Hip Pathology in the Adolescent athlete Dr.EMAD KARIM

1. Hip Pathology in the Adolescent athlete Dr.EMAD KARIM

2. This article will review the more common causes of hip and groin pain in the adolescent athlete, as well as advances in diagnostic and therapeutic interventions.

3. Risk factorsto adolescent hip pathology include: musculoskeletal balance open physes and growing

4. Physical examination Patients with intra-articular hip pain place a hand in the shape of a C around the hip. Groin pain often has an intraarticular etiology lateral hip pain is usually associated with extraarticular causes. Isolated posterior buttock pain is often related to lumbar and sacroiliac joint dysfunction.

5. Physical examination of the hip includes The four layers : osseous, cartilaginous, muscular, and neural. The examination includes evaluation of gait and physical tests in the standing, supine, lateral, and prone positions. Trendelenburg patterns manifest as lateral trunk flexion while shifting weight over the stance leg.

6. The (FABER) test is used to diagnose injuries to the labrum. The anterior impingement test is performed with the patient in the supine position; the hip is flexed to 90°, and a dynamic assessment of the hip joint is performed with flexion,adduction, and internal rotation. The scour test is performed with the patient in the supine position. The hip is brought to 90° of flexion and abducted, followed by compression with internal and external rotation.

7. Acetabular Labral Tears Injury is a source of hip pain. 5 Injury may occur as a result of hypermobility or repetitive mechanical stresses with excessive flexion and rotation. Underlying bony disorders of the hip, such as hip dysplasia, femoral retroversion, coxa valga, and slipped capital femoral epiphysis, can place the labral tissue at a greater risk of tear.

8. Acetabular labral tears commonly found in the anterior superior aspect of the acetabulum. These tears usually present with sharp anterior hip and groin activity related pain. Pain is described as sharp or pinching and is usually with locking. anterior impingement and FABER test may be positive. Magnetic resonance arthrography is the most reliable study .

9. T2-weighted axial magnetic resonance arthrogram demonstrating a tear of the anterosuperior labrum (arrow).

10. Nonsurgical treatment for labral tears : intra-articular injections (diagnostic and therapeutic). rest, activity modification,Oral anti-inflammatory medication,and physical therapy.

11. Hip arthroscopy It is : the preferred surgical approach for the management of isolated labral tears. safe and effective، good results

12. Study 30 patients underwent arthroscopic debridement. At 17-month follow-up: significant improvements were found in the Harris hip score (preoperative, 57.6; postoperative, 89.2). Three of the patients in this group experienced a recurrent labral tear.

13. Femoroacetabular Impingement (FAI) is a process by which a nonspherical femoral head exists within a hemispheric acetabulum, leading to labral and chondral pathology and hip arthritis. Patients present with anterior groin pain, which is worsened by flexion and rotation of the hip. Round lucencies seen in the femoral neck due to a herniation of synovium through a cortical defect.

14. Surgical management of FAI is: aimed at correcting the abnormal osseous anatomy. Both arthroscopic and open techniques have been successful. A peripheral compartment arthroscopic view of an adolescent hip following femoral osteoplasty for the management of impingement. The proximal femoral physis is visualized.

15. Coxa saltans is classified as intra articular,internal, or external. The intra-articular variant is the result of : labral tears,loose bodies, or cartilage flaps with in the hip joint. Coxa saltans external is usually associated with snapping of the iliopsoas tendon band or the anterior border of the gluteus maximus muscle over the greater trochanter.

16. Patients with symptomatic internal snapping hip syndrome often present with anterior groin pain and snapping. A dynamic external rotation test may reproduce snapping or pain. Recurrent snapping of the psoas tendon may cause impingement on the labrum and lead to labral tears.

17. Treatment nonsurgical treatment of symptomatic coxa saltans externa consists of stretching, physical therapy, (NSAIDs), and corticosteroid injections. Surgical intervention: open surgery or arthroscopic to lengthen the iliopsoas tendon band and manage associated trochanteric bursitis

18. Apophyseal Avulsions commonly encountered around the adolescent hip because of the inherent weakness of the remaining open physis combined with repetitive stress to the epiphyseal plate. These injuries result from indirect trauma caused by a sudden forceful muscular contraction

19. Avulsion injuries are commonly seen in athletes whose sports require rapid acceleration and deceleration. Study: In 203 avulsion fractures ischial tuberosity 54% anterior inferior iliac spine fractures 22%, and anterior superior iliac spine fractures 19%. Patients present with acute pain and swelling that follows a sudden, noncontact traumatic incident. tenderness to palpation and pain with passive stretch of the muscle attached to the avulsed fragment.

20. Radiographic evaluation is to confirm the diagnosis and allows to assess the size of the avulsed fragment and the amount of fracture displacement. The initial management rest, ice,NSAIDs, and protected weight bearing with crutches until symptoms resolve; physical therapy. surgical indications :are for ischial tuberosity fractures with >2 cm displacement and for symptomatic nonunion, chronic pain, and impaired function.

21. Arthroscopic images of iliopsoas tendon lengthening. A, The iliopsoas tendon (arrow) identified via a transcapsular approach in the central compartment. B, The tendinous portion is lengthened under direct visualization (arrow).

22. AP radiograph of a 13-year-old boy with right anterior superior iliac spine avulsion fracture (arrow).

23. AP radiograph of a 14 years-old girl demonstrating a right lesser trochanteric avulsion fracture (arrow).

24. AP radiograph (A) and AP (B) and lateral (C) three-dimensional CT images demonstrating evidence of subspine impingement from a previous anterior inferior iliac spine avulsion fracture (arrow), which later required arthroscopic decompression and labral repair

25. Hip Instability classified as traumatic or atraumatic Traumatic hip dislocation generallyresults from an axially applied force against a flexed knee with the hip in the neutral or adducted position. Generally follows a high-energy trauma, and associated injuries are common. clinicaly severe pain and the hip held in the flexed, adducted, and internally rotated position.

26. Hip Instability Plain radiographs confirm the diagnosis, and emergent reduction is indicated. Following reduction,plain radiographs and CT or MRI are indicated to confirm a congruent reduction and to evaluate for intra-articular pathology.

27. Management of hip instability restricted weight bearing for 6 weeks postreduction management. consider capsular or other soft-tissue laxity as a cause of persistent hip instability. Initially,this is managed with physical therapy.

28. Management of hip instability Arthroscopic thermal capsulorrhaphy hasalso been proposed. In patients with a nonconcentric reduction or notable acetabular fracture of the posterior wall, surgical intervention should be undertaken. Arthroscopy has been used to remove loose bodies.

29. Summary It is the role of the pediatric orthopaedic surgeon and sports medicine provider to properly diagnose and manage Hip pathology in the adolescent athlete. Appropriate workup and management can be often used effectively in adolescent athlete. Nonsurgical management includes activity modification, physical therapy and anti-inflammatory medication Surgical management of both intra- and extra-articular hip pathology can safely be used when clinically indicated.

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