differential diagnosis of hip pain -...
TRANSCRIPT
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Differential Diagnosis of Hip
PainWilliam G. Hamilton, MD
Alexandria, VA
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Disclosures
Consultant and Product Development: DepuyPrinciple Investigator: Depuy, BiometInstitutional Support: Inova Health System
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Hip: History• Important to Listen
• Have patient tell you why they are there and let them expand on their symptoms– Sit down– Ask Open ended questions
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“Hip” Pain• Patients may present with chief complaint
of “hip” pain, but it may not actually be coming from their hip– Intrarticular hip– Extrarticular hip– Lumbar spine– Sacroiliac joint– Other
• Intra-abdominal, hernia, GI, GU
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History• Common symptoms
– Groin Pain– Thigh Pain– Some lateral pain– “C-sign”
– Buttock Pain: More likely lumbar in origin
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History• Knee pain
– Can be the initial complaint of hip pathology– Not uncommon for a patient with hip arthritis
to present with knee pain• Differentiate with exam, X-rays, injections
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Physical Exam• Stinchfield
– Pain with resisted hip flexion
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Physical Exam• Trendelenburg Sign
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Physical Examination
• Gait description– Antalgic – shortened stance phase– Trendelenburg – trunk shift to involved side– Short leg– Combination
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Physical Exam
• TrendelenbugGait
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Imaging• Standard Imaging
– AP Pelvis– AP of involved hip– Frog Lateral– Shoot thru Lateral
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Unsure if pain is coming from hip?
• Diagnostic/therapeutic injection– Perform under imaging– Carefully instruct patient and
provider to document the response to injection
– Have patient write it down– Specify you are interested in
the HOURS after the injection
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Differential Diagnosis• Osteoarthritis• Rheumatoid arthritis• Avascular necrosis• Trochanteric pain syndrome• Femoral-acetabular impingement
– Labral tear
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Osteoarthritis• Hip OA accounts for 75-80% THA’s• Hip OA is primary or secondary
– Secondary• FAI, AVN, Post traumatic, DDH
– Primary• No obvious cause-dx of exclusion
• Caucasians 3-6% – Males more common– 1% or less for Blacks, Chinese, Native
Americans
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OA- Radiographic Findings• Joint space
narrowing- often asymmetric
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OA- Radiographic Findings• Osteophytes
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OA- Radiographic Findings• Subchondral cysts
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Radiological Assessment of Osteo-ArthrosisKellegren and LawrenceAnn. Rheum Dis. 1957
G2-Narrowing and osteophytes
G1-Doubtful narrowing, possible osteophytes
G3-Multiple osteophytes, narrowing, sclerosis, possible deformity
G4-Large osteophytes, marked narrowing, severe sclerosis, definite deformity
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Inflammatory Arthritis• Less common source of hip pathology• Any age- usually begins after age 40• More common in women• Can affect multiple joints• Systemic symptoms
– Skin, eyes, lungs, blood vessels
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Inflammatory Arthritis• Early stage, suspected diagnosis
– Refer to rheumatologist for workup– Learn tests to order to work up for yourself
• Sed rate, Rheum Factor, anti-CCP antibodies, ANA
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Inflammatory Arthritis• Tender, warm, swollen joints• Morning stiffness that lasts for hours• Firm bumps of tissue on arms (rheumatoid
nodules)• Fatigue, fever, weight loss• Hands- RA affects PIP and MCP joints,
DIP is OA
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Rheumatoid Arthritis- XrayFindings
• Concentric loss of joint space
• Periarticularosteporosis
• Erosions• Fewer osteophytes
than OA
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Avascular Necrosis• Loss of blood supply to the femoral head• Age 30-60• Men>Women
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Avascular Necrosis- causes• Trauma- hip fracture or dislocation• Steroid use• Alcoholism• Systemic diseases
– Gaucher’s, Lupus, Sickle cell, HIV, Caisson’s• Idiopathic
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Avascular necrosis- Xray findings• Early stages normal• Look carefully at
femoral head– AP and especially
LATERAL view• Lesion in
superolateralfemoral head
• Collapse of head with progression
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Avascular necrosis- Xray findings• Early stages normal• Look carefully at
femoral head– AP and especially
LATERAL view• Lesion in
superolateralfemoral head
• Collapse of head with progression
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MRI
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Femoral-acetabularImpingement (FAI)
• Pinching of abnormal anatomy of the femoral head and acetabulum during hip range of motion– Cam- males– Pincer- females– Combination- 70%
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Femoral-acetabularImpingement (FAI)
• Can lead to tear of acetabular labrum
• MRI or MR arthrogram can help visualize tear
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Trochanteric Pain Syndrome• Lateral hip pain• Pain with laying on side• Tender to palpation• Lack of groin pain/pain with hip ROM
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Trochanteric Pain Syndrome• Trochanteric bursitis• Gluteus medius/minimus tendinopathy
• Treatment for both conditions similar:– PT- stretching/strengthening– NSAID– Corticosteroid injection
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Trochanteric pain syndrome• Advanced imaging:
– Failed non-op mgmt• MRI or Ultrasound
– Distinguish bursitis from tendinopathy or tear
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Trochanteric pain syndrome• Advanced imaging:
– Failed non-op mgmt• MRI or Ultrasound
– Distinguish bursitis from tendinopathy or tear
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When should I order an MRI• Infrequently• Rarely on initial visit
– Initiate non-op treatment for presumptive dx
• Never when the X-ray shows OA
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When should I order an MRI• Concern for AVN
– Normal Xray– Early stage, no
collapse– Size lesion or
examine contralateral hip
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When should I order an MRI• Concern for occult
fracture• Normal Xray-
– Labral tear
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Do I order MRI?• NO!• Diagnosis is made• MRI provides no
treatment guidance
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Do I order MRI?
NO!
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Do I order an MRI?74 yr old femaleTwisted hip 3 days agoDifficulty bearing weight++Stinchfield and internal rotation
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Do I order an MRI?Yes!Occult hip fracture
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Summary• Take a good history
– Is it the hip?• Exam
– Confirm it’s the hip– R/O other source
• Imaging– X-rays are the workhorse– MRI for specific indications only
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Thank You