Hip Pain (Cary)

Describe blood supply to the hip.

*Medial Circumflex Femoral Artery* supplies most blood to the femoral head. The Retinacular branches come off it, and supply the hip joint. These arteries can be disrupted in intracapsular fractures (subcapital fractures), leading to risk of avascular necrosis.

Pediatric Hip Pain: A 6 year old girl presents to the urgent treatment center with the sudden onset of intense right hip pain. She has not had any injuries that her mom knows of but she did wake up this morning with a fever and has been experiencing chills. She is refusing to bear weight on her right leg and cries out with intense pain if anyone attempts to move the leg. On exam you note that she has a fever of 40°C and is crying intensely. She refuses to move her right leg and passive range of motion testing is unable to be completed due to intense pain. There is nor overlying erythema or swelling of the right hip. What is the most likely infectious agent?

*Staph aureus* causes the vast majority of septic arthritis cases (Strep also common in kids; Salmonella for Sickle Cell patients)

Lumbar Spine Stenosis: Physical Exam

- "Kemp Sign:" Unilateral radicular pain from foraminal stenosis made worse by back extension. - Straight leg raise, Valsalva test, all other tests normal - May have lower leg muscle weakness after ambulation - May have impaired reflexes of knee or ankle

Septic Arthritis: Physical Exam

- *Acute* monoarticular pain - Most commonly the *knee* - *Erythema and warmth not seen with septic arthritis of the hip in pediatrics* but seen over other joints - Febrile illness - Intense pain with passive movement

Causes of hip pain in children 0-4 years old:

- *Developmental Dysplasia of the Hip* - Septic Arthritis - Osteomyelitis - Fracture

Osteonecrosis: Non-Traumatic Causes

- *Glucocorticoids* - *Alcohol* - Sickle Cell Disease - Idiopathic

Classic history for SCFE:

- *Painful limp* - Insidious onset - Some may have history of minor trauma or noticing the pain after jumping - Dull ache exacerbated by exercise - Pain located in the groin to the *medial knee*

Describe the anatomy of the hip.

- A ball and socket joint - Head of the femur joins the acetabulum

Legg-Calve-Perthes Disease: Epidemiology

- Accounts for 2% of childhood limping, with 1/1200 kids affected - Children ages 4-8 - Males more than females (4:1) - Kids tend to be short & have delayed bone age

Osteonecrosis: History

- Anterior groin pain with movement; may lead to thigh and buttock pain - Frequent pain on walking *and at rest* and sometimes even *at night* - May have history of corticosteroid use - If multiple joints involved, may suggest a multicfocal process

Lumbar Spine Stenosis: Symptoms

- Back pain and referred buttock pain - Neurogenic claudication - Pain with with extension (walking downhill, standing upright) - Pain relieved with flexion (bending forward, leaning over shopping cart) - Leg pain often unilateral - Weakness - Bladder disturbance (*recurrent UTI* due to autonomic sphincter dysfunction) - RARELY, cauda equine syndrome

Transient (Toxic) Synovitis

- Benign, self-limited condition - *ONLY IN PRE-PUBESCENT CHILDREN* - No known cause - Causes *sterile* joint effusions for 7-10 days - No or *low grade* fever - Can ambulate with limp (range of motion only mildly limited) - ESR *less than 40 mm/hour* - WBC *less than 12K*

Transient Synovitis: Epidemiology

- Boys - 3-8 years old (most under 5)

Sacroiliac Joint Dysfunction: Management

- Determine cause - *Analgesics* and *TNF Inhibitors* (if Ankylosing Spondylitis) - Physical Therapy - Joint Injection - Just fusion (rare)

Meralgia Paresthetica: Management

- Education to control obesity and diabetes - Avoid tight garments - Weight Loss

Femoral Neck Fractures: Epidemiology

- Elderly (the number of fractures is increasing as the number of elderly increases) - Females - Those with osteoporosis, on long-term steroids - Falls

Septic Arthritis: Management

- Emergent treatment is necessary to prevent severe joint destruction and permanent deformity and disability. - Antibiotics (IV); start broad spec and then tailor therapy once the pathogen has been identified - Change to oral antibiotics only after improvement - Drainage and surgery may be required in hip, knee, and shoulder cases

Physical exam of SCFE

- Examine above/below the joint in question - Examine the contralateral side - Examine if obese, adolescent male - Hold lower extremity in external rotation - Note *decreased internal rotation and increased external rotation*

Sacroiliac Joint Dysfunction: Physical Exam

- FABER test shows posterior pain localized to the SI joint; there is SI joint line tenderness

Risk factors for DDH?

- Female (increased estrogen and relaxin increases joint laxity?) - Breech position & swaddling (minimizes contact) - Genetics

Osteonecrosis: Traumatic Causes

- Femoral Neck Fracture (blood supply lost) - Fracture or Dislocation (blood supply lost)

What are the mechanisms of spread leading to Osteomyelitis?

- Hematogenous (common in children) - Extension from local soft tissue infection - Direct inoculation (open fracture, etc.)

Femoral Neck Fracture: Treatment

- IV analgesia for pain - Younger Patients: ORIF with *parallel pinning* of femoral neck - Older Patients: Hip arthroplasty ("joint replacement")

Femoral Neck Fractures: Major Complications

- Immobility - Avascular necrosis and nonunion - Increased risk of *Deep Vein Thrombosis* and *Pulmonary Embolism* (due to prolonged recumbency and immobilization) which requires *prophylactic anticoagulation* - *Pneumonia*; also a complication of prolonged recumbency and immobilization

Femoral Neck Fractures: Physical Exam

- Limb shortened - Limb externally rotated

What imaging is available to check for Osteonecrosis?

- MRI is the *most sensitive*; look for the "double line" sign showing borders of high and low intensity - X-ray is insensitive in early phases of disease, but can show collapsed bone ("crescent sign") in late phases - Bone scan will show no uptake in early stages, but increased uptake in late stages

Legg-Calve-Perthes Disease: Management

- Maintain hip motion - Pain relief as necessary - Containment (make sure you maintain normal contact between femoral head and acetabulum)

Greater Trochanteric Bursitis: Management

- NSAIDs - Physical Therapy - Corticosteroid Injection

Lumbar Spine Stenosis: Management

- NSAIDs - Physical Therapy - Steroid injections (epidural and transforaminal) for advanced symptoms - Surgery (may have recurrence, though)

Calve-Perthes Disease: Presentation

- No systemic signs - *Insidious onset* of persistent *painless* limp (persistent pain is mild if present, and may include both hip and knee) - Kids tend to be *short* & have *delayed bone age* - Bilateral in 15% of cases

Management of SCFE

- Non-weight bearing, strict *bed rest* - Surgical fixation with screws - Close follow up, especially of *contralateral hip* (the second hip may have problems within 18 months!)

What groups get SCPE?

- Obese adolescents - Males slightly more than females (1.5:1) - 11-14 years old

Clinical manifestations of Slipped Capital Femoral Epiphysis?

- Often chronic presentation, but rarely can be acute directly following trauma like a fall from height - Dull, nonradiating groin and thigh pain, often involving the knee - Pain worse with activity - *Decreased internal rotation* - Bilateral 25% of the time - Ranging severities

Osteoarthritis: History

- Over 40 - Pain radiates to groin (hip OA) - Stiffness (does not last long in the morning) - Pain worse with activity, improves with rest

Sacroiliac Joint Dysfunction: History

- Pain radiates to the lumbar back, buttock, and groin - May have history of trauma or recent pregnancy (*more common in females*)

Osteoarthritis: Physical Exam

- Pain with hip rotation or Patrick (FABER) test - Limited range of motion late in disease process

Legg-Calve-Perthes Disease: Physical Exam

- Painless Limp - *Shortening of affected limb* - Decreased *internal rotation* and *abduction* of the hip (SCFE also causes decreased internal rotation) - Atrophy of muscles in the upper thigh

What are important components of the history when evaluating hip pain?

- Patient age - Mechanism of injury - Details about the pain - Limitations of ability - Associated symptoms (check for red flags)

Osteoarthritis: Management

- Physical Therapy - Analgesics - Hip replacement

Osteonecrosis: Radiography

- Radiography (anterior, lateral films); however, can be normal for months after the symptoms of osteonecrosis begin. - Earliest findings will be density changes, then sclerosis and cysts. - "Pathognomonic Crescent Sign" is subchondral radiolucency that indicates subchondral collapse - Joint space narrowing and degenerative changes int he acetabulum are visible

Slipped Capital Femoral Epiphysis

- Salter-Harris 1 fracture leads to the inferior and posterior slippage of the proximal femoral epiphysis - One of the most common hip problems in adolescence

Clinical Exam for DDH?

- Screen all newborns - Ortolani Test - Barlow Test - Galeazzi Test

Femoral Neck Fractures: Presentation

- Severe hip and groin pain worse with movement - Unable to move hip - May have history of fragility fractures, vertebral compression fractures, or Colle's fracture (particular if this was a FOOSH)

Causes of hip pain in children over 10:

- Slipped Capital Femoral Epiphysis (a type 1 Salter Harris causes the "scoop to slide off the cone") - *Osteochondritis Dissecans* (lack of blood supply causes cracks to form in the articular cartilage and subchondral bone) - Apophysitis - Osteomyelitis - Septic Arthritis (note: in teens, also think about *Gonococcal* infections)

What are some tests that test the functionality of the hip?

- Squatting - Resting foot on the opposite knee - Jumping - Hopping on one leg - Running + twisting )changing directions) - ADLs: getting in and out of car; walking up steps or uphill; use of rail to walk down steps

Causes of hip pain in children 4-10 years old:

- Transient synovitis - *Legg-Calve-Perthes Disease* (avascular necrosis of the femoral head) - *Juvenile Idiopathic Arthritis* - Septic Arthritis - Osteomyelitis - Fracture - *Leukemia*

Greater Trochanteric Bursitis

- Trochanteric bursa separates the gluteus maximus from the lateral side of the greater trochanter -Irritation of the bursa produces *lateral hip pain* - Patient will be *point tender over the greater trochanter*

Osteonecrosis: Management

- Try to preserve the native joint with non-operative management, joint preserving procedures. - Joint replacement if all else fails

Describe the pelvis.

- Two innominates meet at the pubic symphysis anteriorly, and joint at the sacroliliac joints posteriorly - SI joints are partly synovial, allowing some motion - SI joints have no muscles controlling their movement; they are controlled by muscles of the lumbar spine

Osteomyelitis in children

- Usually acute hematogenous - Better prognosis (due to better blood supply and actively remodeling bone) - Easier to treat

Osteomyelitis in adults:

- Usually due to contiguous spread to direct inoculation - Often can involve foreign bodies (joint replacements, hardware) - More likely to become chronic - More difficult to treat

Plain film findings for SCFE

- Widened femoral physis - Displacement

Developmental Dysplasia of the Hip

Abnormal contact between the femoral head and acetabulum, leading to abnormal development of the hip joint.

Barlow Test

Adduct and flex the hip to 90*. Hold distally, and push posteriorly. The test is positive if the femoral head slides posteriorly and dislocates.

Treatment for Developmental Dysplasia of the Hip

After urgent referral to an orthopedist, will be put in a *Pavlik Harness* that maximizes contact between the femoral head and acetabulum.

A 4 month old female infant comes into the pediatrician's office. A caesarian section was done because the baby was breech. Baby has a left lower extremity shorter than the right and lays externally rotated with a reduction of hip abduction. Next step?

An urgent orthopedic consultation should be ordered for the infant. This could be Developmental Dysplasia of the Hip, which has to be corrected early.

Osteonecrosis

Both traumatic and atraumatic factors are associated with osteonecrosis or the death of bone tissue. Though pathogenesis is unclear, it is likely a result of genetic and environmental (vascular damage, substances, mechanical stress) factors that alter local blood supply and starve the bone of blood, leading to its death.

Meralgia Paresthetica: History

Burning pain, paresthesia (numbness and tingling), and hypesthesia (diminished sensation) over the upper outer thigh is the classic presentation of meralgia paresthetica. The onset of pain is typically subacute. Sensory loss is quite discrete, and it is often possible to clearly demarcate the area of numbness.

Adult Hip Pain: A 50 year old diabetic patient presents to her primary care physician with worsening hip pain. She reports that she had no trauma to the area but has gained about 10 pounds in the last month. She describes the pain as a burning pain with occasional pins and needles sensations that is localized over her right hip. She has tried Ibuprofen for pain relief but it has not helped. Her past medical history is significant for diet controlled diabetes mellitus. She notes that while she may have gained weight she has maintained the same pants size. Her exam is normal and she has full range of motion of the right hip. What should management include?

Counseling on disease pathology and lifestyle modification.

Osteoarthritis

Degradation of the cartilage within joints leads to joint damage, osteophyte formation, etc.

Meralgia Paresthetica

Entrapment or compression of the *Lateral Femoral Cutaneous Nerve*, a pure sensory nerve, causing burning and tingling. Common causes are obesity, diabetes mellitus, and old age.

What are red flags associated with hip pain?

Fever, chills, weight loss, pain during the night, and neurological symptoms.

Ortolani Test

Flex the hip to 90* and gently abduct while fingers lift the greater trochanter. The test is positive if the femoral head relocated into the acetabulum.

Femoral Neck Fracture ("Hip Fracture")

Fractures of the femoral neck, often in old, osteoporotic women, that lead to substantial morbidity and death.

Hip pain in the groin is usually...

Genuine hip joint pain (intra-articular)

What two "causes" are associated with over 80% of Osteonecrosis cases seen?

Glucocorticoid and Alcohol use

Adult Hip Pain: A 22-year-old collegiate runner complains of lateral right hip pain. The pain has been getting worse since she started training for a marathon. She runs on the same road every morning, in the same direction relative to traffic. There is a fluctuant, tender mass over the greater trochanter. Hip motion is full and painless and weight bearing does not elicit pain. What is the most likely cause?

Greater Trochanteric Bursitis

Adult Hip Pain: A 72 year old woman *falls on an icy sidewalk* while shopping with her husband. She attempts to stand but immediately experiences *sharp groin pain* and her *right lower extremity gives way*. A bystander calls 911 and she is rushed to a local emergency room. Her exam shows *normal distal pulses* in her bilateral lower extremities with *no sensory deficits*. She is clearly in pain and her *right lower limb is shortened and externally rotated*. Her past medical history is significant for *osteoporosis* and hypertension. What is her risk for developing deep vein thrombosis or pulmonary embolism?

High.

Pediatric Hip Pain: A 9-year-old male basketball player presents to the pediatrician with a limp and knee pain. His past medical history is unremarkable but his mom thinks that he is smaller than the rest of the kids in his class. On exam his knee seems normal, however it is noted that he has some atrophy in his upper thigh, some asymmetry in leg length, and decreased range of motion in his left hip. Radiograph shows increased density in the femoral head. What is the risk of osteoarthritis developing in the affected joint for this patient?

High; this looks like Legg-Calves-Perthes disease.

Greater Trochanteric Bursitis: History

Hip pain with exercise or direct pressure

Legg-Calve-Perthes Disease

Idiopathc avascular necrosis of the femoral epiphysis over 1-3 weeks. New blood supply causes bone to regenerate over 2-3 years.

What are the three bones forming the acetabulum also called?

Innominate

Hip pain that is posterior is usually...

It may be pain in the jip joint, but is often also sacroiliac joint pain, pain of the buttock muscles, or pain of the lumbosacral spine.

Septic Arthritis: Diagnosis & Tests

Joint aspiration and fluid analysis/culture

One of the best tests for the passive range of motion of the hip joint is the:

Log Roll Test: Patient's leg is extended and relaxed on examination table as the examiner internally and externally rotates the leg

Meralgia Paresthetica: Physical Exam

Loss of sensation, burning, or tingling over a discrete portion of the outer thigh, but no motor loss. No change based on pressure applied, hip movement, or back movement.

When doing a physical exam of the hip, the most "neutral" position is...

Lying supine.

Lumbar Spine Stenosis: Tests

MRI and CT can see narrowing of the spinal canal.

Adult Hip Pain: You are seeing a patient in for evaluation of continued low back pain. He is in his mid 50s and describes the pain as located in the lower back with radiation to the left buttock that worsens when he is walking downhill but relieved if he leans over a table with his elbows resting on it. He has had no skin changes or trauma. The pain is causing him issues at work and he has called in multiple times in recent weeks. He denies any loss of bowel or bladder functions He has never smoked and is on no medications. The clinician performs a targeted physical examination and orders plain radiographs of the lumbar spine. Next step?

MRI lumbar spine

Lumbar Spine Stenosis: Epidemiology

Middle-aged and elderly

Lumbar Spine Stenosis

Narrowing of central or lateral lumbar spinal canal caused by degenerative joint disease, leading to compression of nerve roots.

Greater Trochanteric Bursitis: Tests

None

Meralgia Paresthetica: Tests

None

Adult Hip Pain: A 70 year old male presents to his primary care physician for the evaluation of worsening groin pain. He has had pain off and on for the last 20 years. He notes the pain was worse when he was working as a custodian but has eased a little since his retirement last year. The pain now is causing him to change his daily activities. He gets no relief from NSAIDs and cannot tolerate stretching or exercising at this time. The pain *does improve and dissipate with rest*. His exam shows reproducible left hip pain when holding the knee in full extension and externally rotating the leg. Review of his x-rays shows joint space narrowing and osteophyte formation in the left hip space.

Osteoarthritis

Adult Hip Pain: A 70 year old male presents to his primary care physician for the evaluation of worsening groin pain. He has had pain off and on for the last 20 years. He notes the pain was worse when he was working as a custodian but has eased a little since his retirement last year. He cannot work in his yard or take walks with his wife without significant pain. He gets no relief from NSAIDs and cannot tolerate stretching or exercising at this time. The *pain does NOT improve and dissipate with rest.* His past medical history is significant for *refractory COPD* that has required oral steroids to control the disease. Etiology of disease?

Osteonecrosis

Hip pain that is lateral, such as over the greater trochanter, is usually...

Pain involving soft tissues, but not involving the hip joint itself.

What are factors we have to consider regarding the prognosis of osteomyelitis?

Patient age and vascular status. Young, growing patients with good blood flow heal from Osteomyelitis better than older folks with vascular problems.

Osteonecrosis: Physical Exam

Patient has pain with range of motion exercises

Some patients with femoral neck fractures are at risk for avascular necrosis. Which ones?

Patients with *subcapital femur fractures* (that is, an intracapsular fracture where the neck and head meet) can damage the *Medial Circumflex Femoral Artery's Retinacular vessels*, disrupting blood supply and leading to avascular necrosis. Patients with *peritrochanteric femoral fractures* (that is, an extracapsular fracture over the greater trochanter) are not going to damage the Medial Circumflex Femoral Artery, and do not have a risk of disrupting blood supply.

Femoral Neck Fracture: Tests

Radiography

Osteoarthritis: Tests

Radiography

Sacroiliac Joint Dysfunction: Tests

Radiography (may not show anything) may show narrowing and sclerotic changes to the sacroiliac joint

Review: Gonococcal Septic Arthritis

Septic arthritis following an infection by (gram negative) Neisseria gonorrhoeae, causing a classic triad of: - Migratory joint swelling and pain, often monoarticular - Pustules on hands and feet (*dermatitis*) - Tenosynovitis (Inflammation and swelling of a tendon, such as in the hand)

What is the "C" sign?

Some patient will form a "C" with their hands and grasp around the greater trochanter when trying to localize their pain. Even though they are not pointing to their groin, this is another common way of "pointing" to hip joint pain.

Adult Hip Pain: A 21-year-old man complains of severe morning back pain over the past three months. His pain improves as the day progresses and improves with exercise. Physical exam shows *diminished anterior flexion of the lumbar spine*, *muscle spasms in the lower back*, and *forward-stooping* when the patient walks. Radiography of the lumbar spine shows *bilateral sclerotic changes in the sacroiliac area*. What other findings may be present?

Squaring of the vertebral bodies of the lumbar spine. This looks like sacroiliac joint dysfunction.

What is the most common organism causing Osteomyelitis?

Staph aureus

Acute Osteomyelitis

Symptoms present over days-weeks

Chronic Osteomyelitis

Symptoms present over months-years

Greater Trochanteric Bursitis: Physical Exam

Tender bursa over the greater trochanter or iliopsoas tendon. May have accompanying intra-articular pathology

Acetabulum

The "socket" of the hip joint, formed by the fusion of the ilium, ischium, and pubis.

Pediatric Hip Pain: An 11 year old obese male was noted by your nursing staff to be limping while entering the exam room. He has been having right knee pain for 6 months with no inciting event or trauma. He denies having fever or chills. He describes the pain as a deep achy pain over the medial aspect of his right knee and he noticed that is recently felt like it "gave away" but prior to that he could do his daily activities without any limitations. Examination of his right knee is unremarkable. When examining his hip he denies any tenderness to palpation over the joint and is noted by the examiner to have decreased internal rotation and increased external rotation.

The patient should immediately be placed in a non-weight bearing state. This could be Slipped Capital Femoral Epiphysis.

Femoral Neck Fracture: Mechanisms

They may occur after falls, but can occur spontaneously

Pediatric Hip Pain: A 15 year old high school baseball player presents to his pediatrician with a worsening limp. He reports that last week in practice he was covering second base and took a hit to his hip by a runner sliding into base. He had some initial pain with *bruising and abrasions* from the incident. Since then he has had decreased ability to run and has a *noticeable limp* now in his left leg. His mom became concerned because for the last couple of days he has had a *fever that is not going away*. His exam shows a resolving bruise over the left hip with *pain on palpation and decreased range of motion*. A hip ultrasound is obtained with *no evidence of a joint effusion* seen. What is the disease process?

This could be osteomyelitis (too old for Toxic Synovitis; plus has no effusion; no effusion and not acute enough to look like Septic Arthritis). Pediatric patients are more likely to develop disease from acute hematogenous spread than through contiguous spread.

Pediatric Hip Pain: A 7-year-old male presents with a one week history of low grade fever, irritability, reduced oral intake, and right hip pain and limping. Physical exam reveals a crying child with 38°C fever. The right lower limb lies flexed, abducted and externally rotated at the hip. There is local tenderness and range of motion is limited by pain. Lab investigations reveals a WBC 9,750 cells/ml (that is normal) and an ESR 12mm/hr (that's normal). What should we tell the mother?

This is a self limited and benign condition (transient synovitis) that will resolve with time and conservative management

Galeazzi Test

With the infant lying supine on a firm surface, such as an examination table, and the hips and knees flexed 90 degrees, a unilateral dislocated hip usually demonstrates that the *knee on the side of the dislocated hip appears lower* than that of the other side.