irritable hip

IRRITABLE HIP

PYOGENIC ARTHRITIS


seen in children under the age of 2 years. The organism (usually a staphylococcus) reaches the joint either directly from a distant focus OR by local spread from osteomyelitis of the femur.

PATHOPHYSIOLOGY

The Limping Child: Age 3 – 6Septic Arthritis Bacteria
Enzymes
Destroy cartilage
Irreversible joint damage
White cells
Enzymes

Clinical features

child is ill and in pain. The affected limb may be held absolutely still and all attempts at moving the hip are resisted. With care and patience. it may be possible to localize a point of maximum tenderness over the hip;

Diagnosis

Confirmed by aspirating pus from the joint. In neonates the most common presenting feature is a total lack of movement in the affected limb (pseudo paralysis). Local signs of inflammation are usually absent .

X-rays

During the acute stage of bone infection, x-rays may show slight lateral displacement of the femoral head, suggesting the presence of a joint effusion.

The Limping Child:Age 3 – 6 Septic arthritis Child refuses to walk Movement of hip is painful May have fever Elevated WBC Progressively sicker Progressive joint destruction
WIDENED JOINT SPACE


In children the epiphysis may become necrotic and later appear unusually dense or 'fragmented' on x-ray.

Ultrasound scans also will help to reveal a joint effusion.

In adults the defining feature is rapidly progressive erosion of the articular surfaces.

Antibiotics should be given as soon as the diagnosis is reasonably certain,

but not before obtaining a sample of joint fluid (or pus) for microbiological investigation and testing for antibiotic sensitivity.

The joint is aspirated under general an aesthesia and.

if pus is withdrawn, arthrotomy is advisable.

antibiotics are instilled locally and the wound is closed without drainage.

The hip is kept on traction or splinted in abduction until all evidence of disease activity has disappeared.

TUBERCULOSIS

The disease may start as a synovitis, or as an osteomyelitis in one of the adjacent bones. Once arthritis develops, destruction is rapid and may result in pathological dislocation.

Healing usually leaves a fibrous ankylosis with considerable limb shortening and deformity.


Clinical features


Pain in the hip is the usual presenting symptom, The patient walks with a limp; though in late, neglected cases a cold abscess may point in the thigh or buttock. muscle wasting may be obvious and joint movements are limited and painful.

Investigations

Blood examination E S R. Mantoux test ELAIZA TEST .

X-rays

The first x-ray change is general rarefaction of bone around the hip,

In a child, the femoral epiphysis may be enlarged, again suggestive of chronic synovitis.

Later changes are erosion and eventually destruction of the articular surfaces on both sides of the joint.

Complications

However, if the joint is destroyed, the usual result is an unsound fibrous ankylosis. The leg is scarred and thin. and shortening is likely to be severe.

Treatment

If the disease is caught early, anti-tuberculosis chemotherapy should result in healing. During the acute phase, the joint may need to be splinted in abduction or held in traction until the symptoms subside.

An abscess in the femoral neck is best evacuated. If the joint has been destroyed, arthrodesis may become necessary, but usually nor before the age of 14. In adults joint replacement is feasible

RHEUMATOID ARTHRITIS

The hip joint is frequently affected in rheumatoid arthritis.

The hallmark of the disease is progressive bone destruction on both sides of the Joint without any reactive osteophyte formation.

Clinical feature

Usually the patient already has rheumatoid disease affecting many joints. Pain in the groin comes on insidiously.

limp, though common, may be ascribed to pre-existing arthritis of the foot or knee.

With advancing disease the patient has difficulty getting into or out of a chair. and even movement in bed may be painful.

Clinical signs

Wasting of the buttock and the thigh is often marked, and the limb is usually held in external rotation and fixed flexion. ALL movements arc restricted and painful.

X-rays

During the early stages there is osteoporosis and diminution of the joint space.

Later the acetabulum and femoral head are eroded.

In the worst cases (and especially in patients on corticosteroids) there is gross bone destruction and the floor of the acetabulum may be perforated.


Treatment


If the disease can be arrested by general treatment( non steroidal anti-inflammatory drugs). hip deterioration may be slowed down. But once cartilage and bone are eroded.

Total joint replacement is then the best answer.

A fairly common complaint is of swelling - either of the entire joint or asymmetrically on one or other aspect of the joint. The following conditions should be considered.

Swelling of the knee

Acute swelling
Chronic swelling

Acute swelling

Post-traumatic haemarthrosis
Swelling immediately after injury means blood in the joint. The knee is very painful Feels warm, tense and tender, Later there may be a 'doughy' feel. Movements are restricted.


X-rays
essential to see if there is a fracture.

suspect a tear of the cruciate ligaments.

Non-traumatic haemarthrosis
In patients with clotting disorders (hemophilia ). the knee is the most common site for acute bleeds. If the appropriate clotting factor is available, the joint should be aspirated and splinted

Acute septic arthritis

The organism is usually Staphylococcus aureus, but in adults gonococcal infection is almost as common. The joint is swollen, painful and inflamed. The white cell count and ESR are elevated . Aspiration reveals pus in the joint.

Fluid should be sent for microbiological investigation, including anaerobic culture. This should always be done before starting antibiotic treatment.

Treatment consists of intravenous antibiotics and drainage of the joint.

Traumatic synovitis
Injury stimulates a reactive synovitis; typically, the swelling appears only after some hours, unlike the almost immediate appearance of a haemarthrosis, and subsides spontaneously over a period of days.


There is inhibition of quadriceps action and the thigh wastes. If the amount of fluid is considerable, its aspiration hastens muscle recovery.


Aseptic non-traumatic synovitis
Acute swelling, without a history of trauma or signs of infection.

suggests gout or pseudo gout.

Aspiration will provide fluid which may look turbid, resembling pus, but it is sterile and microscopy (using polarized light) reveals the crystals.

Treatment

with anti-inflammatory drugs is usually effective. And antigout (allopurinol ).

CHRONIC SWELLING OF THE ENTIRE JOINT

Arthritis
The commonest causes of chronic swelling are osteoarthritis . rheumatoid arthritis.

Other signs, such as deformity, loss of movement or instability, may be present

x-ray
Examination will usually show characteristic features. Narrowing joint space sclerosis, cystic changes.


Synovial disorders
The most important condition to exclude is tuberculosis. the condition should be seriously considered whenever there is no obvious alternative diagnosis.

Investigations

should include Mantoux testing. synovial biopsy. microbiological investigations.

SWELLINGS IN FRONT OF THE JOINT

Prepatellar bursitis ('housemaid's knee')
This fluctuant swelling is confined to the front of the patella, and the joint itself is normal. It is an un infected bursitis due to constant friction between skin and bone.

As such, it is seen mainly in carpet layers. paving workers, floor cleaners and miners who do not use protective knee pads.

Treatment

consists of firm bandaging, and kneeling is avoided; occasionally aspiration is needed. In chronic cases the lump is best excised.

Infra patellar bursitis ('clergyman's knee')

The swelling is below the patella and superficial to the patellar ligament being more distally placed than prepatellar bursitis. Treatment is similar to that for prepatellar bursitis

SWELLINGS AT THE BACK OF THE KNEE

Semimembranosus bursa
The bursa between the semimembranosus and the medial head of gastrocnemius may become enlarged in children or adults. It presents usually as a painless lump behind the knee,

slightly to the medial side of the midline, and is most conspicuous with the knee straight.

The lump is fluctuant and trans -illuminate. The knee joint is normal.

Treatment
A waiting policy is wise, even if the lump causes an ache, as it usually disappears with time.

Popliteal 'cyst'

Bulging of the posterior capsule and synovial herniation may produce a swelling in the popliteal fossa. It is most likely to be caused by rheumatoid arthritisor osteoarthritis, but it is still often called a 'Baker's cyst' (even though the original description by William Motranr Baker in 1877


Occasionally the 'cyst‘ Ruptures and the Synovial contents spill into the muscle planes, causing pain . swelling in the calf- a combination which can easily be mistaken For deep vein thrombosis.


Treatment
The swelling may diminish following aspiration and injection of hydrocortisone; excision is not advised, because recurrence is common unless the underlying condition is treated.

OSGOOD-SCHLATTER'S DISEASE

Painful swelling of the tibial tubercle . common complaint among adolescents, particularly those engaged in strenuous sports. Although often called osteochondritis.

it is nothing more than a traction injury of the apophysis into which part of the patellar ligament is inserted.

On examination

the tibial tuberosity is unusually prominent and tender.

Sometimes active extension of the knee against resistance is also painful.

X-rays
show displacement or fragmentation of the tibial apophysis.

Treatment

Spontaneous recovery is usual, but takes time, and it is wise to restrict such activities as cycling and football.



By the end of growth, the knees are normally in 5-7 degrees of valgus, Theoretically, anything more or less than that would be classed as deformity, In practice, deformity is usually gauged from simple observation; this is best done with the patient standing and bearing weight. Bilateral genu

A etiology

Idiopathic . Ricket . Osteoarthritis . Traumatic of the condoyle fracture around the knee. Ligament injure. Blount's disease.

can be recorded by measuring the distance between the knees with the legs straight and the medial malleoli just touching. it should be less than 6 cm.
varum (bow-leg) Examination

Blount's disease

This is a progressive bow-leg deformity associated with abnormal growth of the posteromedial part of the proximal tibia. Children are often overweight and start walking early; deformity is usually bilateral and may include a rotational element.

X-rays

show characteristic features such as abnormal sloping of the medial half of the epiphysis.

Treatment

Spontaneous resolution is rare and operative correction is usually needed


can be estimated by measuring the distance between the medial malleoli when the knees are held touching with the patellae facing forwards; it is usually less than 8 cm.


A etiology
in children age of 10-12 these deformities are so common that they are considered to be normal stages of development (physiological). Ligaments injure. Fracture condyle. Renal Ricket. Bone dysplasia. Rheumatoid arthritis .

Treatment

is unnecessary. but the parents should be reassured and the child should be seen at intervals of 6 months to record progress. in the occasional case where, by the age of 10, the deformity is still marked, operative correction should be advised.

This can be done by stapling one side of the physis to slow growth on that side (epiphyseodesis). or at a later stage by osteotomy (supracondylar femoral for valgus deformity and proximal tibial for varus). Bone dysplasia and rickets are associated with more intractable deformities which are likely to need operative correction.

Osteoarthritisof the knee

It is a degenerative wear and tear process occurring in joints .it is by far the commonest variety of arthritis

Predisposing factors

(primary) Congenital ill development.

(secondary) Irregularity of joint surface from previous fracture. Internal derangements, e.g. torn meniscus.

Previous disease. e.g. rheumatoid arthritis. Mal-alignment of a joint .e.g. bow leg. Obesity and over weight.


Pathology
Any joint may be affected. The lower more than upper. The articular cartilage is slowly worn away until underlying bone is exposed.


Subchondral bone becomes hard. At the margins hypertrophies to form osteophytes. Capsule later on became slightly thickened and fibrosis.

Articular cartilage is the main tissue affected

Increased swelling. Change in color. Cartilage fibrillation. Cartilage erosion down to subchondral bone.

Normal articular cartilage from 21-year old adult

Osteoarthritic cartilage

Clinical features

Most patient past middle age. In younger there is underlying disease of the joint. Pain gradual onset. Movements slowly become restricted. In later stages deformity is a common features.

On examination

Depending on the stage. Swelling.

No increased local warmth. Crepitus. Joint Deformation.

Loss of Mobility. Quadriceps weakness.

Radiographic features

Diminution of cartilage space. Subchondral sclerosis. Spurring or (lipping )of the joint margins from osteophytes.

Asymmetrical joint space narrowing from loss of articular cartilage

Differential diagnosis
Rheumatoid arthritis.Reiter’s disease.Gouty arthritis.Brucellosis.

Arthroscopic Diagnosis

Bone Arthroscopy allows earlier diagnosis by demonstrating the more subtle cartilage changes that are not visible on x-ray
Osteoarthritic cartilage with exposed subchondral bone
Normal Articular Cartilage

Treatment

Conservative treatment. Operative treatment.

Conservative treatment.

Physical therapy Pain medications Walking aids (Unloading) Re-alignment (Orthosis)


Physical therapy
Accomplishes all 3 goals : reduce pain.

increase range of motion.

and strength.

Heat, electrical stimulation, & ultrasound ((((decrease pain))).Manipulate muscles & tendons surrounding joint. (((Concentric and eccentric quadriceps strengthening)))��

Teach body awareness (rest and joint protection).

Loss of weight

Pain medications

(1)Non-Steroidal Anti-Inflammatory Drugs (NSAID) Drugs that reduce pain, inflammation and fever Inhibit prostaglandins which play role in inflammation Are not made from steroids or narcotics No sedation, depression, addiction/dependence

Examples:

Ibuprofen . Naproxen. Diclofenac (Voltaren) Aspirin Acetamenophen is NOT an NSAID because has no anti inflammatory use



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COX-2 is secondary enzyme that selectively inhibit without disrupting GI system Examples: Meloxicam (Mobic), Celecoxib (Celebrex), Rofecoxib (Vioxx)

Pain Management

(11)Steroid Injections: 2-types A. Various Corticosteroids. Reduce inflammation response around joints Tend to have more rapid effect than NSAIDs. E.g. Depo-Medrol

B. Viscous supplement

Replace modified synovial fluid in joints Increase viscosity & elasticity of fluid. E.g. Hyalgan. Orthovisc

Knee Bracing

By correction of the knee deformity.

Operative treatment

Arthroscopic Treatment. removal loose body. Debridement. drilling of the chondral surface.

Debridement of the knee joint:. Cleaning out the joint of all debris and loose bodies. Saline solution.

Micro-fracture techniques Badly worn areas may be treated with sub-chondral holes (fracture) to promote growth of new cartilage . Usually offer temporary relief of symptoms 6 months to 2 years.


Graft-transplantation

Realignment Surgery: Proximal Tibial Osteotomy

Osteoarthritis usually affects the inside half (medial compartment) of the knee more often than the outside (lateral compartment). •This can lead to the lower extremity becoming slightly bowlegged or a genu varum deformity

Proximal Tibial Osteotomy

Physiological: Decrease venous congestion. Removed fibrosed sensory end. Increased blood supply ,due to fracture induction

Mechanical : re-aligning the angles (This places more of the weight-bearing force into a healthier compartment ).

In the procedure to realign the leg, a wedge of bone is removed or added to the upper tibia. A staple or plate and screws are used to hold the bone in place until it heals

Total Knee Replacement

Exscion of the patella. Knee arthrodesis

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