Hip Pain in Adults: Evaluation 67th Annual McGill Refresher Course for Family Physicians Dec6/2016
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1 Hip Pain in Adults: Evaluation 67th Annual McGill Refresher Course for Family Physicians Dec6/2016 David J Zukor MD FRCSC Chief Department of Orthopedic Surgery SMBD-Jewish General Hospital Associate Professor Surgery McGill University Montreal
2 Faculty/Presenter Disclosure Dr David J Zukor I have no disclosures
3 Disclosure of Commercial Support None received for this program No Conflicts of Interest
4 N/A Mitigating Potential Bias
5 Review: Common adult hip problems (ahp) Relevant: H&P Imaging studies Objectives
6 Outcomes Be able to apply this knowledge to develop an approach to the assessment of ahp s Feel comfortable to: Perform an appropriate H&P Order appropriate imaging studies and ancillary tests
7 Hip Pain Important / prevalent problem Affects about 15% (8-20%) esp. > 60 yo Family MD s q 1-2 wk.6% of office visits 1/164 cases
8 Hip Pain Leads to substantial in HR QOL especially in the elderly: Physical Function ADL s / stairs Pain
9 Etiology Extra-articular: Intra-articular: Bursitis Muscular/Tendon IT band Contusion/strain Referred Arthritis (OA/inflammatory) AVN Fracture Mechanical e.g. labrum, loose bodies
10 Remember that the hip can be an important source of referred pain to the knee (Obturator nerve) Pain can also be referred to the hip
11 Anatomy
12 Anatomy
13 History Age / General health Occupation Activities / level Past hx (gen. and hip ) Onset Trauma Aggravating / relieving factors Location Groin / anterior thigh Lateral Posterior / buttock
14
15 History Focus on FUNCTION! Work Leisure Dwelling Be open minded!
16 History Activities (especially how they are interfered with i.e. what they can no longer do?) Quality of Life Many QOL scoring systems providing more objective data are easily available (PRO s)
17 Physical Exam Gait / standing Observe LLD / Pulses Palpation ROM (NB IR, Abduction) Special Trendelenburg Log roll FABER (Flex, ABd,ER) FADIR (Flex,Add,IR) Ober SLR
18 Physical Exam Can you reproduce the patient s symptoms with the exam?
19 Physical Exam Observe Deformities / contractures Atrophy Leg lengths Pedal pulse
20 Physical Exam Trendelenburg Patient stands on affected limb Test is positive if contralateral hemi pelvis drops. (T-burg gait - pt tries to avoid this and lurches over the hip on the affected side) Abductor weakness
21 Physical Exam Trendelenburg Gait
22 Physical Exam FABER Flexion- ABduction- External Rotation Helps differentiate hip from SI joint as source of pain
23 Physical Exam FADIR Flexion ADduction- Internal Rotation Impingement test
24 Physical Exam Ober Test for IT band tightness
25 Log Roll Physical Exam Positive with intrarticular pathology
26 Imaging Hip x-ray: PELVIS! AP/Lateral of hip
27 Imaging
28 Imaging Cross table lateral vs Frog-leg lateral
29 Imaging U/S- operator dependent MRI- most sensitive CT- bony detail, # Nuclear Medicine
30 Imaging MRI Does NOT replace x- rays! Best modality for: Soft tissues ( labrum) Early detection # s, AVN ( extent and contra-lateral hip)? overly sensitive? over used
31 Diff Dx Anterior: Usually intra-articular C sign Arthritis FAI Labrum Fracture AVN Synovitis / Septic Arthritis
32 OA Most common diagnosis seen by Family MD s in patients >40 yo (44%)
33 Inflammatory Arthritis RA, AS, etc Remember IBD
34 AVN
35 Trauma Steroids ETOH Metabolic Caisson s Radiation Thrombotic Transplant Idiopathic AVN Etiology
36 Traumatic AVN Femoral neck # Hip dislocation? Minor trauma Must follow least 2 years
37
38
39 Normal AVN
40 AVN Staging Stage 0: abnormal MRI (silent hip) Stage 1: abnormal scan (silent hip) Stage 2: non-specific x-ray changes Stage 3: subchondral collapse(crescent sign) Stage 4: femoral head collapse/arthritis Stage 5: arthritic changes both sides of joint
41 Fracture Femoral Neck Inter/Sub Trochanteric Stress # s Pelvis especially pubic rami Atypical # s with Bisphosphonates (especially pre #) NB if strong index of suspicion and negative x- rays consider MRI,Bone scan
42 Intertrochanteric Fracture
43 Atypical Fracture
44 Atypical Fracture
45 Labral Tears Usually insidious onset (worse prognosis) 50% have mechanical symptoms + FABER 88% + FADIR 75-96%
46 Labral Tears Can be difficult to detect even on MRI Addition of MR Arthrography increases sensitivity to 90% (vs 30%)
47 Mechanical symptoms: Snapping Popping Catching/locking Sharp stabbing pain Can be difficult to diagnose on H&P U/S (dynamic) MRI but remember sensitivity and often specificity
48 Snapping Hip Often pops are felt by pt but not by MD During physical exam many pops / clicks are normal and not indicative of an intraarticular problem
49 Snapping Generalisation: Easily audible = Iliopsoas Easily visible = IT band
50 Lateral; Greater Trochanteric pain syndrome Bursitis IT band Tendonapathy Meralgia Paresthetica Diff Dx
51 Bursitis Trochanteric most common Usually tender on palpation May respond to topical Rx, injection
52 Diff Dx Posterior: LS causes SI joint Piriformis syndrome Vascular
53 L2-S1 innervation Especially L3 (dermatome) LS causes SI joint (FABER test) Anecdotal evidence for trial of intraarticular local anesthetic infiltration to assess contribution of hip joint as source of pain
54 Hip Pain in Adults : Evaluation Hip Pain Diff Dx Always remember to consider infection/neoplastic etiology if appropriate (CBC,CRP,ESR) Any painful THR is infected until proven otherwise
55 Review: Common adult hip problems Relevant: H&P Imaging studies Conclusion
56 Conclusion Be able to apply this knowledge to develop an approach to the assessment of ahp s Feel comfortable to: Perform an appropriate H&P Order appropriate imaging and ancillary tests
57
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