Transcript hip pointer (1)

What is this?
What is this?
Name of the lecture today
Hip Pointer
• A hip pointer injury is a
deep bruise caused by
impact or trauma to
your hip, or to the iliac
crest of your pelvis.
• pain can be intense.
Hip Pointer
• Because the hip is so close to
the surface of the body, there
isn’t much padding in an
impact situation –
• deep bruising in both the
bone and surrounding muscle.
• Hip bruises, and other bone
bruises, are more severe than
regular muscle bruises
• often take a long time to
recover.
Epidemiology
Frequency
• United States
• No specific statistics for the frequency of hip
pointer injuries are available; however, hip
injuries generally comprise 5-9% of high
school athletic injuries.
Cause
• The primary cause of hip
pointers is a direct blow or
fall onto the iliac crest or
greater trochanter.
• Risk factors include
participation in contact
sports and wearing limited
or no padding or protective
equipment in the region.
Mild to severe hip pointers are extremely common in all sports
that involve full contact with others and/or their equipment or
the potential for collisions, such as:
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martial arts
baseball
football
rugby
ice hockey
field hockey
Functional Anatomy
• The anterior iliac crest region of the hip and the greater
trochanter of the femur have a minimal amount of
overlying fatty tissue or muscle and are more
susceptible to contusion and injury than more
protected regions of the body.
Functional Anatomy
• The iliac crest has multiple muscle origins and
insertions, including the sartorius, the tensor
fascia lata, the internal and external obliques,
and a portion of the rectus femoris muscle.
Differentials
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compartment syndrome
AVN of femoral neck
Femoral Neck Fracture
Femoral Neck Stress Fracture
Hip Dislocation
Hip Fracture
Hip Tendonitis and Bursitis
Iliotibial Band Syndrome
Osteitis Pubis
Sacroiliac Joint Injury
Slipped Capital Femoral Epiphysis
Snapping Hip Syndrome
Femoroacetabular impingement
History
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Obtain a detailed history, including
the mechanism of injury and the
patient's description of his or her
symptoms.
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A hip pointer is usually an acute
injury, and the patient can typically
recall a precipitating event, although
some may present 24-48 hours after
the initial injury.
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Hip pointer injuries are usually
caused by a direct blow to the iliac
crest or greater trochanter in contact
sports such as football or hockey.
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A hip pointer may also be caused by a
fall onto the hip in sports such as
soccer or skiing.
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Typically, the patient presents with
the sudden onset of hip pain in the
iliac crest or greater trochanteric
region after sustaining trauma.
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The pain is localized and may be
exacerbated with activities such as
running, jumping, twisting, or
bending.
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The pain can limit range of motion
(ROM) at the hip joint and/or
rotation of the trunk if the abdominal
musculature is in
Physical exam
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Physical examination in a person
with a suspected hip pointer should
include abdominal examination to
exclude trauma to intra-abdominal
organs.
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Examination should consist of visual
inspection, palpation, passive and
active ROM assessment, sensory
testing, and gait analysis.
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Contusion or swelling may be
evident upon visual inspection. The
athlete usually reports increased
pain with palpation of the affected
iliac crest or greater trochanter.
Limited ROM of the hip secondary to
pain may also occur.
Physical Exam
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Motor strength of the hip flexor and
extensors should be intact.
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Strength of the hip abductors and
external rotators may be limited by
pain if the contusion includes the
sartorius muscle and/or the iliotibial
tract.
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Sensation should be intact to light
touch, although this portion of the
examination may be limited if the
patient has severe pain.
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Initial gait analysis may also be
limited secondary to pain, but it
provides a baseline from which to
evaluate recovery.
Laboratory Studies
• Typically, laboratory studies are not useful in
the diagnosis of hip pointers.
Imaging Studies
• Plain radiographs: Order radiographs if fracture or myositis
ossificans is considered possible.
• Computed tomography (CT) scans: Consider obtaining CT
scans if the patient has continued pain or if his or her pain
exceeds that expected from examination findings. CT scans
can help clinicians to diagnose deep hematoma or internal
injuries (eg, spleen).
• Bone scans: Order a bone scan to exclude a stress response
or fracture if initial radiographic findings are normal and the
symptoms do not resolve or improve.
Consultations
• Emergent consultation with an orthopedic surgeon is
necessary if neurovascular compromise is considered
possible in a patient with a hip pointer.
• Consider consultation with an orthopedic surgeon for
patients who have avulsion fractures or unresolved pain
lasting longer than 2 weeks.
• Consult with a surgeon for patients with intraabdominal injuries.
Medical Issues/Complications
• The formation of a hematoma, with increasing pain and
possible cutaneous neurologic compromise, may be an early
complication of a hip point, usually arising within the first 24
hours.
• Additional complications can include development of
myositis ossificans.
• Failure to diagnose a fracture or an intra-abdominal injury
frequently leads to complications.
Hip Pointer
• If the injury is mild:
• The athlete has a good range of
motion in the hip and abdominals.
• Swelling is limited.
• The athlete shows a normal gait.
• Recovery time is one week
Hip Pointer
• If the injury is moderate:
• The athlete has an abnormal gait.
• The athlete has a decreased range of motion in the hip and
abdominals.
• The athlete has noticeable bruising and swelling.
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• Recovery can take up to two weeks
Hip Pointer
• If the injury is severe:
• The athlete has great pain when walking and during hip and
trunk movements.
• The athlete has a lot of bruising and swelling.
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• Recovery can take three to four weeks
Procedures
• If a significant hematoma is present, then aspiration can
provide some pain relief and help prevent development
of myositis ossificans or pressure and compression of
local nerves (eg, lateral femoral cutaneous nerve).
• Injection of a local anesthetic (eg, lidocaine) may
provide short-term pain relief from a hip pointer.
• Compartment pressures can be measured if a thigh or
gluteal compartment syndrome is considered possible.
Rehabilitation Program
• Initial therapy of a hip pointer injury consists of ice, antiinflammatory and pain medication, compression, and
relative rest of the affected hip until symptoms improve.
• Crutches can be used in the initial treatment phase if
walking or bearing weight on the affected leg is painful.
• As the pain decreases, ROM and active resistance exercises
for the hip may be initiated. Patients may also begin
strength and aerobic conditioning, as tolerated.
Other Treatment
• Aspiration of a hematoma, if present, may provide some
pain relief. Injection of a local anesthetic (eg, lidocaine,
bupivacaine) may provide short-term pain control.
• No evidence supports or refutes the use of corticosteroid
injections in hip pointer injuries.
• Corticosteroid injections may provide relief if greater
trochanteric bursitis develops.
Rehabilitation Program
Physical Therapy
• Rehabilitation programs should focus on returning the
athlete back to his or her sport. Rehabilitation exercises
should emphasize sport-specific strength and motions.
• Additional padding at the injury site may help limit
recurrence or reinjury (padding that is 0.25-0.5-inch thick
may alleviate pain and allow the athlete to return to play
sooner).
Rehabilitation Program
Physical Therapy
• The maintenance phase of the rehabilitation program should
focus upon reducing the chance of re-injury.
• Additional padding or protection added to the hip may limit
the risk of re-injury.
Medication Summary
• The goals of pharmacotherapy in patients with hip point
injuries are to reduce morbidity and to prevent
complications.
• When the athlete returns to
participation, extreme care
should be taken to protect the
injured hip with proper padding
(below).
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A good way to prevent a hip
pointer is to make sure hip pads
are large enough to come up
over the crest of the hip bone.
• Football hip pads can be used by
athletes for most sports to
protect and prevent hip injuries.
Hint?
Proper wearing of equipment
Treating hip pointers
• Hip pointers can be very painful and debilitating.
• Ice and crutches are the recommended immediate treatment.
• Electrical stimulation to relieve pain can also be used with the ice. Ice is
continued for 20 minutes, every hour, until the pain resolves.
• The athlete can gradually return to jogging and sport-specific drills as the
pain allows.