CHIR12007

Clinical Assessment and Diagnosis Portfolio Exercises Week 9 & 10

Exercise 1

Differential Chart

Please create a chart that lists as many differential diagnoses for hip pain as you can, including but not limited to the
following conditions

historical physical finding specific testing or any

other factor that may be
helpful

Hip Fractures - Predisposition of hip fracture is A fall onto the hip, X ray
Osteoporosis Present with hip pain,
unable to bear weight Result serious
- Bone fatigue and axial muscular complications such as
compressive forces Intracapsular (subcapital osteonecrosis, nonunion,
and transcervical) and thromboembolic disease,
- Paget’s disease, and osteomyelitis
endocrinopathies, multiple extracapsular
myeloma, renal osteodystorphy (basicervical,
trochanteric, and
- young patient pathologic subtrochanteric)
fracture may be due to benign
and malignant tumors
Congenital Hip diagnosed on physical exam of upon weight-bearing, Ortolani’s click test and
Dislocation and the neonate have a limp and Barlow’s maneuver,
Hip Dysplasia diminished active MRI, X-Ray (until 4-6 wks
abduction. of age)
Osteoarthritis Middle-aged or senior adult Slow stiffening The restriction to passive
with hip and possibly buttock, (specifically internal internal rotation and
groin, or knee pain that was rotation) extension of the hip
insidious in onset
patient’s walking with Abductor or adductor
Primary OA is due to progressive the hip held in external contracture may develop
degeneration of femoral and rotation
acetabular articular cartilage Pain may be produced by
low back pain due to axially compressing the
History of trauma to the hip, or excessive extension with femur into the
the patient may have other joint weight-bearing to acetabulum.
involvement if crystal deposition compensate for limited
(i.e., gout) is a factor hip extension. Nonuniform loss of joint
space is found
radiographically.

Superior joint space

narrowing with associated
findings of subchondral
cysts and osteophytes is
the hallmark of OA.

Avascular necrosis In the child or adolescent Male limitation of hip Positive test of The
History of past trauma or abduction and internal Trendelenburg test
metabolic disease rotation (secondary to
muscle Atrophy and limb length
spasm). inequality may be evident

The knee is a common

referral site for hip
disorders
slipped Capital In the child or adolescent present The physical examination X-ray
Epiphysis with a traumatic history (50%) may be generally the knee is a common
unremarkable; however, referral site for hip
sometimes when disorders
the hip is taken passively
into flexion, it rotates
externally
Femoroacetabular sharp, deep hip pain with decrease in flexion and Pincer lesions (middle-
Impingement squatting internal rotation aged athletic women)
deformity on the
Running, stopping and External rotation may acetabular side
starting or changing direction also be affected
may also cause pain Cam impingement (young
Anterior impingement athletic men)
pain if felt anteriorly deformity on the femoral
side
Acetabular Labrum moderate to severe pain with There are many suggested The history clues most
Tears groin pain predominant, night causes including macro- to often reported
pain micro- (repetitive)
trauma. hip locking or catching
The pain is worse with activity
and causes the patient to limp FABER, FAI tests, long-axis
Predispositions could distraction, and ROM
include FAI, capsular findings
laxity, or hip dysplasia MRI
Iliopectineal and presents with a severe, acute These anterior bursitises deep anterior tenderness
Iliopsoas Bursitis’ anterior hip pain with an antalgic are possibly due to hip at the hip
gait flexor tightness coupled
with repetitive activity the bursa is located about
pain radiating down the anterior 1 to 2 cm below the
aspect of the leg. (pressure on middle third of the
the femoral nerve) inguinal ligament

The iliopsoas bursa may

be palpated with the
supine patient’s hip
flexed to 90° while
palpating over the lesser
trochanter.

Resisted hip flexion or

more specific iliopsoas
testing will reproduce the
pain
Ischial Bursitis sitting for long periods of time on pressing the foot down on Well-localized tenderness
hard surfaces(benchwarmer’s the brake pedal (or gas over the ischial
bursitis) or during horseback pedal) of a car may tuberosity
riding. relieve the pain
referral down the back of the leg
mimicking sciatica
Trochanteric Pain Several bursae are capable of Any condition that leads Tenderness and
Syndrome producing symptoms to altered hip mechanics, sometimes swelling are
including low back pain, found over the greater
The two major bursae are the leg length discrepancy, trochanter
subgluteus medius and arthritic conditions,
subgluteus maximus surgery, and neurologic Palpation may cause a
conditions with paresis “jump” sign when
between 40 and 60 years of age , may cause localized to the lower
subtrochanteric bursitis portion of the trochanter
with the knee and hip
loss of internal rotation flexed.

Repetitive activity can be Patrick test or Ober’s test

a major cause in the
younger population
Snapping Hip Many patients do not have pain Snapping at the hip is The location and
Syndrome If traumatic, consider an often due to tendons that movement pattern are
acetabular labrum tear. snap over bony often helpful
prominences or bursae
Lateral hip snapping
occurring on hip flexion
with the hip in adduction
is most often due to the
iliotibial band’s snapping
at the greater trochanter.

Anterior snapping or
popping occurring with
active extension of the
flexed, abducted, and
externally rotated hip
often indicates
 iliopsoas tendon
involvement or
occasionally snapping of
the iliofemoral ligaments
over the anterior joint
capsule.

Posterior snapping in the

buttocks region is
probably due to
the biceps femoris
tendon’s snapping over
the ischial tuberosity.

Hamstring Strain athlete or “weekend warrior” An overcontraction of the Palpation of a site of

who feels a sudden pull or pop at hamstrings while in a tenderness at the distal
the back of the thigh following a position of stretch muscle belly associated
forceful knee extension with increased pain
maneuver. Tearing occurs most often on resisted knee flexion is
at the junction of the diagnostic.
muscle and aponeurosis.
Pain is correlated to the
Avulsion of the degree of injury.
ischial apophysis is
possible in younger Full ruptures are quite
athletes. painful.

Piriformis buttock and posterior leg pain may be an anatomically SLR test with internal
Syndrome with a nontraumatic onset short leg, pronation, or rotation to distinguish
pelvic rotation. between nerve root or
piriformis involvement
GROIN Osteitis Sudden, forced adduction injury Direct compressive or Tenderness at the pubic
Pubis or a repetitive minor trauma distractive injury may joint with compression
seen with kicking or running cause pain at the pubic
Pregnant women joint Resisted adduction is also
provocative
Exercise 2

Osteonecrosis will be presented in lecture in week 10 however, this can occur in locations other than the hip.

Please create a table/ chart that lists the locations where Osteonecrosis can occur.

Osteonecrosis
(is result of skeletal ischemia)
Trochlea Spontaneous osteonecrosis (SONC) of the immediate subchondral regions
medial tibial palteau of the proximal femur, distal
femur, and the proximal humerus

Capitellum Navicular in the adult Femoral head

Knee (medial knee joint pain) Wrist

Exercise 3

There are 4 major conditions that can affect the paediatric hip and may present with hip pain. Please list these,
nothing the main clinical features and identify those features which may help to differentiate these.

Transient Synovitis Transient synovitis is a common cause of limping and hip pain in children.
(irritable hip) It is generally considered to be an acute inflammatory reaction in the acetabulum that
peaking at 3-8 years follows an upper respiratory infection.
The condition is self-limiting and usually lasts about 10 days.

Features:
It classically affects children between the ages of 3 and 8 years.
The patient usually walks with a limp and an antalgic gait.
Hip pain is unilateral and some patients refuse to bear weight on the involved limb.
Radiographic findings are usually normal.
Before making a diagnosis of transient synovitis, it is important to rule out slipped capital
femoralepiphysis, LCP (Legg-Calve-Perthes) disease, pyogenic arthritis of the hip joint,
and osteomyelitis of the proximal femur.

Treatment:
involves bedrest to reduce weight-bearing during the acute phase.
Patients with transient synovitis may respond to spinal adjustments to the lumbopelvic
and sacro-iliac regions, especially if referred pain is involved
Septic Arthritis
H. Influenza type B infection is the leading cause of septic arthritis in children younger
(Osteomyelitis)
than 2 years of age. It affects large joints and may cause contiguous in the knees, ankles,
hips, or elbows
any age
(peaking at 0-6 Symptoms and Signs:
years).
The clinical picture starts with an upper respiratory tract infection, which is followed later
by pain in the involved joint; the child appears toxic with fever.

Patient Management :

A culture of joint fluid and blood can be made. There may be antibodies in the blood or
urine. The medical management includes the administration of antibiotics for at least 10
to 14 days and longer if osteomyelitis is suspected.

Draining the joint through repeated needle aspiration or open drainage is often useful.

Legg-Calvé-Perthes LCP disease is an osteochondritis of unknown etiology that affects the epiphysis of the
Disease (3-12 years femoral head.
peaking at 5-7 years)
It occurs in children usually in the age range 5 to 10 years and is more common in boys
who are short in stature.

Boys are four times more likely to be affected than girls . The incidence is 1 in 10,000
children

The femoral head is temporarily softened and may become deformed.

The condition, which usually affects only one hip, passes through the three classic
pathological stages:

condensation (avascularization), fragmentation (resorption), and regeneration

(revascularization).

The condition is self-limiting and progresses through the three stages in about 36
months.
The child with LCP disease usually presents with a limp of insidious onset and may
complain of pain in the groin or knee. Because of the mild nature of the symptoms, many
patients will have well-advanced disease by the time of presentation

Upon examination, the most prominent sign is restriction of all hip movements,
abduction and medial rotation in particular.

Restriction upon medial rotation of the hip joint is the earliest sign

Flexion is usually preserved. An internally rotated ilium may be noted and could be
contributing to the groin pain symptoms.

Diagnosis is usually established by radiographic findings in which the earliest

changes show the shadow of a swollen joint capsule and widening of the joint space.

The first osseous changes consist of widening of the epiphyseal plate, with widening of
the femoral neck adjacent to the epiphyseal plate.

Softening and flattening of the epiphysis may appear as a “jockey’s cap” deformity.

Eventually the texture of the bone returns to normal, but if flattening has occurred, the
femoral head will be permanently deformed.

In the natural history of LCP, the younger the age of onset, the more likely that the
spherical shape of the femoral head will be retained

Treatment:
Medically, there are various forms of treatment that range from operations to minimal
management. The goal is to retain the spherical shape of the femur head and reduce
restriction of hip motion, thereby reducing the risk of hip restriction and degenerative
arthritis

Treatment in the acute phase includes bed rest with containment of the femoral
head deep within the acetabulum because the acetabulum is the “mold” for the shape
of the femur head.

A regular program of non-weight-bearing leg abduction exercises may provide the best
results for eliminating femoral head deformity.
 The most important factor in this management protocol is considered to be the
maintenance of joint mobility, which enhances synovium and cartilage nutrition. When
joint pain and muscle spasms have subsided, use of crutches may be permitted; however,
the patient should be advised to avoid bearing any weight on the hip until the
regeneration phase is completed. The primary goal of any treatment program for LCP is
the reduction or elimination of degenerative joint disease later in life

Slipped Capital Slipped capital femoral epiphysis (SCFE) is a condition of later childhood and adolescence
Femoral Epiphysis in which the upper femoral epiphysis is displaced from its normal position on the femoral
SCFE (early neck. It is the most common hip disorder during adolescence, with an incidence of 1 in
adolescence - 50,000
usually in obese
children) The patient is usually adolescent and is more frequently a boy who is either obese or tall,
thin, and growing rapidly. Twenty-five percent of the cases are bilateral

Studies state that contralateral slippage after a symptomatic SCFE occurs in up to nearly
70% of cases. Contrary to some thoughts, chronological or bone age was not a predictor of
contralateral SCFE.

The cause of the slippage is unknown but mechanical factors, such as pelvic
asymmetry caused by spinal or pelvic subluxation that contribute to an uneven weight
load distribution on the femur heads, may contribute.

Acute SCFE can result from shear forces applied to the area from severe trauma, motor
vehicle accidents, sports injuries, child abuse, falls from heights, or obstetric accidents.
Hormonal factors have also been suspected.

Much SCFE is chronic, and patients present with a painful limp that occurred suddenly
without identifiable cause. Patients with SCFE may also present with only the symptom of
knee or groin pain. Examination of the hip will reveal restriction of internal rotation and a
tendency to external rotation and flexion, a position that minimizes the discomfort.

Flexion of the involved hip will exacerbate the symptoms.

The hip rotation test is used for screening: the patient is prone with the knees flexed
90 degrees and the hips medially rotated. Restriction in medial rotation is a positive sign .
Definitive diagnosis can be made radiographically from the frog-leg view, which should
always be included because this condition may not be evident on an AP view (Fig. 13-8).

Patients with SCFE should be referred for surgical consultation, with the surgical objective
being to pin the epiphysis in situ to prevent further disruption to the vascular supply to
the femoral head. The child should not bear weight (e.g., provided crutches) after the
entity has been identified.

Complications with this condition include avascular necrosis, ankylosis, and sequestration
of the epiphysis.

A controversial area, surgically, is prophylactic fixation of the contralateral, asymptomatic

hip. Some surgeons state that if unilateral SCFE is found at a certain bone age—11 to 13
years of age for boys and 11 to 12 years of age for girls—that the contralateral hip should
be pinned whether or not it appears to be slipped and/or symptomatic. Gorva et al. state
the bone age does not predict slip of the contralateral hip, and the risk of complications
is too great for a prophylactic procedure. Close monitoring of the contralateral hip is
recommended

FIGURE 13.8 Analysis for slipped capital femoral epiphysis. For the AP projection, (A) is
normal, where the line superimposed on the superior femoral neck normally intersects a
 portion of the femoral head. In the frog-leg projection (B), the line should also intersect the
femoral head. If it does not in either the AP projection (C) or in the frog-leg view (D), then a
slipped capital femoral epiphysis is identified. Modified from Chung S. Diseases of the
developing hip joint. Pediatr Clin North Am 1986;33:1457.

Exercise 4

Self directed learning:

Please research ‘Myositis ossificans’ and present the history, clinical findings and importance of this condition.
Note: this does not solely apply to the hip!

Myositis ossificans
History soft tissue abnormalities

Heterotopic bone formation at a site of trauma can occur alone or in combination with a
fracture.

It is recognizable as an increasingly confluent ossification in muscle tissue most commonly

at the thigh (the quadriceps) or anterior arm

Myositis ossificans is less dense centrally and often has a halo-like rim of peripheral cortical
bone

Clinical findings The patient will report a direct blow to the knee followed by swelling and decreased ability
to flex the knee

A direct blow causes damage to the underlying muscle with subsequent hematoma
formation. When the hematoma is encouraged to remain, myositis ossificans may occur.

Ossification within this hemorrhage (myositis ossificans) can result in bony bridging
between transverse processes (lumbar ossified bridging syndrome; LOBS)

Myositis ossificans is unusual in the foot and ankle but can be observed in the Achilles
tendon, interosseous membrane, and inter-metatarsals

In children, an avulsed medial epicondyle may become entrapped in the joint. A small
percentage of posterior dislocations will develop post-traumatic myositis ossificans at the
anterior aspect of the joint, usually in the brachialis muscle.
Importance of this Early features
condition Hazy soft tissue mass
Cloudy ossification

Later features
Round or linear
Smooth, dense, outer border
Relatively lucent center
No connection with adjacent bone

Forcefully stretching after injury, deep massage to the area of injury, and the use of deep
heat such as ultrasound.

Application of a tensor bandage with an ice pack in a flexed knee position for several
hours (alternating icing for 20 minutes, no ice for 10 to 20 minutes) is helpful in preventing
accumulation of blood into the area. With moderate to severe contusions, use of crutches
for two to three days may be helpful. Mild stretching may begin after two to three days.

Treatment decisions regarding myositis ossificans development are made after several
weeks, based on the deformity and degree of knee flexion restriction. Surgical excision may
then be performed if deemed desirable