chapter 14 pelvis, hip, and thigh conditions
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Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 14
Pelvis, Hip, and Thigh Conditions
Chapter 14
Pelvis, Hip, and Thigh Conditions
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anatomy Anatomy Skeletal features of the pelvis, hip, and thigh
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Anatomy (cont’d)Anatomy (cont’d)
• Pelvis
– Function
• Protects organs
• Transmits loads between trunk and lower extremity
• Provides site for muscle attachments
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Anatomy (cont’d)Anatomy (cont’d)
• Pelvis (cont’d)
– 4 fused bones
• Sacrum
• Coccyx
• Innominate bones
• Ilium, ischium, and pubis
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Anatomy (cont’d)Anatomy (cont’d)
• Pelvis (cont’d)
– SI joint
• Critical link between the two pelvic bones
• Strong ligamentous support
– Sacrococcygeal joint
• Fused line symphysis united by a fibrocartilaginous disc
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Anatomy (cont’d)Anatomy (cont’d)
• Pelvis (cont’d)
– Pubic symphysis
• Interpubic disc located between the two joint surfaces
• Femur
– Weakest at femoral neck
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Anatomy (cont’d)Anatomy (cont’d)
• Hip Joint
– Head of femur and acetabulum of pelvis
– Ball and socket joint
– Very stable
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Anatomy (cont’d)Anatomy (cont’d)
• Hip Joint (cont’d)
– Strong ligament support
• Iliofemoral ligament
• Limits hyperextension
• Pubofemoral ligament
• Limits abduction and hyperextension
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Anatomy (cont’d)Anatomy (cont’d)• Hip Joint (cont’d)
– Strong ligament support (cont’d)
• Ischiofemoral ligament
• Limits extension
Ligaments of the pelvis and hip
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Anatomy (cont’d)Anatomy (cont’d)
• Femoral Triangle
– Borders
• Inguinal ligament—superior
• Sartorius—lateral
• Adductor longus—medial
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Anatomy (cont’d)Anatomy (cont’d)
• Femoral Triangle (cont’d)
– Contents
• Femoral nerve
• Femoral artery
• Femoral vein
Femoral triangle
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Anatomy (cont’d)Anatomy (cont’d)
• Bursae
– Iliopsoas
• Reduces friction between iliopsoas and articular capsule
– Deep trochanteric bursa
• Provides cushion between greater trochanter and gluteus maximus at its attachment to iliotibial tract
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Anatomy (cont’d)Anatomy (cont’d)
• Bursae (cont’d)
– Gluteofemoral bursa
• Separates gluteus maximus from origin of vastus lateralis
– Ischial bursa
• Weight-bearing structure during sitting
• Cushions ischial tuberosity where it passes over gluteus maximus
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Anatomy (cont’d)Anatomy (cont’d)
• Nerves
– Lumbar plexus
• Femoral nerve
• Obturator nerve
– Sacral plexus
• Sciatic nerve
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Anatomy (cont’d)Anatomy (cont’d)
• Blood Vessels
– External iliac
• Femoral
• Deep femoral
• Femoral circumflex
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Kinematics and Major Muscle ActionsKinematics and Major Muscle ActionsMuscles of the pelvis, hip, and thigh. Anterior view
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Kinematics and Major Muscle Actions (cont’d)Kinematics and Major Muscle Actions (cont’d)Muscles of the pelvis, hip, and thigh. Lateral view
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Kinematics and Major Muscle Actions (cont’d)
Kinematics and Major Muscle Actions (cont’d)
Muscles of the pelvis, hip, and thigh. Posterior view
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Kinematics and Major Muscle Actions (cont’d)
Kinematics and Major Muscle Actions (cont’d)
• Hip flexors
– Iliopsoas, pectineus, rectus femoris, sartorius, and tensor fascia latae
– Two-joint muscles
• Rectus femoris—active during hip flexion and knee extension
• Sartorius—active during hip flexion and knee extension
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Kinematics and Major Muscle Actions (cont’d)
Kinematics and Major Muscle Actions (cont’d)
• Hip extensors
– Gluteus maximus and hamstrings (biceps femoris, semitendinosus, and semimembranosus)
• Hamstrings—two-joint; hip extension and knee flexion
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Kinematics and Major Muscle Actions (cont’d)
Kinematics and Major Muscle Actions (cont’d)
• Hip abductors
– Gluteus medius, gluteus minimus
– Active in stabilizing pelvis during single-leg support and during support phase of walking and running
• Hip adductors
– Adductor longus, adductor brevis, and adductor magnus
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Kinematics and Major Muscle Actions (cont’d)
Kinematics and Major Muscle Actions (cont’d)
• Lateral rotators
– Piriformis, gemellus superior, gemellus inferior, obturator internus, obturator externus, and quadratus femoris
– Lateral rotation of femur of swinging leg accommodates lateral rotation of pelvis during stride
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Kinematics and Major Muscle Actions (cont’d)
Kinematics and Major Muscle Actions (cont’d)
• Medial rotators
– Gluteus minimus
– Tensor fascia latae, semitendinosus, semimembranosus, gluteus medius, and adductors
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Kinematics and Major Muscle Actions (cont’d)Kinematics and Major Muscle Actions (cont’d)
PRIMARY ACTION
MUSCLES
Flexion Iliopsoas; rectus femoris; pectineus; sartorius; tensor fasciae latae
Extension Gluteus maximus; biceps femoris; semitendinosus; semimembranosus; adductor magnus
Abduction Gluteus medius; gluteus minimus
Adduction Adductor brevis; adductor magnus; adductor longus; adductor magnus; gracilis
Medial rotation Gluteus minimus; gluteus medius; tensor fasciae latae; semitendinosus; semimembranosus; adductor muscles
Lateral rotation Piriformis; obturator internus; obturator externus; superior gemelli; inferior gemelli; quadratus femoris; gluteus maximus
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Kinematics and Major Muscle Actions (cont’d)
Kinematics and Major Muscle Actions (cont’d)
• Hip joint – movement in 3 planes
– Sagittal
• Flexion and extension
– Frontal
• Abduction and adduction
– Transverse
• Medial rotation and lateral rotation of the femur
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Injury PreventionInjury Prevention
• Physical conditioning
– Flexibility
– Strength
• Protective equipment
– Hip joint well protected but iliac and pelvis need protection
– Thigh
• Shoe selection
– Cushion forces
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Contusions Contusions
• Hip pointer
– MOI: direct blow to iliac crest
– S&S
• Any trunk movement is painful (incl. coughing, laughing, & breathing)
• Immediate pain, discoloration, spasm, and loss of function
• Unable to rotate trunk or laterally flex the trunk toward injured side.
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Contusions (cont’d)Contusions (cont’d)
• Hip pointer (cont’d)
– S&S (cont’d)
• Any trunk movement is painful
• Extreme tenderness
• Abdominal muscle spasm may be present
• Severe injury – unable to walk or bear weight, even with crutches
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Contusions (cont’d)Contusions (cont’d)
• Hip pointer (cont’d)
– Management
• Standard acute; rest; protect with hard-shell pad for return to activity
• Severe pain over iliac crest – physician referral
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Contusions (cont’d)Contusions (cont’d)
• Quadriceps contusion
– MOI: direct blow
– Common – anterolateral thigh
– S&S
• Pain may be extensive immediately after impact
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Contusions (cont’d)Contusions (cont’d)
• Quadriceps contusion (cont’d)
– S&S (cont’d)
• Grade I
• Mild pain and swelling
• Able to walk without a limp
• Passive flexion beyond 90° – painful; resisted knee extension may cause less discomfort.
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Contusions (cont’d)Contusions (cont’d)
• Quadriceps contusion (cont’d)
– S&S (cont’d)
• Grade II
• Can flex the knee between 45 and 90°
• Walks with a noticeable limp
• Grade III
• Unable to bear weight or fully flex the knee.
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Contusions (cont’d)Contusions (cont’d)
• Quadriceps Contusion (cont’d)
– Management:
• Standard acute; with knee in maximum flexion
• Hard-shell pad for return to activity
• Physician referral if S&S persist >48 hours
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Contusions (cont’d)Contusions (cont’d)
• Quadriceps contusion (cont’d)
Management of a quadriceps contusion
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Contusions (cont’d)Contusions (cont’d)
• Myositis ossificans
– Develops secondary to single significant blow or repetitive blows to same area
– Evident on radiograph 3–4 weeks after injury
Myositis ossificans
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Contusions (cont’d)Contusions (cont’d)
• Myositis ossificans (cont’d)
– S&S
• Warm, firm, swollen thigh; 2–4 cm larger
• Palpable, painful mass may limit passive knee flexion to 20–30°
• Active quadriceps contractions and straight leg raises—difficult
– Management: standard acute; physician referral
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Bursitis Bursitis • MOI
– Excessive friction orshear forces due to overuse
• Greater trochanteric bursitis
– Influence of Q-angle
Bursa of the hips
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Bursitis (cont’d)Bursitis (cont’d)
• Greater trochanteric bursitis
– S&S
• Burning or aching over or posterior to greater trochanter
• Aggravated with:
• Hip abduction against resistance
• Hip flexion and extension on weight bearing
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Bursitis (cont’d)Bursitis (cont’d)
• Iliopsoas bursitis
– Pain medial and anterior to joint; cannot be easily palpated
pain with passive hip rotation; resisted hip flexion, abduction, and external rotation
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Bursitis (cont’d)Bursitis (cont’d)
• Ischial bursitis
– Pain aggravated by prolonged sitting and uphill running,
– Point tenderness directly over ischial tuberosity
pain with passive and resisted hip extension
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Bursitis (cont’d)Bursitis (cont’d)
• Bursitis management
– Do not permit to continue activity until seen by a physician
– Suggest cold to decrease pain and inflammation
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Bursitis (cont’d)Bursitis (cont’d)
• Snapping hip syndrome
– Can result from chronic bursitis
– S&S
• Snapping sensation heard or felt during hip motion, especially with lateral rotation and flexion while balancing on one leg
• Iliopsoas bursa affected—snapping in medial groin
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Bursitis (cont’d)Bursitis (cont’d)
• Snapping hip syndrome (cont’d)
– Management
• Do not permit to continue activity until seen by a physician
• Suggest cold to decrease pain and inflammation
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Hip Sprains and DislocationsHip Sprains and Dislocations
• MOI
– 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
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Hip Sprains and Dislocations (cont’d)Hip Sprains and Dislocations (cont’d)
• Management
– Mild/moderate—standard acute; physician referral
– Severe—activate EMS; immobilize in position found – do not move; monitor and treat for shock
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Hip DislocationsHip Dislocations
Hip dislocations
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Strains Strains
• Quadriceps
– Typically rectus femoris
– S&S
• Grade I
• Normal gait, but tightness in the anterior thigh
• Pain with passive knee flexion beyond 90°
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Strains (cont’d)Strains (cont’d)
• Quadriceps (cont’d)
– S&S (cont’d)
• Grade II
• Snapping or tearing sensation, followed by immediate pain and loss of function.
• Knee held in extension – protection
• Pain with passive knee flexion; Pain & weakness with knee extension
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Strains (cont’d)Strains (cont’d)
• Quadriceps (cont’d)
– S&S (cont’d)
• Grade III strains
• Extreme pain
• Ambulation not possible
• Defect in the muscle may be visible
• Resisted knee extension not possible; ROM is severely limited
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Strains (cont’d)Strains (cont’d)
• 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
– Additional risk factors (Box 14.2)
– Strength imbalance
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Strains (cont’d)Strains (cont’d)
• Hamstrings (cont’d)
– S&S
• Grade 1
• Tightness and tension
• Pain with passive stretching
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Strains (cont’d)Strains (cont’d)
• Hamstrings (cont’d)
– S&S (cont’d)
• Grade II
• Tearing sensation or feeling a “pop,” leading to immediate pain and weakness in knee flexion.
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Strains (cont’d)Strains (cont’d)
• Hamstrings (cont’d)
– S&S (cont’d)
• Grade III
• Sharp pain may occur during midstride
• Limps; unable to do heel-strike or fully extend the knee.
• Pain and muscle weakness with active knee flexion
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Strains (cont’d)Strains (cont’d)
• Adductors
– Quick changes of direction, and explosive propulsion and acceleration
– Strength imbalance
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Strains (cont’d)Strains (cont’d)
• Adductors (cont’d)
– S&S
• An initial “twinge” or “pull” of the groin muscles, and is unable to walk because of the intense, sharp pain
• As the condition worsens, increased pain, stiffness, and weakness in hip adduction and flexion
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Strains (cont’d)Strains (cont’d)
• Adductors (cont’d)
– S&S (cont’d)
• Running straight ahead or backward may be tolerable, but any side-to-side movement leads to more discomfort and pain
• Pain with passive stretching with the hip extended, abducted, and externally rotated
• Pain with resisted hip adduction
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Strains (cont’d)Strains (cont’d)
• Predisposing factors
– Beginning of season – too much too soon
– Fatigue
– History of strains; reinjury common
– Restricted flexibility of involved muscle group
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Strains (cont’d)Strains (cont’d)
• Management:
• Grade 1 – standard acute; If symptoms persist > 2-3 days, physician referral
• Grade 2 or 3 – standard acute; physician referral
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Vascular and Neural DisordersVascular and Neural Disorders
• Legg-Calvé-Perthes disease
– Avascular necrosis of proximal femoral epiphysis
– Seen especially in males ages 3–8
– Osteochondrosis of femoral head
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Vascular and Neural DisordersVascular and Neural Disorders
• Legg-Calvé-Perthes disease (cont’d)
– S&S
• Gradual onset of limp and mild hip or knee pain of several months in duration
• Pain is generally activity related
ROM in hip abduction, extension, and external rotation due to spasm in hip flexors and adductors
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Vascular and Neural Disorders (cont’d)Vascular and Neural Disorders (cont’d)
• Legg-Calvé-Perthes disease
– Management
• Do not permit to continue activity until seen by a physician
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Hip FracturesHip Fractures
• Avulsion fractures
– Due to rapid, sudden acceleration and deceleration
– Apophyseal sites
• ASIS with displacement of sartorius
• AIIS with rectus femoris displacement
• Ischial tuberosity with hamstrings displacement
• Lesser trochanter with iliopsoas displacement
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Hip Fractures (cont’d)Hip Fractures (cont’d)
• Avulsion fractures (cont’d)
– S&S
• Sudden, acute, localized pain—may radiate down muscle
• Swelling and discoloration
• Palpable gap between tendon attachment and bone
pain with AROM, PROM, RROM of involved muscle
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Hip Fractures (cont’d)Hip Fractures (cont’d)
• Avulsion fractures (cont’d)
– Management: fit with crutches; immediate physician referral
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Hip Fractures (cont’d)Hip Fractures (cont’d)
• Slipped capital femoral epiphysis
– Boys ages 12–15
– Femoral head slips at epiphyseal plate—displaces inferiorly and posteriorly
Slipped capital femoral epiphysis
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Hip Fractures (cont’d)Hip Fractures (cont’d)
• Slipped capital femoral epiphysis (cont’d)
– S&S
• Early S&S often undetected other than diffuse knee pain
• Later stages
• More comfortable holding leg in slight flexion
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Hip Fractures (cont’d)Hip Fractures (cont’d)
• Slipped capital femoral epiphysis (cont’d)
• Later stages
• Unable to touch the abdomen with the thigh because the hip externally rotates with flexion
• Unable to rotate the femur internally or stand on one leg.
– Management: Do not permit to continue activity until seen by a physician
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Hip Fractures (cont’d)Hip Fractures (cont’d)
• Stress fractures
– Pubis, femoral neck, and proximal one-third of femur
– Risk factors
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Hip Fractures (cont’d)Hip Fractures (cont’d)
• Stress fractures (cont’d)
– S&S
• Diffuse or localized aching pain in anterior groin or thigh during weight-bearing activity, relieved with rest
• Night pain
• Antalgic gait may be present
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Hip Fractures (cont’d)Hip Fractures (cont’d)
• Stress fractures (cont’d)
– S&S (cont’d)
• ↑ pain on extremes of hip rotation, abduction lurch
• Inability to stand on involved leg
– Management: Do not permit to continue activity until seen by a physician
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Sacral and Coccygeal FracturesSacral and Coccygeal Fractures
• Rare in sports
• Direct blow to area due to fall on buttock
• S&S: extremely painful; unable to sit
• Management: immediate referral to a physician
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Femoral Shaft FractureFemoral Shaft Fracture
• MOI
– Tremendous impact forces
– Direct compressive forces
• Potential for neurovascular damage
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Femoral Shaft Fracture (cont’d)Femoral Shaft Fracture (cont’d)
• S&S
– Severe pain and a total loss of functions
– Swelling at fracture site
– Present with the thigh externally rotated
– Shortened limb deformity
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Femoral Shaft Fracture (cont’d)Femoral Shaft Fracture (cont’d)
• Management
– Activate emergency plan, including summoning of EMS
– Do not attempt to immobilize
– Assess and treat for shock as necessary
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Femoral Fractures (cont’d)Femoral Fractures (cont’d)
• S&S
– Previous history of femoral stress fracture ↑ risk of complete fracture
– Extreme pain and inability/unwillingness to move involved side
– Shock
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Femoral Fractures (cont’d)Femoral Fractures (cont’d)
• S&S (cont’d)
– Neck
• Individual supine, lower extremity in external rotation and abduction; appears shortened compared with other side
– Shaft
• Limb appears shortened; thigh appears externally rotated
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Femoral Fractures (cont’d)Femoral Fractures (cont’d)
• Management
– Activate EMS
– Assess distal vascular integrity
– Monitor and treat for shock
– Defer immobilization until emergency medical personnel arrive (traction splint will typically be applied)
– NPO—possible surgical intervention
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Coach and Onsite AssessmentCoach and Onsite Assessment
• S &S that require activation of emergency plan, including summoning EMS
– Obvious deformity suggesting a dislocation or fracture
– Significant loss of motion or loss of function
– Palpable defect in a muscle
– Severe joint disability that may be evident by a noticeable limp
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Coach and Onsite Assessment (cont’d)Coach and Onsite Assessment (cont’d)
• S &S that require activation of emergency plan, including summoning EMS
– Excessive soft tissue swelling, particularly in the quadriceps
– Abnormal cutaneous sensations or an absent or weak pulse
• Refer to Application Strategy 14.2
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