Billy Lane,Gage Brewer,Jay Metcaf
Stress Fracture of the Hip and Femur
2/18/11
Evaluation of Injuries II
AH 324

I. Injury1.
A. Predisposing factors
1. Stress on the bone over and over again causes stress fractures of the hip and femur (continuous pounding on the hip joint).
2. Women are up to 10 times more likely to develop fatigue and stress fractures than men. Also, age makes stress fractures of the hip and femur more likely people who are more active such as athletes are prone to this type of injury.
B. Causes- Mechanisms of Injury
1. There are two types of stress fractures. Insufficiency fractures (a stress fracture that occurs during normal stress on a bone of abnormally decreased density) are breaks in abnormal bone under normal force. Fatigue fractures are breaks in normal bone that has been put under extreme force.
2. Running, Birth Defects and Osteoarthritis
3. Jumping and any type of initial contact to the Femur or Hip
C. Presentation
D. Signs and Symptoms
1. Pain with weight bearing activities standing, walking, running. Pain usually subsides when resting.
2. Major sign patients have changed their workout routine and there body is not accustom to the stress.
3. Local tenderness and swelling are often found at the fracture site.
4. Reluctant to do physical activity due to the pain of the possible stress fractures.
E. Examination and evaluation procedure
1. Palpation
A. Palpate at the sight of tenderness and look for discoloration, abrasions and deformities.
B. Notice the gait of the patient and ask for predisposing conditions. Also, the magnetic resonance imaging (MRI) scan is especially useful in telling fatigue fractures from other types of injuries with similar symptoms.
2. Range of Motion
A. Normal Range of motions(for hip): Internal rotation - 35°,External rotation - 45°,Flexion - 135°Extension - 15°,Abduction - 45°,Adduction - 25°
B. With stress fractures ROM will be greatly decreased.
3. Manual Muscle Test
A. Hang Test- Ask patient to sit and hang their legs over the table ask is there any discomfort. Also remember to check bilaterally
B. Compression Test- ask patient to lay supine and apply pressure with heel of your hands. Also check bilaterally.
4. Reflexes
A. Check the Femoral, Obturator and Sciatic Nerves.
5. Joint instability test
A. Ask the patient to stand on one leg and ask is there pain associated with the exercise.
B. Ask the patient to squat down slightly and with the loading of weight on the femur and hip bone ask is there pain if there is it is a positive sign.
H. Referral and Diagnostic
1. The Athletic Trainer may ask for X-ray’s or a MRI.
I. Treatment and Management
1. Surgical intervention is dependent upon the type of fracture. Compression-side fractures can be treated with therapy. Non-displaced tension-side treatment is controversial, with some physicians advocating prophylactic surgical fixation and others advocating a trial of conservative therapy.
2. Check the patient's diet; make sure there is adequate calcium and vitamin D intake, and take supplement as needed. Consider oral contraceptives for amenorrheic women such agents may aid in the recovery of bone mass in these women. Also Athletes with eating disorders may need psychological and nutritional support.
J. Special emergency considerations
1. Along with the Fracture make sure to check for any spinal injuries or compressed nerves. Do thorough evaluations of the patient make sure what got them in this condition that they do not repeat the same action.
K. Rehabilitation
1. Protection – Crutches with non–weight-bearing ambulation until relief of pain at rest is achieved: Rest – Non- weight bearing if there is pain at rest; may do alternative exercises to maintain cardiovascular conditioning (swim, upper-extremity: Ice – To assist with pain reduction; Elevation – Usually difficult;Medication – Consider low-dose non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief or narcotics, if the patient has severe pain.
2. As the patient’s pain decreases, gradually increase activity from non-weight bearing to touchdown weight bearing, then to partial weight bearing, and eventually, discontinuation of the crutches. This process usually takes 4-6 weeks. Coordinate the patient's rehabilitation with the orthopedic specialists for those individuals who have hips with surgical pinning. After the patient is able to walk 1.5 miles without pain (usually in 8-12 wk, but sometimes longer), begin a gradual return to a running program. Usually, it takes approximately 2.5 months to be able to run 3 miles pain free. If pain returns during the rehabilitation period, decrease the patient's activity until walking is pain free again.
L. Protection & Other Return to Competition Factors
1. Take the patient through a round of test to make they can return to work or their sport safely without any pain.

2. Tell the patient to warm up and gradually return to sports such as running and if problems still occur then remind them of (RICE). Also, if problems persist then they should come and see the trainer for follow up checkups.

Questions

1.Signs and symptoms of a stress fracture of the hip or femur
A.ecchymosis
B.abrasions
C.Abnormal gait
D.Pain with weight bearing activities
E. All the above
2.Who is prone to this injury
A.Runners
B.Football Players
C.Basketball Players
D. All the above
3. When the patient returns to there sport they should
A. Jump out and go full speed
B.Gradually work into it
C.Not Participate
D.A and C
4.Special test for hip and femur stress fractures
A. Allens test
B. Hopenfills test
C.Hang test
D. Filler test
5.Ways to Rehab the stress fracture
A.Rest
B. Ice
C.Elevate
D. All the above


Answers
E,D,B,C,D





Hip Dislocation – Gage Brewer, Billy Lane, Jay Metcalf

A. Predisposing Factors
1. Most dislocations occur posteriorly with the hip and knee in a flexed position.
2. A direct blow transmitted up the shaft of the femur, or less commonly an indirect internal rotational force with the foot firmly planted, can cause the femoral head to displace posteriorly to the acetabulum.


B. Mechanism of Injury
1. Knee-to-dashboard contact during a traffic collision.
2. Landing hard on a flexed knee with the full weight directed through the long axis of the femur.
3. A hip dislocation normally occurs only after a violent force is directed along the femur when the hip is flexed.

C. Signs 1. Obvious deformity

2. Unwillingness to move the extremity
3. Swelling
4. Symptoms
5. Extreme pain
6. Totally disabled immediately
7. Muscle spasms
8. Numbness


D. Examination and Evaluation
1. The leg will appear shortened and internally rotated.
2. Because the hip usually dislocates posteriorly, the athlete normally assumes a characteristic position of flexion, adduction, and internal rotation of the hip.
3. The greater trochanter appears quite prominent.
4. Dislocations of the hip as a result of athletic activity are rare, although they are more likely to occur than hip fractures.


E. Palpation
1. There will be pain among palpation
2. Possible temperature change
3. Sensitivity around the head of the femur will be present
4. The hip joint will also be sensitive

F. Special Tests
1. Nelaton's Line - an imaginary line drawn from the ischial tuberosity of the pelvis to the ASIS of the pelvis on the same side. If the greater trochanter is palpated well above the line it is an indication of a dislocated hip or coxa vara. Compare bilaterally.
2. Bryant's Triangle - Pt. lies supine. Examiner imagines a perpendicular line from ASIS to table. Second imaginary line is projected up from tip of greater trochanter to meet the first line at a right angle. Line is measured & two sides are compared. Differences may indicate conditions such as coxa vara or congenital dislocation of hip. Can be done with radiographs.

G. Classification
Type 1 – With or without minor fracture
Type 2 – With large, single fracture of posterior acetabular rim
Type 3 – With comminution of rim of acetabulum, with or without major fragments
Type 4 – With fracture of the acetabular floor
Type 5 – With fracture of the femoral head

H. Reduction Procedures
1. A hip dislocation needs to be reduced immediately and if not in the first two tries, immobilize and refer.
2. With closed reduction, lay patient supine and pull femur 90 degrees by placing the head of the femur back in the acetabulum.
3. With open reduction, surgery is probable especially with a fracture of femur or pelvic bones.




I. Referral
1. The athlete should be immobilized and immediately transported to emergency medical care via emergency medical services.
2. Complications of hip dislocation include rupture of the artery to the head of the femur and avascular necrosis of the femoral head.
3. With posterior dislocations, the sciatic nerve may also be affected.
4. The primary danger or complication of a hip dislocation is the possibility of damage to the blood supply to the head of the femur.

J. Rehabilitation
1. Theraband exercises
2. Cardiovascular and stretching exercises
3. Weight bearing exercise progression


Questions: 1) In which direction do most dislocations occur? A. Inferior B. Superior C. Posterior 2) The leg will appear shortened and rotated? A. Internally B. Externally 3) Which of the following is a special test is used to determine a hip dislocation? A. Valgus Stress B. Lachmans C. Anterior Drawer D. Nelaton's 4) How many classifications of hip dislocations exsist? A. 7 B. 5 C. 2 D. 3 5) How many times should the dislocation try to be reduced before the athlete is referred? A. 2 B. 7 C. 5 D. 3