25

special considerations in adolescents

FARES S. HADDAD, MD (RES), FRCS (ORTH), DIP SPORTS MED, FFSEM

FERAS YA’ISH, FRCS (ORTH), MBBS

KONSTANTINOS TSITSKARIS, MSC, MRCS, FRCS (TR & ORTH)

Editor’s Note: The fact of the matter is that there are special considerations for children and adolescents who have pain in the “hip” region. We all need to be aware of these conditions. I called on Fares Haddad and his colleagues in his world-leading adolescent hip orthopedic group to identify and simplify some of these conditions.

WHAT WE ARE TALKING ABOUT

A 15-year-old athletic, but slightly overweight, boy had pain in the right “hip area” for about 6 weeks. He saw his primary care physician, who got an X-ray that was interpreted as normal. Figure 25-1 shows the X-ray. The yellow lines are ours; they were not there during the initial radiologic evaluation.

To any practitioner aware of the diagnosis, this is no-brainer—slipped capital femoral epiphysis (SCFE).

The point is that parents should know to whom the patient is being referred. So many times, particularly with these core, or “black box” problems, the person is sent to a “specialist” in this area and the resultant diagnosis is absolutely useless. It is possible for the specialist to just happen to come up with the right diagnosis, but it is by chance. More likely, this turns out to be a fishing expedition without a fish finder. With hip area pain, the patient might see a general surgeon, urologist, gynecologist, colorectal surgeon, or general orthopedist. They will only rule in or out only the diagnoses with which they are familiar. (See Figure 25-2.)

From the symptoms, this young boy could have had a variety of things. The fact of the matter is that the diagnosis is obvious from the X-ray. Note the difference in lengths of the heads and necks of the 2 sides. The yellow lines are called Klein’s lines. The right side is much shorter, and you can see the ball looks compressed.

Any good pediatric orthopedic surgeon will have tales to tell about misdiagnoses in this region of the body, and usually dramatically bad outcomes. In fairness to the physicians who missed this diagnosis, no one has the ability to diagnose a condition or spot a sign he/she is not aware of. Coxa saltans and hip impingement are 2 diagnoses that many pediatric orthopedic surgeons missed just a few years ago.

Awareness of the hip conditions that can affect the adolescent hip can prevent detrimental, lifelong complications. The primary care doc and radiologist who missed the above case did not need to know details of the staging or controversial management of SCFE. All that was needed was to be mindful of such a diagnosis, and then one is prepared to identify the pathology and initiate appropriate care.

THE WAY IT WAS

Until just the past decade, “active neglect” was the name of the game when it came to treating hip deformities in adolescents. We ignored the adolescent patient in the room with all the symptoms while the doctor-patient relationship flourished, and we chose to treat all deformities such as residual hip dysplasia or from Legg-Calvé-Perthes disease (LCPD) or SCFE, without surgery, until such degenerative changes occurred that we had no choice. Any kind of snapping or impingement was simply dismissed. We had no awareness of the pathology or potentially available treatments.

Evolving understanding of these disorders and the consequences in adult life of not doing anything during childhood, combined with revolutionary, new corrective techniques, have changed everything. Direct targeting of the underlying pathology has abolished the classical “active neglect” or what was euphemistically called the conservative approach in many cases. Identifying applicable abnormalities in a timely manner can have such a wonderfully positive effect on the adolescent’s future.

We are diagnosing adolescent hip disorders more commonly. We know more about them, and more young individuals are competing at high levels earlier in life. With better diagnostic acumen,1 hip problems now represent 10% to 24% of all athletic injuries in children. These are most common in ballet dancers, runners, martial artists, hockey, football, and rugby players.²

Certainly, the increase in hip diagnoses in this patient group could be due simply to increased awareness. One hypothesis for the large number of hip injuries is accelerated growth and a resultant mismatch between limb length and body mass that impairs coordination and muscular flexibility. The hamstrings and hip flexors are implicated in one study.³ Open physes are at their highest risk for fractures and avulsions during the growth spurts and closures. Compared to adults, adolescents have stronger ligaments, which exert strong loads to the physeal region, likely rendering it more prone to injury.⁴

In addition, athletic activities may unmask neglected or missed childhood hip disorders (eg, DDH, SCFE), and these patients may develop their first symptoms during adolescence. Sometimes, diagnosis is essential before those patients should be allowed to return to their sports.

We feel compelled to harp on proper communication within this important medical triad. Communicating with adolescents may be a challenge in itself. In early childhood, the communication and ultimate decision-making usually lies primarily with the parents. With young adults, of course, the individual decides for oneself. The adolescent lies very much in the middle. He/She, obviously, is the focus, yet there may be heavy reliability on the immediate family to assist with the history and decision-making even despite being encouraged by everybody to participate actively in the process.5 Managing the parents may be tricky as well. They are usually anxious and burdened by the decision-making responsibility. They may not say it, but they also may be worried about their own difficulties in life (eg, financial concerns, single parent issues, immigration status, language difficulties). The parents may also have high, even unrealistic expectations (eg, a professional athletic career). Sometimes grandparents get involved.⁶

One must also be careful whether the main complaint is truly just a parental concern rather than the patient’s complaint. When that is recognized, the medical decision-making is easy compared to your interaction with the parent and child. The child may feel compelled to go along with the parent, so addressing both firmly and with conviction turns out to be key in these circumstances. Mercer Rang has written: “Paediatric visits are particularly challenging in requiring that the physician engage in a dance with not one but at least 2 partners—parent and child—and that the physician be able to lead at times and follow at others.”⁵

The child’s participation in the medical conversation is influenced by many factors, including the communicative behavior of the doctor and the parents. The child’s engagement and perception of bodily function also varies with age, sex, family background, and cognitive development. Communication with the child is more complex than with the adult. The language may involve multiple modalities—verbal, electronic, and body, and even the surrounding environment. Innocent-appearing factors may influence the relationships, and sometimes shape the child’s future attitude toward health providers.

The treating doctor needs to invite the child’s input as well as maintain a balance between the child’s and parents’ rights and the doctor’s view of the patient’s best interests.

The History and Physical Examination

Owing to its communal anatomy with nearby structures, the hip shares symptoms with the lower spine, sacroiliac joint, muscles, and organ systems.⁷ The initial symptoms may also seem far away from the hip, such as the low back or knee. The experienced diagnostician may quickly narrow the list of potential diagnoses.

The history should include presenting symptoms, precise location, duration, radiation, aggravating and relieving activities, related injuries, previous surgery/injuries, pain at rest vs exertion, and associated symptoms anywhere considering the body’s various functions (eg, gastrointestinal, genitourinary, gynecologic, vascular, and neurologic). Probing carefully the past medical history or even perinatal history may provide clues to LCPD or DDH. The precise site of pain, if identifiable, may be immensely helpful. Table 25-1 describes what orthopedists have commonly thought about with respect to some pain patterns. These descriptors are inherently imprecise and sometimes deceiving.

The sitting position helps assess hip internal/external rotation in 90 degrees of flexion. Because much hip pathology exhibits signs in the sitting position, this portion of the exam, with the pelvis fixed by body weight,8 may be particularly helpful.

Gait patterns are usually easily identifiable and further guide the diagnostic thinking. Table 25-2 lists common gait patterns and common underlying pathology. Infrequently, complex patterns require formal gait analysis.

Most of our important information comes from the supine position. The examination is performed bilaterally and includes the Thomas test for fixed flexion, limb length assessment, rotational profile, and range of motion in both flexion and extension. Compromised or painful internal rotation often indicates articular hip pathology.⁹ Obligatory external rotation in flexion often suggests SCFE. Localizing tenderness also may aid in the clinical diagnosis.

Special tests include McCarthy’s¹⁰ flexion-extension maneuvers for anterior impingement, FABER (flexion-abduction-external rotation), leg roll, and Ober’s. These all help differentiate intra- vs extra-articular pathology. Remember that the FABER test (aka Patrick’s test) can also localize sacroiliac joint pathology. The test classically includes pressing down on the knee in certain positions, which may result in either low back or groin pain. The former relates to the sacroiliac joint and the latter to intra-articular pathology.¹¹

The lateral position allows easier palpation of lateral and posterior structures, as well as assessment of gluteal muscles and iliotibial band strength and tightness (Ober’s test).¹²

The prone position permits easier palpation of posterior structures, such as the ischial tuberosity and sacroiliac joint. This position also allows the Duncan-Ely test¹³ for a tight rectus femoris.

Radiologic Assessment

Standard for proper evaluation of the adolescent hip are plain anterior pelvic radiographs and lateral views of the hips. Frog lateral views are important for diagnosing SCFE. CT scan may identify occult fractures and unusual bony anatomy. MRI remains the investigation of choice for soft tissues, osteonecrosis, and labral and articular cartilage. Intra-articular and occasionally intravenous contrast may enhance its diagnostic accuracy.¹⁴

Defined by posterior and inferior slippage of the proximal femoral physis over the femoral neck through the physeal interface, SCFE occurs in 10.8 per 100,000 children and most commonly in boys 10 to 16 years of age.15 The etiology is multifactorial and not completely understood, and probably associated with factors that increase stress on the physis or that render the physis vulnerable to stress, such as obesity, accelerated growth, or hormonal imbalance. Examples of accelerated growth are the adolescent growth spurt and growth hormone abnormalities. Hormonal imbalances include hypothyroidism, hypopituitarism, and hypogonadism. Endocrine disorders should be suspected in age groups outside the usual one mentioned previously and when there is bilateral disease. Mechanical factors such as proximal femoral retroversion and vertical physis are also risk factors.¹⁶

Loder classifies SCFE into “stable” or “unstable” slips.¹⁷ The patient is able to ambulate in the former but not in the latter, even with crutches. The unstable slip is perilous and associated with a high risk of avascular necrosis. It needs urgent treatment.¹⁸

A high index of suspicion is the only way to make this diagnosis. Most commonly, the young person has a limp with pain vaguely localizing to the hip. Fifteen percent have knee pain.¹⁹ Physical findings depend on classification, duration, and severity of the slip. It may be normal with an early slip. Classical findings include limited internal rotation, obligatory external rotation on flexion, and, in late cases, shortening. Comparing the normal side to the painful side is quite important both on physical and radiographic assessment. Contralateral hip SCFE may be observed in as many as 25% of the cases, and is seen most commonly, as suggested above, with underlying endocrine or growth disorders.

Radiographic assessment includes AP pelvis and bilateral frog lateral views. A line along the lateral neck cortex (Klein’s line) normally overlaps a portion of the lateral physis, and does not in SCFE.²⁰ Other signs include widened and irregular physis in the early stage, reduced epiphyseal height, and the relative displacement of the epiphysis over the metaphysis (neck) on the frog lateral view. We use Wilson’s classification¹⁸ to grade the relative displacement: 1 = less than one-third, 2 = one-third to one-half, and 3 = more than one-half.

Patients with SCFE should be immediately referred to or discussed with an orthopedic surgeon with pediatric interest. Treatment principles include gentle closed or open reduction and internal fixation for unstable slips. Stable ones may undergo in situ pinning, open reduction, or periarticular osteotomies depending on the situation. In situ pinning has been heralded as standard treatment,²¹ but this can lead to residual deformity and degeneration.²² Open reduction greatly reduces the latter worry. Prophylactic pinning of the contralateral hip may be somewhat controversial, but we recommend this for patients with underlying endocrine or growth disorders.

Patients with neglected, missed, or residual treated SCFE deformities may develop anterior hip impingement, usually caused by anterolateral prominence at the head-neck junction. Functionally, this leads to cam impingement, a common consequence even in mild deformities. The severity of the slip/deformity correlates with degenerative changes.²² The anterolateral, metaphyseal prominence leads to labral damage from impact at the acetabular rim. Forced flexion even in mild deformities allows the head to lever and allow the prominence to come into play, which can cause considerable acetabular chondral damage.²³

Radiographic signs for residual SCFE deformity include the α-angle, femoral head ratio, and the anterior femoral head-neck offset ratio.²³ The former 2 are performed on both anteroposterior and lateral views, and the latter on the lateral. The α-angle seems to be the most predictive.²³ Chronic SCFE deformities resulting in impingement can be treated by restoring head morphology and congruent head-acetabulum coupling. This may be achieved via proximal femoral osteotomy. The osteotomy may be subcapital, basi-cervical, intertrochanteric, or subtrochanteric. The more proximal the osteotomy the greater the potential for correction, but a higher risk of osteonecrosis and chondrolysis.²⁴

Legg-Calvé-Perthes Disease

This disorder results from avascular necrosis of the proximal femoral head and subsequent deformity and loss of head’s sphericity. Again, the etiology is not fully understood and likely multifactorial and involving both genetic and environmental factors.²⁵ The prevalence is 1 in 10,000 children under the age of 15. The onset is usually between the ages of 2 and 14 years, most commonly between 4 to 8 years.²⁶ Classically, LCPD occurs in hyperactive boys with delayed skeletal maturity. Other risk factors include a positive family history and low birth weight. Pathologically, one sees osteonecrosis of the femoral head, revascularization and resorption. Pathologists call this creeping substitution.

Functional remodeling occurs more completely in individuals who develop the disorder under 6 years of age.²⁷ Treatment during the active disease process focuses on pain relief, maintenance of range of motion, and “head containment” (ie, prevention of lateral subluxation of the flattened femoral head out of the acetabulum). Those principles theoretically allow molding the head into a spherical shape by the growing acetabulum. Various different options have roles. These include physiotherapy, orthosis, femoral osteotomy, and pelvic osteotomy. Severity and age at onset matter in the selection of modality of treatment.

Residual deformities can result in adolescent hip pain.24 The resulting abnormal femoral head shape, disturbance of the physis, and acetabular dysplasia can result in femoroacetabular impingement (FAI), hip instability, or a combination.²⁸ The acetabular dysplasia in LCPD is due to retroversion, remodeling process, or following innominate pelvic osteotomy. Intra-articular impingement can result from abnormal head morphology, similar to SCFE, or by creating a lateral hinge between the head and the superior rim of the acetabulum. Extra-articular impingement results from the short neck, which leads to prominence of the greater, or less commonly lesser, trochanter and bony collision against the hemipelvis.

Surgical treatment of residual LCPD deformities aims to restore joint congruency, reduce impingement and instability, and increase range of motion. This can be achieved by proximal femoral osteotomy (intertrochanteric, subcapital, or trochanteric distal advancement). Periacetabular osteotomies may also be required for the accompanying acetabular dysplasia or retroversion. Sometimes a combined approach is necessary.

Adolescent Hip Dysplasia

This is DDH, developmental dysplasia of the hip. The primary abnormality here is a malformed acetabulum. This leads to unconventional weightbearing and instability of the femoral head. It may also be associated with other anatomic disorders, such as acetabular retroversion, femoral anteversion, coxa valga, and abnormal anterolateral head neck offset. The problem often ends up with FAI, instability, and joint degeneration.

Adolescent DDH comes from a completely missed DDH of infancy, a partially treated infancy DDH, or even a DDH that develops during adolescence.²⁹ As mysterious as it may be, the latter form has a higher rate of bilaterality and ultimate hip arthroplasty.²⁹ Severe untreated hip dysplasia routinely leads to severe osteoarthritis. The natural progression for mild dysplasia is certainly more variable.^30–32

Many of those patients are initially asymptomatic. Classical symptoms are groin or anterolateral pain sometimes associated with coxa saltans. The patients may exhibit impingement signs or positive apprehension tests.

Imaging includes routine AP pelvic X-ray and lateral radiographs. A whole gamut of measurements can be done, including acetabular index, inclination, Tönnis angle, and anterior and lateral center-edge angles. A “cross-over sign” and/or a prominent ischial spine may indicate acetabular retroversion. CT helps with bony anatomy, direct contrast MRA with the identification and significance of intra-articular pathology.

The aim of surgical treatment is primarily to restore anatomy and presumptively minimize the progression to arthritis. Symptomatic patients with severe dysplasia and minimal degeneration seem the ideal candidates for surgery. It is not clear whether or not asymptomatic patients with mild dysplasia should undergo surgery, although there is a recent trend to do that.³² Patients with severe degenerative changes probably should undergo arthroplasty when it seems inevitable.³³

Surgical treatment usually means a focus on correcting the acetabulum, usually with what’s called a Ganz periacetabular osteotomy.³⁴ Arthroscopy may be added for intra-articular pathology. Hip arthroscopy shouldn’t be done when there is severe dysplasia without a corrective acetabuloplasty. Otherwise, it may create instability of the hip and acceleration of arthritis.³³ The proximal femur may have to be addressed if it is deformed or if a previous osteotomy has altered the anatomy enough to require it. Several more complicated osteotomies may also play roles in correction, such as a triple “steel,” Chiari, or shelf osteotomy. These procedures involve such things as intentional leg shortening, bone augmentation, or enhancing the lateral hip with other tissue.³⁵

Apophyseal Avulsions

The adolescent hip is particularly prone to growth plate fractures. The “open” growth plate—or physis—has an inherent weakness. With the normal process of growth, limb length may increase disproportionately compared to the whole mass of the limb. With this musculoskeletal imbalance, repetitive tensile stresses to the epiphyseal plate and open physis then account for the relatively common occurrence of apophyseal avulsion fractures.^3,4 These injuries can appear acutely as a traumatic avulsion or more indolently related to overuse, most commonly with athletes and sports that involve rapid acceleration and deceleration, such as skating or skiing. Table 25-3 lists the potential anatomical sites of the apophyseal avulsions around the hip and their reported prevalences.

Most commonly, the patient will provide a history of sudden onset of well-localized pain after a non-contact trauma. The patient may describe a “pop” and even have trouble walking. Patients often experience tenderness at the relevant part of the hip or hemipelvis, and symptoms or signs may be aggravated by passive stretching or resisted contraction of the muscle group involved in the avulsion fracture.

The initial management of apophyseal avulsion fractures is usually non-operative (ie, rest, cryotherapy, elevation, analgesia and protected weightbearing [eg, crutches]). Physiotherapy begins with gentle passive range of motion and stretching followed by progressive strengthening as the pain resolves.36 Return to sport is usually not advocated until the patient is pain free and radiographs show excellent healing.

Surgery is generally reserved for displaced ischial tuberosity avulsions, symptomatic non-unions, unrelenting pain, or persistently impaired function.^37,38 Some people have used displacement greater than 15 mm as an indicator for surgery. That much displacement for an ischial tuberosity avulsion fracture is certainly an indication. It is risky to leave that much displacement alone. It is a set-up for fibrous non-union and an ischial prominence that causes chronic buttock pain and sciatic nerve impingement. Some young athletes with this may complain simply of indolent ache, decrease in hamstring strength and endurance, with suboptimal performance.³⁷ Even normal healing callus after a mildly displaced fracture sometimes leads to chronic pain, irritation on sitting position, and sciatic nerve symptoms. Perhaps we should be intervening more for less displaced fractures.

McKinney et al³⁹ have recommended probably the best classification for these avulsion fractures (Table 25-4). This provides an imperfect guide for their treatment. According to them, operative intervention should be considered for all type III and type IV injuries, and more selectively for type II.

Labral Tears

Labral tears may occur after a single traumatic event or repetitive mechanical stresses. With respect to labral tears and the adolescent hip, you have really 3 things to think about.

1. Did the tear occur by itself, simply as a result of excessive flexion within an otherwise normal anatomic hip? This is more likely to occur in the adolescent compared to the adult hip.
   
2. In the vast majority of the cases though, one still sees an underlying bony FAI impingement deformity on the radiographs. The question here, of course, is: Does this impingement matter in these young hips?
   
3. Perhaps most importantly, what roles do the developmental abnormalities of the hip mentioned (SCFE, LCPD, and DDH) play in the individual’s problem? Of course, FAI may either share the same pathophysiology just like an adult or be a consequence or anatomic accompaniment of a developmental disorder.²⁴

The adolescent with a labral tear may have more anterior hip or groin pain or more “catching” or “locking.” The symptomatology is more commonly than in the adult just related to activity and not present at rest. Clinical examination usually reveals findings such as a positive test with flexion, adduction, and internal rotation (the FADIR test). Other tests, of course, may also be positive, such as the FABER test. Like with adults, plain radiographs of the pelvis and the affected hip, MRI, and MRA are the best imaging tests. MRA has up to 87% sensitivity.40 Three-dimensional CT may be important to understand whether or not to consider treatment for an underlying developmental abnormality.

The initial management of labral tears may be rest, cessation of sporting activities and analgesia. These initial measures may be followed by physiotherapy aimed at improving the strength and flexibility of the core muscles and the major muscle groups around the hip and pelvis. Modern surgical management of isolated labral tears involves arthroscopic repair or debridement.⁴¹ Of course, the bony abnormalities of FAI and the developmental abnormalities may also have to be addressed.

Femoroacetabular Impingement

Just as for adults, FAI is also recognized as a cause of hip pain in adolescents.²⁴ The basic mechanisms by which impingement can occur is the same, namely cam type, pincer type, or mixed cam/pincer type. Underlying childhood hip disorders can also lead to FAI, as discussed previously. In addition to the anterior symptomatology, the patient may also have pain in the gluteal area, especially with pincer impingement and a postero-inferiorly directed force on the femoral head, leading to overload and damage of the postero-inferior acetabular cartilage (contrecoup injury). The patient may exhibit the classic “C sign.” He/She may identify the pain by cupping the anterior and posterolateral aspects of the thigh between the thumb and the index finger (C sign).

Imaging should always begin with plain radiographs, both in order to facilitate the diagnosis of the type of impingement and also to exclude other, more urgent bony deformity, such as SCFE. Beyond the plain radiographic investigation, MRA and CT are commonly used in the diagnosis of FAI. MRA provides very high diagnostic sensitivity for labral pathology, but has variable sensitivity for articular cartilage pathology (generally 50% to 90%) and significant limitations in detecting acetabular cartilage delamination.^40,42 CT has the benefit of providing 3-dimensional surface renderings of the proximal femoral and acetabular bony anatomy, providing detailed information for surgical planning, especially useful in arthroscopic surgery.⁴³ The major drawback of using CT in adolescents is the substantial radiation exposure. Furthermore, there are limitations in terms of the provision of information on soft tissue pathology, which is typically inferior to MRA.

The main goal of treatment for FAI is to improve the clearance during hip movements, by eliminating the abutment of the femoral head-neck junction to the acetabular rim. This is aimed at primarily achieving relief of symptoms and return to activities in a group of patients who are typically very active. The secondary aim is to help prevent the potential progressive degeneration of the hip joint and early onset of osteoarthritis.⁴⁴ Both open and arthroscopic techniques have been proven to be safe and successful in adolescents.⁴⁵ Hip arthroscopy is currently the most commonly employed technique for FAI, with complication rates equivalent to those found in adults.⁴⁶

Snapping Hip Syndrome (Coxa Saltans)

Snapping hip syndrome is defined purely by an audible snap or pop during range of motion of the hip. A lot of people have this, and it is not important if there are no symptoms or another associated more serious issue. When it is a problem, the phenomenon is usually exacerbated by sporting activities. Think simply here. Think in terms of 3 principal anatomic types that may produce noise (Table 25-5).

1. Coxa saltans externa (or iliotibial band syndrome): Snapping of the iliotibial band (or nearby structure) over the greater trochanter when the hip goes from flexed to extended (iliotibial band syndrome)
   
2. Psoas snap (or internal type): Snapping of the iliopsoas tendon over the iliopectineal eminence or actual femoral head
   
3. Intra-articular type: Clicking or clacking from any kind of intra-articular pathology

The location of the pain or sound and reproducibility of it on physical examination can help distinguish the different types of snapping hip. For coxa saltans externa, the snapping sensation and discomfort are over the greater trochanter during flexion and internal rotation. For both the internal snapping hip and the intra-articular type, the pain and sound are localized in the groin and anterior hip during flexion and a combination of adduction and abduction. The more distal the psoas sound, the closer it is to the lesser trochanter and the easier it is to diagnose.

Initial treatment of the isolated, symptomatic coxa saltans usually is oral nonsteroidal anti-inflammatory drugs (NSAIDs) and/or corticosteroid injection with physical therapy. The focus of the physical therapy depends on the type of snapping hip. Surgical treatment may be considered when non-operative management does not relieve the symptoms. The surgical approach can be open or arthroscopic, and aimed at lengthening the offending structure (eg, iliotibial band or iliopsoas tendon) or repair of the underlying problem (eg, intra-articular pathology).47–49

Other Hip Area Considerations in Adolescents

Table 25-6 provides a brief overview of the other pathological processes near the hip. Some of these are discussed elsewhere in the book. One needs to consider all conditions that affect the bony skeleton or adjacent soft tissues, whether or not they are trauma related. Of course, they may be benign or malignant.⁵⁰ One also needs to consider all the conditions of the core that may mimic the musculoskeletal conditions.

TABLE 25-6 OTHER CONSIDERATIONS IN ADOLESCENTS
Traumatic	Nontraumatic
Physeal hip fracture Non-physeal hip fracture Subtrochanteric femoral fracture Pelvic fracture Hip dislocation Stress fracture of the femoral neck Iliacus hematoma syndrome Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Putting It All Together—A Patient’s Perspective on the Core How the Core Universe Forms The Eureka Moment for the Core Don’t Forget the Thorax Biomechanics Presenting…the Core! Stay updated, free articles. Join our Telegram channel Join Tags: Introducing the Core Demystifying the Body of an Athlete Apr 2, 2020 | Posted by admin in SPORT MEDICINE | Comments Off on Special Considerations in Adolescents Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access