Joint Replacement Infection

Knee and hip replacements are two of the most commonly performed elective operations. For the majority of patients, joint replacement surgery relieves pain and helps them to live fuller, more active lives.

No surgical procedure is without risks, however. A small percentage of patients undergoing hip or knee replacement (roughly about 1 in 100) may develop an infection after the operation.

Joint replacement infections may occur in the wound or deep around the artificial implants. An infection may develop during your hospital stay or after you go home. Joint replacement infections can even occur years after your surgery.

This article discusses why joint replacements may become infected, the signs and symptoms of infection, treatment for infections, and preventing infections.

Any infection in your body can spread to your joint replacement.

Infections are caused by bacteria. Although bacteria are abundant in our gastrointestinal tract and on our skin, they are usually kept in check by our immune system. For example, if bacteria make it into our bloodstream, our immune system rapidly responds and kills the invading bacteria.

However, because joint replacements are made of metal and plastic, it is difficult for the immune system to attack bacteria that make it to these implants. If bacteria gain access to the implants, they may multiply and cause an infection.

Despite antibiotics and preventive treatments, patients with infected joint replacements often require surgery to cure the infection.

A total joint may become infected during the time of surgery, or anywhere from weeks to years after the surgery.

The most common ways bacteria enter the body include:

• Through breaks or cuts in the skin
• During major dental procedures (such as a tooth extraction or root canal)
• Through wounds from other surgical procedures

Some people are at a higher risk for developing infections after a joint replacement procedure. Factors that increase the risk for infection include:

• Immune deficiencies (such as HIV or lymphoma)
• Diabetes mellitus
• Peripheral vascular disease (poor circulation to the hands and feet)
• Immunosuppressive treatments (such as chemotherapy or corticosteroids)
• Obesity

Signs and symptoms of an infected joint replacement include:

• Increased pain or stiffness in a previously well-functioning joint
• Swelling
• Warmth and redness around the wound
• Wound drainage
• Fevers, chills and night sweats
• Fatigue

When total joint infection is suspected, early diagnosis and proper treatment increase the chances that the implants can be retained. Your doctor will discuss your medical history and conduct a detailed physical examination.

Imaging tests. X-rays and bone scans can help your doctor determine whether there is an infection in the implants.

Laboratory tests. Specific blood tests can help identify an infection. For example, in addition to routine blood tests like a complete blood count (CBC), your surgeon will likely order two blood tests that measure inflammation in your body. These are the C-reactive Protein (CRP) and the Erythrocyte Sedimentation Rate (ESR). Although neither test will confirm the presence of infection, if either or both of them are elevated, it raises the suspicion that an infection may be present. If the results of these tests are normal, it is unlikely that your joint is infected.

Additionally, your doctor will analyze fluid from your joint to help identify an infection. To do this, he or she uses a needle to draw fluid from your hip or knee. The fluid is examined under a microscope for the presence of bacteria and is sent to a laboratory. There, it is monitored to see if bacteria or fungus grow from the fluid.

The fluid is also analyzed for the presence of white blood cells. In normal hip or knee fluid, there are a low number of white blood cells. The presence of a large number of white blood cells (particularly cells called neutrophils) indicates that the joint may be infected. The fluid may also be tested for specific proteins that are known to be present in the setting of an infection.

Nonsurgical Treatment
In some cases, just the skin and soft tissues around the joint are infected, and the infection has not spread deep into the artificial joint itself. This is called a «superficial infection.» If the infection is caught early, your doctor may prescribe intravenous (IV) or oral antibiotics.

This treatment has a good success rate for early superficial infections.

Surgical Treatment
Infections that go beyond the superficial tissues and gain deep access to the artificial joint almost always require surgical treatment.

Debridement. Deep infections that are caught early (within several days of their onset), and those that occur within weeks of the original surgery, may sometimes be cured with a surgical washout of the joint. During this procedure, called debridement, the surgeon removes all contaminated soft tissues. The implant is thoroughly cleaned, and plastic liners or spacers are replaced. After the procedure, intravenous (IV) antibiotics will be prescribed for approximately 6 weeks.

Staged surgery. In general, the longer the infection has been present, the harder it is to cure without removing the implant.

Late infections (those that occur months to years after the joint replacement surgery) and those infections that have been present for longer periods of time almost always require a staged surgery.

The first stage of this treatment includes:

• Removal of the implant
• Washout of the joint and soft tissues
• Placement of an antibiotic spacer
• Intravenous (IV) antibiotics
• An antibiotic spacer is a device placed into the joint to maintain normal joint space and alignment. It also provides patient comfort and mobility while the infection is being treated.

Spacers are made with bone cement that is loaded with antibiotics. The antibiotics flow into the joint and surrounding tissues and, over time, help to eliminate the infection.

Patients who undergo staged surgery typically need at least 6 weeks of IV antibiotics, or possibly more, before a new joint replacement can be implanted. Orthopaedic surgeons work closely with other doctors who specialize in infectious disease. These infectious disease doctors help determine which antibiotic(s) you will be on, whether they will be intravenous (IV) or oral, and the duration of therapy. They will also obtain periodic blood work to evaluate the effectiveness of the antibiotic treatment.

Once your orthopaedic surgeon and the infectious disease doctor determine that the infection has been cured (this usually takes at least 6 weeks), you will be a candidate for a new total hip or knee implant (called a revision surgery). This second procedure is stage 2 of treatment for joint replacement infection.

During revision surgery, your surgeon will remove the antibiotic spacer, repeat the washout of the joint, and implant new total knee or hip components.

Single-stage surgery. In this procedure, the implants are removed, the joint is washed out (debrided), and new implants are placed all in one stage. Single-stage surgery is not as popular as two-stage surgery, but is gaining wider acceptance as a method for treating infected total joints. Doctors continue to study the outcomes of single-stage surgery.

A muscle strain (muscle pull or tear) is a common injury, particularly among people who participate in sports.

The thigh has three sets of strong muscles: the hamstring muscles in the back of the thigh, the quadriceps muscles in the front, and the adductor muscles on the inside. The quadriceps and hamstrings work together to straighten (extend) and bend (flex) the leg. The adductor muscles pull the legs together.

The hamstring and quadriceps muscle groups are particularly at risk for muscle strains because they cross both the hip and knee joints. They are also used for high-speed activities, such as track and field events (running, hurdles, long jump), football, basketball, and soccer.

Muscle strains usually happen when a muscle is stretched beyond its limit, tearing the muscle fibers. This injury frequently occurs near the point where the muscle joins the tough, fibrous connective tissue of the tendon. A direct blow to the muscle may also cause a similar injury. Muscle strains in the thigh can be quite painful.

Once a muscle strain occurs, the muscle is vulnerable to reinjury. It is important to let the muscle heal properly and to follow preventive guidelines from your doctor.

A person who experiences a muscle strain in the thigh will frequently describe a popping or snapping sensation as the muscle tears. Pain is sudden and may be severe. The area around the injury may be tender to the touch, with visible bruising if blood vessels are also broken. Swelling and areas of ecchymosis (“black and blue”) may often extend below the thigh into the calf and ankle. This may even occur one or two days after the injury.

Your physician will ask about the injury and examine your thigh for tenderness or bruising. You may be asked to bend or straighten your knee and/or hip so the doctor can confirm the diagnosis.

An x-ray may be needed if there is a possible fracture or other injury to the bone. Your doctor may also order a magnetic resonance imaging (MRI) scan to further evaluate the muscles and tendons in your leg.

Muscle strains are graded according to their severity. A grade 1 strain is mild and usually heals readily, whereas a grade 3 strain is a severe tear of the muscle that may take months to heal.

Most muscle strains can be treated with the RICE protocol. RICE stands for Rest, Ice, Compression, and Elevation.

Rest. Take a break from the activity that caused the strain. Your physician may recommend that you use crutches to avoid putting weight on the leg.
Ice. Use cold packs for 20 minutes at a time, several times a day. Do not apply ice directly to the skin.
Compression. To prevent additional swelling, lightly wrap the injured area in a soft bandage or ace wrap.
Elevation. To minimize swelling, raise your leg up higher than your heart.

Your doctor may recommend a nonsteroidal anti-inflammatory medication, such as ibuprofen, for pain relief. As the pain and swelling subside, physical therapy will help improve range of motion and strength. The muscle should be at full strength and pain-free before you return to sports. This will help prevent additional injury.

Risk Factors
Several factors can predispose you to muscle strains, including:

Muscle tightness. Tight muscles are vulnerable to strain. Athletes should follow a year-round program of daily stretching exercises.
Muscle imbalance. Because the quadriceps and hamstring muscles work together, if one is stronger than the other, the weaker muscle can become strained.
Poor conditioning. If your muscles are weak, they are less able to cope with the stress of exercise and are more likely to be injured.
Muscle fatigue. Fatigue reduces the energy-absorbing capabilities of muscle, making them more susceptible to injury.
Precautions
You can take the following precautions to help prevent muscle strain:

Condition your muscles with a regular program of exercises. You can ask your physician about exercise programs for people of your age and activity level.
Warm up before any exercise session or sports activity, including practice. A good warm up prepares your body for more intense activity. It gets your blood flowing, raises your muscle temperature, and increases your breathing rate. Warming up gives your body time to adjust to the demands of exercise and can help increase range of motion and reduces stiffness.
Take time to cool down after exercise. Stretch slowly and gradually, holding each stretch to give the muscle time to respond and lengthen. You can find examples of stretching exercises on this website or ask your physician or coach for help in developing a routine.
If you are injured, take the time needed to let the muscle heal before you return to sports. Wait until your muscle strength and flexibility return to preinjury levels. This can take 10 days to 3 weeks for a mild strain, and up to 6 months for a severe strain, such as a hamstring strain.

Nerves are fragile and can be damaged by pressure, stretching, or cutting. Injury to a nerve can stop signals to and from the brain, causing muscles not to work properly, and a loss of feeling in the injured area.

Nerves are part of the «electrical wiring» system that carries messages between the brain and the rest of the body. Motor nerves carry messages between the brain and muscles to make the body move. Sensory nerves carry messages between the brain and different parts of the body to signal pain, pressure, and temperature.

A ring of tissue covers the nerve, protecting it just like the insulation surrounding an electrical cable. Nerves are composed of many fibers, called axons. These axons are separated into bundles within the nerve. The bundles are surrounded by tissue layers, just like the outer tissue layer that surrounds the nerve.

Pressure or stretching injuries can cause fibers within the nerve to break. This may interfere with the nerve’s ability to send or receive signals, without damaging the cover.

When a nerve is cut, both the nerve and the insulation are severed. Sometimes, the fibers inside the nerve break while the insulation remains intact and healthy. If the insulation has not been cut, the end of the fiber farthest from the brain dies. The end that is closest to the brain does not die. After some time, it may begin to heal. New fibers may grow beneath the intact insulating tissue until it reaches a muscle or sensory receptor.

If both the nerve and insulation have been severed and the nerve is not fixed, the growing nerve fibers may form a painful nerve scar, or neuroma.

The insulation around both ends of the injured nerve is sewn together. The goal in fixing the nerve is to save the insulating cover so that new fibers can grow and the nerve can work again.

If a wound is dirty or crushed, surgery may be delayed until the skin has healed.

If there is a space between the ends of the nerve, it may be necessary to take a piece of nerve (nerve graft) from a donor part of the body to fix the injured nerve. This may cause permanent loss of feeling in the area where the donor nerve graft was taken.

Once the insulating cover of the nerve is repaired, the nerve generally begins to heal three or four weeks after the injury. Nerves usually grow one inch every month, depending on the patient’s age and other factors. With an injury to a nerve in the arm above the fingertips, it may take up to a year before feeling returns to the fingertips. The feeling of pins and needles in the fingertips is common during the recovery process. While this can be uncomfortable, it usually passes and is a sign of recovery.

Physical therapy will keep joints flexible. If the joints become stiff, they will not work, even after the muscles begin to work again.
If a sensory nerve has been injured, care must be taken not to burn or cut fingers because there is no feeling in the affected area.
With a nerve injury, the brain may need to be «re-educated.» After the nerve has recovered, sensory re-education may be needed to improve feeling to the hand or finger. The physician will recommend appropriate physical therapy based on the nature and location of the injury.
Factors that may affect results after nerve repair include age, the type of wound and nerve, and location of the injury. Although nerve injuries may create lasting problems, proper treatment helps patients return to more normal function.

Pelvic Fractures

The pelvis is the sturdy ring of bones located at the base of the spine. Fractures of the pelvis are uncommon—accounting for only about 3% of all adult fractures.

Most pelvic fractures are caused by some type of traumatic, high-energy event, such as a car collision. Because the pelvis is in proximity to major blood vessels and organs, pelvic fractures may cause extensive bleeding and other injuries that require urgent treatment.

In some cases, a lower-impact event—such as a minor fall—may be enough to cause a pelvic fracture in an older person who has weaker bones.

Treatment for a pelvic fracture varies depending on the severity of the injury. While lower-energy fractures can often be managed with conservative care, treatment for high-energy pelvic fractures usually involves surgery to reconstruct the pelvis and restore stability so that patients can resume their daily activities.

The pelvis is a ring of bones located at the lower end of the trunk—between the spine and the legs. The pelvic bones include the:

• Sacrum (the large triangular bone at the base of the spine)
• Coccyx (tailbone)
• Hip bones

Each hip bone contains three bones—the ilium, ischium, and pubis—that are separate during childhood but fuse together as we grow older. These three bones meet to form the acetabulum—the hollow cup that serves as the socket for the ball-and-socket hip joint.

Bands of strong connective tissues called ligaments join the pelvis to the sacrum, creating a bowl-like cavity below the rib cage.

Major nerves, blood vessels, and portions of the bowel, bladder, and reproductive organs all pass through the pelvic ring. The pelvis protects these important structures from injury. It also serves as an anchor for the muscles of the hip, thigh, and abdomen.

Because the pelvis is a ring-like structure, a fracture in one part of the structure is often accompanied by a fracture or damage to ligaments at another point in the structure. Doctors have identified several common pelvic fracture patterns. The specific pattern of the fracture depends upon the direction in which it was broken and the amount of force that caused the injury.

In addition to being described by the specific fracture pattern, pelvic fractures are often described as «stable» or «unstable,» based on how much damage has occurred to the structural integrity of the pelvic ring.

Stable fracture. In this type of fracture, there is often only one break in the pelvic ring and the broken ends of the bones line up adequately. Low-energy fractures are often stable fractures. Stable pelvic fracture patterns include:

Unstable fracture. In this type of fracture, there are usually two or more breaks in the pelvic ring and the ends of the broken bones do not line up correctly (displacement). This type of fracture is more likely to occur due to a high-energy event. Unstable pelvic fracture patterns include:

Both stable and unstable pelvic fractures can also be divided into «open» fractures, in which the bone fragments stick out through the skin, or «closed» fractures, in which the skin is not broken. Open fractures are particularly serious because, once the skin is broken, infection in both the wound and the bone can occur. Immediate treatment is required to prevent infection.

High-Energy Trauma
A pelvic fracture may result from a high-energy force, such as that generated during a:

• Car or motorcycle collision
• Crush accident
• Fall from a significant height (such as a ladder)
• Depending on the direction and magnitude of the force, these injuries can be life-threatening and require surgical treatment.

Bone Insufficiency
A pelvic fracture may also occur due to weak or insufficient bone. This is most common in older people whose bones have become weakened by osteoporosis. In these patients, a fracture may occur even during a fall from standing or a routine activity such as getting out of the bathtub or descending stairs. These injuries are typically stable fractures that do not damage the structural integrity of the pelvic ring, but may fracture an individual bone.

Other Causes
Less commonly, a fracture may occur when a piece of the ischium bone tears away from the site where the hamstring muscles attach to the bone. This type of fracture is called an avulsion fracture and it is most common in young athletes who are still growing. An avulsion fracture does not usually make the pelvis unstable or injure internal organs.

A fractured pelvis is almost always painful. This pain is aggravated by moving the hip or attempting to walk. Often, the patient will try to keep his or her hip or knee bent in a specific position to avoid aggravating the pain. Some patients may experience swelling or bruising in the hip area.

Emergency Stabilization

Patients with high-energy fractures will almost always go or be brought to an urgent care center or emergency room for initial treatment due to the severity of their symptoms.

These patients may also have additional injuries to the head, chest, abdomen, or legs. If their injuries cause significant blood loss, it could lead to shock—a life-threatening condition that can result in organ failure.

The care of patients with high-energy pelvic fractures requires a multidisciplinary approach with input from a number of medical specialists. In some cases, doctors must address airway, breathing, and circulatory problems before treating the fracture and other injuries.

Physical Examination

Your doctor will carefully examine your pelvis, hips, and legs. He or she will also check for nerve injury by assessing whether you can move your ankles and toes and feel sensation on the bottom of your feet.

Your doctor will also carefully examine the rest of your body to determine if you have sustained any other injuries.

Imaging Studies

X-rays. These studies provide images of dense structures, such as bones. All pelvic fractures require x-rays—usually from a number of different angles—to help the doctor determine how displaced place the bones are.

Computed tomography (CT) scans. Because of the complexity of this type of injury, a CT scan is commonly ordered for pelvic fractures. A CT scan will provide a more detailed, cross-sectional image of the pelvis. Your doctor will use this information to better determine the specific pattern and extent of your injury, look for associated injuries, and aid in preoperative planning.

Magnetic resonance imaging (MRI) scans: In rare cases, your doctor may order an MRI scan to discover a fracture that cannot be seen on x-ray or CT scan.

Treatment is based on a number of factors, including:

• The specific pattern of the fracture
• How much the bones are displaced
• Your overall condition and associated injuries

Nonsurgical Treatment

Your doctor may recommend nonsurgical treatment for stable fractures in which the bones are nondisplaced or minimally displaced.

Nonsurgical treatments may include:

Walking aids. To avoid bearing weight on your leg, your doctor may recommend that you use crutches or a walker for up to three months—or until your bones are fully healed. If you have injuries above both legs, you may need to use a wheelchair for a period of time so that you can avoid bearing weight on either leg.

Medications. Your doctor may prescribe medication to relieve pain, as well as an anti-coagulant, or blood thinner, to reduce the risk of blood clots forming in the veins of your legs and pelvis.

Surgical Treatment

Patients with unstable pelvic fractures may require one or more surgical procedures.

External fixation. Your doctor may use external fixation to stabilize your pelvic area. In this operation, metal pins or screws are inserted into the bones through small incisions into the skin and muscle. The pins and screws project out of the skin on both sides of the pelvis where they are attached to carbon fiber bars outside the skin. The external fixator acts as a stabilizing frame to hold the broken bones in proper position.

In some cases, an external fixator is used to stabilize the bones until healing is complete. In patients who are unable to tolerate a lengthy, more complicated procedure, an external fixator may be used as a temporary treatment until another procedure can be performed.

Skeletal traction. Skeletal traction is a pulley system of weights and counterweights that helps realign the pieces of bone. Skeletal traction is often used immediately after an injury and removed after surgery. Occasionally, acetabular fractures can be treated with skeletal traction alone. This is rare, however, and will be a decision made jointly with input from your doctor.

During skeletal traction, metal pins are implanted in the thighbone or shinbone to help position the leg. Weights attached to the pins gently pull on the leg, keeping the broken bone fragments in as normal a position as possible. For many patients, skeletal traction also provides some pain relief.

Open reduction and internal fixation. During this operation, the displaced bone fragments are first repositioned (reduced) into their normal alignment. They are then held together with screws or metal plates attached to the outer surface of the bone

Pain Management
After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.

Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

Early Movement
In most cases, your doctor will encourage early movement. Most patients begin walking—with weight-bearing restrictions—and performing foot and leg exercises as soon as possible after surgery.

Physical Therapy
Specific exercises will help you regain flexibility and restore range of motion in your hip. Other exercises will help you build strength and endurance so that you are better able to perform your daily activities.

Blood Clot Prevention
Although early movement is encouraged, your mobility after surgery will still be somewhat limited. For this reason, your doctor may prescribe an anticoagulant, or blood thinner, to help prevent blood clots from forming in the deep veins of your pelvis and legs.

Weight Bearing
Your doctor may recommend that you use crutches or a walker for a period of time. Full weight bearing is usually allowed by 3 months—or when your bones are fully healed. You may require the use of a cane or walking aid for a longer period of time.

Snapping hip is a condition in which you feel a snapping sensation or hear a popping sound in your hip when you walk, get up from a chair, or swing your leg around.

The snapping sensation occurs when a muscle or tendon (the strong tissue that connects muscle to bone) moves over a bony protrusion in your hip.

Although snapping hip is usually painless and harmless, the sensation can be annoying. In some cases, snapping hip leads to bursitis, a painful swelling of the fluid-filled sacs that cushion the hip joint.

The hip is a ball-and-socket joint formed where the rounded end of the thighbone (femur) fits into a cup-shaped socket (acetabulum) in the pelvis. The acetabulum is ringed by strong fibrocartilage called the labrum that creates a tight seal and helps to provide stability to the joint.

Encasing the hip are ligaments that surround the joint and hold it together. Over the ligaments are tendons that attach muscles in the buttocks, thighs, and pelvis to the bones. These muscles control hip movement.

Fluid-filled sacs called bursae are located in strategic spots around the hip to provide cushioning and help the muscles move smoothly over the bone.

Snapping hip can occur in different areas of the hip where tendons and muscles slide over knobs in the hip bones.

Outside of the hip. The most common site of snapping hip is at the outer side where the iliotibial band passes over the portion of the thighbone known as the greater trochanter.
When the hip is straight, the iliotibial band is behind the trochanter. When the hip bends, the band moves over the trochanter so that it is in front of it. The iliotibial band is always tight, like a stretched rubber band. Because the trochanter juts out slightly, the movement of the band across it creates the snap you hear.
Eventually, snapping hip may lead to hip bursitis. Bursitis is thickening and inflammation of the bursa, a fluid-filled sac that allows the muscle to move smoothly over bone.

Front of the hip. Another tendon that could cause a snapping hip runs from the front of the thigh up to the pelvis (rectus femoris tendon). Snapping of the rectus femoris tendon is felt in the front of the hip. As you bend the hip, the tendon shifts across the head of the thighbone, and when you straighten the hip, the tendon moves back to the side of the thighbone. This back-and-forth motion across the head of the thighbone causes the snapping.
In addition to the rectus femoris tendon at the front of the hip, the iliopsoas tendon can catch on bony prominences at the front of the pelvis bone.

Back of the hip. Snapping in the back of the hip can involve the hamstring tendon. This tendon attaches to the sitting bone, called the ischial tuberosity. When it moves across the ischial tuberosity, the tendon may catch, causing a snapping sensation in the buttock region.

Cartilage problems. The labrum that lines the socket of the hip can tear and cause a snapping sensation. Damaged cartilage can loosen and float in the joint causing the hip to catch or «lock up.» This type of snapping hip usually causes pain and may be disabling.

Snapping hip is most often the result of tightness in the muscles and tendons surrounding the hip. People who are involved in sports and activities that require repeated bending at the hip are more likely to experience snapping hip. Dancers are especially vulnerable.

Young athletes are also more likely to have snapping hip. This is because tightness in the muscle structures of the hip is common during adolescent growth spurts.

Home Remedies
Most people do not see a doctor for snapping hip unless they experience some pain. If the snapping hip bothers you — but not to the point of seeing a doctor — try the following conservative home treatment options:

Reduce your activity levels and apply ice to the affected area.
Use nonsteroidal anti-inflammatory drugs, such as aspirin or ibuprofen, to reduce discomfort.
Modify your sport or exercise activities to avoid repetitive movement of the hip. For example, reduce time spent on a bicycle, and swim using your arms only.
If you are still experiencing discomfort after trying these conservative methods, consult your doctor for professional treatment.

A sports hernia is a painful, soft tissue injury that occurs in the groin area. It most often occurs during sports that require sudden changes of direction or intense twisting movements.

Although a sports hernia may lead to a traditional, abdominal hernia, it is a different injury. A sports hernia is a strain or tear of any soft tissue (muscle, tendon, ligament) in the lower abdomen or groin area.

Because different tissues may be affected and a traditional hernia may not exist, the medical community prefers the term «athletic pubalgia» to refer to this type of injury. The general public and media are more familiar with «sports hernia,» however, and this term will be used for the remainder of this article.

The soft tissues most frequently affected by sports hernia are the oblique muscles in the lower abdomen. Especially vulnerable are the tendons that attach the oblique muscles to the pubic bone. In many cases of sports hernia, the tendons that attach the thigh muscles to the pubic bone (adductors) are also stretched or torn.

Sports activities that involve planting the feet and twisting with maximum exertion can cause a tear in the soft tissue of the lower abdomen or groin.

Sports hernias occur mainly in vigorous sports such as ice hockey, soccer, wrestling, and football.

A sports hernia will usually cause severe pain in the groin area at the time of the injury. The pain typically gets better with rest, but comes back when you return to sports activity, especially with twisting movements.

A sports hernia does not cause a visible bulge in the groin, like the more common, inguinal hernia does. Over time, a sports hernia may lead to an inguinal hernia, and abdominal organs may press against the weakened soft tissues to form a visible bulge.

Without treatment, this injury can result in chronic, disabling pain that prevents you from resuming sports activities.

During your first appointment, your doctor will talk to you about your symptoms and how the injury occurred. If you have a sports hernia, when your doctor does a physical examination, he or she will likely find tenderness in the groin or above the pubis. Although a sports hernia may be associated with a traditional, inguinal hernia, in most cases, no hernia can be found by the doctor during a physical examination.

Physical Tests
To help determine whether you have a sports hernia, your doctor will likely ask you to do a sit-up or flex your trunk against resistance. If you have a sports hernia, these tests will be painful.

Imaging Tests
After your doctor completes a thorough exam, he or she may order xrays or magnetic resonance imaging (MRI) scans to help determine whether you have a sports hernia. Occasionally, bone scans or other tests are recommended to rule out other possible causes of the pain.

Nonsurgical Treatment

Rest. In the first 7 to10 days after the injury, treatment with rest and ice can be helpful. If you have a bulge in the groin, compression or a wrap may help relieve painful symptoms.

Physical therapy. Two weeks after your injury, you may begin to do physical therapy exercises to improve strength and flexibility in your abdominal and inner thigh muscles.

Anti-inflammatory medications. Your doctor may recommend non-steroidal anti-inflammatory medicines (ibuprofen or naproxen) to reduce swelling and pain. If your symptoms persist over a prolonged period, your doctor may suggest a cortisone injection, which is a very effective steroid anti-inflammatory medicine.

In many cases, 4 to 6 weeks of physical therapy will resolve any pain and allow an athlete to return to sports. If, however, the pain comes back when you resume sports activities, you may need to consider surgery to repair the torn tissues.

Surgical Treatment

Surgical procedure. Surgery to repair the torn tissues in the groin can be done as a traditional, open procedure with one long incision, or as an endoscopic procedure. In an endoscopy, the surgeon makes smaller skin incisions and uses a small camera, called an endoscope, to see inside the abdomen.

The end results of traditional and endoscopic procedures are the same.

Some cases of sports hernia require cutting of a small nerve in the groin (inguinal nerve) during the surgery to relieve the patient’s pain. This procedure is called an inquinal neurectomy.

Your doctor will discuss the surgical procedure that best meets your needs.

Surgical rehabilitation. Your doctor will develop a rehabilitation plan to help you regain strength and endurance. Most athletes are able to return to sports 6 to 12 weeks after surgery.

Surgical outcomes. More than 90% of patients who go through nonsurgical treatment and then surgery are able to return to sports activity. In some patients the tissues will tear again during sports and the surgical repair will need to be repeated.

Additional surgery. In some cases of sports hernia, pain in the inner thigh continues after surgery. An additional surgery, called adductor tenotomy, may be recommended to address this pain. In this procedure, the tendon that attaches the inner thigh muscles to the pubis is cut. The tendon will heal at a greater length, releasing tension and giving the patient a greater range of motion.

The thighbone (femur) is the largest and strongest bone in the body. It can break when a child experiences a sudden forceful impact.

Statistics
The most common cause of thighbone fractures in infants under 1 year old is child abuse. Child abuse is also a leading cause of thighbone fracture in children between the ages of 1 and 4 years, but the incidence is much less in this age group.

In adolescents, motor vehicle accidents (either in cars, bicycles, or as a pedestrian) are responsible for the vast majority of femoral shaft fractures.

Risk
Events with the highest risk for pediatric femur fractures include:

• Falling hard on the playground
• Taking a hit in contact sports
• Being in a motor vehicle accident
• Child abuse
• Types of Femur Fractures (Classification)
• Femur fractures vary greatly. The pieces of bone may be aligned correctly (straight) or out of alignment (displaced), and the fracture may be closed (skin intact) or open (bone piercing through the skin). An open fracture is rare.

Specifically, thighbone fractures are classified depending on:

• Location of fracture on the bone (proximal, middle, or distal third of the bone shaft)
• Shape of the fractured ends — bones can break all kinds of ways, such as straight across (transverse), angled (oblique), or spiraled (spiral)
• Position of the fractured edges (angulated or displaced)
• Number of fractured parts
• Two parts
• Several fractured parts (comminuted)

A thighbone fracture is a serious injury. It may be obvious that the thighbone is fractured because:

• Your child has severe pain
• The thigh is noticeably swollen or deformed
• Your child is unable to stand or walk, and/or
• There is a limited range of motion of the hip or knee allowed by the child because of pain.
• Take your child to the emergency room right away if you think he or she has a broken thighbone.

It is important that the doctor know exactly how the injury occurred. Tell the doctor if your child had any disease or other trauma before it happened.

The doctor will give your child pain relief medication and carefully examine the leg, including the hip and knee. A child with a thighbone fracture should always be evaluated for other serious injuries.

Imaging Tests
Your orthopaedic doctor will need x-rays to see what the broken bone looks like (refer to «Classification»). Your child’s healthy leg may also be x-rayed for comparison.

The orthopaedic doctor will also check the x-ray for any damage to the growth area (growth plate) near the end of the femur. This is the part that enables the child’s bone to grow. If needed, surgery may help to restore the growth plate’s function, and regular x-rays may be taken for many months to track the bone’s growth.

To treat a child’s thighbone fracture, the pieces of bone are realigned and held in place for healing. Treatment depends on many factors, such as your child’s age and weight, the type of fracture, how the injury happened, and whether the broken bone pierced the skin.

Nonsurgical Treatment

In some thighbone fractures, the doctor may be able to manipulate the broken bones back into place without an operation (closed reduction). In a baby under 6 months old, a brace (called a Pavlik Harness) may be able to hold the broken bone still enough for successful healing.

Spica casting. In children between 7 months and 5 years old, a spica cast is often applied to keep the fractured pieces in correct position until the bone is healed.

There are different types of spica casts, but, in general, a spica cast begins at the chest and extends all the way down the fractured leg. The cast may also extend down the uninjured leg, or stop at the knee or hip. Your doctor will decide which type of spica cast is most effective for treating your child’s fracture.

Your doctor will sedate your child for the closed reduction, and apply a spica cast immediately (or within 24 hours of hospitalization) to keep the fractured pieces in correct position until healing occurs.

When a bone breaks and is displaced, the pieces often overlap and shorten the normal length of the bone. Because children’s bones grow quickly, your doctor may not need to manipulate the pieces back into perfect alignment. While in the cast, the bones will grow and heal back into a more normal shape.

In general, for the best results, the broken pieces should not overlap more than 2 cm when in the cast. The growth of the thighbone may be temporarily increased by the trauma. The mild shortening from the overlap will resolve.

Traction. If the shortening of the bones is too much (more than 3 cm) or if the bone is too crooked in the cast, it may be helpful to put the leg in a weight and counterweight system (traction) to make sure the bones are properly realigned.

Surgical Treatment

Doctors generally agree that displaced femur fractures that have shortened more than 3 cm are not acceptable and require treatment to correct at least a portion of the shortening.

In some more complicated injuries, the doctor may need to surgically realign the bone and use an implant to stabilize the fracture.

Doctors are treating pediatric thighbone fractures more often with surgery than in previous years due to the benefits that have been recognized. These include earlier mobilization, faster rehabilitation, and shorter time spent in the hospital.

In children between 6 and 10 years old, flexible intramedullary (inside the bone) nails are often used to stabilize the fracture. Over the past decade, this treatment method has gained great acceptance.

Occasionally, the broken bone has too many pieces and cannot be treated successfully with flexible nails. Other options that can lead to successful outcomes in this situation include:

• A plate with screws that «bridges» the fractured segments
• An external fixator — this is often used if there has been a large open injury to the skin and muscles
• Prolonged traction with a pin temporarily placed into the thighbone

As the child nears the teenage years (11 years to skeletal maturity), the most common treatment choices include either flexible intramedullary nails or a rigid locked intramedullary nail. The rigid nail is particularly useful when the fracture is unstable. Both types of nails allow for the child to begin walking immediately.