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PAINMEDICINE ACASE-BASED LEARNINGSERIES TheHipandPelvis STEVEND.WALDMAN,MD,JD
Elsevier 1600JohnF.KennedyBlvd. Ste1800 Philadelphia,PA19103-2899
PAINMEDICINE:ACASE-BASEDLEARNINGSERIES THEHIPANDPELVIS Copyright © 2022 by Elsevier, Inc. All rights
ISBN:978-0-323-76297-7
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It’s Harder Than It Looks MAKING THE CASE FOR CASE-BASED LEARNING For sake of full disclosure, I was one of those guys. You know, the ones who wax poetic about how hard it is to teach our students how to do procedures. Let me tell you, teaching folks how to do epidurals on women in labor certainly takes its toll on the coronary arteries. It’ s true, I am amazing. . .I am great. . .I have nerves of steel. Yes, I could go on like this for hours. . .but you have heard it all before. But, it’ s again that time of year when our new students sit eagerly before us, full of hope and dreams. . .and that harsh reality comes slamming home. . .it is a lot harder to teach beginning medical students “doctoring” than it looks.
A few years ago, I was asked to teach first-year medical and physician assistant students how to take a history and perform a basic physical exam. In my mind I thought “this should be easy. . .no big deal” . I won ’t have to do much more than show up. After all, I was the guy who wrote that amazing book on physical diagnosis. After all, I had been teaching medical students, residents, and fellows how to do highly technical (and dangerous, I might add) interventional pain management procedures since right after the Civil War. Seriously, it was no big deal...I could do it in my sleep with one arm tied behind my back blah blah blah.
For those of you who have had the privilege of teaching “doctoring,” you already know what I am going to say next. It’s harder than it looks! Let me repeat this to disabuse any of you who, like me, didn’t get it the first time. It is harder than it looks! I only had to meet with my first-year medical and physician assistant students a couple of times to get it through my thick skull: It really is harder than it looks. In case you are wondering, the reason that our students look back at us with those blank, confused, bored, and ultimately dismissive looks is simple: They lack context. That’ s right, they lack the context to understand what we are talking about.
It’ s really that simple. . .or hard. . .depending on your point of view or stubbornness, as the case may be. To understand why context is king, you have to look only as far as something as basic as the Review of Systems. The Review of Systems is about as basic as it gets, yet why is it so perplexing to our students? Context. I guess it should come as no surprise to anyone that the student is completely lost when you talk about let’ s say the “constitutional” portion of the Review of Systems, without the context of what a specific constitutional finding, say a fever or chills, might mean to a patient who is suffering from the acute onset of headaches. If you tell the student that you need to ask about fever, chills, and the other “constitutional” stuff and you take it no further, you might as well be talking about the
InternationalSpaceStation.Justsaveyourbreath;itmakesabsolutelynosenseto yourstudents.Yes,theywanttoplease,sotheywillmemorizetheelementsofthe ReviewofSystems,butthatisaboutasfarasitgoes.Ontheotherhand,ifyoupresentthecaseofJannettePatton,a28-year-oldfirst-yearmedicalresidentwithafever andheadache,youcanseethelightsstarttocomeon.Bytheway,thisiswhat Jannettelookslike,andasyoucansee,Jannetteissickerthanadog.This,atitsmost basiclevel,iswhat Case-BasedLearning isallabout.
Iwouldliketotell youthat,smartguy thatIam,Iimmediatelysawthelight andbecameaconvert to Case-BasedLearning. Buttruthbetold,it wasCOVID-19that reallygotmethinkingabout Case-Based Learning.Beforethe COVID-19pandemic, Icouldjustdragthestudentsdowntothemed/surgwardsandwalkintoa patientroomandriff.Everyonewasawinner.Forthemostpart,thepatients lovedtoplayalongandthoughtitwascool.ThepatientandthebedsidewasallI neededtoprovidethecontextthatwasnecessarytoillustratewhatIwastrying toteach thewhyheadacheandfeverdon’tmixkindofstuff.HadCOVID-19 notrudelydisruptedmyabilitytoteachatthebedside,Isuspectthatyouwould notbereadingthis Preface,asIwouldnothavehadtowriteit.Withinaveryfew daysaftertheCOVID-19pandemichit,mydaysofbedsideteachingdisappeared,butmystudentsstillneededcontext.Thisgotmefocusedonhowto providethecontexttheyneeded.Theanswerwas,ofcourse, Case-BasedLearning. Whatstartedasadesiretoprovidecontext becauseitreallywas harderthanit looked ledmetobeginworkonthiseight-volume Case-BasedLearning textbookseries.Whatyouwillfindwithinthesevolumesareabunchoffun,real-life casesthathelpmakeeachpatientcomealiveforthestudent.Thesecasesprovide thecontextualteachingpointsthatmakeiteasyfortheteachertoexplainwhy, whenJannette’schiefcomplaintis, “MyheadiskillingmeandI’vegotafever,” itis abigdeal.
Havefun!
StevenD.Waldman,MD,JD
Spring2021
Averyspecialthankstomyeditors,MichaelHoustonPhD,JeannineCarrado, andKarthikeyanMurthy,foralloftheirhardworkandperseveranceintheface ofdisaster.GreateditorssuchasMichael,Jeannine,andKarthikeyanmaketheir authorslookgreat,fortheynotonlyunderstandhowtobringtheThreeCsof greatwriting...Clarity 1 Consistency 1 Conciseness ...totheauthor’swork,but unlikeme,theycanactuallypunctuateandspell!
StevenD.Waldman,MD,JD
P.S. ...Sorryforalltheellipses,guys!
14 MeredithGrace A32-Year-OldFemaleWithRightIll-Defined LowBackandButtockPain184
15 BuddyJohnson A32-Year-OldMaleWithTailbonePain FollowingaFalloffaLadder198
Index211
1 AddieBrooks A52-Year-OldWomanWith RightHipandGroinPain LEARNINGOBJECTIVES • Learnthecommoncausesofhippain.
• Developanunderstandingoftheuniqueanatomyofthehipjoint.
• Developanunderstandingofthecausesofhipjointarthritis.
• Learntheclinicalpresentationofosteoarthritisofthehipjoint.
• Learnhowtousephysicalexaminationtoidentifypathologyofthehipjoint.
• Developanunderstandingofthetreatmentoptionsforosteoarthritisofthe hipjoint.
• Learntheappropriatetestingoptionstohelpdiagnoseosteoarthritisofthe hipjoint.
• Learntoidentifyredflagswavinginpatientswhopresentwithhippain.
• Developanunderstandingoftheroleininterventionalpainmanagementinthe treatmentofhippain.
AddieBrooks AddieBrooksisa52-year-oldrancher withthechiefcomplaintof, “I’vegot ahitchinmygit-along.” Addiewent ontosaythatshewouldn’thave botheredcomingin,but “itiscoming uponcalvingseasonandthosecows gottaeat.” IaskedAddieifanything likethishashappenedbefore.She shookherheadandsaid, “Youcan’t runcattleandnothavesomething achingorpaining.Butthishitchis reallywearingmeout,andtheold heatingpadandaspirinjustaren’t cuttingthemustard.Doc,Iwouldn’t complain,butIcanbarelygetmoving inthemorningbecausemysleepisall jackedup.IthurtseverytimeIroll overonthatdamnrighthip.Hell, somemorningsIjustwanttosit downandcry.Doc,canyoujustgive meaquickshotorsomethingtoget methroughcalvingseason?You knowaswellasanybodyifIdon’tgetthosecalvestomarket,mykidsandI don’teat.”
IaskedAddieaboutanyantecedenttraumatotherighthip.Shethought aboutitforaminuteandsaidthatshegotthrownfromherhorseontoherright hipwhenshewasateenager.ShewentontosaythatOldDocJones “thoughtI justsprainedmyhipandIwouldbefine,anduntilthelastfewweekswhenI wasunloadingbalesofhay,hewasright.Hewasarealcrackerjack OldDoc Jones.Hedeliveredmymomandhedeliveredme.WeputalotofstockinwhateverDocJonestoldusandalwaysdidwhathesaid.”
IaskedAddietopointwithonefingertoshowmewhereithurtsthemost. Shepointedtothefrontofherrightgroinandsaid, “Doc,Igotahitchrighthere, especiallywhenIfirstgetupinthemorning.Thecrazythingis,sometimesIfeel likethehipispoppingorcatching.” Iaskedifshehadanyfeverorchillsandshe shookherheadno. “Whataboutsteroids?Didyouevertakeanycortisoneor drugslikethat?” Addieagainshookherheadnoandsaid, “Doc,youknowme.I amhealthyasahorse.Iloveworkingtheranch,butthishitchhasreallygotme downforthecount.” Addiedeniedanyothergynecologicsymptomsorbloodin herurine.
Fig.1.1 ElicitingthePatrick(FABER)test.(FromWaldmanSD, PhysicalDiagnosisofPain:AnAtlasof SignsandSymptoms.3rded.StLouis:Elsevier;2016:Fig.185-1.)
Onphysicalexamination,Addiewasafebrile.Herrespirationswere18andher pulsewas74andregular.Herbloodpressure(BP)wasnormalat122/74.Her head,eyes,ears,nose,throat(HEENT)examwasnormal,aswashercardiopulmonaryexamination.Herthyroidwasnormal.Herabdominalexaminationrevealed noabnormalmassororganomegaly.Therewasnocostovertebralangle(CVA)tenderness.Therewasnoperipheraledema.Herlowbackexaminationwasunremarkable.Ididarectalexamandpelvic,whichwerebothnormal.Visual inspectionoftherightgroinandhiprevealednocutaneouslesionsorobviousherniaorotherabnormalmass.Theareaoverlyingtherighthipwascooltotouch. Palpationoftherighthiprevealedmilddiffusetenderness,withnoobviouseffusionorpointtenderness.Therewasmildcrepitus,butIdidnotappreciateanypoppingorcatching.Rangeofmotionwasdecreased,withpainexacerbatedwith activeandpassiverangeofmotion.WhenIperformedthePatrick(FABER:flexion, abduction,externalrotation)testontherighthip,Addiecriedoutinpainandsaid, “Doc,that’sthehitchinmygit-along!” (Fig.1.1).Thelefthipexaminationwasnormal,aswasexaminationofherothermajorjoints,otherthansomemildosteoarthritisintherighthand.Acarefulneurologicexaminationoftheupperandlower extremitiesrevealedthattherewasnoevidenceofperipheralorentrapment neuropathyandthedeeptendonreflexeswerenormal.
KeyClinicalPoints
’ Adistanthistoryofacutetraumatotherighthipsecondarytofallingfrom ahorse
’ Nohistoryofprevioussignificanthippainotherthantheshort-termpain secondarytotheacutehiptrauma
’ Nofeverorchills
’ Gradualonsetofrightgroinandhippainoverthelastseveralweekswith exacerbationofpainwithhipuse
’ Poppingsensationintherighthip
’ Sleepdisturbance
’ Difficultywalkingsecondarytopainuponfirstarisingfromthesupineor recumbentposition
THEPHYSICALEXAMINATION ’ Thepatientisafebrile
’ Normalvisualinspectionofhip
’ Palpationofrighthiprevealsdiffusetenderness
’ Nopointtenderness
’ Noincreasedtemperatureofrighthip
’ Crepitustopalpation
’ PositivePatrick(FABER)testontheright(see Fig.1.1)
OTHERFINDINGSOFNOTE ’ NormalBP
’ NormalHEENTexamination
’ Normalcardiovascularexamination
’ Normalpulmonaryexamination
’ Normalabdominalexamination
’ Noperipheraledema
’ Nogroinmassoringuinalhernia
’ NoCVAtenderness
’ Normalpelvicexam
’ Normalrectalexam
’ Normalupperextremityneurologicexamination,motorandsensory examination
’ Examinationofjointsotherthantherighthipwerenormal
WhatTestsWouldYouLiketoOrder? Thefollowingtestswereordered:
’ Plainradiographsoftherighthip
TESTRESULTS Theplainradiographsoftherighthiprevealedsignificantjointspacenarrowing andosteophyteformationconsistentwithsevereosteoarthritis(Fig.1.2).
Fig.1.2 (A)Anteroposterior(AP)radiographofapatientwithtypicalosteoarthritis(OA)ofthehipwithjointspacenarrowingandosteophyteformation. (B)Aradiographofthesamepatientacquired18monthslatershowsrapidprogressionoftheOAchanges,withmoremarkedsuperiorjointspacenarrowing, supralateralmigrationofthefemoralhead,prominentsubchondralcystformation,andbuttressingofthemedialaspectofthefemoralneck (whitearrow).(From WaldmanSD,CampbellRSD. ImagingofPain.Philadelphia:Saunders;2011:Fig.138-1.)
Whatisthediagnosis?
’ Osteoarthritisoftherighthipjoint
TheScienceBehindtheDiagnosis ANATOMYOFTHEJOINTSOFTHEHIP Theroundedheadofthefemurarticulateswiththecup-shapedacetabulumof thehip(Fig.1.3).Thearticularsurfaceiscoveredwithhyalinecartilage,whichis susceptibletoarthritis.Therimoftheacetabulumiscomposedofafibrocartilaginouslayercalledthe acetabularlabrum,whichissusceptibletotraumashouldthe femurbesubluxedordislocated.Thejointissurroundedbyacapsulethatallows thewiderangeofmotionofthehipjoint.Thejointcapsuleislinedwithasynovialmembranethatattachestothearticularcartilage.Thismembranegivesrise tosynovialtendonsheathsandbursaethataresubjecttoinflammation.Thehip jointisinnervatedbythefemoral,obturator,andsciaticnerves.Themajorligamentsofthehipjointincludetheiliofemoral,pubofemoral,ischiofemoral,and transverseacetabularligaments,whichprovidestrengthtothehipjoint.The musclesofthehipandtheirattachingtendonsaresusceptibletotraumaandto wearandtearfromoveruseandmisuse.
CLINICALPRESENTATIONOFARTHRITISOFTHEHIPJOINT Mostpatientspresentingwithhippainsecondarytoarthritiscomplainofpain localizedaroundthehipandupperleg(Fig.1.4).Mostpatientswithintrinsichip disordershaveapositivePatrick(FABER)testresult(see Fig.1.1).Patientsmay initiallypresentwithill-definedpaininthegroin;occasionally,thepainislocalizedtothebuttock.Activitymakesthepainworse,whereasrestandheatprovidesomerelief.Thepainisconstantandischaracterizedasaching;itmay interferewithsleep.Somepatientscomplainofagratingorpoppingsensation withuseofthejoint,andcrepitusmaybenotedonphysicalexamination.
Inadditiontopain,patientsoftenexperienceagradualdecreaseinfunctional abilitycausedbyreducedhiprangeofmotionthatmakessimpleeverydaytasks suchaswalking,climbingstairs,andgettingintoandoutofacarquitedifficult. Withcontinueddisuse,musclewastingmayoccur,andafrozenhipsecondary toadhesivecapsulitismaydevelop.
TESTING Plainradiographyisindicatedinallpatientswhopresentwithhippain.Based onthepatient’sclinicalpresentation,additionaltestingmaybewarranted,
Acetabulum of pelvic bone
Acetabular labrum
Superior view
Lateral rotation
Medial rotation
Fig.1.3 Theanatomyofthehipjoint.(A)Articularsurfaces.(B)Movementofthefemurduringrotation. (FromDrakeR,VoglAW: Gray’sAnatomyforStudents.4thed.Philadelphia:Elsevier;2020:Fig.6-30.)
Head of femur
Fig.1.4 Patientspresentingwithhippainsecondarytoarthritiscomplainofpainlocalizedaroundthe hipandupperleg.(FromWaldmanSD. AtlasofCommonPainSyndromes.4thed.Philadelphia: Elsevier;2019:Fig.98-1.)
includingacompletebloodcount,erythrocytesedimentationrate,andantinuclearantibodytesting.Magneticresonanceandultrasoundimagingofthehip areindicatedifasepticnecrosisoranoccultmassortumorissuspectedorifthe diagnosisisinquestion(Figs.1.5,1.6,and1.7).
DIFFERENTIALDIAGNOSIS Manydiseasescancausehippain(Table1.1).Lumbarradiculopathymaymimic thepainanddisabilityassociatedwitharthritisofthehip;however,insuch patients,hipexaminationresultsshouldbenegative.Entrapmentneuropathies, suchasmeralgiaparesthetica,andtrochantericbursitismayconfusethediagnosis; bothoftheseconditionscancoexistwitharthritisofthehip.Primaryandmetastatic tumorsofthehipandspinemayalsomanifestsimilarlytoarthritisofthehip.
TREATMENT Initialtreatmentofthepainandfunctionaldisabilityofarthritisofthe hipincludesacombinationofnonsteroidalantiinflammatorydrugsor
Arthritic hip joint
Fig.1.5 (A)Anteroposterior(AP)radiographofa60-year-oldpatientwithhippain,whichshowsno significantosteoarthritis(OA)changes.(B)However,thecoronalT2-weightedwithfatsuppression (FST2W)magneticresonance(MR)imageclearlydemonstratesahigh-signalintensity(SI)hipjoint effusionwithdiffuseareasofcartilagelossacrossthefemoralheadduetoearlyOA.(C)Comparewith theFST2WMRimageofanormalhipwithintermediate-SIcartilageoverlyingthelow-SIsubchondral boneplate (whitearrows).(D)Thecartilagelossisalsoseenonthesagittalprotondensityimage (brokenblackarrows) butwithsomeareasofcartilagepreservation (blackarrows).(FromWaldmanSD, CampbellRSD. ImagingofPain.Philadelphia:Saunders;2011:Fig.138-2.)
cyclooxygenase-2inhibitorsandphysicaltherapy.Thelocalapplicationofheat andcoldmayalsobebeneficial.Forpatientswhodonotrespondtothesetreatmentmodalities,intraarticularinjectionoflocalanestheticandsteroidisareasonablenextstep.
Fig.1.6 Ultrasoundimageofthehipdemonstratingtherelationshipoftheacetabulumtothefemoral headandjointcapsule.(CourtesyStevenD.Waldman,MD.)
Ultrasoundimagedemonstratingavascularnecrosisofthehip.(CourtesyStevenD.Waldman,MD.)
Fig.1.7
TABLE1.1 ’ CausesofHipPainandDysfunction
LocalizedBonyorJointSpace
PathologyPeriarticularPathologySystemicDisease
Sympathetically MediatedPain ReferredFromOther BodyAreasVascularDisease
FractureBursitisRheumatoid arthritis CausalgiaLumbarplexopathyAortoiliac atherosclerosis
PrimarybonetumorTendinitisCollagenvascular disease Reflexsympathetic dystrophy LumbarradiculopathyInternaliliacartery occlusion
PrimarysynovialtissuetumorAdhesivecapsulitisReitersyndromeLumbarspondylosisEntrapment neuropathies
JointinstabilityJointinstabilityGoutFibromyalgia
LocalizedarthritisMusclestrainOthercrystal arthropathies Myofascialpain syndromes
OsteophyteformationMusclesprainCharcot neuropathic arthritis Inguinalhernia
OsteonecrosisoffemoralheadPeriarticularinfectionnot involvingjointspace
Jointspaceinfection
Hemarthrosis
Villonodularsynovitis
Intraarticularforeignbody
Slippedcapitalfemoralepiphysis (Leggdisease)
Chronichipdislocation
FromWaldmanSD. AtlasofCommonPainSyndromes.4thed.Philadelphia:Elsevier;2019:Table98-1.
Intraarticularinjectionofthehipisperformedbyplacingthepatientinthe supineposition.Theskinoverlyingthehip,subacromialregion,andjointspaceis preparedwithantisepticsolution.Asterilesyringecontaining4mLof0.25% preservative-freebupivacaineand40mgmethylprednisoloneisattachedtoa 2-inch,25-gaugeneedlebyusingstrictaseptictechnique.Thefemoralarteryis identified;then,atapointapproximately2incheslateraltothefemoralartery,just belowtheinguinalligament,thehipjointspaceisidentified.Theneedleiscarefully advancedthroughtheskinandsubcutaneoustissuesthroughthejointcapsuleinto thejoint.Ifboneisencountered,theneedleiswithdrawnintothesubcutaneoustissuesandisredirectedsuperiorlyandslightlymoremedially.Afterthejointspaceis entered,thecontentsofthesyringearegentlyinjected.Littleresistancetoinjection shouldbefelt.Ifresistanceisencountered,theneedleisprobablyinaligamentor tendonandshouldbeadvancedslightlyintothejointspaceuntiltheinjectioncan proceedwithoutsignificantresistance.Theneedleisremoved,andasterilepressuredressingandicepackareappliedtotheinjectionsite.Ultrasoundneedleguidancewillsimplifythisprocedure,improvetheaccuracyofneedleplacement,and decreasetheincidenceofneedle-relatedcomplications(see Fig.1.6).Recentclinical experiencesuggeststhattheintra-articularinjectionofplatelet-richplasmaand/or stemcellsmayprovideimprovementofthepainandfunctionaldisabilityof patientssufferingfromosteroarthritisofthehip.
HIGH-YIELDTAKEAWAYS • Thepatientisafebrile,makinganacuteinfectiousetiology(e.g.,septicarthritis) unlikely.
• Thepatient’ssymptomatologyisnottheresultofacutetraumabutmorelikely theresultofrepetitivemicrotraumathathasdamagedthejointovertime.
• Thepatient’spainisdiffuseratherthanhighlylocalized,aswouldbethecase withapathologicprocessliketrochantericbursitis.
• Thepatient’ssymptomsareunilateralandonlyinvolveonejoint,whichismore suggestiveofalocalprocessthanasystemicpolyarthropathy.
• Sleepdisturbanceiscommonandmustbeaddressedconcurrentlywiththe patient’spainsymptomatology.
• Plainradiographswillprovidehigh-yieldinformationregardingthebonycontents ofthejoint,butultrasoundimagingandmagneticresonanceimagingwillbemore usefulinidentifyingsofttissuepathology.
SuggestedReadings CaughranAT,GiangarraCE.Thearthritichip.In:GiangarraCE,ManskeRC,eds. ClinicalOrthopaedicRehabilitation:ATeamApproach.4thed.Philadelphia:Elsevier; 2018:432 435.
El-BakouryA,WilliamsM.Managementofhippaininyoungadults. Surgery(Oxford) 2020;38(2):74 78.
FoyePM,StitikTP,ShahVP,etal.Hiposteoarthritis.In:FronteraWR,SilverJK,Rizzo TD,eds. EssentialsofPhysicalMedicineandRehabilitation.4thed.Philadelphia: Elsevier;2020:307 314.
WaldmanSD.ArthritisandOtherAbnormalitiesoftheHipJoint.In: Waldman’ s ComprehensiveAtlasofDiagnosticUltrasoundofPainfulConditions.Philadelphia: WoltersKluwer;2016:613 622.
Arthritispainofthehip.In:WaldmanSD,ed. AtlasofCommonPainSyndromes.4thed. Philadelphia:Elsevier;2019:383 386.
WaldmanSD. HipJointPainReview.2nded.Philadelphia:Elsevier;2017:140 141.
WaldmanSD.Intra-articularinjectionofthehip.In: AtlasofPainManagementInjection Techniques.4thed.Philadelphia:Elsevier;2017:385 390. WaldmanSD,CampbellRSD.OsteoarthritisoftheJipJoint.In: ImagingofPain. Philadelphia:Saunders;2011:351 352.
2 SandyBrooks A69-Year-OldFemaleWithLeft HipandGroinPain LEARNINGOBJECTIVES • Learnthecommoncausesofhippain.
• Developanunderstandingoftheuniqueanatomyofthehipjoint.
• Developanunderstandingofthecausesofavascularnecrosisofthehip.
• Learntheclinicalpresentationofavascularnecrosisofthehipjoint.
• Learnhowtousephysicalexaminationtoidentifypathologyofthehipjoint.
• Developanunderstandingofthetreatmentoptionsforavascularnecrosisofthe hipjoint.
• Learntheappropriatetestingoptionstohelpdiagnoseavascularnecrosisofthe hipjoint.
• Learntoidentifyredflagsinpatientswhopresentwithhippain.
• Developanunderstandingoftheroleininterventionalpainmanagementinthe treatmentofhippain.
SandyBrooks SandyBrooksisa69-year-oldretired teacherwiththechiefcomplaintof, “ MylefthiphurtswheneverI walk. ” Shevolunteeredthather lefthiphadbeenbotheringherfor thelastcoupleofyears,butshe hadn ’ trealizedhowbadithad gottenbecause,untilherpulmonologistuppedherprednisone dose,herbreathinghadbeenso badthatshewasprimarilystayinginherreclineralldaylong. “ Doc, whateveryoudo,don ’ tsmokethosecoffinnails!Theydidmein,andI don ’ twantthattohappentoyou.Dealingwiththisoxygen24hoursa dayisnopicnic. ” IreassuredSandythatIneversmokedandhadlittle intentionofstartingnow,andshepattedmyhandandsaid, “ Thank God! ” Iaskedher, “ Otherthanprednisoneandbreathingmedicines,have youtriedanythingelsetohelpthepain? ” Sandysaidshehad “ triedrubbingontheAustralianDreamandtooksomeTylenol,butIguessthepain wasjustdowntoodeepforthemtowork. ” Sandyalsonotedthatshehad tostopusingherheatingpadbecauseshefellasleepwithitonandshe accidentlyburnedherself. “ Doc,Ijustdon ’ thaveanystrengthanymore. I ’ llhaveyouknowthatIwasquiteanathletewhenIwasyounger.Now, it ’ sallIcandotogetupandgototheladies ’ room. ”
IaskedSandyifshehadeverinjuredherlefthipbeforeandshethoughtfora moment,andsaid, “Youknow,whenIwas5or6yearsold,Igothitbyacar whenIranoutintothestreettogetmyballandhadadislocatedhip.Ican’t rememberwhichone itwassolongago.It’sawonderIremembermyown nameanymore. ” Igavehershoulderasqueeze,smiled,andtoldherthatshe wasdoinggreatandthatweweregoingtofigureoutwhatwaswrongwiththat hipanddowhatwecouldtogetitbetter.
IaskedSandytopointwithonefingertoshowmewhereithurtthemost.She pointedtothefrontofherleftgroinandsaid, “Doc,ithurtswaydowndeep,and itreallygetsmyattentionwhenItrytobearweightonit.Ireallydreadhavingto getuptogototheladies’ room.Itreallyhurts,butIdon’twanttohaveanaccident.” Iasked, “Doesthepaingoanywhere?” andSandynotedthatsometimesit radiatedtothesideofherthigh.Sandydeniedanygynecologicsymptomsor bloodinherurine.
Onphysicalexamination,Sandywasafebrileanddyspneicatrest.Her respirationswere22.Herpulsewas88andregular.Herbloodpressure (BP)wasnormalat112/76.Inspiteoftherecentincreaseinher
prednisonedose,Sandydidnotappearcushingoid,butshelookedlikeshe hadlostalittleweightsinceIhadseenherforherflushot.Herhead, eyes,ears,nose,throat(HEENT)examwasnormal,aswasherthyroid examination.Hercardiopulmonary examinationrevealeddiminished breathsoundswithprolongedexpirationandafewwheezes.Herabdominalexaminationrevealednoabnorm almassororganomegaly.Therewas nocostovertebralangle(CVA)tender ness.Therewasnoperipheraledema. Herlowbackexaminationwasunremarkable.Ididarectalandpelvic exam,whichwerebothnormalotherthanmildatrophicvaginitis.Visual inspectionoftheleftgroinandhiprevealednocutaneouslesionsorobviousherniaorotherabnormalmass.Theareaoverlyingthelefthipwas cooltotouch.Palpationofthelefthiprevealedmilddiffusetenderness, withnoobviouseffusionorpointtenderness.Therewasmildcrepitusand IthoughtIdetectedaclickwithran geofmotion.Theoverallrangeof motionwasdecreasedwithpainexacerbatedwithactiveandpassiverange ofmotion.IhadSandywalkdownthehallandnoticedthatshehada positiveHopalongCassidysignforantalgicgait( Fig.2.1 ).Therighthip examinationwasnormal,aswasexaminationofherothermajorjoints, exceptforsomemildosteoarthritisinthelefthand.Acarefulneurologic examinationoftheupperandlowere xtremitiesrevealedtherewasno
Fig.2.1 TheHopalongCassidysignforantalgicgait.(FromWaldmanSD. PhysicalDiagnosisofPain: AnAtlasofSignsandSymptoms.3rded.StLouis:Elsevier;2016:Fig.184-3.)
evidenceofperipheralorentrapmentneuropathy,andthedeeptendon reflexeswerenormal.
KeyClinicalPoints THEHISTORY ’ Ahistoryofarecentincreaseinprednisonedosetotreatanexacerbationof chronicobstructivepulmonarydisease(COPD)
’ Aquestionabledistanthistoryofacutetraumatothelefthip/dislocation afterbeinghitbyacar
’ Aseveral-yearhistoryofsomelefthippainwitharecentacute exacerbationafteranincreaseinprednisonedosage
’ Increaseinpainwithweightbearing
’ Nofeverorchills
THEPHYSICALEXAMINATION ’ Thepatientisafebrile
’ Normalvisualinspectionofhip
’ Palpationoflefthiprevealsdiffusetenderness
’ Nopointtenderness
’ Noincreasedtemperatureoflefthip
’ Crepitustopalpationduringrangeofmotionoflefthip
’ Clicksensationduringrangeofmotionoflefthip
’ PositiveHopalongCassidysignontheleft(see Fig.2.1)
OTHERFINDINGSOFNOTE ’ NormalBP
’ NormalHEENTexamination
’ Normalcardiovascularexamination
’ Abnormalpulmonaryexamination
’ Normalabdominalexamination
’ Noperipheraledema
’ Nogroinmassoringuinalhernia
’ NoCVAtenderness
’ Normalpelvicexam
’ Normalrectalexam
’ Normalupperextremityneurologicexamination,motorandsensory examination
’ Examinationsofjointsotherthanthelefthipwerenormal
WhatTestsWouldYouLiketoOrder? Thefollowingtestswereordered:
’ Plainradiographofthelefthip
’ Magneticresonanceimaging(MRI)ofthelefthip
TestResults Theplainradiographsofthelefthiprevealedscleroticchangesofthefemoral headconsistentwithadvancedavascularnecrosis(Figs.2.2 and 2.3).
ClinicalCorrelation—PuttingItAllTogether
Whatisthediagnosis?
’ Avascularnecrosis(osteonecrosis)ofthelefthipjoint
TheScienceBehindtheDiagnosis ANATOMYOFTHEHIPJOINTS Theroundedheadofthefemurarticulateswiththecup-shapedacetabulum ofthehip.Thearticularsurfaceiscoveredwithhyalinecartilage,whichis A B
Fig.2.2 Anteroposterior(A)andfrog-leg(B)viewsofthelefthipshowingscleroticchangesofthe femoralheadtypicalofadvancedosteonecrosis.(FromFiresteinG,etal. KelleyandFirestein’s TextbookofRheumatology.10thed.Philadelphia:Elsevier;2017:Fig.103-4.)
