CHIR12007

Clinical Assessment and Diagnosis

Portfolio Exercises Week 9 & 10

Exercise 1
Differential Chart
Please create a chart that lists as many differential diagnoses for hip pain as you can, including but
not limited to the following conditions

Hip conditions
Child Perthes 4-8; males; insidious onset;
associated risk factors;
groin/hip/thigh/knee pain;
limp; LLD, need to justify x-ray
to confirm diagnosis
Slipped Epiphysis 10-15 years; generally
overweight compared to age-
matched; males; 50/50
trauma/atraumatic; knee pain
referred from hip
Developmental Hip Dysplasia Newborn, LLD; asymmetric
gait, no specific symptoms
Infection Fever; generally unwell; rapid
progressive, nothing makes it
better, hop is a deep jt so may
not see erythema
Synovitis Low grade fever, cranky and
uncomfortable
Joint Degenerative arthritis/ OA Age; previous injury or hip
disease or other risk factor;
insidious onset, stiffness –
worse in 30min-1hr on
walking, mostly limited
internal rotation, pain with
exercise, weight bearing; gait
disturbance, chronic pain as
cartilage wears away
Inflammatory arthritis/ RA and Systemic; usually multiple jt
others inflammations
FAI Positive impingement test –
pain on flexion and int. rot,
weight bearing activity (uphill
walking/ squatting/jumping),
groin/ant hip pain; usually
athletic; generally younger
than OA
Labral Tear Non-specific; clicking or
clunking with orthopaedic
tests, previous trauma/other
hip conditions
Infection Fever; generally unwell;
 progressive, positive lab
values; rapid progression
Bursa Iliopsoas Tenderness in femoral triangle;
pain on ant. thigh, radiates to
knee, snapping sensation; pain
hip flexion and internal
rotation, worse with act.
Trochanteric Tenderness directly over
trochanter; difficulty sleeping
on side
Ischial Buttock pain, posterior upp
thigh pain; tender of ischial
tuberosity palpation, difficulty
sitting
Bone Fracture (overt/stress or Mechanism of injury
insufficiency)) High velocity – younger
Overt – visible fracture Low velocity – older,
Insufficiency – type of stress fx associated fall; may be less
which result from normal symptomatic
stresses on abnormal bone Chronic pain – unresponsive to
conservative treatment
Dislocation Mechanism of injury
Posterior – dashboard;
Anterior – blow from behind
Avascular Necrosis 10-35; 80% bilateral;
associated risk factors;
insidious onset similar to OA
but at younger age usually
Infection Fever; generally unwell;
progressive; positive lab
values; rapid progression
Groin Osteitis Pubis Groin pain; athlete; pain on
palpation of pubic symphysis
Muscle – general pain on Adductor Longus Stabbing groin pain; external
specific muscle resisted rotation and adduction force
movement
Gluts Pain over greater trochanter
and lateral thigh referral;
increased with sitting leg cross,
may interfere with sleep,
similar to trochanteric bursitis
but increase butt pain
Rectus Femoris Pain ant. to acetabulum;
instability to extend the knee;
pain on resisted hip flexion/
knee extension
Psoas LB/groin/ medial thigh pain;
pain with upright posture
Rectus Abdominis Groin pain and lower
abdominal pain; pain with
contraction (sit-ups)
 Hamstring Posterior thigh pain
Piriformis Buttock pain, SI pain
Tendon As above
Calcific tendonitis
Nerve Radiculopathy Associated LBP
Maigne’s Referred from thoracolumbar
junction
Ilioinguinal Burning, shooting pain to
medial thigh, tender at ASIS,
exacerbated by
hyperextension
Obturator Medial thigh pain; previous
surgery; altered sensation at
adductor origin
Genitofemoral Elliptical area on medial thigh;
chronic burning pain
Sciatic Posterior leg pain to knee
Other Snapping Hip Click/ crepitus in the hip
Hernia Tissue bulge; inguinal pain
Referred Possible from knee
Myofascial pain syndrome

Exercise 2
Osteonecrosis will be presented in lecture in week 10 however, this can occur in locations other than
the hip.
Please create a table/ chart that lists the locations where Osteonecrosis can occur.

Osteonecrosis
Femoral Head Traumatic or atraumatic; superior aspect of
femoral head most common; 80% bilateral; end
stage femoral head flattening and collapse
Humeral Head Usually traumatic; subarticular, end stage
flattening of the humeral head
Knee Classically medial femoral condyle; medial knee
pain mimics medial meniscal lesion
Talus Increased incidence with dislocations
Lunate Collapse of the carpal lunate; repetitive trauma,
biomechanical factors
Intramedullary infarct

Exercise 3
There are 4 major conditions that can affect the paediatric hip and may present with hip pain. Please
list these, nothing the main clinical features and identify those features which may help to
differentiate these.
Disorder Description Main clinical features Differentiating
features
Congenital dislocation In hip dysplasia, the The leg on the side of Positive Barlow
of the hip and socket (acetabulum) is the dislocated hip may manure to test if the
acetabular dysplasia too shallow and the appear shorter. hip can be passively
ligaments too loose, dislocated. Examiner
allowing the ball of The leg on the side of adds the hip while
the thigh bone the dislocated hip may applying a posterior
(femoral head) to slip turn outward. force on the knee to
partially or completely cause the head of the
in and out of the hip The folds in the skin of femur to dislocate
socket. The risk for hip the thigh or buttocks posteriorly from the
dysplasia and hip may appear uneven. acetabulum. A
instability increases palpable clunk may be
with any situation that The space between detected as the
stretches the baby’s the legs may look femoral head exits the
hip ligaments (an issue wider than normal. acetabulum.
of stability) or causes The Ortolani
the legs and hips to be maneuver identifies a
positioned so that the dislocated hip that can
ball of the thigh bone be reduced. The infant
slips out of the hip is positioned in the
socket same manner as for
the Barlow maneuver,
in a supine position
with the hip flexed to
90º. From an add
position, the hip is
gently abducted while
lifting or pushing the
femoral trochanter
anteriorly. In a
positive finding, there
is a palpable clunk as
the hip reduces back
into position. Hip
examination should
occur soon after birth
and at every visit until
the child is walking
normally.

Perthes’ disorder  It occurs when the Typically occurs in Disorder typically
blood supply to the children who are limits internal rotation
rounded head of the between 4 and 10 and abduction
femur (thighbone) is years old.
temporarily
disrupted. Without It is five times more
an adequate blood common in boys than
supply, the bone cells in girls, however, it is
die, a process called likely to cause more
avascular necrosis. extensive damage to
the bone in girls.
 
Pain in the hip or
groin, or referred to
the thigh or knee

Pain that worsens

with activity and is
relieved with rest.
Exercise 4
Self directed learning:
Please research ‘Myositis ossificans’ and present the history, clinical findings and importance of this
condition. Note: this does not solely apply to the hip!

Myositis ossificans’ - a condition where bone tissue forms inside muscle or other soft tissue after an
injury. It tends to develop in young adults and athletes who are more likely to experience traumatic
injuries.

History
The most common area is the quadriceps. The patient will report a direct blow to the knee followed
by swelling and decreased ability to flex the knee.

Cause
A direct blow causes damage to the underlying muscle with subsequent hematoma formation. When
the hematoma is encouraged to remain, myositis ossificans may occur. The contributing factors for
myositis ossificans are forcefully stretching after injury, deep massage to the area of injury, and the
use of deep heat such as ultrasound

Clinical findings

Noticeable changes in the affected muscle, including:

 Warmth
 Swelling
 A lump or bump
 Decreased range of motion

There is an obvious area of swelling and often discoloration. The patient’s active and passive ability
to flex the knee is limited. If the injury occurred several weeks before, a painful lump may be
palpable, indicating possible myositis ossificans. Radiographs often will demonstrate the degree of
maturation of this calcification response.

Can also occur in the arm - The patient will report having been struck on the arm, with subsequent
swelling that never resolved.

Management
Application of a tensor bandage with an ice pack in a flexed knee position for several hours
(alternating icing for 20 minutes, no ice for 10 to 20 minutes) is helpful in preventing accumulation
of blood into the area. Treatment decisions regarding myositis ossificans development are made
after several weeks, based on the deformity and degree of knee flexion restriction.

Myositis ossificans usually resolves on its own. Taking pain relievers, such as naproxen or ibuprofen,
can help relieve discomfort.

Other things that a person can do at home include:

  Resting the area
 Icing the injury
 Elevating the affected area
 Gentle stretching
 Wrapping the affected muscle with an elastic bandage to reduce swelling
 After the first 48 to 72 hours, a person can start physical therapy to build up strength in the
muscle.
Surgery is usually only used in cases with:
 severe pain
 growths that interfere with nearby nerves, joints, or blood vessels
 poor range of motion that makes it difficult to perform daily activities