Group 7.

AVN of the femoral head

The following questions should be answered

1. What is a classic history or capsule summary for this presentation? Specifically a typical
mechanism of injury and the typical aggravating and relieving factors.

 People aged 30 – 50
 People with groin pain but have normal radiographs
 People will be asymptomatic in the early stages but as the condition progresses
people will have pain whilst standing which will eventually lead to pain while at rest.
 Often patients will present with hip in slight flexion and external rotation
 It has been linked to several medical conditions such as heavy alcohol abuse, sickle
cell disease, lupus, oral steriods and complications of HIV infection


2. What red flags and other conditions you need to eliminate? (include systemic and peripheral
presentations.

 Femoral neck fractures

 Hip dislocation
 HIV, lupus, sickle cell disease
 Children aged 4 – 8, this is referred to as Legg-Calve-Perthes disease
 Chronic renal failure
 Gaucher disesae

3. What outcome assessments would you use?

4. If there is a grading scale, can you briefly describe it?

Four stages:
Stage 1. Pain, minimal changes but can be seen on MRI
Stages 2, 3 & 4 the hip degrades until at stage 4 a replacement is required.

5. What imaging techniques would you use and why?

MRI must be used in the initial stages as plain film X-ray will not detect AVN. Nuclear bone
scan can detect AVN in the early stages but MRI is the gold standard.

6. On the provided Images, please indicate the pathology and describe it?

Idiopathic AVN, this is because the necrosis is located anterolateral and shows as low signal
intensity which represents oedema. Traumatic causes of AVN will reduce blood supply to
the entire femoral head.
7. What relevant orthopaedic, quantitative and qualitative tests would you use? Demonstrate
one of each on the patient to the class.

Due to the pain pattern that people will present with that have AVN the only orthopaedic
tests will be to rule out other conditions.
Palpation will be used to check for hernia or bursitis.
There will be many false positives with orthopaedic testing for this condition so patient
history will be vital and MRI the only way to make a diagnosis.

8. Outline your management strategy including chiropractic and other techniques, treatment
plan; including your visit schedule, home advice, exercises and progressions. Include
expectations of what they can achieve at relevant time frames and what exercises you would
use in the relevant time frames.

If AVN is suspected the patient must be sent to their GP for referral to an Orthopaedic
surgeon for evaluation.
Thanks to technology advancements if a person is diagnosed with AVN in stage 1 or 2 then
the head of the femur has a high probability of being saved. Bone marrow is extracted from
the ilium and spun in a centrifuge. This separates stem cells and osteoblasts which then get
deposited directly into the femoral head. Due to the age of the people usually suffering
from AVN this is a far better course of management as hip replacements generally only last
15 – 20 years and these people would then have to get multiple throughout their lives.
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