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Can’t move your hips: Pelvic fractures
Case 1 presentation
A 14-year-old male presents with a complaint of acute right hip pain. The patient is an avid soccer player and was kicking a ball “pretty hard.” Immediately upon full extension of the right leg, he felt a “pop.” Thereafter, he began to experience pain that was radiating to the right upper thigh. He was unable to continue the game. He denies other injury and denies numbness or weakness involving the right leg.
His physical examination reveals appropriate-for-age vital signs. He weighs 59 kg (body mass index of 18.7—normal for his height of 180 cm). He has a completely unremarkable examination, with the exception of his right hip. He has mild tenderness to palpation of the anterior superior iliac spine. While he has full range of motion of the right leg at the hip joint, flexion and extension produce pain. He has no spine tenderness, deformity, or crepitus. He is able to ambulate but does so with a slight limp. There is no lower extremity tenderness, swelling, deformity, or crepitus. He is grossly neurovascularly intact.
Imaging considerations: Low-energy mechanisms
Imaging is often employed in the evaluation of children with musculoskeletal complaints, including hip issues, although not all patients require radiographic testing. A thorough history and physical examination can help identify which patients would benefit from imaging.
Plain radiography
This modality is the initial test of choice for the majority of patients in whom imaging is indicated. Previous studies have shown plain radiography to be generally effective in identifying pelvic avulsion fractures. , In a large study of 228 patients with pelvic avulsion fractures, 99% were identified by plain radiography; only two patients required advanced imaging (such as computed tomography [CT] or magnetic resonance imaging); fracture displacement and fracture size were identified in 90% and 97% of cases, respectively. , Patients with acute onset of pain or pain that is continuous, not improving, or worsening should have plain radiography performed. ,
Ultrasound (US)
The use of US to detect fractures is controversial. Studies have indicated US as an effective imaging modality for the identification of hip avulsion fractures, , but other studies have not supported these findings, especially when compared to more advanced imaging modalities. , US may show a widened physis on the injured side, compared to the nonaffected side. US can also detect nondisplaced or minimally displaced fractures, which may be difficult to see radiographically. ,
US is attractive because of the lack of ionizing radiation and general availability, but expertise is required to obtain a meaningful study and interpret the images obtained.
Computed tomography
CT is not a first-line imaging modality when there is a low-energy mechanism or an avulsion fracture is suspected. CT may be employed as a secondary imaging modality when plain radiography does not reveal a fracture but clinical suspicion for a fracture remains high.
This modality is often employed when a patient is involved in a high-energy mechanism, such as a motor vehicle accident or significant fall and is typically part of an abdomen/pelvis study for trauma (see later, “High Energy Mechanisms”).
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