Diagnosis of Hip Replacement
Hip Replacement Diagnosis: Book Excerpts
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Diagnostic Tests for Hip Replacement: Online Medical Books
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HIP PAIN:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there a positive straight-leg raising test or other neurologic signs? The presence of positive straight-leg raising tests or other neurologic signs would suggest a herniated disk, a cauda equina tumor, or other neurologic disorders of the lumbar spine. Meralgia paresthetica will cause characteristic loss of sensation in the distribution of the lateral femoral cutaneous nerve.
- Is there a positive Patrick's test or limitation of the range of motion of the hip? These findings suggest a greater trochanter bursitis or hip joint pathology such as fracture, osteoarthritis, rheumatoid arthritis, metastasis, slipped femoral epiphysis, Legg-Perthes disease, rheumatic fever, or transient synovitis.
- Is there tenderness of the greater trochanter bursa? Tenderness of the greater trochanter bursa will help differentiate greater trochanter bursitis. It is also seen in hysteria.
- Is the patient a child or an adult? If the patient is a child, transient synovitis, slipped femoral epiphysis, Legg-Perthes disease, and rheumatic fever should be considered. If the patient is an adult, it is more likely that the problem is osteoarthritis, a fracture, rheumatoid arthritis, metastasis, or avascular necrosis.
- Is there a history of trauma? A history of trauma would suggest that there is a fracture or a sprain of the hip joint, but the clinician should remember that a fracture in the elderly often occurs with no history of trauma.
DIAGNOSTIC WORKUP
A CBC, sedimentation rate, chemistry panel, arthritis panel, tuberculin test, and x-rays of the lumbosacral spine and hip will diagnose 90% of the cases. These are relatively expensive in comparison to MRI. A bone scan may be necessary to diagnose occult fractures. A serum protein electrophoresis will help diagnose multiple myeloma. A trigger point injection of the greater trochanter bursa or ischiogluteal bursa will assist in the diagnosis of these conditions. An orthopedic surgeon should be consulted before ordering MRI of the lumbar spine or hip. However, MRI is especially important if the diagnosis of avascular necrosis is suspected.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Hip Pain:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
-
Septic arthitis
–Surgical emergency due to irreversible chondrolysis and epiphyseal injury
–Acute process leading to decreased hip range of motion, severe pain with passive range of motion
-
Slipped capital femoral epiphysis (SCFE)
–Typically in obese, adolescent males with aching groin, hip, or knee
–May have externally rotated hip position and gait
-
Legg-Calvé-Perthes
–Presents at younger age than SCFE (3–8 years old)
–Five times greater incidence in boys than girls
–Pain in hip or knee, decreased active and passive ROM, and Trendelenburg gait
-
Developmental dysplasia of the hip (DDH)
–Early diagnosis with newborn exam finding
of easily dislocatable hip
–Older infants have limited hip abduction
-
Osteomyelitis
–Vague symptoms may make this a difficult diagnosis
–Limp, fever, pain in the proximal thigh or pseudoparalysis of an extremity in an infant may be the only sign
-
Fracture
–Consider accidental and nonaccidental trauma
–Pain, limited ambulation, limited active and passive ROM, or inability to bear weight
-
Transient monoarticular synovitis
–Often preceded 1–2 weeks by upper respiratory infection
–Antalgic gait, moderate pain in hip, groin, or knee, and uncomfortable range of motion
-
Neoplasia
–Although primary bone disorders do not generally present with hip pain, other malignancies such as acute leukemia may initially present with bone or joint pain
-
Vertebral osteomyelitis/diskitis
–Referred pain from lumbrosacral region may present as hip pain
Workup and Diagnosis
-
Despite urgency of surgical emergencies, a thorough history is essential
–Onset and duration of symptoms, location, and character of pain
–Previous trauma, preceding illness, or associated symptoms
–Past medical history/family history: Bone,
hematologic, and metabolic disorders
-
Labs
–CBC with differential, platelets, PT/INR, ESR, CRP
- Radiographic evaluation
–Plain X-ray: AP pelvis and frog-leg lateral of the pelvis, full length femur, and knee films
–CT scan: Helps define bony anatomy especially with 3D reconstruction images
–MRI may demonstate joint effusion in synovitis and infection, marrow edema in osteomyelitis, physeal widening in SCFE, or occult fracture such as femoral neck stress fracture
–Ultrasound for newborn DDH
-
Nuclear medicine
–Triple-phase bone scan may be helpful when the diagnosis is questionable, or if differentiating between bone and joint infections
-
Interventional radiology
–Joint aspiration to evaluate for septic arthritis
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
HIP PAIN:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
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.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Hip Pain:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Pain characteristics. What is the exact location of the pain? Pain arising from the lumbar spine is perceived in the buttock and, less commonly, in the groin and anterior thigh. This must be differentiated from radicular pain arising from the spine. True hip pain more often localizes to the anterior midgroin or midthigh area. Lateral hip or thigh pain most likely represents trochanteric bursitis (1). How is the pain described? A “snapping” type discomfort is most commonly caused by iliotibial band syndrome. Constant pain can indicate infection or cancer.
B. Involved joints. Hip osteoarthritis (OA) can have a monarticular onset, or other joints may be involved. Of hip OA patients, 20% will develop bilateral involvement.
C. Precipitating factors. Has there been a recent fall or other trauma? In an elderly or an osteoporotic patient, hip fracture can occur after a very minor incident. A contusion over the greater trochanter can lead to persistent bursitis; a contusion over the iliac crest, to a tear of the muscle aponeurosis. Has there been any preceding athletic or overuse activity that could cause muscle strain? Ischial bursitis usually develops after prolonged sitting.
D. Other symptoms. Bacterial involvement of the hip joint can be accompanied by fever and shaking chills (2). Other symptoms may be present in cancer, pelvic, intraabdominal, or retroperitoneal pathology. Sciatica commonly accompanies trochanteric bursitis.
E. Past medical history. Any prior hip problems or hip surgery? A patient with a hip replacement may develop loosening of prosthetic components, which can be a source of pain, or can seed the joint during a recent infection or invasive procedure. Aseptic necrosis of the femoral head is more likely in patients with sickle cell disease. Previous occult hip fracture or delayed treatment, can also lead to aseptic necrosis. Patients receiving long-term steroids may manifest constant hip pain. Congenital or developmental defects are found in 80% of patients with hip OA.
Physical examination
A. General. If referred pain is suspected, evaluate the appropriate organ system. Palpate the groin and thigh for hernias, lymph nodes, and vascular cords. Assess gait. An unwillingness to bear weight suggests fracture, even with a negative preliminary x-ray finding. Check the neurovascular status of the distal extremity after any traumatic episode.
B. Musculoskeletal. Observe the involved extremity. In femoral neck fractures, the involved leg may appear slightly shortened and externally rotated. Intertrochanteric fractures can cause the involved leg to be internally rotated and shortened. Evaluate the spine, including the straight leg raise test, if spinal pathology is being considered. Compression of the patient’s pelvis with the patient side lying may localize pain to the sacroiliac joint. Check for leg length discrepancy by measuring each extremity from the anterior superior iliac spine (ASIS) to the medial malleolus; for hip joint shortening, measure from the ASIS to the greater trochanter.
Palpate the greater trochanter, ischial tuberosity, and surrounding muscle groups for tenderness. The hip joint is not easily palpated; palpable warmth is produced only when intensely inflamed. Document joint range of motion. Nondisplaced or impacted fractures may not be painful, except at extremes of motion. Pain in all directions suggests intraarticular disease. Pain arising from the hip is typically elicited at the extreme ranges of motion, as well as with motion against resistance. With the patient supine, bend the uninvolved leg at the knee and hip and bring it toward the chest. Watch the opposite hip for flexion (Thomas test), indicating a flexion contracture of that hip. Loss of internal rotation occurs early in OA, followed by the loss of extension, adduction, and flexion. Pain and an inability to fully abduct or extend the hip can also be seen in rheumatoid arthritis (RA). Trochanteric bursitis may present with pain on external rotation only. Muscle strain (e.g., a “groin pull”) will produce pain on passive stretch or resisted contraction of the involved muscles only. In iliotibial band syndrome, the “snapping” of the band may be audible and palpable as the hip is flexed and extended. Document any muscle weakness or muscle atrophy.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Hip Pain:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑Hip osteoarthritis
❑Trochanteric bursitis
❑Ischial bursitis
❑Iliopectineal bursitis
❑Iliopsoas bursitis
❑Nerve root compression
❑Meralgia paresthetica
❑Obturator inflammation
❑Iliac apophysitis
❑Hip fracture
❑Aortoiliac insufficiency
❑Polymyalgia rheumatica
❑Ankylosing spondylitis
❑Septic arthritis
❑Osteonecrosis
❑Sacroiliitis
Diagnostic Approach
Pain arising from the hip joint is aggrevated with or after use, particularly weight-bearing, and improved with rest. In contrast, constant pain, particularly pain at night, should suggest an infectious, inflammatory, or neoplastic process.
In disease of the hip joint, the earliest limitation is internal rotation with the hip hyperextended. The hip joint is palpated just below the inguinal ligament lateral to the femoral artery. Tenderness and/or crepitance are usually felt there with movement. Manual internal and external rotation of the hip with the knee and hip in flexion usually reproduces pain as does concussion of the heel with the examiner’s palm.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
HIP PAIN:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
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 that fractures of the hip can occur
in elderly persons without a history of trauma. A positive
straight-leg-raise (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 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.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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