Pelvic stress fracture: assessment and risk factors

OBJECTIVE: To discuss the case of a patient with a pelvic stress fracture and the differential considerations among patients presenting with hip and/or groin pain. FEATURES: A 42-year-old woman had hip pain after running. Initial radiograph of the pelvis was negative. Subsequent films showed a right inferior pubic ramus stress fracture. Stress fractures of the pelvis are relatively uncommon, accounting for only 1% to 2% of all stress fractures. INTERVENTION AND OUTCOME: Treatment included high-velocity, low-amplitude chiropractic manipulation, ultrasound, and stretching of the psoas and piriformis muscles. After 8 weeks, care was discontinued because the patient's hip pain had resolved. The pelvic fracture was left to heal with time. After 1 year, the patient still had delayed union of the fracture. CONCLUSION: When predisposing factors are present, such as osteoporosis and rheumatoid arthritis, pelvic stress fracture should be suspected in patients with groin or hip-area pain. However, because pelvic stress fractures are relatively rare, radiographic studies are often postponed, making diagnosis difficult.     

A clinical comparison of psoas compartment and inguinal paravascular blocks combined with sciatic nerve block

The extent of inguinal paravascular blockade and psoas compartment blockade with sciatic nerve block was evaluated in 60 patients. Volumes of 30 ml and 20 ml 0.35% bupivacaine with 1/200,000 epinephrine were injected for lumbar plexus and sciatic nerve block, respectively. Complete lumbar plexus blockade was achieved in 73% of the group who were treated with the psoas compartment technique and 43% of the group who were treated with the inguinal paravascular technique. Sensory blockade of the femoral, lateral femoral cutaneous and obturator nerves was obtained in 100%, 97% and 77% of the patients in the psoas compartment group, and 93%, 63% and 47% of the patients in the inguinal paravascular group, respectively. Sensory blockade of the lateral femoral cutaneous and obturator nerves was more rapid with psoas compartment block. The study suggests that the psoas compartment block is effective in blocking the femoral, lateral femoral cutaneous and obturator nerves, but the inguinal paravascular block is only effective in blocking the femoral nerve.     

连续髂筋膜阻滞和硬膜外阻滞下行全髋置换后镇痛的比较

背景：硬膜外持续镇痛曾被认为是下肢术后镇痛的金标准,其效果确切,全身不良反应较少,临床上普遍采用。但此法有低血压及尿潴留等不良反应,且患者在术后常规需应用低分子肝素抗凝,有增加硬膜外血肿的可能性,限制了硬膜外镇痛的临床使用。目前超声引导下连续髂筋膜腔隙阻滞技术的相关研究报道甚少。 目的：评价连续髂筋膜间隙阻滞和连续硬膜外阻滞两种不同镇痛方法对全髋关节置换后镇痛效果和关节功能恢复的影响。 方法：将60例择期行全髋关节置换患者分为2组：连续髂筋膜间隙阻滞组和连续硬膜外镇痛组（n=30）。两组患者在全身麻醉诱导前均接受预注量,连续髂筋膜间隙阻滞组经髂筋膜间隙注入0.25%罗哌卡因30 mL,连续硬膜外阻滞组经硬膜外导管注入0.20%罗哌卡因10 mL,均留置导管。待镇痛效果明确后,全麻插管。术毕两组分别经髂筋膜间隙、硬膜外连接镇痛泵持续给药,未使用术后自控镇痛单次给药。若疼痛难以忍受时,视其疼痛程度,予补救镇痛（帕瑞昔布20-40 mg/次）。记录目测类比评分、帕瑞昔布补救剂量、麻醉并发症、髋关节Harris评分、下床时间和住院时间。 结果与结论：目测类比评分、额外追加的镇痛药量、Harris 评分、住院日两组无明显差别。但是下床时间连续髂筋膜间隙阻滞组早于连续硬膜外阻滞组,而且连续髂筋膜间隙阻滞组并发症明显低于连续硬膜外阻滞组。提示全髋关节置换后,两种镇痛方式均可提供满意的术后镇痛效果,髋关节功能可得到良好的恢复;但连续髂筋膜间隙阻滞并发症少且有利于患者早期下床活动,对于髋关节置换后镇痛是更好的选择。     

硬膜外和腰大肌肌沟两种阻滞治疗坐骨神经痛的临床观察

本文对４４０例神经根性坐骨神经痛病人采用硬膜外阻滞，用药配方为类固醇、维生素Ｂ族和利多卡因。对１２７例神经干性坐骨神经痛病人采用腰大肌肌沟阻滞，用药配方１．５％利多卡因和０．１％丁卡因混合液。按ＶＡＳ法及直腿抬高试验评分，分级分析疗效。硬膜外阻滞者总优良率为８５．２２％，腰大肌肌沟阻滞者总优良率为７４．８０％。腰大肌肌沟阻滞操作简便，疗效较好，适合于在门诊处理大量病人，是神经干性坐髓神经痛治疗的首     

Phenol block for hip flexor muscle spasticity under ultrasonic monitoring.

Hip flexor spasticity, which is often associated with central nervous system (CNS) diseases, is a major impediment in rehabilitation. In order to cope with this problem, lumbar nerve blocking techniques developed by Meelhuysen and major and minor psoas muscle blocking techniques developed by Awad have been used in combination with physical therapies. Based on these techniques, we conducted major and minor psoas muscle phenol block (motor point block or intramuscular nerve block) under ultrasonic monitoring. Phenol block was conducted in nine patients with cerebral infarction (13 blocking procedures) and three with spinal cord injuries (six blocking procedures) while keeping them in a lateral position with the operation side upside. The beginning of the femoral nerves and part of the lumbar artery were visualized by ultrasound in some patients. As a result of the improvement of hip flexor spasticity, the range of hip joint motion (determined by the Mundale technique, prone hip extension and Thomas test) improved shortly after blocking. When physical therapy was conducted after blocking, improvement of skin care management was observed in eight cases, ability to keep in a stable sitting position in nine, improvement of a standing posture in three, increases in the ability to walk in two and alleviation of pain in three. Although nerve block is reported to result in hematoma, decreases in muscle force, pain, cystic/rectal disorders and hypogonadism, we have observed no such complication in our patients.     

Pain Management of Malignant Psoas Syndrome Under Epidural Analgesia During Palliative Radiotherapy

Malignant psoas syndrome is a rare malignant condition presenting as lumbosacral plexopathy and painful fixed flexion of the hip. Metastasis to the psoas muscle is observed, which damages the nerve bundles in the lumbosacral plexuses. The syndrome presents as refractory lower back pain with several other neurological symptoms. The pain is difficult to control because it is a mixture of nociceptive and neuropathic pain, which indicates that treatment requires a versatile approach. The authors report a case of severe back pain caused by metastasis to the psoas muscle of advanced gastric cancer in a patient who underwent palliative radiotherapy under epidural analgesia. Despite conventional analgesics and subcutaneous oxycodone, he had difficulties in maintaining supine position because of the back pain and had a problem to receive radiotherapy, which required him to stay still in the same position during the treatment. By epidural analgesia, he could remain in supine position and complete radiotherapy without increasing opioid administration. His back pain was improved after the radiotherapy. Epidural analgesia is an effective treatment choice for a patient who is unable to keep the position during palliative radiotherapy.     

Nerve guidance with versus without prepuncture ultrasound visualization for psoas compartment block and perineural catheter insertion: A randomized, prospective, blinded study

Lumbar plexus block may offer significant advantages in terms of postoperative analgesia, patient satisfaction, surgical outcome and patient rehabilitation. Ultrasound guidance has been used to describe psoas compartment block-related anatomy and to estimate transverse process depth before needle insertion and prediction of actual needle-to plexus intercept depth. The aim of this prospective randomized blinded study is to compare the Nerve-Stimulation Guidance with versus without the Pre-puncture Ultrasound Visualization in terms of onset time of the lumbar plexus sensory and motor block in patients undergoing total hip replacement.46 patients undergoing total hip replacement were randomly allocated to receive posterior lumbar plexus block (LPB) using nerve stimulation guidance with (group US, n = 23) or without pre-puncture ultrasound imaging (group NS, n = 23).Onset time of sensory and motor blocks was recorded every 5 min for the first 30 min starting from the injection of the local anesthetic injection. Readiness for surgery was defined as complete numbness to pinprick test in the region supplied by the lumbar plexus and Bromage’s score = 3.Need for additional local anesthetic boluses or general anesthesia, intraoperative opioid consumption and first postoperative 24 h local anesthetic and rescue Analgesics consumption were also recorded.The time required for the execution of the block was 3 (2–15) min in Group US and 5 (2–20) min in Group NS (p = 0.06). The mean time to readiness for surgery was 12 ± 5 in Group US and 19 ± 6 min in Group NS (p = 0.04) . 3 Patients in Group US (13%) and 4 patients in Group NS (17%) (p = 0.73) required general anesthesia due to failed block. Intraoperative opioid consumption was similar in the two groups. There were no differences in complications, postoperative local anesthetic and rescue analgesics consumption and pain scores.Nerve-Stimulation technique combined with Pre-puncture Ultrasound Visualization for continuous lumbar plexus blocks is comparable to Nerve-Stimulation technique in terms of percentage of block success, intraoperative opioid consumption and postoperative pain relief. Pre-puncture Ultrasound Visualization may reduce the time required for readiness to surgery.     

Pain in the hip: Spontaneous retroperitoneal hemorrhage in an elderly patient on apixaban

As many as 5% of patients using oral anticoagulants suffer from a major bleeding event annually. Spontaneous retroperitoneal hemorrhage is a rare but serious complication, with a mortality rate as high as 20%. Oral anticoagulants were responsible for 2.83 million office visits per quarter in 2014 and use is increasing, therefore, rapid recognition of life threatening complications is critical. We present a case of an 86-year-old female taking apixaban for atrial fibrillation who presented with right hip pain upon standing. Laboratory tests revealed leukocytosis and anemia. A CT scan of the right hip revealed a moderately sized retroperitoneal hematoma. She was transferred to the intensive care unit, treated with supportive care, and was discharged two days later without any invasive intervention needed. Due to vague presentations, spontaneous retroperitoneal hemorrhages can be misdiagnosed as a number of abdominal or pelvic processes. While our patient presented with hip pain, other presentations include abdominal masses, back pain, or hypotension. Some patients may progress to hemodynamic instability, femoral neuropathy, or abdominal compartment syndrome requiring rapid intervention to prevent further morbidity. In patients with vague abdominal or pelvic complaints who have risk factors such as advanced age and the use of anticoagulation therapy, spontaneous retroperitoneal hemorrhage should be considered to allow for early diagnosis before severe complications arise.     

The comparison of two lower extremity block techniques combined with sciatic block: 3-in-1 femoral block vs. psoas compartment block

The objective of this study was to compare clinical and postoperative analgesic effects of femoral or psoas compartment blocks in patients undergoing arthroscopies. Fifty patients were randomly assigned to one of the two groups. Either femoral (group F) or psoas compartment (group P) block was applied followed by sciatic nerve block. All nerve blocks were provided with a 15 ml of bupivacaine 0.5% + 10 ml of lignocaine (lidocaine) 2%. Systolic and diastolic blood pressure (SBP and DBP), heart rate, and pulse oxymetry (SpO2) were recorded. Quality of anaesthesia, time to first analgesic use, verbal pain scores (VPS), sensorial and motor blockade resolution times and side effects were also recorded. Quality of anaesthesia, complete sensory blockade of obturator and lateral cutaneous nerves were higher in the group P than in group F. However, complete motor blockade findings were similar in both groups. In the group P, VPS values measured at 10 and 15 min were lower than that of group F. These values decreased at 10 min and thereafter as to baseline values. VPS values of the group F declined at 20 min and following measurement times as to baseline values. Durations of motor and sensorial block, and time to first analgesic use were similar between two groups. Total analgesic consumption at first 24 h in group P was lower than those of group F. Regarding heart rates, SpO2, SBP and DBP values, no significant differences were found between the groups. Combined psoas-sciatic technique provided more comfortable intraoperative anaesthesia and better postoperative analgesia when compared with femoral-sciatic technique for arthroscopic procedures.     

The Efficacy of Levobupivacaine, Ropivacaine, and Bupivacaine for Combined Psoas Compartment–Sciatic Nerve Block in Patients Undergoing Total Hip Arthroplasty

Background and Objectives:   The aim of our study was to compare postoperative analgesic efficacy, and the extent of sensory and motor blockade of levobupivacaine, ropivacaine, and bupivacaine administered in a combined psoas compartment–sciatic nerve block (PCSNB) for total hip arthroplasty.
Methods:   Forty-five patients undergoing total hip arthroplasty under general anesthesia combined with PCSNB, were randomly assigned to receive either 50 mL levobupivacaine 3 mg/mL, 50 mL ropivacaine 4.5 mg/mL or 50 mL bupivacaine 3 mg/mL with epinephrine. Postoperative, the pain intensity at rest, the degree of motor block (Modified Bromage Scale) and the extent of sensory block (pin prick test) were recorded at 4, 8, 12, 24, and 48 hours following initial injection in a double blind fashion.
Results:   The postoperative pain intensity was low and did not differ between groups, except for a significantly lower pain intensity in group ropivacaine compared with group levobupivacaine at 4 hours. Five patients (11%), equally divided over three groups, needed parenteral rescue opiates postoperatively. The extent of sensory block was not different between the three groups. In each group the majority of patients showed no sensory block in dermatome L1. Group levobupivacaine initially showed the least motor impairment. Motor impairment was found to be significantly higher in bupivacaine group compared with both ropivacaine and levobupivacaine groups at 12 ( P  = 0.012) and 48 hours ( P  = 0.003).
Conclusions:   Levobupivacaine, bupivacaine and ropivacaine are equally effective for PCSNB in patients undergoing total hip arthroplasty. Residual pain may be due to the lack of sensory block in dermatome L1, suggesting that modification of this technique should be considered for this type of surgery. ▪     

Combined fascia iliaca compartment block and monitored anesthesia care for geriatric patients with hip fracture: Two case reports

BACKGROUNDMajor hip surgery usually requires neuraxial or general anesthesia with tracheal intubation and may be supplemented with a nerve block to provide intraoperative and postoperative pain relief.CASE SUMMARYThis report established that hip surgical procedures can be performed with a fascia iliaca compartment block (FICB) and monitored anesthesia care (MAC) while avoiding neuraxial or general anesthesia. This was a preliminary experience with two geriatric patients with hip fracture, American Society of Anesthesiologists status III, and with many comorbidities. Neither patient could be operated on within 48 h after admission. Both general anesthesia and neuraxial anesthesia were high-risk procedures and had contraindications. Hence, we chose nerve block combined with a small amount of sedation. Intraoperative analgesia was provided by single-injection ultrasound-guided FICB. Light intravenous sedation was added. Surgical exposure was satisfactory, and neither patient complained of any symptoms during the procedure.CONCLUSIONThis report showed that hip surgery for geriatric patients can be performed with FICB and MAC, although complications and contraindications are common. The anesthetic program was accompanied by stable respiratory and circulatory system responses and satisfactory analgesia while avoiding the adverse effects and problems associated with either neuraxial or general anesthesia.     

The Effects of Manual Physical Therapy and Therapeutic Exercise on Peripartum Posterior Pelvic Pain: Two Case Reports

Abstract

Peripartum posterior pelvic pain is a clinical enigma commonly encountered by physical therapists. It is hypothesized that the release of relaxin hormone during pregnancy may result in ligament laxity, which could lead to sacroiliac instability resulting in pain and decreased function. The purpose of these case reports was to describe the effects of manual physical therapy and therapeutic exercise on a peripartum patient with reports of posterior pelvic pain. Two patients referred to physical therapy by their obstetrician during their pregnancy were recruited for these case reports. During the initial examination, both patients completed a number of self-report measures including the Oswestry Disability Index, a body diagram, and the Numeric Pain Rating Scale. Both patients were treated with muscle energy techniques directed at pelvic and sacral positional faults and therapeutic exercise consisting of transverse abdominis and multifidus neuromuscular re-education; isometric hip abduction and external rotation; and a force closure sacroiliac stabilization program directed at neuromuscular re-education of the anterior and posterior oblique sling systems (hip adductors-contralateral obliques and gluteus maximus-contralateral latissimus dorsi combinations). At the time of discharge, both patients again completed the self-report outcome measures as well as a global rating of change. Both patients demonstrated a clinically meaningful improvement in their pain levels as well as perceived disability. In addition, both rated their global rating of change as "a great deal better." These case reports provide preliminary evidence suggesting that manual physical therapy and therapeutic exercise may be an effective intervention strategy for peripartum patients reporting posterior pelvic pain.     

Tramadol Added to Bupivacaine Does Not Prolong Analgesia of Continuous Psoas Compartment Block

The primary aim of our study was to evaluate the quality and duration of analgesia when tramadol was added to 0.25% bupivacaine for continuous psoas compartment block (CPCB) using visual analog pain scores. Thirty patients were prospectively randomized into two equal groups ( n  = 15). Visual analog scale pain score was not significantly different between the groups during the 48-hour follow-up period. Rescue analgesic consumption, nausea and vomiting, and the satisfaction scores were comparable between the groups ( P  > 0.05). Success with catheter placement adjacent to the lumbar plexus was 100%, and none of the patients developed any catheter-related complications. In conclusion, tramadol does not provide a clinically significant analgesic action as an adjunct to 0.25% bupivacaine for CPCB.     

Les lésions de la jonction myotendineuse du psoas-iliaque en traumatologie du sport

The psoas muscle, the main flexor of the hip joint, is highly solicited in sports activities. Sports injuries are however rarely encountered and described. We report a retrospective series of 33 cases of psoas musculotendinous tears at the point where the muscle changes direction over the iliopectineal eminence. History taking is essential to identify anterior hip pain with rapid or progressive onset. The physical examination searches for pain at hip flexion against resistance, observed in 78% of our cases, and a less sensitive sign, pain at muscle stretching. The morphology should be explored with ultrasound, which is highly contributive in the acute phase. MRI can provide complementary information if the injury is older or recurrent. If there is doubt about the diagnosis, the examination should be able to rule out other hypotheses: traumatic injury to the lower tendons, associated or not with bone detachment, abscess formation, or the more widely encountered psoas hematoma. Early management should focus on puncture aspiration of a hematoma associated with selective rest then rehabilitation over 4 to 6 weeks. Chronic and recurrent injuries may require local injections. An analysis of the sports movement should enable a specific management for each sport.     

Combined Sciatic and Lumbar Plexus Nerve Blocks for the Analgesic Management of Hip Arthroscopy Procedures: A Retrospective Review

Hip arthroscopy is a minimally invasive alternative to open hip surgery. Despite its minimally invasive nature, there can still be significant reported pain following these procedures. The impact of combined sciatic and lumbar plexus nerve blocks on postoperative pain scores and opioid consumption in patients undergoing hip arthroscopy was investigated. A retrospective analysis of 176 patients revealed that compared with patients with no preoperative peripheral nerve block, significant reductions in pain scores to 24 hours were reported and decreased opioid consumption during the post anesthesia care unit (PACU) stay was recorded; no significant differences in opioid consumption out to 24 hours were discovered. A subgroup analysis comparing two approaches to the sciatic nerve block in patients receiving the additional lumbar plexus nerve block failed to reveal a significant difference for this patient population. We conclude that peripheral nerve blockade can be a useful analgesic modality for patients undergoing hip arthroscopy.     

Abscess of the iliopsoas muscle diagnosed by magnetic resonance imaging and ultrasonography

We have reported a case of abscess of the iliopsoas muscle, in which a limp and hip pain pointed toward pathology of the hip. The diagnosis in such cases may be difficult unless there is close attention to the clinical history and a good physical examination is obtained. One ultrasonographic examination of the hip in such a patient, subtle differences between the iliopsoas muscles should alert the radiologist to examine the psoas muscle. Ultrasonography is instrumental in demonstrating the solid or cystic nature of the iliopsoas mass, while MRI depicts the extent and proximity of adjacent organs. Once an iliopsoas abscess is diagnosed, treatment includes parenteral antibiotics and drainage.     

Computed tomography-guided anterior approach to the superior hypogastric plexus for noncancer pelvic pain: a report of two cases

The objective of this study was to evaluate the possibility and describe the methodology of a computed tomography-guided anterior approach to superior hypogastric plexus block for noncancer pain. A computed tomography-guided anterior approach to the superior hypogastric plexus was used in 2 patients with pelvic pain and anatomic disturbance of the lumbar spine, which was a contraindication to the conventional dorsal approach. The first case was a 43-year-old patient suffering from burning pain of the urethra. Pain relief using analgesics and antidepressants was insufficient. The posterior approach was excluded due to coexisting irritation of the L5 nerve root. The second case was a 68-year-old man suffering from chronic burning and itching pain of the urethra and glans penis. Conservative therapy (anti-inflammatory drugs, tramadol, spasmolytics) failed to provide satisfactory pain relief. The posterior approach was contraindicated because of laterally prominent L5 vertebral body osteophytes. Both patients received a prognostic block to the superior hypogastric plexus via the anterior approach guided by computed tomography. Visual analog scale scores prior to the block were 6 to 7 and 5 to 6, respectively. The visual analog scale scores 24 hours after the block were 1 and 0, respectively. The second patient received a permanent neurolytic block via the anterior approach to provide long-term pain relief. In conclusion, the authors describe the computed tomography-guided anterior approach to the superior hypogastric plexus for chronic pelvic pain. The technique is simple to perform, and the analgesic effect is satisfactory. More extensive studies are necessary to evaluate the safety of this approach.     

Groin and hip pain due to fractures at or near the pubic symphysis

Three patients with fractures at or near the pubic symphysis presented with groin pain simulating hip fracture or arthritis. A 71-year-old osteoarthritic woman was treated with a nonsteroidal antiinflammatory drug (NSAID) and exercises for right-sided sciatic pain after a minor fall, but developed left groin pain and tenderness over the pubic symphysis after two days of exercise. She had an impacted fracture of the left pubic symphysis which responded to use of a cane. The second patient was a 90-year-old woman with rheumatoid arthritis (on steroids) who complained of right hip pain after a series of falls in her home. Initially treated with Buck traction for a presumed hip fracture, she was later treated with heat and exercises after negative hip x-rays were obtained. Retrospective analysis of pelvic films and bone scan revealed a right pubic symphysis fracture. The third patient was an 83-year-old rheumatoid arthritic woman with inability to walk secondary to left groin pain. Pubic tomograms revealed disruption of the superior aspect, and bone scan showed increased uptake of the left pubic bone. She was treated with moist heat, rest, and NSAID. Twenty-four cases of os pubis fractures without major trauma or symphysis disruption have been reported. All patients had osteoporosis, and six had rheumatoid arthritis. Our three cases are presented to increase awareness of pubic symphysis fractures as a cause for groin pain, especially in patients with osteoporosis and rheumatoid arthritis.     

Extraartikuläres Weichteil-Impingement des Hüftgelenks

Introduction

Conservative treatment is the gold standard for painful extra-articular snapping abnormalities of the hips caused by the psoas tendon, trochanteric bursitis and the iliotibial band. Arthroscopic tenotomy, bursectomy or tractus release are indicated if conservative management is not successful. In addition to open techniques, various arthroscopic techniques have also been described.

Therapeutic options

There are three different arthroscopic techniques described for psoas tenotomy: the extra-articular method (tenotomy at the level of the lesser trochanter), the transcapsular technique (tenotomy through the peripheral compartment) and the central technique (tenotomy at the level of the anterior rim with distracted hips). Good results have been published for all three methods. The mechanical irritation of the psoas tendon after total hip replacement is a special indication for arthroscopic tenotomy. The results are good and it is less invasive than the complicated cup replacement procedure with fewer complications. A newly described syndrome is iliopsoas impingement where an atypical tear of the labrum at the anterior rim of the acetabulum occurs. Treatment is carried out by arthroscopic refixation of the labrum and tenotomy of the psoas tendon. Open or arthroscopic procedures are recommended to perform a bursectomy or tractus release but comparative studies are currently lacking.

Conclusion

If conservative treatment of internal snapping hip syndrome and mechanical psoas irritation after total hip replacement fails, arthroscopic psoas tendon tenotomy is an effective method. Bursectomy and tractus release for extra-articular snapping hip syndrome can be carried out by open or arthroscopic procedures with similar results. The scientific evidence in other extra-articular abnormalities of the hip remains poor.