HIP PAIN

HIP PAIN: Excerpt from Differential Diagnosis in Primary Care

When confronted with a case of hip pain in an adult, the clinician is most likely to think of fracture or joint inflammation such as osteoarthritis, realizing however that there are many other possibilities (Table 38). How can the clinician think of them on the spot? Anatomy is the key. The hip is composed of skin, muscle, bursa, ligament, joint, and bone. It is also supplied by nerves, arteries, and veins. Looking at each of these structures in terms of etiology, skin should prompt the recall of herpes zoster while muscle should prompt the recall of contusion or sprain. The bursa should allow one to recall greater trochanter bursitis—a common and easily treated form hip pain. Thinking of the ligaments, consider sprain. Visualizing the joint would prompt consideration of osteoarthritis, gout, and rheumatoid arthritis as well as congenital dislocation of the joint, slipped femoral epiphysis, Legg–Perthes disease, and rheumatic fever. Visualizing the bone should prompt recall of fracture and primary and metastatic tumors. Visualizing the nerves, one should think of the sciatic nerve and consider a herniated lumbar disc; cauda equina tumor; or sciatic neuritis, which is rare. Considering the arteries and veins may prompt one to think of avascular necrosis.

HIP PAIN

Approach to the Diagnosis

The history and physical examination will allow differentiation of many of the conditions listed above. For example, the history of trauma suggests sprain, fracture, or contusion. Remember fractures of the hip can occur in the elderly without a history of trauma. A positive straight leg raising (SLR) test suggests a herniated disc or other cauda equina pathology. X-ray of hip and lumbosacral spine will help rule out fracture or osteoarthritis but CT scan, bone scan, or an MRI may be necessary. If x-rays and laboratory examinations are negative, a trial of lidocaine injections into the greater trochanter bursa or other trigger points may be diagnostic.

Other Useful Tests

1. CBC (infection)
2. Chemistry panel (metastatic neoplasm)
3. Urinalysis (multiple myeloma, gout)
4. Sedimentation rate (osteomyelitis, arteritis)
5. RA tests (rheumatoid arthritis)
6. ANA analysis (collagen disease)
7. Joint fluid analysis (all types of arthritis)
8. Tuberculin test (tuberculosis of the joint)
9. Bone biopsy (neoplasm)
10. Exploratory surgery

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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