What are the management guidelines for a 25-year-old patient with a fall onto the left hip (greater trochanter) from a skateboard, presenting 1 week later with pain and significant edema (3+), but normal range of motion and strength?

Management of Suspected Greater Trochanter Contusion with Significant Edema

This 25-year-old patient with isolated greater trochanter trauma, preserved function, and significant delayed edema requires urgent advanced imaging to exclude occult fracture, followed by conservative outpatient management with structured pain control, edema reduction, protected weight-bearing, and close follow-up.

Immediate Diagnostic Workup

Rule Out Occult Fracture First

• Obtain CT hip without IV contrast immediately if not already done, as plain radiographs miss 24.1% of hip fractures and CT changes management in 20% of cases 1
• CT has 94% sensitivity and 100% specificity for detecting radiographically occult hip fractures that are invisible on plain films 1
• The 1-week delay with worsening edema raises concern for an occult fracture, particularly given that isolated greater trochanter fractures can extend to the femoral neck 1
• Do not rely on preserved range of motion and weight-bearing ability to exclude fracture—patients with basicervical and minimally displaced fractures can maintain function initially 2

If Imaging Confirms No Fracture

• Diagnosis is severe soft tissue contusion with hematoma formation
• The 3+ edema extending from ischial tuberosity to upper lateral thigh one week post-injury suggests significant soft tissue injury with possible evolving hematoma 3

Pain Management Protocol

First-Line Analgesia

• Start with scheduled NSAIDs (ibuprofen 600-800mg three times daily or naproxen 500mg twice daily) as first-line therapy for anti-inflammatory and analgesic effects 4
• Add acetaminophen 1000mg three times daily for multimodal analgesia targeting separate pain pathways 4
• Avoid NSAIDs only if patient has gastrointestinal, renovascular, or cardiovascular risk factors 4

Escalation if Needed

• If pain remains moderate to severe despite NSAIDs and acetaminophen, add short-term opioid therapy (e.g., oxycodone 5-10mg every 4-6 hours as needed for 5-7 days maximum) 4
• Use acetaminophen/opioid combinations to target multiple pain pathways simultaneously 4
• Prescribe only enough opioids for short-term use and counsel on proper disposal of unused medications to prevent misuse and diversion 4

Edema Management

Active Edema Reduction

• Initiate aggressive edema control immediately, as persistent edema beyond the inflammatory phase delays healing and contributes to pain and stiffness 3
• Elevate the affected hip above heart level for 20-30 minutes, 4-6 times daily 3
• Apply ice for 15-20 minutes every 2-3 hours during the first 48-72 hours, then as needed for pain and swelling 3
• Consider compression garments or elastic wraps (applied distal to proximal) if tolerated, though this may be difficult given the anatomical location 3

Monitor for Complications

• The extensive edema pattern (ischial to upper lateral thigh) requires monitoring for compartment syndrome, though this is rare in the hip region
• Reassess edema progression at 48-72 hours—worsening edema may indicate evolving hematoma requiring drainage

Activity Modification and Weight-Bearing

Protected Mobilization

• Allow weight-bearing as tolerated with assistive device (crutches or walker) for the first 2-3 weeks to reduce pain while preventing deconditioning 2, 5
• Avoid activities that reproduce pain, particularly forward ambulation which the patient identifies as most painful
• Permit activities of daily living within pain tolerance
• Do not prescribe complete bed rest, as immobility increases complications 2

Gradual Return to Activity

• Begin gentle range-of-motion exercises (hip flexion, abduction, adduction) after initial pain subsides, typically 3-5 days
• Progress to resistance exercises and impact activities only after pain-free range of motion is achieved, typically 3-4 weeks
• Return to skateboarding only after full pain-free function is restored, typically 6-8 weeks for severe contusions

Follow-Up Schedule

Structured Monitoring

• Recheck at 48-72 hours to assess edema progression, pain control, and functional status
• Repeat evaluation at 1-2 weeks to confirm clinical improvement
• If pain or edema worsens or fails to improve by 2 weeks, obtain MRI to evaluate for occult fracture, muscle tear, or hematoma requiring intervention 2, 1

Red Flags Requiring Urgent Re-evaluation

• Worsening pain despite appropriate analgesia
• Progressive edema or development of tense swelling
• New inability to bear weight
• Fever or signs of infection
• Numbness or weakness in the affected limb

Common Pitfalls to Avoid

• Do not assume normal radiographs exclude fracture in a patient with significant trauma and delayed presentation with worsening symptoms—proceed to CT or MRI 1
• Do not dismiss significant edema as "just a bruise"—extensive edema one week post-injury warrants investigation for occult fracture or hematoma 3
• Do not prescribe prolonged opioid therapy for soft tissue injury—limit to 5-7 days maximum and transition to non-opioid multimodal analgesia 4
• Do not recommend complete immobilization—early mobilization as tolerated prevents complications and promotes healing 2