Hip Pain In A Female Military Trainee: A Cautionary Tale Of Catastrophic Complications

Abstract

Hx: A 31 y/o F client presented to a PT by self-referral, with a primary c/o R hip and groin pain. The client was a previously competitive runner and triathlete and was currently undergoing US Army Initial Entry Training. PE: The client presented with a moderately antalgic gait, exhibiting a “compensated gluteus medius” gait pattern. Grossly limited ROM in the R hip complex due to pain. No apparent edema, erythema, ecchymosis, atrophy, or deformity on observation. Positive heel tap, fulcrum, patellar-pubic percussion test. DDx: 1. Femoral Neck Stress Fx 2. Pelvic stress fx 3. Adductor strain/avulsion 4. Hip flexor strain/avulsion 5. Femoral shaft stress fx 6. Lumbar spinal referral 7. Non-organic etiology Tests & Results: Plain radiography, bone scan, and MRI: consistent with the primary clinical hypothesis following the clinical examination, a FNSF. Final Diagnoses: FNSF, mid-femur fx, osteomyelitis Treatment & Outcomes: Pre-op the client was given crutches and instructed in a NWB gait. She underwent an uncomplicated ORIF. The immediate post-op course, including PT, was uneventful and included reinforcement of the importance of compliance with the post-op instructions, including NWB progressing to TTWB gait with crutches. The client experienced a fall shortly after being d/c’d from her inpatient stay, which resulted in a fx of the ipsilateral femur. She underwent a 2nd uncomplicated ORIF of her R femur fx. Again, the immediate post-op course, including PT, was uneventful. However, approximately 2 weeks following her d/c from the inpatient stay, the client began to report vague constitutional symptoms including fatigue, fever, and nausea. The PT ordered lab studies including CBC/diff, CMP, and ESR. Results were broadly abnormal and the ortho surgical service was contacted directly and a same-day referral made. Subsequent imaging and serial lab studies confirmed an infection and the patient was taken back for a 3rd surgery, ultimately resulting in an osteotomy and revision of the FNSF ORIF. After a brief stay in the ICU, the patient was transferred to the ortho floor and remained there for several weeks, while receiving IV antibiotics and serial imaging and lab studies. The client was d/c’d and transferred to the medical hold unit to begin the process to be removed from military service.