Hip

The hip joint is essentially a ball and socket joint, similar to the shoulder, and is the connection between the pelvis and the femur bone. It provides us the extensive circular range of motion that allows us to walk, climb stairs and perform sports like gymnastics, skating, hockey and soccer.

Acute hip injuries

Hip fractures

Children’s bones are very strong and these injuries are quite rare. There are typically only two circumstances in which a child can sustain a hip fracture:

  1. A high-energy injury, such as a motor vehicle collision or being hit by a car
  2. A low-energy injury where the bone fractures through a weak portion, usually a bone cyst

A common type of hip fracture occurs through a portion of the femur bone that has a rich blood supply. They typically occur through a benign (non-cancerous) bone cyst. These fractures are often fixed with a plate that is placed during surgery.

A less common hip fracture occurs near the head or neck of the femur bone. This is an emergency situation because the blood supply to the bone can be temporarily compromised. Some believe that if the fracture is fixed early, it may decrease the chance that the blood supply is lost from the bone permanently.

The doctor will want to follow up with your child for at least 18 months after the fracture since it may take a long time for a loss of blood supply (known as avascular necrosis) to occur and since it’s possible for a bone cyst to reoccur.

 

Apophysitis

What is apophysitis?

Apophysis is the cartilage site found throughout the body where muscles and tendons attach. When your child is diagnosed with apophysitis they have an irritation from repetitive pulling, which can cause the cartilage to partially pull away. It typically occurs in athletes. Apophysitis is an overuse injury. Repeated movement and stress to the muscles attached to the bone can inflame and irritate the muscles. This can cause inflammation at the point where the tendon (soft tissue) attaches to the bone. The results can be pain, swelling and tenderness in the hip area.

The injury is common in children and teens, ages 12 to18, who have:

  • Growth spurts, when bone growth can put added stress on the muscle
  • Tight hips and thigh muscles
  • Training or competing in sports for long periods of time
  • Knock-knees and pronation (inward roll of the foot)

Young athletes are prone to apohpysitis, especially:

  • Dancers
  • Hockey players
  • Runners
  • Soccer players
  • Sprinters

There are several apophyses that are located in the hip and pelvic region. 

Commonly injured apophyses of the hip

Apophysitis of the Ischial Tuberosity

The ischial tuberosity is the portion of the pelvis bone we sit on. The hamstring muscles start in this area and help the hip extend backwards. Avulsion fractures (injuries where the tendon or ligament attach to the bone) are more common at this location than overuse pains.

Apophysitis of the ASIS

The anterior superior iliac spine (ASIS) is located on the front part of the pelvis bone. It is the large area just underneath the iliac crest (the top of the hipbones you typically rest your hands on), and roughly in line with the kneecap. The sartorius muscle starts at the ASIS and bends the hip up (flex). When this muscle is repetitively stretched out, an ASIS apophysitis may develop. It is more common to experience an avulsion fracture in this location.

Iliac apophysitis

The iliac apophysis is located on the iliac crest on the upper pelvis. Muscles of the back, abdomen, and sides of the torso connect here. Athletes who participate in activities that involve repetitive twisting and bending of the torso, such as a long-distance runner, are at risk. Symptoms of iliac apophysitis include pain and tenderness over the iliac crest.

Lesser trochanter

The Lesser trochanter is anotehr area at risk for injury, and is located on the top inside portion of the femur (thigh) bone. A strong muscle named the iliopsoas inserts on this bony prominence, which is the most powerful flexor of the hip. Injury may occur during activities, such as kicking, sprinting, and jumping, when the muscle is repeatedly stretched beyond its limits. Symptoms include pain in the groin, and difficulty walking or bending at the hip when seated.

How to spot apophysitis

Symptoms of apophysitis can include:

  • Dull pain in the groin or front side of the hip
  • Pain or discomfort that gets worse with continued activity
  • Tenderness and swelling at the site of the injury

Apophysitis is often mistaken for muscle strain.

How we diagnose apophysitis

We help make diagnosing this injury as simple as possible. Most cases are identified through:

  • A complete medical history and physical examination
  • X-ray

How we treat apophysitis

Our team will recommend a recovery plan tailored for your child’s needs.

Treatment may include:

  • Rest from the activity that is causing the pain and inflammation
  • Icing the injured area for 15 to 20 minutes during a three-hour span every day
  • Medication to reduce inflammation
  • Physical therapy to build strength and flexibility

Be careful about letting your child return to sports after the pain has subsided. If the child or teen can’t walk normally without a limp, he or she likely isn’t ready to return to sports. When the pain is gone, gentle stretching and strengthening of the area can begin. Returning to sports and other activity should be gradual.

The symptoms of apophysitis may come and go as your child gets older. They will stop when he or she stops growing.

Apophysitis can happen in other body parts too:

  • Bottom of knee cap: Sinding-Larsen-Johansson Syndrome (SLJ)
  • Just below knee at tibial ttuberosity: Osgood-Schlatter Disease (OSD)
  • Bottom of Heel:  Sever's apophysitis

Apophyseal Hip Avulsion Fracture

Apophyseal hip avulsion fractures occur where the tendon or ligament attaches to the bone. It is in the same location where young athletes can experience pain from apophysitis (irritation from repetitive pulling) of the hip.

The injury occurs with a sudden contraction of the muscle, including activities such as:

  • Sprinting
  • Hurdling
  • Kicking
  • Jumping
  • Splits

How to spot hip avulsion fractures

The symptoms of a pelvic (hip) apophyseal avulsion fracture include:

  • Sudden onset of tenderness
  • Swelling
  • Pain with stretching the involved muscle
  • Weakness and pain with active contraction of the involved muscle
  • A limp, but can usually walk

How we diagnose hip avulsion fractures

To diagnose hip avulsion fractures we use:

  • A complete medical history and physical examination
  • X-ray

How we treat hip avulsion fractures

Treatment may include:

  • Ice 
  • Protected weight bearing (through crutches or a wheelchair)
  • Physical therapy: a progressive program to help with recovery
  • Medications to help relieve pain (Ibuprofen)
  • Rest
  • Surgery (in rare situations is needed to reattach the tendon)

Femur

The pelvis and femur are two of the strongest bones in the body, and the muscles surrounding this area are also extremely strong. Some of the more familiar muscles around the hip joint and femur are the quadriceps muscle in the front (flexes the hip and straightens the knee), and the hamstrings in the back (straightens hip and flexes the knee). Other important muscles for the hip include the gluteal muscles (buttocks) that move the hip out to the side (abduction), and the iliopsoas muscle that is one of the main hip flexors.

Acute femur injuries

Femur (shaft) fractures

Femur fractures are very common in children. The treatment is based upon the age and size of your child, as well as the location of the fracture.

If your child is four years old or younger, your doctor will likely recommend a cast for treatment. This cast is called a spica cast—it begins in middle of the chest, extends the entire length of the fractured limb, and then the entire length or half the length of the other limb.

Spica casts are applied in the operating room with your child completely asleep to prevent any discomfort and so the surgeon can properly fit the large cast. Your child can usually be discharged from the hospital and go home the same day. It may be necessary to make some modifications like adding straps to your car seat and possibly using a wheel chair if your child is too big to fit in a stroller. Our team will help you with equipment prior to being discharged from the hospital.

For a femur fracture, children typically stay in the spica cast for a total of six weeks. Once the cast is removed, your child may experience:

  • Stiffness and perceived pain
  • Inability to walk for a few days to a few weeks
  • Walking with a limp for a few months
  • Rash on the skin where the cast was removed

For children age 5 and older, the treatment of the femur fracture is more dependent on the location of the fracture and the size of the child. We often insert flexible rods into the femur bone near the knee to line up the broken ends of the femur fracture. The surgery is minimally invasive and most children recover quickly. Your child will need another surgery to remove the rods, usually nine to 12 months after the injury.

Other times, a plate is used to fix the fracture, or a rod may run the length of the femur bone.

How to spot a femur fracture

  • Severe pain
  • Swelling and discoloration
  • Inability to stand or walk
  • Limited range of motion in the knee or hip

How we diagnose a femur fracture

We use X-rays and pediatric trained radiologists and orthopaedic surgeons to help diagnose these fractures. If the growth plate is damaged, the bone can become deformed. Problems can worsen as your child grows. A damaged growth plate can also lead to limb-length discrepancy, where one leg is shorter than the other.

How we treat a femur fracture

Our team takes care not to damage the growth plate during treatment. Children are more likely to have long-term bone damage and hip deformities after a femur fracture and our specialists can help prevent this.

The treatment of a fractured femur in a child depends on:

  • The child’s age
  • The pattern of the fracture
  • Whether there are other injuries

Younger children, below age 5, are most often treated without surgery. The bone is gently moved back into place and stabilized with either a Pavlik harness or a spica cast.

In older children, surgical treatment is more common. Flexible rods or nails are placed into the hollow part of the bone, avoiding the growth plate, to hold the femur together.

broken femur illustration

Femur physis (growth plate) fractures

Fractures can occur in either the distal (bottom) physis or the proximal (top) physis and are rare. The top growth plate is located between the head and neck of the femur bone. The concern with this type of fracture is a permanent loss of blood supply to the hip joint that can result in avascular necrosis (bone tissue death).

Fractures to the bottom growth plate require a great amount of force to occur, such as direct blow from a soccer collision, football tackle or getting hit by a car. The main concern is permanent growth problems and the risk increases with the severity of injury. Approximately 50 percent of children may suffer from some type of growth problems as a result of this injury. If only a portion continues to grow, there can be a difference in limb length when your child is fully grown, and the bones could be crooked.

Upper thigh bone stress fracture

A stress fracture of the upper thigh bone or femoral neck is the result of repetitive stress from weight-bearing activities. This causes breakdown or absorption of the bone. Normally the bone is able to repair itself, but with excessive activity, the rate of bone absorption exceeds the rate of repair, resulting in a stress fracture.

Stress fractures of the femoral neck (upper thigh bone) occur most commonly in long distance runners. There is an increased risk of this injury in females, especially those with the female athlete triad which includes disordered eating (inadequate calories), menstrual irregularities, and osteoporosis.

How we spot upper thigh (femoral neck) bone fractures

Signs of upper thigh bone fractures may include: 

  • Decreased hip motion
  • Pain during motion
  • Groin pain
  • Limping
  • Tenderness 

How we treat upper thigh (femoral neck) bone fractures

Treatment may include:

  • Rest
  • Restricted weight bearing
  • Surgery:
    • If surgery is needed, metal screws are inserted to stabilize and strengthen the weakened bone to allow proper healing. Screws are left permanently in place.

How we diagnose upper thigh (femoral neck) bone fractures

Diagnostics may include:

  • A complete medical history and physical examination
  • Magnetic resonance imaging (MRI)
  • X-ray

Muscle Injuries

Groin muscle pain

An adductor or groin strain is due to a stretch or tearing of the adductor muscle of the inner thigh. It commonly occurs in sports with side-to-side movement in which a sudden external rotation occurs such as during soccer and tennis.

How to spot a groin strain

The most common signs include:

  • Pain in the inner thigh or groin
  • Pain with stretching
  • Swelling or bruising of the inner thigh
  • Weakness bringing the thigh together

Treatment may include

Treatment may include:

  • Ice 
  • Reduced activity
  • Rest
  • Physical therapy with gentle stretching and strengthening
  • Sports medicine physical therapy
  • Very gradual return to sports activity is important due to the risk of re-injury

Sports hernias 

Commonly occurring in athletes, an injury or tear occurs in the tissues, such as lower abdominal wall or muscles, and causes a groin pain. This is known as athletic pubalgia or sports hernia.

How we spot sports hernias

Symptoms of sports hernias include:

  • Groin pain that becomes worse with activities, such as running, twisting, turning, kicking and hip extension. The pain may radiate to the inner thigh or the testicles. The pain may increase with coughing, sneezing or doing sit-ups.
  • Tenderness in the extreme lower abdomen or groin, or pain from bringing the thighs together.

With sports hernias, there is not a noticeable swelling or bulging.

How we treat sports hernias

Sports hernias are usually not found by X-rays. Treatment is rest and avoidance of pain, and physical therapy or surgery may help.