Endgames Picture Quiz

An adolescent athlete with groin pain

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2766 (Published 28 April 2014) Cite this as: BMJ 2014;348:g2766
  1. James Thing, specialist trainee year 6, sport and exercise medicine registrar1,
  2. Chris Coates, orthopaedic surgeon 2,
  3. Mike Bundy, sports medicine physician3
  1. 1Medical Centre, Cranleigh School, Cranleigh GU6 8QQ, UK
  2. 2Royal Surrey County Hospital, Guildford, UK
  3. 3Pure Sports Medicine, Cranleigh School, Cranleigh, UK
  1. Correspondence to: J Thing thing.james{at}gmail.com

A 14 year old boy felt a mild aching discomfort in his left groin while playing rugby but still continued to play. He subsequently tackled an opponent and developed a severe pain of sudden onset in the left upper thigh and groin. A “snapping” sound was heard and he fell to the ground. He was unable to bear weight on the left leg and appeared pale, clammy, and nauseated. His pitch-side vital observations were normal and he was offered combined gaseous nitrous oxide and oxygen for pain relief. Ice was applied to the area of maximum discomfort and he was accompanied to the emergency department in an ambulance. At the emergency department he was advised that he had probably “strained” a muscle and was given conservative advice. He was discharged with crutches and analgesia.

The next day he was seen by the school doctor, who documented that he could not fully bear weight on the left leg or actively flex his leg on the examination couch. A radiograph was arranged (fig 1) and the diagnosis made on the basis of the report.

Questions

  • 1. What is the most obvious abnormality seen on the radiograph?

  • 2. What is the likely diagnosis?

  • 3. Who is most at risk of sustaining such an injury?

  • 4. What is the standard management regimen for such an injury?

  • 5. What are the indications for surgical management of this injury?

Answers

1. What is the most obvious abnormality seen on the radiograph?

Short answer

There is bony irregularity and displacement of the lesser trochanter of the left femur.

Long answer

There is bony irregularity and displacement of the lesser trochanter of the left femur. When compared with the right side, the left femur shows obvious asymmetry, with separation and proximal displacement of the superior …

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