Chapter I

I.1 Introduction
The differential diagnosis of hip pain is broad, presenting a diagnostic
challenge. Deciphering the etiology of the pathology versus the pain generator is
essential in prescribing the proper treatment.
Acute hip pain is a common presenting complaint among patients attending
Emergency Departments particularly following a traumatic event. Pain following
hip fracture has been associated with delirium, depression, sleep disturbance,and
decreased response to interventions for other disease states.

I.2 Anatomy of Hip

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 Chapter II

II.1 Diagnoses of Hip Pain

II.1.1 Intraarticular Disorder
Recent studies have demonstrated a high rate of abnormal MRI findings in
asymptomatic patients.
■ 60 to 80% prevalence of labral tears
■ 25% prevalence of chondral defects
■ 20% prevalence of acetabular paralabral cysts
■ Loose bodies
■ Often result from trauma or diseases such as
synovial chondromatosis
■ Should be removed, either in an open procedure
or arthroscopically, to prevent third-body wear
■ Labral tears
■ Often a cause of mechanical hip pain manifesting
with vague symptoms
■ MR arthrography is the most sensitive and
specific test.
■ Incidence of labral tears is highest in patients
with acetabular dysplasia.
■ Underlying hip disease should be addressed in
addition to the labral tear for the best results.
■ Arthroscopic labral débridement has yielded good short-term
and midterm results.
■ Labral repair may yield better results than débridement
according to emerging data on new techniques. ■
Chondral injuries
■ Articular surface injury is often a cause of
mechanical hip pain.

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■ Microfracture is effective in the treatment of
focal lesions.
■ Ruptured ligamentum teres
■ Associated with mechanical hip pain as the
ruptured ligament catches within the joint after a
hip dislocation.
■ Débridement is often necessary.
■ The viability of the femoral head is not
in jeopardy with a ruptured ligamentum teres.
II.1.2 Extraarticular Disorder
 Femoroacetabular Impingement
Abnormal contact between proximal femur and acetabulum
that leads to chondral damage and symptoms.
 Athletic Pubalgia
Injury to the muscles of the abdominal wall
or adductor longus produce anterior pelvis or
groin pain (or both) without the classic physical
findings of a true inguinal hernia
 Ilioinguinal nerve entrapment
This nerve can be constricted by hypertrophied
abdominal muscles as a result of intensive
training
 Obturator nerve entrapment
Can lead to chronicmedial thigh pain, especially in
athletes with well-developed hip adductor
muscles (e.g., skaters)
 Lateral femoral cutaneous nerve entrapment
Can lead to meralgia paresthetica, a painful
condition ■ Tight belts and prolonged hip flexion may
exacerbate symptoms.

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 Sciatic nerve entrapment
Can occur anywhere along the course of the nerve,
but the two most common locations are at
the level of the ischial tuberosity and by the
piriformis muscle, known as piriformis syndrome
 Stress fractures
A history of overuse, an insidious onset of
pain, and localized tenderness and swelling are
typical. Stress fractures occur via propagation of a
crack.
 Avascular necrosis
Traumatic hip subluxation can disrupt the arterial blood
supply to the hip and result in avascular
necrosis.
 Snapping hip (coxa saltans): two types—external and internal
o External : The iliotibial band abruptly catches on
the greater trochanter or the iliopsoas
impinges on the hip capsule
o Internal : Iliopsoas tendon abruptly catches on
underlying bony prominences

II.2 Diagnoses of Hip Pain Based on Regio

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II.3 Differential Diagnoses
II.3.1 Hip Dislocation
A hip dislocation a disruption of the joint between the femur and pelvis.
Specifically it is when the ball–shaped head of the femur comes out of the cup–
shaped acetabulum of the pelvis. Symptoms typically include pain and an inability
move the hip.
 Mechanism of Injury
o Posterior dislocation(most common): A posterior dislocation
usually occurs when force is applied to the knee, commonly in a
seated car passenger when the knee strikes the dashboard.
o Anterior dislocation: Anterior dislocations usually result after a
high energy trauma, which determines forced abduction and
external rotation and of the hip.
o Central dislocation: A fall on the side, or a blow over the greater
trochanter, may force the femoral head medially through
the floor of the acetabulum. Although this is called
a ‘central dislocation’, it is really a fracture of the acetabulum
 Clinical Manifestation
o Symptoms: Acute pain, Inability to bear weight, Deformity.
o Signs: Head of femur maybe palpated, ROM passive and active
decreased or gone, Neurovascular injury may present.
 Anterior Dislocation:

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 Leg lies externally rotated, abducted and slightly flexed. It is not
typically short, because the attachment of rectus femoris prevents
the head from migrating proximally by a significant amount.

 Posterior Dislocation:

Leg is shortened and lies in an adducted, internally rotated and

slightly, flexed position.
 Radiological Findings
 Anterior Dislocation

In the anteroposterior view the dislocation is usually obvious, but

occasionally the head is almost directly in front of its normal position. The femoral
will appear larger than the unaffected contralateral side. A lateral film helps confirm
the diagnosis.

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  Posterior Dislocation

In the anteroposterior view X-ray, the femoral head is seen to be

high-riding and smaller than expected when compared to the contralateral
normal hip. Associated femoral head and posterior wall acetabular fractures
may be evident.
 Managment
 Reduction done in <6 hours
 Technique done by flexing until 90, abduction and external rotation of hip
for posterior dislocation
 Technique done by flexing until 90, adduction and internal rotation of hip
for anterior dislocation
 Reduction under analgesia or muscle relaxan
 Stability must be tested

Captain morgan maneuver East Baltimore lift maneuver Lefkowitz maneuver. Piggyback method
Bigelow maneuver.

Stimson grsvity maneuver Tulsa technique/Rochester

Traction counter traction maneuver Allis maneuver.
method/Whistler technique Stimson grsvity maneuver

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II.3.2 Fracture of Hip
Hip fractures are defined as fractures that occur between the articular
margin of the femoral head to 5 cm below the lesser trochanter. They are
subdivided into intracapsular and extracapsular fractures. The blood
supply to the femoral head is typically damage in intracapsular fractures and
rarely in extracapsular fractures. Extracapsular fractures are further
subdivided into pertrochanteric (including the reverse oblique type) and
subtrochanteric fractures.

II.3.2.1 Fracture Neck of Femur

Femoral neck fractures account for 50% of hip fractures and are common in
the elderly beyond the age of 70 years. About 80% of neck fractures occur in
women, and the incidence doubles every 5–6 years in women above the age of 30
years. The incidence in younger patients is low and is associated mainly with high-
energy trauma. Risk factors include female sex, increasing age, poor health, tobacco
and alcohol use, a previous fracture and a low oestrogen level. Fractures of the neck
of the femur (NOF) occur in an area with a thin or absent periosteum and are
intracapsular,1 where the synovial fluid prevents haematoma consolidation,
predisposing these fractures to non-union. In displaced fractures, the precarious
femoral head blood supply may be impaired or entirely lacking, predisposing to
osteonecrosis and secondary degenerative changes of the femoral head.
 Mechanism of Injury:
In elderly patients NOF fractures are mostly low-energy injuries occurring
as a result of an indirect twisting injury causing a forced external rotation of
the lower extremity. This impinges the osteoporotic neck onto the posterior
lip of the acetabulum, resulting in a fracture of the neck with posterior
comminution. A fall with direct impact on the greater trochanter can result in
a valgus impaction fracture. In the younger age group NOF fractures occur
secondary to high-energy trauma and can be associated with severe
comminution and other associated injuries.

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  Clinical Evaluation:
Patients with displaced NOF fractures are non-ambulatory,
with the lower limb typically shortened and externally rotated.
However, patients with an impacted fracture have no deformity and
may be able to bear weight. Anterior hip tenderness and pain with
bi-trochantric compression and hip movements are however present.
The presence of prior hip pain should alert the physician to the
possibility of a pathological fracture. About 10% of these patients
have associated upper limb osteoporotic fractures in the wrist and
shoulder.
 Radiologic Evaluation:
An anteroposterior view of the pelvis and a cross-table lateral
view of the involved hip should be performed. An internal rotation
view of the injured hip helps to evaluate the fracture pattern. If a
fracture is suspected and the radiographs fail to confirm the
diagnosis, bone scanning, CT scan or MRI may be used. Thin slice
CT cuts with threedimensional reformations are used to look for a
crack in the cortex or trabecular discontinuity. T1-weighted MRI has
been found to be 100% sensitive in patients with equivocal
radiographic findings. It is important to note that the technetium
bone scan may not be positive until at least 3 days have passed since
the injury
 Classification

Garden's classification of fracture of the neck of t Pauwels' classification of fracture of the neck of the femur .
he femur

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II.3.2.2 Fracture Intertrochanteric of Femur

Intertrochanteric fractures, more correctly referred to as pertrochanteric

fractures, occur in the region between the greater and lesser trochanters of the
proximal femur, occasionally extending into the subtrochanteric region. They
account for nearly 50% of all fractures of the proximal femur, with reported
mortality rates ranging from 15% to 30%. Intertrochanteric fractures occur more
commonly in women (2:1 to 8:1) in the sixth or seventh decade. Intertrochanteric
fractures differ from fractures of the neck of femur in the following respects:

● The deforming muscle forces produce greater shortening and more external
rotation of the lower limb than in fractures of the neck of femur.

● Extracapsular fractures occur in cancellous bone with an abundant blood supply.

As a result, non-union and osteonecrosis are not major problems; however,
malunion is a complication.

 Mechanism of Injury
Ninety per cent of intertrochanteric fractures in the elderly
result from a simple fall, whereas in younger individuals they are
usually the result of a high-energy injury.
 Clinical Evaluation
Patients with displaced intertrochanteric fractures present
with the injured lower extremity shortened and externally rotated,
whereas those with undisplaced fractures present with painful
ambulation, deep trochantric tenderness and painful hip movements
 Radiological Evaluation
An anteroposterior view of the pelvis and an anteroposterior
and a cross-table lateral view of the involved proximal femur are
adequate to assess the fracture morphology.

 Classification

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 Boyd and Griffin classification of trochanteric fract
ures.
II.3.2.3 Fracture Subtrochanteric of Femur
A subtrochanteric fracture is a fracture between the lesser trochanter and the
isthmus of the femoral diaphysis. They account for 10–34% of hip fractures and
have a higher potential for non-union as the bone is mainly cortical and the
fragments are displaced by muscle forces which abduct the proximal fragment and
adduct the distal fragments considerably.
 Mechanism Of Injury
In young adults subtrochanteric fractures are the result of
high-energy trauma, whereas in the elderly they can occur even with
low-energy trauma. The subtrochanteric region is also a frequent site
for pathological fractures, accounting for 17–35% of all
subtrochanteric fractures. A history of previous pain at the site even
before the fracture and a transverse fracture with sclerosed or
irregular margins must arouse suspicion of a pre-existing pathology.
 Clinical Evaluation
Subtrochanteric fractures are high-energy injuries, and
associated major organ and skeletal injuries should be looked for.
Significant haemorrhage may occur into the thigh, and frequently
these patients are haemodynamically unstable. The fracture must be
splinted immediately and early definitive fixation should be
performed to limit further soft-tissue damage and haemorrhage.

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  Radiographic Evaluation
Standard anteroposterior and lateral radiographs are
adequate to evaluate fracture morphology and plan treatment. The
hip and knee joints should also be included in the study
 Classification

Russell–Taylor classification of subtrochanteric fracture of the femur based on involvement of p

iriformis fossa.

II.3.3 Avascular Necrosis of Femoral Head

Osteonecrosis (avascular necrosis) of the femoral head may be causally
related to trauma, especially dislocation or subluxation of the hip.36 However, it
may also occur coincidentally in active individuals. It may be idiopathic, but a
search should be made for other causative factors (i.e. alcohol abuse, catabolic
steroids, decompression sickness, etc.) Radiographs will vary from normal to
advanced collapse depending on the stage of the disease. MRI is important for both
diagnosis and accurate staging
 Sign and Symptoms:
o Symptoms:
 insidious onset of pain
 pain commonly in groin
 The quality of pain increased with mobilization

o Physical exam:
 mostly normal initially

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  advanced stages similar to hip OA (limited motion,
particularly internal rotation)
 Classification
Steiberg (modified Ficat) Classification

Steinberg (Modified Ficat) Classif

ication:

Chapter III

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 Case Report

III.1 Identity

Name : Bainang
Age : 82 y.o
Admission : July 24th, 2018 at 03,30
Registration : 850164

III.2 Anamnesis
Chief Complain :Pain at left groin
Suffered since 2 weeks before admitted to Wahidin General
Hospital. Patient fell down from her bed that her buttock as the first contact
to the floor. After the accident, patient cannot sit and walk and just laid
down on bed.
No history of diabetes mellitus, history of hypertension is denied.
Patient was referred from Mamuju Hospital and got skin traction
at her left lower limb.

III.3 General Status

Conscious / Well-nourished
Vital Signs:
Blood pressure : 150/80 mmHg
Pulse rate : 88 x/min
Respiratory rate : 18 x/min
Temperature : 37,5 0C
NRS : 3

III.4 Local Status

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Pelvic Region

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Look : Deformity (+), hematoma (-) , wound (-), Swelling (-)
Feel : Tenderness (-)
Move : Active and passive movement of left hip joint cannot be evaluated due to
pain.
Active and passive movement of left knee joint can not be evaluated due to
pain
NVD : Sensibility is good. Dorsalis pedis and tibialis posterior pulsation are
palpable. Capillary refill time < 2 seconds.

Left Right

TLL 83 cm 85 cm

ALL 88 cm 90 cm

LLD 2 cm

III.5 Laboratory Finding

 WBC : 14  SGOT : 27
3 3
x10 /mm U/L
 HGB : 12,8  SGPT : 26

g/dL U/L
 HCT : 39%  Sodium :
 PLT : 147 mmol/l
3 3  Potassium :
III.6 Radiographic Finding

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  Pelvic AP
- Fine Pelvic ring alignment
- Fracture line in intertrochanteric of left femur
- Fine bone density
- Both sacroiliaca and hip joint are fine
- Fine soft tissue

Conclusion: Fracture Intertrochanteric of Femur

III.7 Diagnose
Closed Fracture Intertrochanter of Femur

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