ARE YOU PREPARED?

1. ARE YOU PREPARED?

2. TASK BASED LEARNING CASE 2 • Adi, Afiq, Amni, Azfar, Rachel & Sufian • 18 June 2009

3. HISTORY • A 46 year old man was complaining of bilateral hip painon walking for the past one year. The pain was initially mild but the last two months it is getting worse especially to the right side.

4. Where is the origin of pain?

5. ANATOMY OF THE HIP JOINT • A multiaxial ball and socket synovial joint between the head of the femur and the acetabulum.

6. Acetabulum • Femoral head: semispherical, covered with articular cartilage • connected by ligament of head of femur

7. Acetabulum • Acetabular labrum deepens the socket. • Acetabular notch bridged by the transverse ligament of the acetabulum.

8. Fibrous Capsule • Formed by: external fibrous layer & internal synovial • membrane. • 1. Proximal attachment - encircles rim of acetabulum • 2. Distal Attachment • a. anterior - greater trochanter, intertrochanteric line • b. posterior - neck of femur (capsule incomplete posteriorly )

10. Intrinsic Ligaments • Anterior: iliofemoral ligament (Bigelow ligament)prevent hyperextension • Medial: pubofemoral ligament. • Prevent overabduction • Posterior: ischiofemoral ligament • Limits medial rotation

12. Blood Supply • Medial and lateral circumflex artery (femoral artery) • Artery to head of femur (obturator artery)

13. Muscles of Hip Joint • Hip flexors: Iliopsoas, sartorious, Rectus femoris • Abductors: Gluteus medius (inserts into greater trochanter) • Adductors: Adductor brevis/longus/magnus, Gracilis, Pectineus • Extensors: Hamstrings, Gluteus maximus (Inserts into the gluteal tuberosity and joins tensor fascia lata distally to form the iliotibial tract.)

14. Nerve Supply • Flexors: femoral nerve • Lateral rotators: Obturator nerve and nerve to quadratus femoris • Adductors: superior gluteal nerve

15. AETIOLOGY CAUSES OF CHRONIC JOINT PAIN • A 46 year old man was complaining bilateral hip pain on walking for the past one year.

16. Hip osteonecrosis • Osteroarthritis • Rheumatoid arthritis • Ankylosing spondylitis • Tuberculosis of the hip • Gout of the hip (uncommon) • Osteochondritis (Perthe’s disease of the hip) • Bone tumor

17. 1.Hip osteonecrosis • Disease process that results in focal areas of bone death within femoral head. • AKA. Avascular necrosis (AVN) - impairs the blood supply to bone.(head of femur) cause collapse and flattening of the bone at the end epiphysis region. • Usually affects people between 30 and 50 years of age. • Clinical features: • Aching pain in the groin • Pain with movement of the hip accompanied with stiffness. (Restricted movement) • Nearby joint may be swollen • Local tenderness maybe present • Difficulty walking or limp • Usually bilateral.

18. 2.Osteroarthritis • Non-inflammatory degenerative joint disease characterized by the breakdown of the joint's cartilage. • There is progressive softening and disintegration of articular cartilage accompanied by new growth of cartilage and bone at the joint margins(osteophytes) and capsular fibrosis • Described as ‘Wear & Tear’ arthritis • Common in elderly (>60 yo) and usually unilateral. • Clinical features: • Pain at the affected joint that starts insidiously and increases slowly over months or years. • Aggravated by exertion and relieved by rest. • Stiffness after periods of rest. • Swelling and fixed flexion deformity with loss of mobility and muscle wasting. • Shortening of the affected limb. • Abnormal gait • Antalgic gait – walking so that the load of the hip joint is reduced

19. 3.Rheumatoid arthritis • It is involve the small joint with the hallmark of the disease is progressive bone destruction on both sides of the joint without any reactive osteophyte formation. • Starts in the synovium and is mainly “inflammatory”. • Usually bilateral in affecting many joints. • Common in women in child bearing age • Usually develops in middle age, but may occur in the 20s and 30s. • Clinical features: • Pain and swelling in the groin comes on insidiously. • Has difficulty getting into or out of a chair. • Movement from the bed maybe painful • Limp • Morning stiffness. • Wasting of the buttock and thigh is often marked. • The limb is usually held in external rotation and fixed flexion. • All movements are restricted and painful.

20. 4.Ankylosing spondylitis • This is generalized chronic inflammatory disease but mainly seen in the spine and scroiliac joints that may involve of the hip joint. • It is a complete fusion results in a complete rigidity of the spine, a condition known as “bamboo spine” or “poker back”. • Involved bilaterally. • Usually - Male > female and affects at the age of 15 – 25 years old • Clinical features: • Persistent backache and stiffness of the spine. • Often worse in the early morning or after inactivity. • Pain at the peripheral joints ( More common). • All movements are diminished • May go on to complete ankylosis. • Swollen and tender at the affected joints and sometimes complaint of painful heels. • General fatigue and loss of weight. • Ocular inflammation with causing eye pain and photophobia.

21. 5.Tuberculosis of the hip • The disease may start as a synovitis, or as an osteomyelitis in one of the adjacent bones. • Usually unilateral. • Affects at the young age and children. • Clinical features: • Pain in the hip • Limp • Muscle wasting • Limited joint movement and painful • Limb shortening and deformity • Neglected cases a cold abscess in the thigh or buttock

22. 6.Osteochondritis • There is compression, fragmentation or separation of a small segment of bone, usually at the bone end involving the attached articular surface where the cartilage and bone in a joint is inflamed. ( features of ischaemic necrosis) • Common in boys at the age of 5 – 10 yo. ( Children and adolescent). • Clinical features: • Joint pain • Limited range of motion • Stiffness • Tenderness is sharply localised- Crushing osteochondritis • Feel of excessive pull by a large tendon – Pulling osteochondritis. • Intermittent pain, swelling and joint effusion – shearing osteochondritis.

23. 7.Bone tumors • Which can be used for both benign and malignant abnormal growths found in bone, but is most commonly used for primary tumors of bone, such as osteosarcoma. • Common in elderly (>60 yo) and usually unilateral and causing pathological fracture. • Clinical features: • Loss of sensation due to nerve compression • Poor blood circulation • Pain and accompanied with tenderness and swelling at the affected joint.

24. Bone Tumors

25. 8. Trauma- Articular destruction • More common fracture is in the proximal end of the femur (the long bone running through the thigh), near the hip joint. • More frequently related with the osteoporotic factors in pathological fracture. • Common in old age. (>55yo) • Most hip fractures in people with normal bone are the result of high-energy trauma such as car accidents. • Clinical features: • Pain at the affected joint • Swelling and tenderness • Short limb at the affected region – Limb length discrepancy • Can be bilateral or unilateral joint pain – depending on type of trauma and fracture. • Stiffness and decreased range of mortion.

26. CAUSES OF UNILATERAL AND BILATERAL HIP JOINT PAIN.

27. ACUTE JOINT PAIN • Hip fracture • Hip dislocation ( Posterior dislocation) • Septic arhtritis • Trochanteric bursitis • Infective tendonitis.

28. We have arrived at several likely causes of his pain: • Infective • Non-infective inflammatory • Trauma • Malignant change

29. Past History • What other important history that must be looked into in order to arrive at the differential diagnoses?

30. Past History • Past medical/surgical history • Drug history • Family history • Personal and Social history

31. He claimed to have pain after he had renal transplant for his end stage renal failure done four years ago followed by taking medication also

32. What is the most likely etiology of the pain? Which diagnoses can be safely discarded from the list of differentials?

33. What would you look for in physical examination?

34. Physical Examination: • Trendelenburg’s sign was elicited • Movement of right hip joint: • Range from 0 – 90 degrees on flexion, 0 – 30 degrees on external rotation, 0 – 25 degrees on internal rotation. • Movement of left hip joint: • Range from 0 – 80 degrees on flexion, 0 – 10 degrees on external rotation, 0 – 15 degrees on internal rotation.

35. What is Trendelenburg test? • It is a simple manoeuvre to evaluate the strength of the gluteus medius and gluteus minimus muscle.  • The patient is asked to stand, unassisted on each of the leg in turn. • While standing on one leg, he or she has to lift the other leg by bending the knee (but not the hip). • Normally, the weight bearing hip is held stable by hip abductors and the pelvis rises on the unsupported side; if the hip is unstable, or very painful, the pelvis drops on the unsupported side.

36. Trendelenburg’s sign

38. Trendelenburg sign is caused by paralysis of the gluteus medius and minimus muscles. Paralysis may arise due to nerve damage, namely, the superior gluteal nerve. • A positive Trendelenburg sign is found in: • subluxation or dislocation of the hip • abductor weakness • shortening of the femoral neck • any painful hip disorder

39. Movement • Normal range of movement: • The hip should flex until the thigh meets the abdomen, 0 - 130° • Internal rotation: 0 – 50° • External rotation 0 – 40°

40. Movement Flexion Extension

41. Movement Flexion with knees bent Internal Rotation

42. Movement External rotation

43. Based on the history and physical examination, what is your primary suspicion?

44. What are the investigations to rule out the causes of the diseases…

45. Full blood count • WBC: infection • Hb: Low in Sickle cell disease blood film (target cell & • Howell jolly bodies) • Mantoux test – Suggest TB of the hip • ESR – Indication for chronic inflammatory diseases. • (Ex: RA, SLE, ankylosing spondylitis, long term of steroid use, • inflammatory bowel disease, vasculitis). • Immunological test/ANA- Rheumatoid arthritis • Renal profile - renal study

46. Blood investigations done revealed normal level ESR and white count.

47. An x-ray of both hips was taken

48. A radiograph, or x ray, is probably the first test the doctor will recommend. • Evaluation includes and AP view and frog-leg lateral x-rays of hip.

49. Sign of avascular necrosis on radiograph • A staging system has been developed by Ficat and Arlet and has been used widely for avascular necrosis. • The classification system of Steinberg et al for radiograph finding proposed a 6 stage classification.