Case Study 5.1: Acute Hip Dislocation
Karen M. Myrick
SETTING: URGENT CARE
Definition and Incidence
Anterior hip dislocations are infrequent, and caused by high-energy trauma, most often from a motor vehicle accident (Bastian, Turina, Siebenrock, & Keel, 2011). Recognition of the injury and expedient reduction are imperative for good patient outcomes.
Patient presents with his wife after being involved in a motor vehicle accident an hour prior to presenting. He is writhing in discomfort, and has to be helped into the center with the use of a wheel chair. His chief complaint is right hip pain, and he is unable to speak in full sentences.
This 28-year-old male is a construction worker with a large company near his hometown. He is married and does not have children.
The patient is a 28-year-old male who is in acute distress. He is 5′10″ and weighs 220 lb, according to his wife. On inspection, his right leg is externally rotated and shortened. He has significant pain and is unable to communicate well. There are mild abrasions and small lacerations that are not actively bleeding on his knee of the right leg.
Radiographs are ordered in the room, and there is a dislocation of the right hip from the acetabulum.
Anterior hip dislocation.
The patient is given pain medication, morphine sulfate 10 mg, and a reduction is accomplished by placing him in a supine position, and using traction under the right knee in an upward and forward plane. After a clunk is felt, the patient is taken to x-ray for postreduction radiographs.
Patients who sustain hip dislocations should be evaluated with the consultation of an orthopedic surgeon. Many patients (65%–90%) will require arthroscopic evaluation and debridement for loose bodies within the joint (Keil, Vorburger, & Dahners, 2016).
Educate the patient on the importance of following up with orthopedics and limiting activity until such follow-up. Typically, the patient will be on crutches for a period of time, and begin touch-down weight bearing with the assistance of physical therapy. The potential long-term consequences of hip osteoarthritis, heterotopic ossification (HO), and avascular necrosis exist, and need to be discussed with patients and their families (Bastian et al., 2011).
Because this injury requires specialist consultation, the nurse practitioner may not follow up directly with the patient. If the nurse practitioner is in a setting where nurses work collaboratively with an orthopedic surgeon, the nurse may have the opportunity to directly follow up and even perform the preoperative and postoperative care of the patient, and may even be in a position to assist in the operating room. For the primary care nurse practitioner, it is likely the patient would return after the specialist consultation and any surgical intervention and rehabilitation has been completed, as the patient has been discharged from the specialist’s care. It is also highly likely that the nurse practitioner will care for patients on occasion who have sustained a hip dislocation at some point in their history. Being astute to the potential sequelae is important for early recognition and treatment.
Bastian, J. D., Turina, M., Siebenrock, K. A., & Keel, M. B. (2011). Long-term outcome after traumatic anterior dislocation of the hip. Archives of Orthopaedic & Trauma Surgery, 131(9), 1273–1278.
Keil, L. G., Vorburger, M. S., & Dahners, L. E. (2016). Junk in the joint: A trend for arthroscopic debridement to improve outcomes following closed reduction of traumatic hip dislocation. Trauma, 18(1), 35–39. doi:10.1177/1460408615606754
Case Study 5.2: Acute Hip Labral Tear
Karen M. Myrick
SETTING: URGENT CARE
Definition and Incidence
The acetabular labrum is a structure within the hip joint that is fibrous cartilage, and attaches to the edge of the acetabulum (Tian, Wang, Zheng, & Ren, 2014). The prevalence of labral tears in painful hips of young athletic individuals is reported as 22% to 55% (Skendzel & Philippon, 2013).
Patient presents with the chief complaint of left hip pain. She describes an insidious onset of hip and groin pain that is worse with certain dance moves that she performs, including twisting while weight bearing on this left leg. The pain is a 2 out of 10, 10 being the worst, at rest, and she experiences occasional episodes of catching, which she defines as an 8 out of 10. She has just completed a busy season while performing, and describes the pain as intolerable when it occurs, and becoming more frequent. There is no associated swelling or numbness, but she describes her leg as feeling weak and achy after an episode of catching. Pain is occasionally associated with a limp, favoring the left leg. She tried ibuprofen, 600 mg two times a day over the past 2 weeks, but really did not find this to make a difference in the discomfort.
This 11-year-old ballerina has been dancing for the past 6 years at a very high level. She lives at home with her mother and two siblings, a brother and sister. She is in the fifth grade.
Labral tears are associated with painful catching episodes, whereas a snapping hip is typically noisy and felt by the patient; however, they are not painful (Zini, Munegato, De Benedetto, Carraro, & Bigoni, 2013).
The patient is an 11-year-old female who is in no acute distress; she is ambulatory without an antalgic gait. She is 5′0″ and weighs 102 lb. On inspection, there is no gross deformity noted. With palpation, she has no bony tenderness, and no palpable snapping or clunking with range of motion (ROM). ROM is full with flexion to 125 degrees, extension at 30 degrees, abduction at 45 degrees, and adduction at 20 degrees. She has external rotation to 45 degrees and internal rotation to 35 degrees, but internal rotation is painful. With The Hip Internal Rotation with Distraction (THIRD) testing she has relief of her symptoms, and therefore a positive THIRD test (Myrick & Nissen, 2013). Hip abductors, adductors, quadriceps, and hamstring strength are 5 out of 5.
A radiograph was not obtained, due to the lack of yield on information that would be likely in this patient. Magnetic resonance imagery with arthrogram (MRA) was obtained. The MRA demonstrated a hip labral tear.
An MRA may not be necessary, depending on the unique patient presentation. The positive predictive value of the THIRD test is 100% (Myrick & Feinn, 2014).
Hip labral tear.
The patient was referred to an orthopedic surgeon for evaluation and consultation. The suggestion was for arthroscopic debridement of the labral tear, followed by physical therapy.
It is very important to educate both the patient and her parents about the likelihood of the diagnosis of labral tear given her history and physical examination findings. The information obtained with an MRA is likely to assist with surgical intervention, including the evaluation for underlying bony abnormalities that might need to be addressed surgically.
Because this injury requires surgical consultation, the nurse practitioner may not follow up directly with the patient. If the nurse practitioner is in a setting where nurses work collaboratively with an orthopedic surgeon, the nurse may perform the preoperative and postoperative care of the patient, and may even be in a position to assist in the operating room. For the primary care nurse practitioner, it is likely the patient would return after the surgical intervention and rehabilitation has been completed, and the patient has been discharged from the specialist’s care
Myrick, K. M., & Feinn, R. (2014). Internal and external validity of THIRD test for hip labral tears … hip internal rotation with distraction. Journal for Nurse Practitioners, 10(8), 540–544. doi:10.1016/j.nurpra.2014.06.021
Myrick, K. M., & Nissen, C. W. (2013). THIRD test: Diagnosing hip labral tears with a new physical examination technique … the hip internal rotation with distraction (THIRD). Journal for Nurse Practitioners, 9(8), 501–505. doi:10.1016/j.nurpra.2013.06.008
Skendzel, J. G., & Philippon, M. J. (2013). Management of labral tears of the hip in young patients. Orthopedic Clinics of North America, 44(4), 477–487. doi:10.1016/j.ocl.2013.06.003
Tian, C., Wang, J., Zheng, Z., & Ren, A. (2014). 3.0T conventional hip MR and hip MR arthrography for the acetabular labral tears confirmed by arthroscopy. European Journal of Radiology, 83(10), 1822–1827. doi:10.1016/j.ejrad.2014.05.034
Zini, R., Munegato, D., De Benedetto, M., Carraro, A., & Bigoni, M. (2013). Endoscopic iliotibial band release in snapping hip. Hip International, 23(2), 225–232. doi:10.5301/HIP.2013.10878
Case Study 5.3: Acute Greater Trochanteric Bursitis
Susan H. Lynch
SETTING: PRIMARY CARE
Definition and Incidence
Greater trochanteric bursitis or greater trochanteric hip pain describes lateral hip that is insidious in onset and chronic in nature. Muscles and tendons that attach to the greater trochanter and bursae which serve to protect the soft tissue are located in this region. The term “bursitis” in the diagnosis implies inflammation in the bursa; however, this is often not found (Mallow & Nazarian, 2014). Complaints of hip pain have an incidence of 10% to 25%, are more common in those older than 60, and more prevalent in women than men (Mulligan, 2015).
Patient presents with right hip pain which has been present for approximately 1 year. He complains that the pain is intermittent and denies any associated trauma with its onset. He does admit to playing golf and carrying his golf bag as he walks. He denies any pain while walking and carrying his bag but states that the pain occurs primarily at night. It wakes him from his sleep and prevents him from sleeping on the right side or his back. He denies radiation to the back, thigh, knee, or calf. He denies walking with a limp or any associated leg weakness or foot drop. He denies pain at rest and when the pain does occur it usually is 5 out of 10, reported as an ache. He does report some relief with nonsteroidal anti-inflammatory drugs (NSAIDs) but states that the pain returns. The patient was treated conservatively and encouraged to continue with NSAIDs as necessary to relieve pain, and to ice after activity. After 8 to 12 weeks the patient returned to the provider without resolution of his symptoms.
The patient is a 59-year-old male who is employed in an office setting. He is active and exercises regularly including weight-bearing exercises several times a week. He plays golf and carries his golf bag three times a week during the spring, summer, and fall. He lives at home with his wife.
On examination, the patient is a well-appearing 59-year-old male in no apparent distress. He is alert and oriented to time, place, and date. He ambulates with a steady, symmetric gait. On examination, no deformities are noted. Skin is warm and intact without edema or erythema. Hips are symmetric. Slight pain to palpation over the greater trochanter was elicited with no pain over surrounding soft tissue. There is no snapping, popping, clicking, or groin pain with ROM. He has full ROM to flexion/extension, abduction/adduction both active and passive. He has 5 out of 5 leg strength bilaterally, full sensation to sharp/dull, 2+ pulses throughout.
Due to the patient’s complaint of persistent yet not progressive symptoms, the patient was referred for x-ray. The results showed no acute trauma or fracture, no irregularities of the greater trochanter, but essentially normal hip joint with slight degenerative changes consistent with age.
Greater trochanteric bursitis.
With negative radiographic results and the patient’s continued complaint of symptoms with conservative treatment of ice, rest, and NSAIDs, the patient was referred to orthopedic surgery. The orthopedic surgeon did not order additional imaging but continued NSAIDs and physical therapy for 6 weeks.
In some cases, it is reasonable and appropriate for the patient to receive steroid injection into the joint (Mulligan, 2015). Less common is surgical intervention, which is used for those cases that do not respond to conservative treatment, physical therapy, or corticosteroid injections into the bursa (Mallow & Nazarian, 2014).
Educate your patients to be fully informed of all options for intervention and therapy. They should also be fully informed of prognosis. The patient should be a participant in the decision making of additional treatments with the goal of treatment being to return the patient to maximum functionality for the diagnosis.
The patient reports at his last annual exam that he has continued with exercises as prescribed by physical therapy and at this time remains pain free. He continues to be pain free and takes part in the activities he enjoys.
Mallow, M., & Nazarian, L. (2014). Greater trochanteric pain syndrome and treatment. Physics Medicine and Rehabilitation Clinics of North America, 25, 279–289. doi:10.1016/j.pmr.2014.01.009
Mulligan, E., Middleton, E., & Brunette, M. (2015). Evaluation and management of greater trochanter pain syndrome. Physical Therapy in Sport, 16, 205–214. doi:10.1016/j/ptsp.2014.11.002