Download Ch 16 - Pelvis Hip and Thigh

Pelvis, Hip and Thigh
Skeletal Features of Pelvis, Hip, and Thigh
Pelvis
•Function
–Protects organs
–Transmits loads between trunk and lower
extremity
–Provides site for muscle attachments
•4 fused bones
–Sacrum
–Coccyx
–Innominate bones (Bilateral)
•Ilium, ischium, and pubis
Pelvis (cont.)
•SI joint
–Critical link between the two pelvic bones
–Strong ligamentous support
•Sacrococcygeal joint
–Fused line symphysis united by a
fibrocartilaginous disc
•Pubic symphysis
–Interpubic disc located between the two
joint surfaces
Bony Structure of Thigh
• Femur
– Weakest at femoral neck
Hip Joint
• Head of femur and acetabulum of
pelvis
• Ball and socket joint
• Very stable
Femoral Triangle
• Borders
– Inguinal ligament—superior
– Sartorius—lateral
– Adductor longus—medial
• Contents
– Femoral nerves
– Femoral artery
– Femoral vein
Q-Angle
• Angle between line of resultant
force produced by quadriceps and
line of patellar tendon
• Males 13°; females 18°
Nerve and Blood Supply
• Nerves
– Lumbar plexus
• Femoral nerve
• Obturator nerve
– Sacral plexus
• Sciatic nerve
• Blood Supply
– External iliac
• Femoral
– Deep femoral
– Femoral circumflex
Kinematics
• ROM
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–
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–
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Hip Flexion
Hip Extension
Hip Abduction
Hip Adduction
Medial Rotation
Lateral Rotation
• Body weight places compression on hip, as
does tension in hip muscles
• Forces are less during standing than with
running and walking
– Forces translated through the lower extremity;
result ↑ compression on hip
Prevention
• Protective equipment
– Hip joint well protected but iliac and
pelvis need protection
– Thigh
• Physical conditioning
• Shoes
– Cushion forces
Contusions
• Hip pointer
– Mechanism: direct blow to iliac crest
• Common—anterior or lateral portion of crest
• Often from improperly fitting (or absent) hip
pads
– S&S
• Point tenderness; swelling; ecchymosis
• Individual prefers slightly forward flexed position to
relieve tension of abdominals and iliopsoas
• Antalgic gait with shortened swing phase
• ↑ pain with active trunk flexion and active hip flexion
• Pain with coughing, laughing, breathing
• Abdominal muscle spasm
– Management: standard acute; rest; protect with
hard-shell pad for return to activity
Contusions (Cont’d)
• Quadriceps contusion
– Mechanism: direct blow
– Common – anterolateral thigh
– S&S
• Transitory loss of function
• With continued play, progressively stiffer and
unresponsive
• ↑ pain with active knee extension and hip flexion
• Limited AROM due to pain; knee flexion limited
actively and passively
– Management:
• Standard acute; with knee in maximum flexion
• Hard-shell pad for return to activity
• Physician referral if myositis ossificans or
compartment syndrome is suspected
Bursitis
• Greater trochanteric bursitis
– Influence of Q-angle
– Effect of IT Band
– S&S
• Burning or aching over or posterior to greater
trochanter
• Aggravated with:
– Hip abduction against resistance
– Hip flexion and extension on weight bearing
• Referred pain—lateral aspect of the thigh
• Bursitis management
– Standard acute; deep friction massage; NSAIDs;
stretching program for involved muscle
– On-going prevention: biomechanical analysis;
technique analysis
Hip Sprains and Dislocations
• Mechanism
– 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
• Management
– Mild/moderate—standard acute
– Severe—activate EMS; immobilize in position
found; assess distal vascular integrity; monitor
and treat for shock; NPO
Strains
• Mechanism
– Explosive movements
– Tensile stress from overstretching
• Muscles
– Quadriceps
• Typically rectus femoris
– 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
• Strength imbalance
• S&S
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–
–
–
Point tender with palpable spasm
Possible palpable defect/divot
Ecchymosis may or may not be present
Pain with AROM; pain with PROM (muscles placed
on stretch)
Strains (Cont’d.)
• Piriformis strain
– In some individuals, sciatic nerve passes
through or above piriformis, subjecting nerve
to compression from trauma, hemorrhage, or
spasm
– S&S
• History of prolonged sitting, overuse, recent ↑ in
activity, or buttock trauma
• Dull ache in midbuttock—worse at night
• Numbness or weakness may extend down posterior
leg
• Predisposing factors
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–
–
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Beginning of season – too much too soon
Fatigue
History of strains; reinjury common
Restricted flexibility of involved muscle group
• Management: standard acute; restrict weight
bearing if unable to assume normal gait
Venous disorders
– Direct blow may damage a vein causing
– Thrombophlebitis
 Superficial thrombophlebitis (ST)
 Deep venous thrombosis (DVT)
– S&S
• ST—acute, red, hot, palpable, tender cord in
course of a superficial vein
• Extension of ST to deep veins—via proximal long
and short saphenous veins to common femoral
and popliteal veins, respectively
– Management: anticoagulant therapy;
external support (e.g., compression
stockings); therapeutic exercise
Femoral Fracture
• Mechanism
– Tremendous impact forces
– Direct compressive forces
• Potential for neurovascular damage
•
S&S
– Previous history of femoral stress fracture ↑ risk of complete
fracture
– Extreme pain and inability/unwillingness to move involved side
– Shock
– Neck
• Individual supine, lower extremity in external rotation and
abduction; appears shortened compared with other side
– Shaft
• appears shortened; thigh appears externally rotated
• Management
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–
–
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Activate EMS
Assess distal vascular integrity
Monitor and treat for shock
Defer immobilization until emergency medical personnel
arrive (traction splint will typically be applied)
Assessment
•
•
•
•
History
Observation/inspection
Palpation
Physical examination tests
ROM
•
•
•
•
AROM
AAROM
PROM
RROM
ROM (cont.)
ROM (cont.)
ROM (cont.)
Stress Tests
• Sacroiliac
compression and
distraction test
• “Squish” test
• Sacroiliac rocking
test
Stress Tests
• Approximation
test
• Patrick’s (FABER)
test
Special Tests
• Leg length
measurement
– Anatomic
– Apparent
Special Tests (cont.)
• Thomas Test for flexion contractures
Special Tests (cont.)
• Straight leg
raising
(Lasegue's) test
• Trendelenburg
test
Special Tests (cont.)
• Piriformis test
• Ober’s test