Disorders of the Hip
From WiserWiki
Contents |
[edit] Disorders of the Hip
Jerry M. Greene
Elinor A. Mody
[edit] PATIENT EVALUATION
Pain in the hip is a frequent complaint of patients seen by primary care physicians (Fig.128-1).A mnemonic device for recalling the many causes of pain in or around a joint is PODAGRA HOT JOINT (Box 128-1).[1]
| Box 128-1 - Mnemonic for Pain in Area of Joint: PODAGRA HOT JOINT✢ |
| Rights were not granted to include this data in electronic media. Please refer to the printed book. ✢From Gravallese EM et al: Synovitis of the knee in a 42-year-old man: clinicopathologic conference, Arthritis Rheum 36:860, 1993. |
[edit] History
The most important elements of the history include the precise location of the pain, its character, areas to which pain radiates, its severity, activities or other factors that aggravate or alleviate the pain, and any functional impairment (Box 128-2).
| Box 128-2 - Causes of Pain in Area of Joint |
Anterior Hip, Medial Thigh, Knee
|
[edit] Location of Pain.
Patients use the term hip to refer to areas from the lower back to midthigh, and many complaints of hip pain do not arise from the hip joint itself.The patient should localize the painful area early in the interview, preferably by pointing to it.Pain in certain areas suggests particular anatomic structures as the possible sites of the problem (Box 128-2).
Anterior hip, inguinal, proximal thigh, medial thigh, and occasionally knee pain may be caused by an intraarticular process.Pain in these areas may also originate in the iliopectineal bursa; quadriceps, iliopsoas, or adductor muscles; femoral artery, nerve, or vein; inguinal lymph nodes; superior and inferior pubic rami; obturator nerve; or structures within the bony pelvis, especially the adnexa, appendix, and small and large intestines.Inguinal pain may also be referred from the kidney or ureter, may be caused by upper lumbar radiculopathy, or may arise from spinal facet joints, intervertebral disk, or vertebral bodies of the lumbar spine.
Lateral hip pain may arise from the greater trochanter of the femur, trochanteric bursa, lateral femoral cutaneous nerve, or iliotibial band.Lateral hip pain may be caused by a back problem, such as fourth lumbar vertebra (L4) root irritation or L4-5 or L5-S1 (first sacral vertebra) facet joint arthritis; intervertebral disk degeneration or infection; vertebral fracture, infection, or neoplasm; or myofascial pain with trigger points.
Posterior hip or buttock pain may also arise from the hip joint.Other structures associated with posterior hip pain include the ischial bursa, sciatic nerve, gluteal muscles, sacroiliac joints, the ischium, and the sacrum.Processes within the pelvis may also cause pain that is experienced in the posterior hip region.Neoplasms or abscesses arising from the rectum, prostate, adnexa, uterus, bladder, and bowel may involve the lumbosacral plexus or cause referred pain.Vascular insufficiency, especially of the external iliac arteries, may cause gluteal claudication.Lumbar spinal stenosis may cause pseudoclaudication (neurogenic) in the buttocks.
[edit] Character of Pain.
Descriptions of the pain may be helpful in determining the underlying pathophysiology.Dysesthesia, paresthesia, and numbness suggests a neuropathic process.Constant pain, including pain at rest and especially pain that interferes with sleep, is most often seen with neurologic, inflammatory, and neoplastic processes.Pain with use and decreased pain with rest suggests a mechanical process and is classic for osteoarthritis of the hip.After characterizing the hip pain, the examiner should determine ifany trauma, recent or remote, has occurred to the hip, pelvis, or lower back.The remaining elements of a general history include medication use, habits, occupation, concomitant medical illnesses, prior surgery, any prior episodes of joint pain, sexual history, history of illicit drug use, and episodes of chills, fevers, and rigors (Table 128-1).
Table 128-1 Selected Causes of Hip Pain
| Disorder | Epidemiology | History | Physical examination | Diagnostic tests | Differential diagnosis | Management |
|---|---|---|---|---|---|---|
| Acute rheumatic fever | Children and young adults; poverty and overcrowding,epidemics of arthritogenic strains of streptococci | Preceding pharyngitis (may be asymptomatic), arthralgia, rash, involuntary movements, migratory oligoarthritis | Fever, evanescent salmon-colored rash, synovitis, heart murmur, CHF, chorea, subcutaneous nodules | ASLO titer increased, ESR increased, ECG PR interval prolonged, echocardiogram may demonstrate regurgita tion, pericardial effusion | As for rheumatoid arthritis (see also Chapter 133 ) | Salicylates in anti-inflammatory dosages, steroids for resistant cases at dosages of 1 mg/kg/day, long-term prophylactic use of penicillin |
| Amyloidosis | Hip involvement unusual but may occur with chronic renal dialysis due to β2-microglobulin– related amyloid deposition, amyloidosis with chronic infections, chronic inflammatory diseases, and with paraproteinemias | Gradual onset of hip pain, symptoms of carpal tunnel syndrome (numbness, paresthesia, pain in thumb, index, and middle fingers), shoulder pain due to rotator cuff infiltration, easy bruising | Skin: waxy appearance, bruises and echymoses; abdomen: hepatosplenomegaly; musculoskeletal: pseudohypertrophy of deltoid muscles (shoulder pad sign) due to amyloid infiltration, limited shoulder motion; neurologic: peripheral neuropathy and Tinel's sign at wrist common | Plain radiographs demonstrate cysts or erosions in femoral head or neck; needle biopsy of lytic lesions; serum and urine immunoelectrophoresis; abdominal fat pad aspiration with Congo red staining is least invasive biopsy method | In chronic renal failure with patient on dialysis, hyperpara-thyroidism with brown tumors, other neoplasms (see tumors) | Control of underlying disease may prevent progression; for amyloid associated with myeloma or paraproteinemia: chemotherapy may be indicated; for dialysis-related amyloid: renal transplantation if possible |
| Avascular necrosis[2] | Predisposing condition; alcohol, glucocorticosteroids, sickle cell disease, decompression, pancreatitis, trauma, SLE, hyperlipo-proteinemias, radiation therapy | Sudden onset of pain, moderate to severe, limits weight bearing, predisposing factors may be present | Despite pain, passive ROM is normal in early disease; motion may be limited once collapse of cartilage and subchondral bone occurs | MRI most sensitive for early disease, demonstrates decreased T1 and increased T2 signal; plain films insensitive until late in course, may show subchondral collapse | Painful transient osteoporosis of hip, bone bruise, pelvic or sacral insufficiency fractures, osteomyelitis, neoplasm | Core decompression with or without vascularized bone or soft tissue grafting; rotational osteotomy; total replacement for hips with collapse and secondary osteoarthritis |
| Fracture of femoral neck | Increased risk with age; osteoporosis due to postmenopausal status; corticosteroid use; alcoholism; anticonvulsant drugs | Severe hip pain and inability to bear weight after fall | Deformity of hip with external rotation, slight flexion; assess neurovascular integrity; monitor vital signs carefully | Plain radiographs of hip and pelvis with minimal movement of affected leg | Pathologic fracture due to tumor or infection of femur; osteomalacia with Looser's line; impacted fracture; SI or pubic ramus fracture | Motion of affected hip should be minimized while assessment proceeds; if fracture documented: provide analgesia, monitor vital signs, obtain orthopedic consultation |
| Gout | Men twice as often as women, predominantly after adolescence; drugs may elevate uric acid level, especially hydrochlorothiazide, pyrazinamide, cyclosporine | Prior episodes of self-limited arthritis, severe pain, sudden onset, fever may be noted by patient | Fever may be present, usually <39° C; tophi; extremely limited ROM in all directions | Plain film may suggest effusion; aspiration positive for needle-shaped, brightly birefringent crystals on compensated, polarized microscopy; synovial WBC 10-100,000/mm3; Gram's stain negative | Septic arthritis, pseudogout, apatite arthritis, RA, ARF, SLE, Reiter's syndrome, reactive arthritis | See Chapter 136 |
| Hemorrhage | Children with hemophilia, adolescents with trauma, adults with trauma or anticoagulation | Sudden onset of pain after minor trauma, or no history of trauma; pain at rest and with use, usually severe with antalgic gait or inability to walk, history of prior bleeding diathesis or anticoagulant drug use | Signs of intraarticular process, evidence of bleeding diathesis (bruising, mucosal bleeding) | Plain radiograph to exclude fracture; CBC, PT/PTT, platelet count; aspiration yields blood; fat droplets on surface of aspirate (after specimen stands) suggest intraarticular fracture; hematocrit on synovial fluid <5% suggests hemorrhagic effusion, not hemorrhage | Hemorrhage: trauma, excessive anticoagulation, bleeding diathesis; bloody effusion: CPDD, pseudogout, apatite arthritis, neuropathic joint, pigmented villonodular synovitis, other joint tumors | Replacement of deficient clotting factors; partial correction to therapeutic range for excessive anticoagulation and clear indication (e.g., prosthetic valve); aspiration of as much fluid as possible; rest; analgesics; ROM exercises after 48 hours |
| Hernias | Associated with strenuous lifting, coughing, or Valsalva's maneuver | Anterior hip pain; patients sometimes note bulge | Hip motion normal; inguinal or femoral hernia palpated with Valsalva's maneuver or cough | If definite hernia, no further tests necessary | Inguinal mass may be tumor, lymphadenopathy, phlebo thrombosis, arterial aneurysm, necessitating abscess from pelvis, abdomen, or psoas muscle, or synovial cyst from hip joint | Emergency repair for incarcerated hernia; elective repair for reducible hernia |
| Iliopectineal bursitis | Most frequent in athletic males and dancers | Anterior hip pain; limited to hip extension, so running or brisk walking is painful; standing or slow walking does not increase pain | Affected hip may be flexed slightly; extension of hip aggravates pain; possible tenderness in anterior hip and inguinal region; palpate inguinal area for inguinal or femoral hernia, mass, aneurysm, lymphadenopathy; examine abdomen to exclude sigmoid colonic or appendiceal disease; pelvic exam for women | Plain films usually negative, rarely demonstrate calcific periarthritis or intrabursal calcifications; CBC, ESR, U/A to exclude infection and ureteral stone | If severe with limited hip ROM: infectious and other hip synovitis; if local anterior pain: iliopsoas tendinitis, psoas abscess, inguinal or femoral hernia, radicular pain, referred pain from kidney, ureter, obturator nerve irritation from pelvic mass or infection, femoral artery aneurysm | Analgesics, rest, local heat, NSAIDs, therapeutic ultrasound; for refractory cases: local corticosteroid injection (referral if necessary); refractory pain warrants bone scan, CT scan |
| Iliopsoas tendinitis | Athletes or coexisting osteoarthritis of hip | Anterior hip pain, active hip flexion may be most painful; stair climbing and putting on shoes and stockings may be difficult | Affected hip may be slightly flexed; possible anterior hip tenderness; pain reproduced by attempted hip flexion against resistance | Plain films negative; CBC, ESR normal | As for iliopectineal bursitis | As for iliopectineal bursitis |
| Iliotibial tendinitis | Athletes, overuse with repeated sitting and standing, leg length discrepancy | Lateral hip pain, aggravated by standing, walking, arising from chair | Tenderness along lateral thigh; pain with forced adduction or resisted abduction of hip | History and physical findings; diagnostic injection with local anesthetic of trochanteric bursa to distinguish trochanteric bursitis | As for trochanteric bursitis | Physical therapy with ultrasound, local heat, stretching of iliotibial band; analgesics, NSAIDs |
| Insufficiency (stress) fractures | Young people after repeated vigorous exercise; anyone after prolonged immobility or limited weight bearing, e.g., after total joint replacement in RA | Onset of pain with activity, aggravated with weight bearing, some relief with rest; may be severe and prevent weight bearing; pain may radiate widely to thigh or buttock | Passive hip motion usually preserved and does not aggravate pain; active motion may be limited by pain; pelvic compression (anteroposterior or lateral) or rocking may reproduce pain | Plain films of hip and pelvis relatively insensitive for insufficiency fracture of sacrum and ilium, better for pubic rami; bone scan sensitive; CT scan helps confirm fracture as cause | Metastatic and primary bone lesions, (see tumors), osteomyelitis, lumbar disk disease, referred pain | Analgesics and rehabilitation with partial weight bearing using walker; avoid prolonged bed rest; assess for osteoporosis or osteomalacia if indicated |
| Ischial bursitis (ischiogluteal bursitis) | Activities that cause repeated trauma to gluteal region pre-dispose to condition, e.g., horseback riding, weaving, skating | Posterior hip pain, increased with forward bending, sitting on hard surface | Tenderness over ischial tuberosity, preserved hip ROM, no sciatic notch tenderness, normal neurologic exam | Plain radiographs usually normal | Pelvic fracture (traumatic, stress related), sciatic nerve compression, pyriformis syndrome, radicular pain, referred pain from within pelvis, bone lesions in ischium | Avoid further repetitive trauma to ischial area; analgesics, NSAIDs, local heat, therapeutic ultrasound, local injection with corticosteroids |
| Lateral femoral cutaneous neuropathy | Recent weight loss or weight gain predisposes to pressure on lateral femoral cutaneous nerve as it passes over pelvic brim | Sudden or gradual onset of pain confined to lateral hip and thigh, accompanied by numbness and paresthesia, in absence of back pain or sensory changes below knee | Decreased sensation over lateral hip and thigh; preserved DTRs; no tenderness over trochanteric bursa | Plain films of pelvis to exclude lytic or blastic lesion of iliac crest | Lumbar radiculopathies should produce neurologic symptoms extending below knee; iliotibial tendinitis or trochanteric bursitis should have local tenderness | Avoid tight-waisted clothing; use suspenders rather than belts; analgesic medications may be necessary; low-dose amitriptyline, imipramine, or desipramine at bedtime; gabapentin |
| Lumbar radiculopathies | May occur in young adults from herniated disks and in older persons from lumbar spondylosis (degenerative disk and facet joint disease) with compression of spinal canal (spinal stenosis) or impingement on exiting nerve roots (lateral recess stenosis) | Posterior, lateral, or anterior pain, extending from back beyond hip, usually below knee; change in sensation; pain aggravated by walking; patient sitting to obtain relief suggests lumbar spinal stenosis | Tenderness of lumbar spine, paraspinal muscle spasm, positive straight leg raising, diminished sensation in dermatomal distribution, loss of DTRs, muscle weakness, no exacerbation of pain with hip motion | LS spine and pelvic radiographs; if cancer diagnosis and radicular pain without weakness: bone scan and follow-up CT scan of involved area; if weakness, bowel/bladder incontinence: MRI or CT scan of LS spine | See Chapter 127 | See Chapter 127 |
| Lyme disease | Children and adults with exposure to ticks in areas with endemic Borrelia burgdorferi | Travel or residence in endemic area, tick bite or removing ticks, slowly enlarging circular or oval erythematous rash, history of painful radiculopathy or cranial nerve palsy, especially Bell's palsy | Fever, usually low grade if present; possible skin rash, usually polycyclic erythematous eruption; hip motion diminished in all directions; cranial nerve VII weakness or other cranial neuropathy or radiculopathy | Aspiration of hip reveals inflammatory fluid with lymphocytic predominance; plain films: swelling or normal; CBC normal; ESR: elevated moderately; Lyme titer usually elevated | Other chronic synovitis: as for rheumatoid arthritis (see also Chapter 133 ) | For proven Lyme arthritis: ceftriaxone 1 gm IV every 12 hr for 2 wk |
| Osteitis deformans (Paget's disease of bone) | Middle-aged to older adults | Pain anywhere in hip; may occur with activity and weight bearing, especially with osteoarthritic change of involved hip joint; rest and night pain with bony involvement alone or advanced osteoarthritis | Preserved ROM without exacerbating pain suggests pain from bony involvement; pain with motion suggests concomitant osteoarthritis of hip | Plain films demonstrate coarse trabeculi; increased size of bone, thickening of cortex, areas of lucency; possible osteoarthritis of hip; alkaline phosphatase elevated; prostate-specific antigen in men | Prostate cancer, sclerosing osteomyelitis, other blastic metastatic disease (e.g., thyroid, breast), transformation of Paget's disease to osteogenic sarcoma (suggested by marked change, rise or fall, in alkaline phosphatase unrelated to therapy) | Alendronate, etidronate, or calcitonin; if severe associated osteoarthritis: total hip replacement, treatment with etidronate or calcitonin for 6 wk to 3 mo before surgery |
| Osteoarthritis | Older more than younger persons; some heritable forms with epiphyseal dysplasias and defined collagen mutations | Pain with use, better with rest, gel phenomenon common; with advanced disease: continuous pain, difficulty sleeping | Antalgic gait or adductor lurch, positive Trendelenburg's sign, limited ROM, pain reproduced by motion, no tenderness, leg lengths may differ slightly | Plain radiographs show joint space narrowing, osteophyte formation, sclerotic bone, subchondral cysts | Secondary osteoarthritis, septic arthritis complicating osteoarthritis, crystal disease | Weight loss, moderate low-impact exercise, cane, acetaminophen, NSAIDs, hip replacement for severe symptomatic disease or rotational osteotomy for younger patients |
| Osteochondromatosis[3] | Rare cause of large joint pain and chronic synovitis | Slowly developing pain, restricted motion in hip | Swelling may be apparent in anterior hip, joint motion restricted | Plain radiographs may demonstrate multiple osteochondral bodies within joint capsule or may suggest joint swelling or effusion; MRI can distinguish multiple cartilaginous bodies from joint fluid when calcification is absent | Chronic inflammatory synovitis (see rheumatoid arthritis), especially with rice bodies, pigmented villonodular synovitis | Synovectomy is curative, secondary osteoarthritis may progress following synovectomy |
| Pseudogout | Older persons; men same as women; some predisposing conditions, including hyperparathyroidism, hypothyroidism, hemochromatosis | Sudden onset of pain; history may suggest disorder associated with pseudogout | Fever possible; pain and limited ROM consistent with intraarticular process; features may suggest underlying disease | Plain radiographs may be normal, suggest effusion, or demonstrate chondrocalcinosis; WBC normal to mildly elevated; aspiration: weakly birefringent, stubby rhomboidal crystals; elevated synovial WBC 10-100,000/mm3 | As for gout; if aspiration proven or chondrocalcinosis extensive, consider hyperparathyroidism, hypothyroidism, hemochromatosis, hypomagnesemia, ochronosis, Wilson's disease, acromegaly | As for gout (see also Chapter 136 ) |
| Reactive arthritis | Sexually active patients at risk for postgonococcal arthritis; HLA-B27 often present, especially with sacroiliac or spinal involvement and in Reiter's syndrome; may follow dysentery | Antecedent urethritis, dysentery, inflammatory bowel disease, psoriasis, known HIV infection, previous or current eye pain, photophobia, conjunctivitis, iritis, back pain, back stiffness, skin rash, especially on palms or soles or genitalia | Psoriasis or psoriasiform lesions on glans penis, vesiculopustular hyperkeratotic lesions on palms or soles, nail pitting or onycholysis, painless oral ulcers, conjunctivitis, irregular pupils, limited back motion, tenderness over sacroiliac region, tenosynovitis, peripheral arthritis | If acute gonococcal dermatitis/arthritis suspected, appropriate cultures should be obtained (see septic arthritis); if risk factors for HIV, counseling and testing; SI joint plain films may demonstrate sacroiliitis; ANA and RF are negative; consider small bowel series for occult Crohn's disease | With evidence of synovitis of hip: gonococcal arthritis, other septic arthritis; if posterior hip pain and evidence of Reiter's syndrome: sacroiliitis | Indomethacin and naproxen may be more effective than other NSAIDs for Reiter's and spondylitis; phenylbutazone effective but risk of marrow aplasia; sulfasalazine or methotrexate for resistant disease; corticosteroids for severe disease; local injection of involved joint |
| Referred pain | Pain may be referred from many structures; pelvic and retroperitoneal inflammation or tumors; ureteral stones; osteoarthritis of facet joint, intervertebral disks of spine, pelvic bones | Hip motion usually preserved and does not exacerbate pain; palpable mass may be present in pelvis on abdominal, pelvic, or rectal examination | Plain films of hip and pelvis help to exclude bony pathology; U/A to assess for ureteral stone; consider pregnancy; ultrasound or CT scan of pelvis for pain that remains obscure | Other causes of pain discussed above and below | For pain referred from back; see Chapter 127; pain due to tumors or infections should be treated while underlying problem addressed | |
| Rheumatoid arthritis | 1% of population, any age, females more than males | Morning stiffness, symmetric pain in hands and feet, fatigue | Limited hip ROM in all directions, nodules, tenderness of small joints of hands and feet | ESR elevated, RF elevated in 80%, joint fluid WBC elevated | Septic arthritis, gout, pseudogout, apatite arthritis, psoriatic and other seronegative arthritis, rheumatic fever, SLE, viral arthritis (parvovirus B19), Lyme disease, sarcoidosis | Rule out septic arthritis with cultures if monoarthritis; NSAIDs, disease-modifying drugs, oral or injected corticosteroids (see Chapter 133 ) |
| Septic arthritis | Children:Haemophilus influenzae, staphylococcal, streptococcal infection; adolescents and young adults: often gonococcal; older adults: impaired hosts (alcoholic, renal disease, immuno suppressed); staphylococcal, streptococcal, gram-negative bacteria; prior joint damage or chronic inflammation predisposes to infection | Anterior hip pain, usually sudden to subacute onset, generally severe; fever and rigors may occur; skin rash may have been noted; source of sepsis should be sought, e.g., cough, dysuria | Fever in 50%; maculopapular, vesicular, or vesiculopustular rash suggests gonococcal dermatitis arthritis; hip motion reduced in all directions; leathery crepitance may be felt | Blood cultures positive in 50% of nongonococcal bacterial arthritides; synovial WBC usually >50,000/mm3, often >100,000/mm3; peripheral WBC elevated in 50%; synovial Gram's stain positive in 50%; plain radiographs may demonstrate effusion or adjacent osteomyelitis; urethral, pharyngeal, rectal, or cervical cultures if appropriate | Purulent fluid aspirated; gonococcal and nongonococcal bacterial arthritis, fungal, mycobacterial infectious arthritis, Lyme disease, Whipple's disease, gout, pseudogout, apatite arthritis, rheumatoid psoriatic arthritis, Reiter's syndrome and reactive arthritis, ankylosing spondylitis, septic iliopectineal bursitis, psoas abscess | Drainage: requires arthrotomy or percutaneous placement of drain under CT guidance; antibiotics: ceftriaxone 1 gm IV every 12 hr for gonococcal arthritis: penicillinase-resistant penicillin (e.g., nafcillin) IV; add aminoglycoside if documented or strongly suspected gram-negative infection, e.g., neutropenic or immunosuppressed patients; analgesics; passive ROM after about 48 hr of treatment |
| Systemic lupus erythematosus | Young women: women more than men; African-American and Hispanic more than white, complement deficiencies, especially C2; drugs, especially INH, hydralazine, procainamide | Arthralgia, arthritis, malar skin rash, pleurisy, pericarditis, nephritis, seizures, psychosis, fever, malaise, fatigue | Oral ulcers, fundal hemorrhages or exudates; skin rash, especially malar or photosensitive; pleural or pericardial rubs; lymphadenopathy; arthritis of small joints of hands, wrists, feet (symmetric) | ANA present in 90%; anti-SM more specific, as are anti-dsDNA antibodies; anti-ssDNA and antihistone antibodies in drug-induced SLE; Coombs' test, VDRL | Pain may result from avascular necrosis of hip, septic arthritis, synovitis due to SLE, bursitis; most other causes of hip pain may occur in patients with SLE | For arthritis due to SLE, NSAIDs are mainstay; antimalarials (e.g., hydroxychloroquine) for arthritis; corticosteroids generally reserved for treatment of life-threatening disease |
| Trochanteric bursitis | Bursitis and tendinitis may result from overuse and may be seen in athletic adolescents; post-traumatic trochanteric bursitis may occur at any age: bursitis and tendinitis may be more common in diabetics and those with chronic inflammatory disorders, especially RA, SLE | Lateral hip pain, often aggravated by weight bearing, rising from chair, climbing or descending stairs; patients may note increased pain lying on affected side at night; night pain may be prominent; some patients unable to walk due to severe pain | Tenderness over greater trochanter of femur, reproduces pain; hip motion may be decreased by pain but internal and external rotation relatively preserved; forced adduction may aggravate pain | Plain radiographs show calcific deposits superior and lateral to greater trochanter, irregularity of trochanter, normal hip joint or early osteoarthritic changes; for severe pain: CBC, ESR may exclude very uncommon septic trochanteric bursitis | Trochanteric fracture or bone bruise due to trauma; impacted fracture of femoral neck; avulsion fracture of greater trochanter (in athletic adolescents); meralgia paresthetica (lateral femoral cutaneous neuropathy); radiculopathy should not produce local tenderness; herpes zoster before appearance of rash | Conservative: local heat, analgesics or NSAIDs, rest, ultrasound with or without 10% hydrocortisone cream (phonopheresis) for 4-6 wk; local injection: 20-40 mg depomethylprednisolone and 2 ml 1% or 2% lidocaine, injected deeply with 1.5-inch 25-gauge or 3.5-inch 22-gauge spinal needle into area of maximal tenderness |
| Tumors | In childhood: leukemia, neuroblastoma most common solid tumor; in adults: metastatic cancer, lymphoma, soft tissue sarcomas | In children: limp may be noted by parents; in adults: hip pain may be aggravated by weight bearing but often prominent at night, gradual worsening, may be severe, other constitutional symptoms, especially weight loss; review of systems important if no cancer history | If bone lesion: joint motion may be unrestricted and does not reproduce pain; if intrasynovial tumor: restricted joint motion, palpation may detect mass or tenderness of bones or soft tissues; thyroid, chest, breast, rectal, prostate, pelvic exam for suspected primary | Plain films may demonstrate lytic or blastic lesions or erosion of bone; bone scans sensitive for metastatic deposits; CT helpful to define bone lesions and guide biopsy if necessary; MRI useful for soft tissue tumors; CBC, ESR, SPEP, CXR, U/A, VDRL, liver enzymes (chest CT if sarcoma) | Infection, especially osteomyelitis, gummatous syphilis, histiocytosis, amyloidosis, tophaceous gout, hyperparathyroidism, Paget's disease | Analgesia including narcotics if necessary; tricyclics in low dose may be helpful; local or regional nerve blocks for proven malignant neoplasms; radiation therapy; consider prophylactic pinning if lesion is large and involves femoral neck or shaft |
| ROM, Range of motion;ESR, erythrocyte sedimentation rate;RF, rheumatoid factor;WBC, white blood cell count;SLE, systemic lupus erythematosus;NSAIDs, nonsteroidal antiinflammatory drugs;CHF, congestive heart failure;RA, rheumatoid arthritis;ARF, acute rheumatic fever;TSH, thyroid-stimulating hormone;DIP, distal interphalangeal;SI, sacroiliac;ANA, antinuclear antibodies;PT, prothrombin time;PTT, partial thromboplastin time;CPDD, calcium pyrophosphate deposition disease;CBC, complete blood count;SPEP, serum protein electrophoresis;CXR, chest x-ray;CT, computed tomography;MRI, magnetic resonance imaging;HIV, human immunodeficiency virus;U/A, urinalysis;DTRs, deep tendon reflexes;LS, lumbosacral;ASLO, antistreptolysin O;ECG, electrocardiogram;VDRL, Venereal Disease Research Laboratories;IV, intravenously. | ||||||
[edit] Physical Examination
The physical examination should be tailored to the acuteness, severity, and complexity of the complaints.The goal is to reproduce the pain through palpation or maneuvers.[4] The essential elements of an examination for hip pain include observing for deformities in patients who cannot walk.A flexed, externally rotated, shortened leg is seen with hip fracture, whereas an internally rotated shortened leg suggests posterior dislocation.Patients with either of these deformities should not undergo hip maneuvers until fracture or dislocation has been ruled out by radiographic studies.
The gait of patients who can walk may demonstrate a limp.The patient with an antalgic gait bears weight only briefly on the affected side.The patient with an adductor lurch shifts upper body weight to the side of the painful hip.Having the patient attempt to stand on one leg at a time (Trendelenburg's test) may demonstrate an inability to bear weight on the affected side or an inability to keep the pelvis level while doing so.The examiner should assess whether the patient rising from sitting to standing exacerbates the pain.The painful hip is inspected for swelling, erythema, and rash.Active range of motion of the hip, knee, and lower back is then assessed.Palpation helps identify masses and tenderness of the vertebral spines; paravertebral muscles; bursae, especially greater trochanteric, ischial, and iliopectineal; inguinal lymph nodes; femoral artery and vein; quadriceps, adductor, and gluteal muscles; superior pubic ramus; symphysis pubis; and sciatic notch.
Limitation of movement can be assessed by passively taking the hip through its range of motion, which normally consists of 90 to 100 degrees of flexion, 30 degrees of extension, and 30 to 45 degrees of rotation, abduction, and adduction.Palpation and passive motion may reproduce the patient's usual hip pain.A regional neurologic examination should be performed if the history or examination suggests a neuropathic process.Provocative testing, including straight leg raising (SLR) and Lasègue's sign (tensing the sciatic nerve by SLR, then dorsiflexing the foot) for nerve root irritation, are also useful (see Chapter 127 ).If the history and examination have not led to a definite working diagnosis, a complete physical examination may be necessary, including abdominal, rectal, and pelvic examinations.
[edit] LABORATORY TESTS AND DIAGNOSTIC PROCEDURES
Laboratory testing is guided by the findings on the history and physical examination.No standard panel of tests is appropriate for all cases of hip pain.(See Table 128-1.)
Depending on the history and physical findings, radiographs may be unnecessary, especially if (1) symptoms are mild; (2) symptoms result from muscular strain, bursitis, or tendinitis, for which conservative therapy is indicated; or (3) the patient can be relied on to return if symptoms persist or worsen.For more severe pain, when conservative therapy has failed, or when local injection of corticosteroids (e.g., trochanteric bursal injection) is anticipated, plain radiographs of the hip and pelvis are indicated to assess for fractures, neoplasm, or infection.(See Table 128-1.)
Aspiration of fluid from the hip is more difficult than from other, more superficial joints.Failure to obtain fluid with blind aspiration is not adequate to rule out an effusion.In patients with suspected septic arthritis or more chronic undiagnosed arthritis of the hip, arthrocentesis should be performed with fluoroscopic guidance and with instillation of contrast medium to confirm the intraarticular location of the needle tip.This procedure is most often performed by interventional or musculoskeletal radiologists or orthopedic surgeons.Any synovial fluid obtained should be analyzed for glucose, cell count and differential, Gram's stain, and crystals by compensated polarized microscopy.Joint fluid should be cultured routinely for aerobic and facultative anaerobic bacteria.If tuberculosis or opportunistic fungal infection is suspected, additional stains and cultures for mycobacteria and fungi should be obtained.
If the history, physical examination, routine laboratory tests, plain radiographs, and aspiration (if appropriate) do not provide a diagnosis, other tests may be helpful.Technetium pyrophosphate bone scans may demonstrate increased tracer uptake in neoplastic and infectious foci before they are apparent on plain radiographs.Bone scans can also identify stress fractures that may be difficult or impossible to detect on plain films.Gallium scans may detect infectious foci or tumors around the hip or within the pelvis.Computed tomography (CT) scans are useful for providing more detailed bone and soft tissue images and are particularly useful for evaluating pelvic structures, spinal elements, and the sacroiliac joints.CT scans are also moderately sensitive for avascular necrosis of the femoral head.Magnetic resonance imaging (MRI) is currently the most sensitive tool for early detection of avascular necrosis and is also very useful for evaluating the spinal canal, neural foramina, intervertebral disks, muscles, and bursae.With gadolinium enhancement, MRI is very useful in delineating septic diskitis.(See Table 128-1.)
[edit] DIFFERENTIAL DIAGNOSIS
See Boxes 128-1 and 128-2 and Table 128-1 for possible causes of pain in the area of the hip.
[edit] MANAGEMENT
See Table 128-1 for treatments appropriate in specific diseases.See chapters on specific diseases for additional information on management.
[edit] REFERENCES
- ↑ EM Gravallese,et al.: Synovitis of the knee in a 42-year-old man: clinicopathologic conference. Arthritis Rheum 1993; 36:860.
- ↑ RR Coombs, RW Thomas: Avascular necrosis of the hip. Br J Hosp Med 1994; 51:275.
- ↑ SR Gilbert, PF Lachiewicz: Primary synovial osteochondromatosis of the hip: report of two cases with long term follow up after synovectomy and a review of the literature. Am J Orthop 1997; 26:555.
- ↑ WN Roberts, RB Williams: Hip pain. Prim Care 1988; 15:783.
