Hip Pain

How do you diagnosis septic arthritis?

Joint aspiration, turbid fluid. High WBCs that are predominately neutrophils.

History of lumbar spinal stenosis?

Lateral and posterior hip pain that may radiate to the lower leg or groin, exacerbated by walking or standing and relieved by sitting and leaning forward to lying down. Back pain.

What disease has an idiopathic avascular necrosis of the femoral epiphysis?

Legg-Calve Perthes disease.

What disease do you find a painless limb, shortening of the limb, decreased internal rotation and abduction of the hip, and atrophy of muscles in the upper thigh upon physical exam?

Legg-Calve-Perthes disease

What history do you find in Meralgia Paresthetica?

Localized area of pain that can range from numbness and tingling to burning pain.

What are the symptoms of transient synovitis?

Low grade or no fever (less that 38C), capable of ambulating but usually with a limp. Hip is usually help flexed and externally rotated.

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. Diagnosis?

Lumbar spinal stenosis.

What are the treatment goals for perthes disease?

Maintenance of hip motion pain relief avoid impact activities containment (maintain normal relationship of femoral head within the acetabulum)

What is lateral femoral cutaneous nerve entrapment?

Meralgia paresthetica.

What is the trendelenberg gait?

Muscle weakness. The pelvis will tilt as they walk to maintain balance.

Treatment for lumbar spinal stenosis?

NSAIDs, PT, Steroids, surgery.

How do you manage greater trochanter bursitis?

NSAIDs, PT, corticosteroid injection.

What are the clinical manifestations of perthes disease?

Persistent hip or knee pain. Limp. short stature

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. Diagnosis? How does his risk for OA change?

Perthes disease. He has a higher risk for OA

What is the treatment for osteonecrosis?

Preserve the native joint. Nonoperative management Joint preserving procedures. joint replacement.

How do you treat DDH?

Refer to an orthopedist. May have an ultrasound to determine for sure that DDH is present. Then you put them in a padlock harness through development to ensure that the hip will stay stable.

What is the most common organism to cause osteomyelitis?

S. aureus

What are some hip problems you would suspect in a patient older than 10 years?

SCFE, Osteochondritis dissecans, apophysitis, osteomyelitis, septic arthritis.

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. Diagnosis? Immediate next step?

SCFE. Eliminate weight bearing immediately.

If you have posterior pain, where do you think about injury?

SI joints, butt muscles, or lumbosacral spine. It could be the hip joint but strongly consider the others first.

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. Diagnosis? Most likely cause?

Septic Arthritis. Staph Aureus.

What is the C sign?

The patient will cup their hand above the greater trochanter when describing deep interior hip pain. The hands forms a C. This could be interpreted as lateral pain, but this usually is describing a deep interior hip pain, so you think about the hip joint. The lateral pain is more point tenderness, not an entire area.

What are some hip problems you would suspect in a patient that is 4-10 years old?

Transient synovitis, Perthes disease, JIA, septic arthritis, osteomyelitis, fractures, leukemia.

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 serum WBC 9,750 cells/ml and an ESR 12mm/hr. Diagnosis? Treatment?

Transient synovitis. Self-limited and benign, will resolve with time and conservative management.

What is a positive Galeazzi sign?

When the infant is lying down with his hips and knees flexed to 90 degrees, the unilateral dislocated hip will appear lower than that of the other side.

Why do you need to follow up and check the contralateral hip in a SCFE patient?

When they occur sequentially, the 2nd hip presents within 18 months in >75% of cases.

what is the pathogenesis of DDH?

You have abnormal contact f the femoral head with acetabulum that leads to abnormal development of the acetabulum and femoral head.

How do you treat septic arthritis?

emergent Antibiotics. Can drain the joint to reduce interarticular pressure and remove bacterial debris.

Where does the patient normally complain of pain in SCFE? Describe the pain.

groin to medial aspect of the knee. It is a dull ache that is exacerbated with exercise. Painful limp.

If they have groin pain, where do you think about injury?

hip joint, intraarticular.

What are the Kocher Criteria for septic arthritis?

ill appearing fever >38.5 refusal to bear weight Severe pain with ROM Usually monoarticular.

What is an antalgic gait?

minimized stance phase on the affected side secondary to pain that produces a limping gait.

Do perthes patient's have systemic symptoms?

no

How do you treat SCFE?

no weight bearing and strict bed rest. Surgical fixation Close follow up, especially of contralateral hip

What is separated in greater trochanter bursitis? What causes the pain?

the gluteus maximus from the lateral side of the greater trochanter. Irritation of the bursa produces lateral hip pain.

What bones are most commonly involved in Osteomyelitis?

tibia, humerus, fibula, radius, calcaneus, and ilium.

How often is SCFE bilateral?

~25% of the time.

Describe the pathophys and course of Perthes disease?

1. Blood flow to femoral head is interupted. 2. Tip of femoral head dies over 1-3 weeks. 3. New blood supply causes new bone cells to appear over the next 6-12 months. 4. New bone then replaces the old bone within 2-3 years.

How often is perthes disease bilateral?

15% of cases

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. Diagnosis?

Ankylosis spondylitis.

What is seen in the history of osteonecrosis?

Anterior groin pain with joint use that can lead to thigh and buttock pain. Frequent pain on walking and at rest. Often with a history of corticosteroid use.

What age do kids usually get transient synovitis?

Boys 3-8 years (but most are younger than 5)

How do you treat meralgia Paresthetica?

Education, avoid tight garments, weight loss.

What are the risk factors for femoral neck fractures?

Falls, osteoporosis.

What is greater trochanter bursitis associated with?

Female runners, who run on banked surfaces.

What are the 4 primary risk factors for DDH?

Female, breech presentation, genetics (fam hx), and swaddling.

What are the traumatic causes of osteonecrosis?

Femoral Neck fracture. Fracture/Dislocation

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. Diagnosis?

Femoral neck fractures.

How do you perform the ortolani test?

Flex the hip to 90, gently ABduct wile fingers lift the greater trochanter. its positive if you hear a really sickening click.

If you have lateral pain over the greater trochanter, where do you think about injury?

Generally not the hip joint. Think about the soft tissues.

What are non-traumatic causes of osteonecrosis?

Glucocorticoids, alcohol, idiopathic, sickle cell disease.

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 most likely causing her pain?

Greater trochanteric bursitis.

What is the acetabulum a fusion of?

Ilium, Ischium, and pubis.

What are possible complications for femoral neck fractures?

Immobility, avascular necrosis and nonunion.

Describe the changes in hip movement in a SCFE patient on physical exam?

Decreased internal rotation, increased external rotation.

What is the treatment for SI joint dysfunctioN?

Determine the cause, TNF inhibitors, PT, joint injections, rarely joint fusion.

4 month old female infant comes into peds office. Was born breech. You notice that her left leg is shorter than the right and lays externally rotated with a reduction go hip abduction. Diagnosis? What is your next step in treatment?

Developmental Dysplasia of the hip. Next step is an urgent orthopedic consultation.

What are the labs for transient synovitis?

ESR < 40, WBC < 12,000.

What do the ortolani, barlow, and galeazzi test test for?

DDH

What are some hip problems that can develop in birth- 4 years.

DDH, Septic arthritis, osteomyelitis, fracture.

What type of injury is SCFE?

A type 1 salter harris where you have inferior and posterior slippage of the proximal femoral epiphysis.

How does septic arthritis usually present?

Acute, monoarthritis with erythema, warmth, swelling and intense pain. This can cause a pseudo paralysis because of the severe pain. Fever.

How do you perform the barlow test?

Adduct and flex the hip to 90. Hold the distal and push posteriorly. Positive when the femoral head slides posteriorly, dislocating the articulated femoral head.

What is the relevant history for OA?

Age >40. Pain radiating to the groin. Stiffness.

Who normally gets SCFE?

An obese preteen boy.

Who does perches disease normally occur in?

Children 4-8 years old. More commonly males.

What are the clinical symptoms of SCFE?

Chronic presentation is the most common. Dull nonradiating groin, thigh or knee pain that is worse with activity. Decreased internal rotation.

What causes transient synovitis?

Could be infectious or post infectious, but we aren't sure

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. Treatment?

Counseling on disease pathology and lifestyle modification.

What is the Kocher criteria for transient synovitis?

No or low grade fever. Capable of ambulating but usually with a limp ESR < 40 mm/hr WBC < 12,000

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. Diagnosis?

Osteoarthritis

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 as he was attempting to catch the throw from the shortstop. 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. Diagnosis?

Osteomyelitis.

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. Diagnosis?

Osteonecrosis

What is the treatment for OA?

PT, Analgesics, surgical hip replacement.

History seen in Sacroiliac joint dysfunction?

Pain that radiates to lumbar back, buttock, and groin. female predominance, common in pregnancy, history of minor trauma.