CHIR12007

Clinical Assessment and Diagnosis

Portfolio Exercises Week 9 & 10

Exercise 1

Differential Chart

LOCATION DDx HIP PAIN DESCRIPTION

Child Perthes 4-8; males; insidious onset
pain; associated risk factors;
groin/hip/thigh/knee pain;
limp; LLD
Slipped Epiphysis 10-15 years old; generally over
weight compared to age0-
matched; males; 50/50
trauma/atraumatic; knee pain
Developmental hip dysplasia newborn
Infection Nothing makes it better; fever;
generally unwell; rapid
progressive
Synovitis Nothing makes it better; low
grade fever; cranky and
uncomfortable
Joint Degenerative arthritis/OA Age; previous injury or hip
disease or other risk factors;
insidious onset
Inflammatory arthritis/RA and
others
FAI Positive impingement test –
pain on flexion/internal
rotation; groin pain/anterior
hip pain; fluctuates between
dull and sharp; usually athletic;
weightbearing pain with
activities-
uphill/squatting/jumping;
generally younger than OA
Labral tears Non-specific; clicking or
clucking with orthopaedic tests
Infection Fever; generally unwell;
progressive; positive lab
values; rapid progression
Bursa Iliopsoas Anterior medial thigh pain,
radiates to the knees,
snapping sensation; pain hip
flexion and internal rotation;
worse with activity
Trochanteric Tenderness directly over
trochanter; difficulty
 Ischial Buttock pain, posterior upper
thigh pain; tender on palpation
of ischial tuberosity, difficulty
sitting
Bone Fracture (overt/stress or Mechanism of injury; high
insufficiency) velocity- younger; low velocity
– older; associated fall; may be
less symptomatic
Dislocation Mechanism of injury;
posterior-dashboard; anterior-
blow rom behind
Avascular necrosis 10-35; 80% bilateral;
associated risk actors;
insidious onset similar to OA
but at younger age usually
Infection Fever; generally unwell;
progressive; positive lab
values; rapid progression
Tumour Discussed later date
Groin Osteitis pubis Groin pain; athlete; pain on
palpation of pubic symphysis
Muscle Adductor longus Stabbing groin pain; external
rotation & abduction force
Rectus femoris Pain anterior to acetabulum;
inability to extend the knee;
pain resisted hip flexion/knee
extension
Glutes Pain over the greater
trochanter and lateral thigh
referral; increases with sitting,
crossed legs, may interfere
with sleep
Psoas LB, groin, medial thigh pain;
difficulty walking and upright
posture
Rectus abdominis Groin pain and lower
abdominal pain; pain wit
contraction (sit-up)
Hamstrings Posterior thig 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
Hernia Tissue bulge; inguinal pain
Referred
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.
Can affect all bones, most commonly the long bones of the body

Most common:

• Femoral head
• Femoral condyles
• Humeral head

(Usually hip or shoulder but can occur in the elbow and ankles)

LOCATIONS WHERE
OSTEONECROSIS CAN OCCUR
Knees - medial femoral condyle
- medial knee pain mimics meniscal lesion

Wrist (Lunate) - Collapse of the carpal lunate;

- Often from repetitive trauma (biomechanical factors)

Ankles (talus) - There is increased incidence with dislocations

Upper arm (humeral head) - Usually trauma; subarticular,

- In end stage there is flattening of the humeral head

- Trauma/atraumatic; superior aspect of the femoral head

- 80% bilateral
Thigh (femoral head) - End stage femoral head flattening and collapse

OSTEONECROSIS/AVASCULAR NECROSIS (AVN)

- Painful condition
- Occurs when the blood supply to the bone is disrupted
- Can ultimately lead to destruction of joints and severe arthritis
- It is not always known what causes the lack of blood supply

Risk factors

- Injury
- Excessive alcohol use
- Corticosteroid medicines
- Medical conditions - including Caisson disease (diver's disease or "the bends"), sickle cell
disease, myeloproliferative disorders, Gaucher's disease, systemic lupus erythematosus,
Crohn's disease, arterial embolism, thrombosis, and vasculitis. 
- It may take from several months to over a year for the disease to progress.
- Important to diagnose early

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.

4 MAJOR CONDITIONS CLINICAL DIFFERENTIATING

AFFECTING THE PAEDIATRIC FEATURES FEATURES
HIP
Congenital dislocation of the • Gestational and Gestational and infancy,
hip and acetabular dysplasia infancy female > male
• female > male
• positive family history
• sleepless nights &
avoid walking or
crawling limping, toe
walking, waddling
‘duck like’ gait
• LLD
Perthes’ disorder • 4-8 4-8 years old, males
• males
• insidious onset pain
• associated risk factors
• groin/hip/thigh/knee
pain
• limp
• LLD

Slipped upper femoral • 12-16 years old 10-15 years old,

epiphysis • generally over weight males>females 2/1, obese,
compared to age
-matched
• males > females 2/1
• trauma/atraumatic
• knee pain

Stress fractures of the femoral • Pain often in groin or X-ray findings

neck anterior thigh
• Usually traumatic even
(requires great force)

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!
Conditions the causes bone to develop deep within muscles. Often found in you athletes who have
traumatic injuries and it can occur due to repetitive injuries. Most commonly found in the thigh, and
sometimes in the forearm, myositis ossificans often occurs in athletes such as football or soccer
players (sports where they may experience repetitive of severe trauma).

• Aching pain within the muscle that persists longer than expected for a normal muscle contusion

• Limited mobility of joints surrounding the injured muscle

• Swelling of the muscle group, and sometimes extending throughout the extremity

Usually very easily identifiable through x-ray, can however be mistaken for tumours.