3-73
Subjective: Symptoms
Constitutional: Fever (joint infection); non-ambulatory.
Local: Traumatic nerve damage causes loss of sensation, cold leg; ecchymosis.
Focused History: Can you walk? (determines if serious problem requiring crutches and evacuation) How
quickly did the pain come on? (sudden onset of severe pain and inability to walk suggest either fracture or
completed stress fracture) Did you fall or get hit on your hip or back? (suggests mechanism of injury) Do
you have back pain, or numbness or tingling in your leg? (suggests pinched nerve from herniated disc or
nerve damage from other etiology).
Objective: Signs
Using Basic Tools: Inspection: deformity indicates obvious injury.
Palpation: tenderness over the greater trochanter, anterior superior or inferior iliac spines (hip flexors), or deep
in the joint area (tendonitis, bursitis, fracture); pain with gentle logrolling (suspect hip fractures); absent or
diminished distal pulses (fracture or dislocation); diminished muscle strength relative to normal side (suggests
muscle strain, tendonitis, or nerve injury).
Range of Motion (ROM): limitations in active or passive full ROM suggest possible serious injury. Always
try active range of motion first, then passive range of motion should be done gently and stopped if patient
is experiencing pain.
Using Advanced Tools: X-rays: imperative for a definitive diagnosis if fracture suspected; Lab: Gram stain
joint fluid if infection is suspected
Assessment:
Differential Diagnosis
Traumatic fractures - deformity, pain, inability to ambulate
Femoral neck stress fracture - pain at the extremes of internal and external hip rotation
Greater trochanteric bursitis and others - chronic pain over particular bursa
Hip joint infection (extremely rare) - unable to conduct any active or passive ROM without severe pain
Osteoarthritis - history of chronic overuse (e.g., excessive weight bearing) or trauma, with degeneration of
the joint on x-ray.
Strains and tendinitis, such as hip flexor strain - point tenderness and diminished strength of muscle
Pyriformis syndrome - chronic posterior hip and thigh pain, numbness or tingling; pain with passive internal
rotation; no back pain
Herniated disc with nerve impingement - back pain; numbness and tingling in distribution of a nerve, including
sciatic nerve (sciatica) and others
Referred Pain - lower leg ailments (injuries, malalignments, etc.) may place abnormal stresses on the hip
Aseptic Necrosis - chronic pain and/or limp typically in pediatric patients; also seen in sickle cell disease.
Other injuries and degenerative changes of the hip, which can be diagnosed only with x-rays or specialty
referral.
Plan:
Treatment
- If the patient is unable to ambulate, use either crutches or a litter for transport.
- Give pain medication, including morphine, as required (see Procedure: Pain Assesment and Control).
- Treatment for specific conditions:
A. Trochanteric bursitis: After sterile preparation, inject a mixture of 1cc Lidocaine, 1cc Marcaine, and
1cc Kenalog using a 25 gauge 11⁄2 needle using a lateral approach. Insert the needle directly over the
palpable greater trochanteric bursae on the lateral proximal thigh, push in until the greater trochanter is
reached, and then slightly withdraw off the bone. Inject the mixture after aspirating slightly to ensure the tip
of the needle is not in a vessel. The mixture should flow in very easily. If not, it is in muscle or tendon
tissue and should NOT be forced. If resistance is met, reposition the needle by going back down to bone,
backing off only slightly, and repeating the attempt to inject. Injection may produce excellent pain relief for a
prolonged period of time.
B. Strains, tendonitis, arthritis and other bursitis: Use stretching, rest, compression (strains, tendonitis)