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Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 14 Pelvis, Hip, and Thigh Conditions.

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Presentation on theme: "Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 14 Pelvis, Hip, and Thigh Conditions."— Presentation transcript:

1 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 14 Pelvis, Hip, and Thigh Conditions

2 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy Skeletal features of the pelvis, hip, and thigh

3 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Pelvis –Function Protects organs Transmits loads between trunk and lower extremity Provides site for muscle attachments

4 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Pelvis (cont’d) –4 fused bones Sacrum Coccyx Innominate bones Ilium, ischium, and pubis

5 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Pelvis (cont’d) –SI joint Critical link between the two pelvic bones Strong ligamentous support –Sacrococcygeal joint Fused line symphysis united by a fibrocartilaginous disc

6 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Pelvis (cont’d) –Pubic symphysis Interpubic disc located between the two joint surfaces Femur –Weakest at femoral neck

7 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Hip Joint –Head of femur and acetabulum of pelvis –Ball and socket joint –Very stable

8 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Hip Joint (cont’d) –Strong ligament support Iliofemoral ligament Limits hyperextension Pubofemoral ligament Limits abduction and hyperextension

9 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Hip Joint (cont’d) –Strong ligament support (cont’d) Ischiofemoral ligament Limits extension Ligaments of the pelvis and hip

10 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Femoral Triangle –Borders Inguinal ligament—superior Sartorius—lateral Adductor longus—medial

11 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Femoral Triangle (cont’d) –Contents Femoral nerve Femoral artery Femoral vein Femoral triangle

12 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Bursae –Iliopsoas Reduces friction between iliopsoas and articular capsule –Deep trochanteric bursa Provides cushion between greater trochanter and gluteus maximus at its attachment to iliotibial tract

13 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Bursae (cont’d) –Gluteofemoral bursa Separates gluteus maximus from origin of vastus lateralis –Ischial bursa Weight-bearing structure during sitting Cushions ischial tuberosity where it passes over gluteus maximus

14 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Nerves –Lumbar plexus Femoral nerve Obturator nerve –Sacral plexus Sciatic nerve

15 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Blood Vessels –External iliac Femoral Deep femoral Femoral circumflex

16 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions Muscles of the pelvis, hip, and thigh. Anterior view

17 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Muscles of the pelvis, hip, and thigh. Lateral view

18 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Muscles of the pelvis, hip, and thigh. Posterior view

19 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Hip flexors –Iliopsoas, pectineus, rectus femoris, sartorius, and tensor fascia latae –Two-joint muscles Rectus femoris—active during hip flexion and knee extension Sartorius—active during hip flexion and knee extension

20 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Hip extensors –Gluteus maximus and hamstrings (biceps femoris, semitendinosus, and semimembranosus) Hamstrings—two-joint; hip extension and knee flexion

21 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Hip abductors –Gluteus medius, gluteus minimus –Active in stabilizing pelvis during single-leg support and during support phase of walking and running Hip adductors –Adductor longus, adductor brevis, and adductor magnus

22 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Lateral rotators –Piriformis, gemellus superior, gemellus inferior, obturator internus, obturator externus, and quadratus femoris –Lateral rotation of femur of swinging leg accommodates lateral rotation of pelvis during stride

23 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Medial rotators –Gluteus minimus –Tensor fascia latae, semitendinosus, semimembranosus, gluteus medius, and adductors

24 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) PRIMARY ACTION MUSCLES FlexionIliopsoas; rectus femoris; pectineus; sartorius; tensor fasciae latae ExtensionGluteus maximus; biceps femoris; semitendinosus; semimembranosus; adductor magnus AbductionGluteus medius; gluteus minimus AdductionAdductor brevis; adductor magnus; adductor longus; adductor magnus; gracilis Medial rotationGluteus minimus; gluteus medius; tensor fasciae latae; semitendinosus; semimembranosus; adductor muscles Lateral rotationPiriformis; obturator internus; obturator externus; superior gemelli; inferior gemelli; quadratus femoris; gluteus maximus

25 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Hip joint – movement in 3 planes –Sagittal Flexion and extension –Frontal Abduction and adduction –Transverse Medial rotation and lateral rotation of the femur

26 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Injury Prevention Physical conditioning –Flexibility –Strength Protective equipment –Hip joint well protected but iliac and pelvis need protection –Thigh Shoe selection –Cushion forces

27 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions Hip pointer –MOI: direct blow to iliac crest –S&S Any trunk movement is painful (incl. coughing, laughing, & breathing) Immediate pain, discoloration, spasm, and loss of function Unable to rotate trunk or laterally flex the trunk toward injured side.

28 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont’d) Hip pointer (cont’d) –S&S (cont’d) Any trunk movement is painful Extreme tenderness Abdominal muscle spasm may be present Severe injury – unable to walk or bear weight, even with crutches

29 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont’d) Hip pointer (cont’d) –Management Standard acute; rest; protect with hard-shell pad for return to activity Severe pain over iliac crest – physician referral

30 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont’d) Quadriceps contusion –MOI: direct blow –Common – anterolateral thigh –S&S Pain may be extensive immediately after impact

31 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont’d) Quadriceps contusion (cont’d) –S&S (cont’d) Grade I Mild pain and swelling Able to walk without a limp Passive flexion beyond 90° – painful; resisted knee extension may cause less discomfort.

32 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont’d) Quadriceps contusion (cont’d) –S&S (cont’d) Grade II Can flex the knee between 45 and 90° Walks with a noticeable limp Grade III Unable to bear weight or fully flex the knee.

33 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont’d) Quadriceps Contusion (cont’d) –Management: Standard acute; with knee in maximum flexion Hard-shell pad for return to activity Physician referral if S&S persist >48 hours

34 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont’d) Quadriceps contusion (cont’d) Management of a quadriceps contusion

35 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont’d) Myositis ossificans –Develops secondary to single significant blow or repetitive blows to same area –Evident on radiograph 3–4 weeks after injury Myositis ossificans

36 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont’d) Myositis ossificans (cont’d) –S&S Warm, firm, swollen thigh; 2–4 cm larger Palpable, painful mass may limit passive knee flexion to 20–30° Active quadriceps contractions and straight leg raises—difficult –Management: standard acute; physician referral

37 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursitis MOI –Excessive friction or shear forces due to overuse Greater trochanteric bursitis –Influence of Q-angle Bursa of the hips

38 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursitis (cont’d) Greater trochanteric bursitis –S&S Burning or aching over or posterior to greater trochanter Aggravated with: Hip abduction against resistance Hip flexion and extension on weight bearing

39 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursitis (cont’d) Iliopsoas bursitis –Pain medial and anterior to joint; cannot be easily palpated – pain with passive hip rotation; resisted hip flexion, abduction, and external rotation

40 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursitis (cont’d) Ischial bursitis –Pain aggravated by prolonged sitting and uphill running, –Point tenderness directly over ischial tuberosity – pain with passive and resisted hip extension

41 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursitis (cont’d) Bursitis management –Do not permit to continue activity until seen by a physician –Suggest cold to decrease pain and inflammation

42 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursitis (cont’d) Snapping hip syndrome –Can result from chronic bursitis –S&S Snapping sensation heard or felt during hip motion, especially with lateral rotation and flexion while balancing on one leg Iliopsoas bursa affected—snapping in medial groin

43 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Bursitis (cont’d) Snapping hip syndrome (cont’d) –Management Do not permit to continue activity until seen by a physician Suggest cold to decrease pain and inflammation

44 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Sprains and Dislocations MOI –Violent twisting actions –With hip and knee flexed to 90°, force through shaft of femur S&S –Mild/moderate: pain with internal rotation –Severe: intense pain; inability to move hip –Position of flexion and internal rotation

45 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Sprains and Dislocations (cont’d) Management –Mild/moderate—standard acute; physician referral –Severe—activate EMS; immobilize in position found – do not move; monitor and treat for shock

46 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Dislocations Hip dislocations

47 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains Quadriceps –Typically rectus femoris –S&S Grade I Normal gait, but tightness in the anterior thigh Pain with passive knee flexion beyond 90°

48 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont’d) Quadriceps (cont’d) –S&S (cont’d) Grade II Snapping or tearing sensation, followed by immediate pain and loss of function. Knee held in extension – protection Pain with passive knee flexion; Pain & weakness with knee extension

49 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont’d) Quadriceps (cont’d) –S&S (cont’d) Grade III strains Extreme pain Ambulation not possible Defect in the muscle may be visible Resisted knee extension not possible; ROM is severely limited

50 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont’d) Hamstrings –Initial swing—flex knee; late swing— eccentrically contract to decelerate knee extension and re-extend hip in prep for stance phase –Overemphasis on stretching without strengthening –Additional risk factors (Box 14.2) –Strength imbalance

51 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont’d) Hamstrings (cont’d) –S&S Grade 1 Tightness and tension Pain with passive stretching

52 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont’d) Hamstrings (cont’d) –S&S (cont’d) Grade II Tearing sensation or feeling a “pop,” leading to immediate pain and weakness in knee flexion.

53 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont’d) Hamstrings (cont’d) –S&S (cont’d) Grade III Sharp pain may occur during midstride Limps; unable to do heel-strike or fully extend the knee. Pain and muscle weakness with active knee flexion

54 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont’d) Adductors –Quick changes of direction, and explosive propulsion and acceleration –Strength imbalance

55 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont’d) Adductors (cont’d) –S&S An initial “twinge” or “pull” of the groin muscles, and is unable to walk because of the intense, sharp pain As the condition worsens, increased pain, stiffness, and weakness in hip adduction and flexion

56 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont’d) Adductors (cont’d) –S&S (cont’d) Running straight ahead or backward may be tolerable, but any side-to-side movement leads to more discomfort and pain Pain with passive stretching with the hip extended, abducted, and externally rotated Pain with resisted hip adduction

57 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont’d) Predisposing factors –Beginning of season – too much too soon –Fatigue –History of strains; reinjury common –Restricted flexibility of involved muscle group

58 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont’d) Management: Grade 1 – standard acute; If symptoms persist > 2-3 days, physician referral Grade 2 or 3 – standard acute; physician referral

59 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Vascular and Neural Disorders Legg-Calvé-Perthes disease –Avascular necrosis of proximal femoral epiphysis –Seen especially in males ages 3–8 –Osteochondrosis of femoral head

60 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Vascular and Neural Disorders Legg-Calvé-Perthes disease (cont’d) –S&S Gradual onset of limp and mild hip or knee pain of several months in duration Pain is generally activity related  ROM in hip abduction, extension, and external rotation due to spasm in hip flexors and adductors

61 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Vascular and Neural Disorders (cont’d) Legg-Calvé-Perthes disease –Management Do not permit to continue activity until seen by a physician

62 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Fractures Avulsion fractures –Due to rapid, sudden acceleration and deceleration –Apophyseal sites ASIS with displacement of sartorius AIIS with rectus femoris displacement Ischial tuberosity with hamstrings displacement Lesser trochanter with iliopsoas displacement

63 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Fractures (cont’d) Avulsion fractures (cont’d) –S&S Sudden, acute, localized pain—may radiate down muscle Swelling and discoloration Palpable gap between tendon attachment and bone  pain with AROM, PROM, RROM of involved muscle

64 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Fractures (cont’d) Avulsion fractures (cont’d) –Management: fit with crutches; immediate physician referral

65 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Fractures (cont’d) Slipped capital femoral epiphysis –Boys ages 12–15 –Femoral head slips at epiphyseal plate— displaces inferiorly and posteriorly Slipped capital femoral epiphysis

66 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Fractures (cont’d) Slipped capital femoral epiphysis (cont’d) –S&S Early S&S often undetected other than diffuse knee pain Later stages More comfortable holding leg in slight flexion

67 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Fractures (cont’d) Slipped capital femoral epiphysis (cont’d) Later stages Unable to touch the abdomen with the thigh because the hip externally rotates with flexion Unable to rotate the femur internally or stand on one leg. –Management: Do not permit to continue activity until seen by a physician

68 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Fractures (cont’d) Stress fractures –Pubis, femoral neck, and proximal one-third of femur –Risk factors

69 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Fractures (cont’d) Stress fractures (cont’d) –S&S Diffuse or localized aching pain in anterior groin or thigh during weight-bearing activity, relieved with rest Night pain Antalgic gait may be present

70 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Hip Fractures (cont’d) Stress fractures (cont’d) –S&S (cont’d) ↑ pain on extremes of hip rotation, abduction lurch Inability to stand on involved leg –Management: Do not permit to continue activity until seen by a physician

71 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sacral and Coccygeal Fractures Rare in sports Direct blow to area due to fall on buttock S&S: extremely painful; unable to sit Management: immediate referral to a physician

72 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Femoral Shaft Fracture MOI –Tremendous impact forces –Direct compressive forces Potential for neurovascular damage

73 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Femoral Shaft Fracture (cont’d) S&S –Severe pain and a total loss of functions –Swelling at fracture site –Present with the thigh externally rotated –Shortened limb deformity

74 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Femoral Shaft Fracture (cont’d) Management –Activate emergency plan, including summoning of EMS –Do not attempt to immobilize –Assess and treat for shock as necessary

75 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Femoral Fractures (cont’d) S&S –Previous history of femoral stress fracture ↑ risk of complete fracture –Extreme pain and inability/unwillingness to move involved side –Shock

76 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Femoral Fractures (cont’d) S&S (cont’d) –Neck Individual supine, lower extremity in external rotation and abduction; appears shortened compared with other side –Shaft Limb appears shortened; thigh appears externally rotated

77 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Femoral Fractures (cont’d) Management –Activate EMS –Assess distal vascular integrity –Monitor and treat for shock –Defer immobilization until emergency medical personnel arrive (traction splint will typically be applied) –NPO—possible surgical intervention

78 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Coach and Onsite Assessment S &S that require activation of emergency plan, including summoning EMS –Obvious deformity suggesting a dislocation or fracture –Significant loss of motion or loss of function –Palpable defect in a muscle –Severe joint disability that may be evident by a noticeable limp

79 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Coach and Onsite Assessment (cont’d) S &S that require activation of emergency plan, including summoning EMS –Excessive soft tissue swelling, particularly in the quadriceps –Abnormal cutaneous sensations or an absent or weak pulse Refer to Application Strategy 14.2


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