Hip Injury

Hip Injury is a topic covered in the 5-Minute Emergency Consult.

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Basics

Description

  • Hip injury includes hip fractures and dislocations of the proximal femur due to minor or major trauma, or overuse
  • Hip fracture: Fracture of proximal femur. Classified as intracapsular or extracapsular
    • Intracapsular fracture: Femoral head or neck; often associated with disruption of femoral neck vessels; significant morbidity due to AVN and higher rate of malunion:
      • Femoral head fracture: Usually associated with hip dislocation (anterior > posterior)
      • Femoral neck fracture: Usually older adults with minor trauma, or young patient with major trauma. Patient may or may not be ambulatory. Often site of stress fracture in runners
    • Extracapsular fractures: Below acetabular capsule to the distal lesser trochanter. Normally do not disrupt blood flow. Morbidity typically due to patient immobilization, DVT, PE:
      • Trochanteric fractures: Greater trochanter usually fractured by avulsion at the site of insertion of the gluteus medius. Lesser trochanter usually fractured by avulsion from forceful contraction of iliopsoas; seen in young athletes and children
      • Intertrochanteric fracture: In line between greater and lesser trochanters. Common in elderly and osteoporotic patients secondary to fall. External rotation and shortening. Can be stable or unstable. Nonambulatory
      • Subtrochanteric fracture: Usually due to direct, major trauma in younger patients or lesser trauma in elderly. Common site of pathologic fracture. Can result in significant blood loss and shock
  • Hip dislocation: Disarticulation of femoral head. Classified as posterior, anterior, and central:
    • Posterior dislocation (most common):
      • Often from motor vehicle accident (MVA) in which knees strike dashboard
      • 10% associated with sciatic nerve injury
    • Anterior dislocation:
      • Often due to trauma with sudden abduction of thigh
      • Associated femoral head fractures, femoral nerve injury
      • Can be anterior superior or anterior inferior
    • Central dislocation with acetabular fracture:
      • Usually from direct impact to greater trochanter
      • Associated with significant blood loss, sciatic nerve injury

Pediatric Considerations
  • Hip dislocation: Uncommon; often spontaneously reduced at time of injury. Concern for tissue trapped in joint space:
    • Trivial force required for posterior hip dislocations in children <10 yr old
  • Proximal femoral physeal fracture: Fracture at growth plate; high risk for osseous necrosis
  • Slipped capital femoral epiphysis: Displacement between the femoral neck and capital femoral epiphysis. Typically in obese children
  • Femoral neck fractures: Relatively common; stress fractures in young athletes
  • Intertrochanteric fractures: Rare
  • Consider pathologic fracture with minor trauma

Etiology

See individual injuries above

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Basics

Description

  • Hip injury includes hip fractures and dislocations of the proximal femur due to minor or major trauma, or overuse
  • Hip fracture: Fracture of proximal femur. Classified as intracapsular or extracapsular
    • Intracapsular fracture: Femoral head or neck; often associated with disruption of femoral neck vessels; significant morbidity due to AVN and higher rate of malunion:
      • Femoral head fracture: Usually associated with hip dislocation (anterior > posterior)
      • Femoral neck fracture: Usually older adults with minor trauma, or young patient with major trauma. Patient may or may not be ambulatory. Often site of stress fracture in runners
    • Extracapsular fractures: Below acetabular capsule to the distal lesser trochanter. Normally do not disrupt blood flow. Morbidity typically due to patient immobilization, DVT, PE:
      • Trochanteric fractures: Greater trochanter usually fractured by avulsion at the site of insertion of the gluteus medius. Lesser trochanter usually fractured by avulsion from forceful contraction of iliopsoas; seen in young athletes and children
      • Intertrochanteric fracture: In line between greater and lesser trochanters. Common in elderly and osteoporotic patients secondary to fall. External rotation and shortening. Can be stable or unstable. Nonambulatory
      • Subtrochanteric fracture: Usually due to direct, major trauma in younger patients or lesser trauma in elderly. Common site of pathologic fracture. Can result in significant blood loss and shock
  • Hip dislocation: Disarticulation of femoral head. Classified as posterior, anterior, and central:
    • Posterior dislocation (most common):
      • Often from motor vehicle accident (MVA) in which knees strike dashboard
      • 10% associated with sciatic nerve injury
    • Anterior dislocation:
      • Often due to trauma with sudden abduction of thigh
      • Associated femoral head fractures, femoral nerve injury
      • Can be anterior superior or anterior inferior
    • Central dislocation with acetabular fracture:
      • Usually from direct impact to greater trochanter
      • Associated with significant blood loss, sciatic nerve injury

Pediatric Considerations
  • Hip dislocation: Uncommon; often spontaneously reduced at time of injury. Concern for tissue trapped in joint space:
    • Trivial force required for posterior hip dislocations in children <10 yr old
  • Proximal femoral physeal fracture: Fracture at growth plate; high risk for osseous necrosis
  • Slipped capital femoral epiphysis: Displacement between the femoral neck and capital femoral epiphysis. Typically in obese children
  • Femoral neck fractures: Relatively common; stress fractures in young athletes
  • Intertrochanteric fractures: Rare
  • Consider pathologic fracture with minor trauma

Etiology

See individual injuries above

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