Hip and Pelvis

Examination

The usual presenting complaints are:

Pain.
Limp.
Discomfort leading to reduced walking/running distances.
Snapping or clicking sensation of the hip.
Stiffness/reduced range of motion.
Deformity.

Inspection

Examine gait:
- Look for evidence of asymmetry or biomechanical abnormality.
- Scars.
- Sinuses.
- Swellings/masses.
- Muscle wasting.
- Apparent limb length by measuring the distance from umbilicus to medial malleolus.
True limb length discrepancy is noted by measuring the distance from anterior superior iliac spine (or any ipsilateral fixed bony point) to medial malleolus after squaring the pelvis (unmask the fixed abduction or adduction deformity of the affected limb so that both anterior superior iliac spine and medial malleolus are levelled, and place the normal limb in a similar position).

See Figs. 21.1, 21.2, and 21.3.

Palpation

Skin temperature.
Tenderness over the greater trochanter and in the groin area.
Palpate swellings/masses if present.

Active and passive movements

The pelvis must be squared and stabilized before hip movements are measured (see Tables 21.1 and 21.2).

A normal hip has:

Flexion range of 0-130°.
Extension of 0-10°.
Abduction of 0-45°.
Adduction of 0-40°.
IR of 0-30°.
ER of 0-60°

Note pain or restriction at the extremes of range of movement. IR is restricted in early osteoarthritis. In advanced osteoarthritis, there is fixed flexion deformity with absent extension, decreased abduction, adduction, and ER and IR. All movements may be associated with pain.

Fig. 21.1 Bones of the lower limb and pelvic girdle: anterior view. Reproduced with permission from Mackinnon P and Morris J. (2005). Oxford Textbook of Functional Anatomy, Vol. 1. Oxford University Press, Oxford. © 2005.

Fig. 21.2 Bones of the lower limb and pelvic girdle: posterior view. Reproduced with permission from Mackinnon P and Morris J. (2005). Oxford Textbook of Functional Anatomy, Vol. 1. Oxford University Press, Oxford. © 2005.

Fig. 21.3 Dermatomes of lower limb; note the axial lines. Reproduced with permission from Mackinnon P and Morris J. (2005). Oxford Textbook of Functional Anatomy, Vol. 1. Oxford University Press, Oxford. © 2005.

Table 21.1 Hip joint: movements, principal muscles, and their innervation. Reproduced with permission from Mackinnon P and Morris J (2005)

Movement	Principal muscles	Peripheral nerve	Spinal root origin
Flexion	Psoas major	Ventral rami of lumbar nerves	L 1, 2, 3
	Iliacus	Femoral nerve	L 2, 3
	Rectus femoris	Femoral nerve	L 2, 3, 4
	Pectineus	Femoral nerve	L 2, 3, 4
Extension	Gluteus maximus	Inferior gluteal nerve	L 5, S1, 2
Extension	Hamstrings (semimembranosus, semitendinosus, biceps femoris (short- and long head)	Sciatic nerve (tibial component-except for the short head of biceps femoris supplied by the peroneal component)	L 4, 5, S1, 2
Adduction	Adductors longus, brevis, magnus, and gracilis	Obturator nerve	L 2, 3, 4
Abduction	Gluteus medius and minimus	Superior gluteal nerve	L 4, 5, S1
Abduction	Tensor fasciae latae	Superior gluteal nerve	L 4, 5, S1
Medial	Tensor fasciae latae	Superior gluteal nerve	L 4, 5, S1
Rotation	Gluteus medius and minimus	Superior gluteal nerve	L 4, 5, S1
Rotation	Adductor longus	Obturator nerve	L 2, 3, 4
Lateral	Obturator externus	Obturator nerve	L 2, 3, 4
Rotation	Sartorius	Femoral nerve	L 2, 3, 4
	Quadratus femoris	Sacral plexus	L 4, 5, S1
	Obturator internus	Sacral plexus	L 5, S1, 2
	Gluteus maximus	Inferior gluteal nerve	L 5, S1, 2
Oxford Textbook of Functional Anatomy, Vol. 1. Oxford University Press, Oxford. © 2005.

Table 21.2 Main spinal nerve root supplying the movements of the lower limb. Reproduced with permission from Mackinnon P and Morris J (2005)

	Movement	Main nerve roots
Hip	Flexion, adduction	L 2, 3, 4
Knee	Extension, abduction	L 4, 5, S1
Knee	Extension	L 3,
Ankle	Flexion	L 5, S1
Ankle	Flexion (plantar flexion)	L 5
Subtalar joint	Extension (dorsiflexion)	L 5, S1
Subtalar joint	Inversion	L 5
Toes (long muscles)	Eversion	L 5, S1
Toes (long muscles)	Flexion (plantar flexion)	L 5, S1, 2
Toes (small muscles of foot)	Extension (dorsalflexion)	L 5, S1, 2, 3
Toes (small muscles of foot)		S1, 2, 3
Because of the rotation of the lower limb, extension of the knee is supplied by higher segments.
Oxford Textbook of Functional Anatomy, Vol. 1. Oxford University Press, Oxford. © 2005.

Special tests

Trendeleburg test

Helps to assess the integrity of the abductor mechanism of the hip. Patients are asked to stand on one leg, and the position of the pelvis is noted. If the pelvis drops and patients sway to loaded leg, the test is positive. Pain on weight-bearing, weakness of hip abductors, shortening of femoral neck, and dislocation or subluxation of the hip joint result in a Trendelenburg +ve test.

Thomas’ test

Fixed flexion deformity of the hip can be masked by the increased pelvic tilt and exaggerated lumbar lordosis. This test helps unmask a fixed flexion deformity of the hip and identify the limitation in the range of hip flexion.

With the patient supine, both hips are flexed until the lumbar lordosis is obliterated (confirmed by examiner’s hand). The normal (or contralateral) hip is kept flexed, and the affected hip is lowered to the maximum possible extent. The angle between couch and the lower limb is the fixed flexion deformity angle.

Tests for suspected labral tears

Pain on flexion, adduction, and IR of the hip joint occurs with anterior superior tears.
Pain on passive hyperextension, abduction, and ER occurs with posterior tears.
Pain moving the hip from a position of full flexion of the hip with ER and full abduction, to extension, abduction, and IR occurs with anterior tears.
Pain moving the hip from extension, abduction, and ER to flexion, adduction, and IR occurs with posterior tears.

The above movements may also be accompanied by a clicking and/or locking sensation.

Complete the examination by performing neurovascular examination of the lower limb, and examining the contralateral hip and ipsilateral knee, and spine.

Faber test

The manoeuvre is performed with the patient in supine position with the affected leg flexed and the foot on the opposite knee (flexion abduction ER of the hip). The patient’s pelvis is stabilized by placing a hand on the iliac crest of the opposite side. The examiner presses down on the flexed knee. The test is positive if there is pain at the hip or sacral joint, or if the leg cannot be placed parallel to the opposite leg. Pain in the groin area suggests a hip pathology, while pain in the sacro-iliac area indicates a sacro-iliac joint (SIJ) pathology.

Piriformis test

The patient lies on the unaffected side or supine. The affected leg is in 60° of hip flexion. The knee should be bent and relaxed with the foot on the unaffected leg. The examiner places one hand on the hip for stabilization
and exerts a downward pressure on the knee with the other hand, while rotating the hip internally. The test is positive if there is pain or tightness. If the sciatic nerve is compressed (piriformis syndrome), the patient experiences radicular-like symptoms.

Ober’s test (ilio-tibial band)

The patient lies on the unaffected side with the hip flexed. The examiner passively extends and abducts the hip. If the leg remains in the abducted position, it indicates a positive test (contracture of the ilio-tibial band). If the leg adducts, the test is considered negative. Localized pain over the greater trochanter during the Ober’s test may indicate an underlying trochanteric bursitis.

Investigation

Plain radiographs, CT, MR, and bone scan, and arthroscopy are helpful to confirm clinical diagnoses.

Femur: acute injury

Femoral shaft fractures, while unusual in most sports, are an emergency and associated injuries must be ruled out. Follow advanced trauma life support (ATLS) guidelines (airway with cervical spine control, breathing, circulation, disability assessment, and exposure) when managing such injuries. A secondary survey will help identify associated injuries.

Fractures are usually closed, and if open, are often within-out injuries. The mechanism is usually a torsional stress causing a spiral fracture that may extend into the proximal or distal metaphysis. A direct force causes transverse or oblique fractures. Severe trauma results in comminuted/segmental fractures. There are often other injuries associated with femoral shaft fractures so, look out for ipsilateral fractures of the neck of the femur and/or the posterior wall of the acetabulum.

Fractures can be classified on the basis of the site of injury, the extent of fracture, the configuration, the relationship of fracture fragments to each other and the relationship to the external environment, with important influence on the prognosis. The AO Classification is widely accepted.

Investigation

Radiographs to include both hip and knee joints. The incidence of ipsilateral femoral shaft and femoral neck fractures is 3%.
CT scan or MRI can provide additional information, especially in complex fractures.

Treatment

Manage shock:
- Two wide bore venous cannulae (brown- or grey-coloured).
- Hartmann’s solution is preferred.
- Urinary catherization.
- Cross-match 2-4units of blood.
Analgesia.
Adequate splint (Thomas splint).
Femoral fractures generally require a surgical treatment, with different techniques according to the type of fracture and patient characteristics.
Gold standard is early closed intramedullary nailing for closed fractures (<24h).
Fix femoral neck first, if present.
Open fractures need emergency debridement and stabilization.
Paediatric femoral shaft fractures can be managed with traction.

Growth plate injury

The growth plate (physis) can be injured in many ways. The most common cause is trauma. Less common causes include disuse, infection, tumour, vascular impairment, neural involvement, metabolic abnormalities, radiation, laser injury, electrical injury, burns, frostbite, chronic stress, and iatrogenic or surgical insults.¹

Physeal fractures

The physis is the weakest structure near a paediatric joint. They occur in a male:female ratio of 2:1. In males, the peak incidence is at 14yrs, and in females it is at 11-12yrs. (The most common sites of injury are the phalanges of fingers (37%) followed by the distal radius (18%).) Children present with pain, inability to use the limb, and, less commonly, deformity. AP and lateral radiographs of the affected part usually confirm the diagnosis. Occasionally, stress views, tomograms, CT scans, MR scan, or a US scan can help detect growth plate injury.

Classification

The Salter-Harris classification of the physeal injuries is widely used:

Separation of the epiphysis from the metaphysis with disruption of the complete physis.
Separation of part of the physis, with a portion of metaphysis attached to the epiphysis (Thurston-Holland sign).
Fracture of the epiphysis extending into the physis.
The fracture traverses metaphysis, physis, epiphysis and the articular cartilage.
This injury is end-on crush of the physis. Diagnosis is retrospective as radiographs are normal at initial presentation. MRI can be useful for the diagnosis.

Femoral neck stress fracture

Stress fractures of the femoral neck or pubic rami may cause hip and groin pain. These fractures usually result either from abnormal forces acting on normal bone, or normal forces acting on abnormal bones.

The most common stress fractures in sport are fatigue fractures, resulting from excessive stress on the bones.

Long distance runners and dancers (especially females) are more prone to femoral neck stress fractures. Predisposing factors include changes in the training programme with increase in intensity, frequency, and duration, changes in shoes, running on a different surface, nutritional deficiency, and abnormal menstrual cycles and hormonal imbalance in female athletes.

Femoral neck stress fractures are classified by Fullerton and Snowdy¹ as tension (type I—superior aspect of the femoral neck), compression (type II—inferior aspect of the femoral neck), or displaced (type III), from the mechanism of injury. This classification has an important influence on the prognosis, as the tension surface femoral neck stress fractures are at significant risk of non-union, deformity, and avascular necrosis. Compression surface femoral neck fractures usually have a good prognosis and may be treated with reduced/altered activity followed by gradual return to sport.

History and examination

Deep aching pain in the groin that may radiate to the knee.
Pain is progressive, occurs with activity, and resolves with rest.
Pain becomes constant if activities are continued without modification.
May present with a limp.
May be no specific site of point tenderness.
Range of motion of the hip, particularly IR, may be limited due to pain.
Walking, static running, or hopping on the affected extremity often reproduces the pain.

The differential diagnosis includes infection, tumour, compartment syndrome, arthritis, ligamentous, or soft-tissue injuries. The history may be non-specific, but clinicians should always be alert to the possibility, especially in high risk groups.

Investigations

Plain radiographs may be negative.
MRI is more sensitive, specific, and accurate than a bone scan in identifying a femoral neck stress fracture.

Prognosis

Any of the above complications may lead to inability to return to pre-injury performance levels.

Trochanteric bursitis

Inflammation of the greater trochanteric bursa. This bursa minimizes the friction between the greater trochanter and the ilio-tibial band, which passes over the bursa. Bursal inflammation may be caused by several conditions, such chronic microtrauma, arthritis, regional muscle dysfunction, over-use, or acute injuries.

Predisposing factors include a broad pelvis (female runners), training on banked surfaces or roads with a slope, and a recent increase in mileage, duration, or intensity of training.

There are many bursae in the hip and groin region, but the most commonly involved sites are the trochanter, the ischial and iliopectineal bursae.

History and examination

Lateral hip pain, occasionally radiating along the distal lateral thigh.
May be associated with snapping or clicking sensation.
Point tenderness over the greater trochanter may be associated with crepitus on hip flexion and extension.
Pain at the extremes of hip rotation, abduction, or adduction (trochanteric)
Pain of contraction of hip abductors against resistance (trochanteric).
Pseudoradiculopathy: pain radiating down the lateral aspect of the thigh (trochanteric).
While diagnostic criteria have been proposed, their sensitivity, specificity, and predictive value have not been established.¹
These criteria propose that lateral hip pain and tenderness around the greater trochanter must be present in combination with 1 of the following:
- Pain at the extremes of rotation, abduction, or adduction.
- Pain of contraction of the hip abductors against resistance.
- Pseudoradiculopathy: pain radiating down the lateral aspect of the thigh.

Provocative positions include ER and adduction.

The differential diagnosis includes:

Stress fractures.
Gluteus medius tendinopathy (dancers).
Lumbosacral radiculopathy.
Avascular necrosis.
Osteoarthritis.
Septic bursitis

Investigations

Diagnosis is usually made by clinical examination:

Radiographs may help rule out other conditions.
The role of US and MRI is unclear.

Treatment

Most patients improve with conservative management, which includes:

Rest.
Ilio-tibial band and tensor fascia lata stretching.
Gluteal muscle strengthening.
Anti-inflammatory drugs.
Iontophoresis.
US.
Injection of local anaesthetic (5mL of 1% lignocaine 10mg/mL) into the point of maximal tenderness.

If surgery is required, the ilio-tibial band is released by a cruciform incision with or without debridement of the trochanteric bursa. The ilio-tibial band may also be Z-lengthened or an ellipse of tissue can be excised. Recently soft tissue endoscopy has been used to excise the bursa.

Treatment of septic bursitis

Uncomplicated superficial septic bursitis responds well to aspiration and appropriate antibiotic therapy. Repeat aspiration may be indicated if swelling, tenderness, and erythema recur. If there are comorbidities or the patient is systemically unwell, IV therapy is recommended. The duration of antibiotic administration may range from 1 to 4 weeks depending on individual response.

Surgical lavage and debridement is indicated if aspiration has not adequately drained the bursa, if an abscess is present, or if a sinus has formed.

Ilio-tibial band syndrome

The ilio-tibial band is a strong tendinous structure originating from the tensor fasciae latae and the gluteus maximus muscle, with insertion on the fibular head and the lateral patellar retinaculum.

The ilio-tibial band syndrome (ITBS) is an over-use injury, characterized by pain on the outer aspect of the knee due to irritation and inflammation of the distal portion of the ilio-tibial band as it crosses the lateral femoral epicondyle. This is seen in long-distance runners, cyclists, and other endurance athletes.

Friction (or impingement) occurs predominantly in the stance phase, between the posterior edge of the ilio-tibial band and the underlying lateral femoral epicondyle. Downhill running predisposes the runner to ilio-tibial band friction syndrome because the knee flexion angle at footstrike is reduced.

History and examination

Pain is usually poorly localized over the lateral aspect of the knee, is aggravated by running long distances or excessive striding, and is more severe running downhill. Pain may be relieved by walking with a stiff or a straight knee.

Point tenderness about 2cm above the joint line when the knee is flexed at 30° and palpated over the lateral femoral epicondyle.

Flexion and extension of the knee may produce a crepitus.
Pain is worse during weight-bearing flexion and extension. Pain is typically worse at the 30° while flexion is occurring.

The differential diagnosis includes knee pathologies including menisceal tears, ligament injuries, and loose bodies.

Investigations

Diagnosis is usually clinical. Investigations including radiographs and MRI scan help rule out other pathologies, but cannot positively confirm ITBS. An MRI may show bone oedema at the lateral femoral epicondyle

Treatment

Conservative treatment is effective in most cases. It includes:

Reduction of activity.
Oral anti-inflammatories.
Ice, heat, US, and/or electrical stimulation.
Stretching exercises to address any excessive ITB tightness.
The optimum treatment is physiotherapy in combination with analgesic/anti-inflammatory medication.
Local anaesthetic and corticosteroid injections repeated twice at two weekly intervals may be helpful in resistant cases

Surgery may be offered to patients who are resistant to conservative management. It is performed with the knee held in 30° of flexion and consists of cruciform incision of the ilio-tibial band or a limited resection of a small triangular piece at the posterior part of the ilio-tibial band covering the lateral femoral epicondyle. Prognosis is good with low morbidity, and quick return to sports.

Thigh contusion

Proximal thigh contusions are common athletic injuries, particularly as a result of direct trauma in contact sports. The muscle is compressed between the external force and the femur below. Severe injuries result in large haematomas that limit range of motion. See Fig. 21.4.

There is often significant haemorrhage and swelling.

History and examination

Classification: ROM assessed at 12—24h after the event.

Mild thigh contusions: active ROM of the knee >90°.
Moderate thigh contusions: active ROM of the knee 45-90°.
Severe thigh contusions: active ROM of the knee <45°.

Treatment

The initial management of an anterior thigh contusion is rest, immobilization with knee in flexion, ice, and compression to maintain motion and minimize haematoma formation.

Weight-bearing should be limited until the patient regains good quadriceps muscle control and 90° of pain-free knee motion.
Functional rehabilitation and non-impact sports are allowed when the range of motion has reached 120°, and there is no residual muscle atrophy.
Return to full activity: normal strength and range of motion (3 weeks). More severe injuries may have a longer recovery time.

Average disability time is 13 days for mild contusions, 19 days for moderate contusions, and 21 days for severe contusions.

If there is a major haematoma and if an athlete struggles to regain motion, refer to an orthopaedic surgeon or a radiologist for evacuation or aspiration of the haematoma. MRI or US scan will demonstrate the size and location of the haematoma. The aspiration can be performed under ultrasound guidance with aseptic technique. Protect the involved area with padding to avoid repeat injury.

Complications

Myositis ossificans development depends on the severity of the initial injury. It is more likely with repeated trauma. This process may appear histologically similar to osteosarcoma, but the history is usually distinct and the periphery of a myositis ossificans lesion is mature. (Myositis ossificans, p. 580).
Loss of range of motion and loss of functional outcome.

Indomethacin may be useful for prevention of myositis.

Monitor high-energy contusions closely for thigh and gluteal compartment syndromes in acute stages. Emergency fasciotomy may be rarely required, but serial examination is an absolute requirement.

Myositis ossificans

Myositis ossificans comprises two syndromes characterized by heterotopic ossification (calcification) of muscle. The first is usually a self-limiting condition in which a mass of heterotopic bone forms within the soft tissues. The term is a misnomer, as the muscle is not inflamed, and the process is not limited to muscle. Other descriptive terms include heterotopic bone formation, pseudomalignant osseous tumour of the soft tissue, extra-osseous localized non-neoplastic bone and cartilage formation, myositis ossificans circumscripta, and pseudomalignant myositis ossificans. The condition develops within 1-2 weeks of direct trauma to the area or unusual muscular exertion. Many patients cannot remember a particular trauma. It is more common in adolescents and young males. Typical sites include the thigh (quadriceps femoris and adductor muscles), elbow (flexor muscles), buttocks (gluteal muscles), the shoulder, and the calf. The proximal portion of the extremity is more frequently affected than the distal part. The pathological process includes muscle necrosis and haemorrhage after trauma. Histologically, there is marked proliferation of spindle cells with a well-recognized zoning phenomenon.

The least differentiated tissue lies in the central zone.
In the middle or intermediate zone, the osteoid is more organized and separated by a loose cellular stroma.
The outer zone is the most mature consisting of well-formed bone which may form a shell around the entire lesion. Cartilage formation may also be present.

Soft tissue or bone sarcomas do not exhibit a similar zonal phenomenon.

The second condition, myositis ossificans progressiva (also referred to as fibrodysplasia ossificans progressiva), is an inherited affliction, autosomal dominant pattern, in which the ossification can occur without injury, and typically grows in a predictable pattern. Specific gene mutations have been identified in two rare inherited disorders that are clinically characterized by extensive and progressive extraskeletal bone formation-fibrodysplasia ossificans progressiva and progressive osseous heteroplasia. In fibrodysplasia ossificans progressiva, activating mutations in activin receptor type-1, a bone morphogenetic protein type I receptor, induce heterotopic endochondral ossification, which results in the development of a functional bone organ system that includes skeletal-like bone and bone marrow. In progressive osseous heteroplasia, the heterotopic ossification leads to the formation of mainly intramembranous bone tissue in response to inactivating mutations in the GNAS gene.

History and examination

There is usually pain, swelling, and stiffness of the surrounding joints.

On examination, there is often a red, warm swelling with soft tissue tenderness. In later stages, a hard mass is palpable.

Investigations

In the early stages, plain radiographs may be unremarkable except for non-specific soft tissue swelling. A periosteal reaction may be seen if the lesion is juxtacortical. By 2-6 weeks there is faint calcification and at
6-8 weeks, a lacy pattern of new bone forms around the periphery of the mass. Complete maturation is usual in 5-6 months.

A bone scan is highly sensitive because of the profuse osteoblastic activity and bone formation, and is non-specific, as soft tissue and bone tumours also show increased activity.

The MRI findings vary according to the stage of the disease.

The differential diagnosis includes soft tissue sarcoma and osteogenic sarcoma.

Treatment

Rest the part in a functional position until pain subsides. Gentle active movements may begin once pain improves. Oral biphosphonates, potent inhibitors of calcification are effective in modifying the process of heterotopic ossification.

Surgical resection is appropriate if the mass causes functional impairment and is best performed when the lesion has matured. Rapid recurrence occurs after resection of an immature lesion. If left alone, the mass may reduce in size with time and, in some instances, disappear.

Osteoarthritis of the hip

A progressive degenerative joint disease of the hip. (Coxarthrosis: coxa is hip, arthrosis is degeneration of a joint. Osteoarthritis is a misnomer as inflammation is not the primary pathologic process). The incidence of idiopathic hip OA increases with age. (It rarely occurs before the age of 24yrs. From 25-34yrs 2%, from 35-44yrs 4%, from 45-54yrs 16%, from 55-64yrs 31%, and 65+yrs 47%). Two million people in the UK suffer with osteoarthritis and, of those, 210,000 have moderate to severe osteoarthritis of the hips.

Ex-professional footballers had a significantly higher prevalence of OA of the hip than an age-matched group of radiographic controls. A Finnish study of international competing athletes showed increased risk OA of the hip for all athletes, but those involved in endurance sports (long distance running, cross-country skiing) were admitted to hospital care for OA at a later age than those involved in power sports (boxing, weightlifting, wrestling, throwing) or mixed sports (soccer, hockey, basketball, track).

Regular cyclical loading of joints is required to maintain normal articular cartilage composition, structure, and function. Prolonged static loading, repeated sudden excessive loading, or the absence of loading may, however, cause degradation of articular cartilage.

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