1-22 Osteoporosis & Hip Pain

8/14/2019 1-22 Osteoporosis & Hip Pain

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OSTEOPOROSIS & HIP PAIN

HAZEM ABDELAZEEM

Egypt April 2008


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Osteoporosis appears 1st in Hip

X rays ( Ward triangle)


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X ray diagnosis means 40 % bone

loss


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Bone Densitometry

More sensitive

Part of full 4 sites

diagnosis

Tests at differentproximal femur sites

May be done

bilaterally Indicates Ca ions loss


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Hip pain with decreased bone

density ( Porosis or Malacia)

Osteoporosis may be

Generalised or local

forms

Osteomalacia may bevit D deficiency or

other diseases


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Osteomalacia itself is PAINFUL

Associated with

pelvic, femoral & other

long bones

deformities Vit D deficiency may

be dietary, or

associated with

celiac,hepatic or renaldisease


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Stress fracture

History of overuse

or osteoporosis

Pain with weight-bearing activity;

Antalgic gait

Limited range ofmotion


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Stress fracture

May be at neck,

subtrochanteric or

less common the

head May be uni or bilateral


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Stress fracture

Pain may be due to

microscopic fr or

progressive

deformation


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Combined osteoporosis&malacia


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Impacted fracture neck femur

Pt may be ambulant &

bearing weight with

pain & limping

Xray AP & LAT arenecessary but may

not show the fr


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Ct scan is diagnostic

in cases not seen in

X ray


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Early internal fixation


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Consequences :Hip fracture

Fall or trauma

followed by inability

to walk

Limb externally

rotated, abducted,

and shortened

Pain with any

movement


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Fracture pubic rami


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LOCAL FORMS OFOSTEOPOROSIS

LOCAL OSTEOPOROSIS IS

ALWAYS PAINFUL


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Algodystrophy

Alogodystrophy is a

Neurodystrophic

Disorders

Pain. Swelling.

Trophic changes.

Functional incapacity.


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The term Algodystrophy covers a group of

painful conditions with association of pain,

vasomotor and trophic changes, functional

impairment localized in the distal parts of

the body


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Terminology

* Algodystrophy (AD)

Sudecks bone atrophy 1900. Reflex sympathetic dystrophy (RSD).

Decalcifying alogdystrophy.


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Post traumatic painful osteoporosis.

Regional migratory osteoporosis.

Shoulder-hand syndrome. Transient osteoporosis.


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ESSENTIAL

ALGODYSTROPHY

Unrecognized cause


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Personal Experience

Post traumatic

Pregnancy

Common among

medical professions

Bilaterality &

involvement of two

joints or more


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Pathophysiology

Theories:

Neurovascular dystrophy

Bone remodeling

Hormonal regulation

Biomechanical


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Disturbance of Bone

RemodellingUnbalanced Cellular Coupling

OsteoblasteXOsteoclast

Result: Localized

trabecular bone loss


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Oedema Pain

Stiffness

NeurovascularVasodilation

ischaemia

Vasospasm

Over sympathetic

tone

Stiffness


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Pathology

Osteoblastic poor activity

Subchondral cortical and

cancellous resprotion

Wide marrow spaces

Micro fractures


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The sites most commonly affected

are the wrist and hand (28%;,

shoulder (27%), ankle and foot

(24%), knee (10%), elbow (6%)

and hip (5%).


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Clinical basis & staging

Radiography

Bone scintography

MRI

Densitometry

Lab. work up

Histopathology

Biopsy [core]

Diagnosis


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Clinical Picture and stages

Stage I: 2 to 3 months.

* Pain : - Dull - Causalgic

* Vasomotor: - Redness to bluishness.

- Swelling. - Wormth - Oedema.

- *Refrain from movement(Painful)(Pseudoinflammatory signs).


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Stage II:

Pain decreases

Trophic changes:

- Skin atrophy. - Atrophic hairs.

- Tappering fingers. - Atrophic nails

- Joints stiffness.


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SPONTANEOUS REGRESSION OR

Stage III ( RARE in Hip):

Joints increase in stiffness to fibrous

ankylosis.

Decrease in the pseudoinflammatory signs.


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Lab:-

not constant

Hydroxyprolinuria

increased erosive remodelling

(osteoclast) Osteocalcin level increase

increased osteoblastic activity

ESR normal


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RADIOLOGY: Early X-ray is

negative


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Radiology Diffuse rarifaction,

spotty, patchy,

widened trabeculations

Cortical erosions

Total loss of bone

structure, by moth

eaten appearance

Normal joints


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CT SCAN


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Bone scan inconclusive

Scintography

Hot area

[remodelling

activity]


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Densitometry Weak photon

densitometry image

[ decrease bone

mass]


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MRI


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Core biopsy:

PathologyPeriosteocytic lysis of

cortical and

cancellous bone

Foci of remodelling

activity

Osteoclastic boneresorption


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ALGODYSTROPHY VERSUS AVN


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Treatment

The short-term aims of the treatment of

algodystrophy are the following:

To relieve the pain.

To correct or prevent vasomotor disorders.

To prevent bone demoralization.

To prevent trophic change and ankylosis.

To reduce the duration of functional incapacity.


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Treatment

Medical treatment.

Local injections.

Sympathetic block.

Nerve block.

Physical and

rehabilitation.

Accupuncture.

Psychotherapy.

Surgical treatment.


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Medical Treatment

NSAIDA.

Vasodilators.

Corticosteroids.

Betabolckers.

Calcitonin.


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Calcitonin *In Moderate Cases:

- 100 I.U. every day. For 3months

*In Severe Cases:

- 100 I.U. every day. For 2 to 4 weeks followed

by 100 IU every other day for 2 months.


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Local Injection

Local anaesthetic + hydrocortisone.

Sympathetic ganglion block.

Nerve block.


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Other conservative modalities

Physical and rehabilitation

therapy.

Acupuncture.

Psychotherapy.


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Surgical Treatment In persistent Acute

Manifestation

Lumber Sympathectomy


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Surgical Treatment Persistant cases & when in doubt that it

may be AVN Core decompression may

be done taking also core biopsy


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Painful focal lesions


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FOCAL LESIONS


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After excision

Post op recovery

1 Year 2 Years


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CONCLUSION

Osteoporosis is a silent disease

Painful hip associated with osteoporosis

needs special attention

Generalized osteoporosis associated with

osteomalacia is painful and leads to

painful conditions


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Back up slides


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Inflammatory arthritis Morning stiffness or

associated systemicsymptoms

Previous history ofinflammatory arthritis ormultiple joint affection

Limited range of motion andpain with passive motion


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T.B. Hip arthritis


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Trochanteric bursitis

Female:male 4:1, fourth to sixth decade Spontaneous, insidious onset

Point tenderness over greater

trochanter

X-rays may show evidence of aprevious fracture, or metal

implant . There may also be

calcification or shadows

suggesting swelling of the soft

tissues


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MRI


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Hip Synovial affections


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p yAutoimune,metabolic,specific & nonspecific infections

synovitis

Synovial tumors and tumor like (PVNS)


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Pyogenic hip arthritis

Changes in chronic caseEarly No Change


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