Hip pain
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Review 3 cases of common & need-to-know ED hip conditions
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Hip pain
- 1. hip pain Laurie Robichaud PGY4 EM McGill University @laurieMcGillEM
- 2. objectives review common & need-to-know ED hip conditions discuss the use of ultrasound for hip pain evaluation
- 3. Ms. B. 26F restrained passenger in high speed MVC two of her friends died on scene right leg pain +++
- 6. presentation high-energy insult (young) low-energy mechanism (artificial hip) leg shortening, flexion, internal rotation &
- 7. xray
- 9. xray acetabular fracture femur in internal rotation & adduction affected femoral head appears smaller femoral head lateral & superior to acetabulum
- 10. complications
- 12. peroneal nerve motor exam great toe extension (most sensitive) foot dorsiflexion foot eversion
- 14. complications avascular necrosis acetabular & femur fractures sciatic nerve injury (peroneal most common)
- 15. management
- 19. Mrs. C. 72F HTN, remote left hip arthroplasty right hip pain x 2 weeks
- 22. presentation localized unilateral hip pain most common in women often related to increased activity/trauma
- 23. ultrasound
- 27. ultrasound well circumscribed anechoic collection (>2mm) lateral aspect of the greater trochanter
- 28. management
- 30. recipe 1ml methylprednisolone (40 mg/ml) 5ml lidocaine (1%)
- 33. Mr. D. 72M HTN, DM, OA right hip pain x 1 day brought in by wife in a wheelchair
- 35. evaluation
- 36. ultrasound
- 39. ultrasound effusion >5mm effusion >2mm difference from asymptomatic contralateral side
- 40. septic hip
- 41. presentation hematogenous spread staph aureus most common pathogen knee, hip & shoulder most common joints
- 42. management
- 45. management antibiotics arthrocentesis (native hips only!) orthopedic consultation
- 46. objectives review common & need-to-know ED hip conditions discuss the use of ultrasound for hip pain evaluation
- 47. questions
- 48. thank you
Notas del editor
- 26F restrained passenger in high speed MVC
- High energy: dashboard injuries, Low energy: hip arthroplasty, most common within 6 weeks of surgery Post hip dislocation 90% of all hip dislocations
- Both femoral heads should be roughly the same size. In a posterior dislocation, the femoral head may appear smaller than the contralateral side. This is because it is further away from the x-ray beam and is magnified less. The opposite is true of anterior dislocations.
- AVN is about 5 % of cases, goes up to 50% when reduction done after 6 hrs! Sciatic nerve injury usually self limited (10% of all dislocations) Peroneal most common (more superficial, prone to stretching/direct bony injury)
- AVN is about 5 % of cases, goes up to 50% when reduction done after 6 hrs! Sciatic nerve injury usually self limited (10% of all dislocations) Peroneal most common (more superficial, prone to stretching/direct bony injury) The most sensitive clinical sign of peroneal nerve palsy is weakness of the extensor hallucis longus; other signs include weakness of dorsiflexion and numbness or tingling over the dorsum of the foot.
- Early corticosteroid injection frequently is the preferred treatment, because it has been shown to be effective with satisfactory duration of effect.10
- 3 most common bacteria involved: S. aureus, Streptococcus, GNR systematic reviews show insufficient evidence for a normal CRP level, ESR, WBC count, or procalcitonin level to rule out septic arthritis.29,30 Serum blood cultures reveal the causative organism approximately 25 to 50% of the time
- The only definitive diagnostic test for septic arthritis is synovial fluid analysis. The fluid WBC count is directly proportional to the probability of a septic joint. Polymorphonucleocyte concentrations above 90% are also associated with an increased likelihood for septic arthritis. Synovial lactate levels greater than 5.6 mmol/L have an LR+ of 2.4 to infinity; smaller values make septic arthritis unlikely.33 Synovial lactate dehydrogenase (LDH) levels above 250 U/L are sensitive for septic arthritis, according to one study,16 whereas LDH levels below this seem to exclude septic arthritis. Low synovial glucose and high protein concentrations are neither sensitive nor specific for septic arthritis.32 Gram’s stain will show bacteria in 50 to 80% of infected joints.17 Synovial fluid cultures for both aerobic and anaerobic organisms should be performed. Vancomycin, ceftriaxone/cefotaxime or ceftaz + genta
- The only definitive diagnostic test for septic arthritis is synovial fluid analysis. The fluid WBC count is directly proportional to the probability of a septic joint. Polymorphonucleocyte concentrations above 90% are also associated with an increased likelihood for septic arthritis. Synovial lactate levels greater than 5.6 mmol/L have an LR+ of 2.4 to infinity; smaller values make septic arthritis unlikely.33 Synovial lactate dehydrogenase (LDH) levels above 250 U/L are sensitive for septic arthritis, according to one study,16 whereas LDH levels below this seem to exclude septic arthritis. Low synovial glucose and high protein concentrations are neither sensitive nor specific for septic arthritis.32 Gram’s stain will show bacteria in 50 to 80% of infected joints.17 Synovial fluid cultures for both aerobic and anaerobic organisms should be performed. Vancomycin, ceftriaxone/cefotaxime or ceftaz + genta