Diagnostic Tests for Hip Replacement
Hip Replacement Tests: Book Excerpts
Hip Replacement Diagnosis: Book Excerpts
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HIP PAIN:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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.
Testing
A. Radiographs. A suspected hip fracture requires anteroposterior and lateral or “frog leg” hip films. A fracture of the femoral neck can be difficult to visualize. In trauma cases, lateral oblique films are needed to evaluate the acetabulum. Radiologic changes of OA are ubiquitous in older patients and do not rule out other causes of hip pain. Radiographs of a septic hip joint often reveal a “moth-eaten” appearance of the subchondral bone on both sides of the joint (2).
B. Clinical laboratory. The sedimentation rate and white blood cell count are normal in synovitis; leukocytosis and an elevated erythrocyte sedimentation rate may be seen with a septic joint. If a septic joint is suspected, synovial fluid aspiration must be done promptly, as a delay of a few hours increases the chance of substantial joint damage. Joint fluid should be examined for glucose, protein, crystals, Gram’s stain, culture, cell count, and differential. Fluoroscopic guidance is needed to confidently localize the joint space.
Diagnostic assessment
A. Intraarticular disease. A deep, aching discomfort that is increased with weightbearing is characteristic of OA. In the later stages, hip OA can lead to rest or night pain. Femoral neck fractures occur most commonly in patients aged more than 50 years; intratrochanteric fractures occur at even older ages. Dislocation of the hip is rarely seen; it is most often associated with severe trauma.
Joint fluid analysis will assist in distinguishing a septic joint from a transient synovitis or crystal-induced arthropathy. Septic arthritis can lead to severe joint destruction within 2 to 3 weeks. Involvement of the hip joint in gout or pseudogout is rare. The femoral neck is a common site for metastatic cancer, which may lead to a pathologic fracture.
B. Referred pain. Lumbosacral disease is the most common cause of hip pain in a postadolescent, nonelderly individual (3).
References
1. Shbeeb MI, Matteson EL. Trochanteric bursitis. Mayo Clin Proc 1996;71:565–569.
2. Medsger TA, Jr. Diagnosis and treatment of arthritis. Emerg Med 1999;31:13–28.
3. Birnbaum JS. The musculoskeletal manual. Philadelphia: WB Saunders, 1986.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Hip Pain:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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.
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Source: Field Guide to Bedside Diagnosis, 2007
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