury. In children and adolescents, these injuries are often avulsion fractures involving the iliac crest, anterior superior and inferior iliac spines, and lesser trochanter or ischial tuberosity. Hip fractures and dislocations are uncommon in sports activities and usually occur as a result of a high-speed collision.32
Avulsion fractures, such as avulsion of the anterior superior iliac spine, are the result of sudden, forceful contraction of the sartoruis muscle. This fracture is usually seen in children and adolescents before the physis closes. The same mechanism in adults results in a strain instead of a fracture.
History And Physical Examination
As with any injury, the surrounding events should be noted. Determine the position the leg was in when the injury occurred, whether there was a pop heard or felt, and whether the patient could ambulate or resume play immediately after the injury. True hip joint pain often localizes to the groin. Examine the involved leg for deformity, shortening, rotation, and ecchymoses. Active and passive range of motion should be evaluated as long as the physician is reasonably sure there is no fracture or dislocation present. Look for tenderness of the iliac crest, pubic rami, or ischial rami. Hip pain with weight-bearing despite negative radiographs may indicate an occult fracture of the joint.
Musculotendinous injuries around the hip are usually the result of an actively contracting muscle that encounters abrupt resistance. This is most commonly seen in track and field but can occur in any sport that involves rapid acceleration and deceleration, such as soccer or missing a kick in football.
Symptoms include a pop or snap and sudden, severe localized pain and immediate disability. Walking is difficult or impossible. The site of the injury is tender, and swelling is variable. The muscle is usually tense. Suspect an avulsion fracture if there is tenderness on palpation at any of the tendon insertions.
Muscular injury is frequently encountered in the three major muscle groups of the leg: the hamstrings, quadriceps, and the iliopsoas. Strain of the hamstrings is common with running and sudden acceleration. The patient develops sudden and severe pain in the posterior thigh. Range of motion of the hip is painful, and no bony tenderness is present. Treatment involves crutches with toe-touch weightbearing(only the toes bear weight) as tolerated.
The quadriceps are the most common muscular groups to suffer complete tears. When the muscles are contracted suddenly against the body's weight, such as stumbling to prevent a fall, the quadriceps can suffer various degrees of tearing. On examination, there is pain with passive and active knee extension; with a complete tear, active knee extension against gravity is impossible. Treatment is limited to weight-bearing with crutches.
Injury of the iliopsoas is commonly seen in gymnasts and dancers and is the result of sudden, forceful hip flexion against resistance. There is sudden, severe pain in the groin, thigh, or low back. There may also be abdominal pain at the origin of the iliopsoas. On examination, the groin is tender to palpation and there is pain with active hip range of motion. Radiographs of the femur should be obtained to exclude a fracture of the lesser trochanter. Treatment is bedrest for 7-10 days with partial flexion at the knee and hip.4
With most muscular injuries, complete the evaluation with a pelvic or hip film to exclude associated avulsion fractures. The standard treatment of compression and ice is difficult to accomplish in the hip. Ambulation with crutches and bedrest are recommended.42 As with other musculotendinous injuries, active and isometric stretching should be started in 48 hours.
A contusion of the iliac crest is also known as a hip pointer. The iliac crest is very vulnerable to direct blows due to its poor protection. This injury may result in severe disability because the iliac crest serves as an anchor for abdominal and hip musculature. The history is significant for a direct blow to the hip, such as from a football helmet or fall onto a hard surface (which is common in soccer, football, and ice hockey). This painful blow is instantly disabling. On examination, the iliac crest is tender and there is a variable amount of swelling. The abdomen is often rigid due to abdominal wall spasm.
Radiographic evaluation of the pelvis may reveal a compression fracture. Consider intraabdominal injury in the presence of significant abdominal tenderness. In addition to ice and analgesics, a six- to eight-day steroid burst may reduce the duration of disability.42
Lisa Freeman; Adam Corley
April 1, 2003