Tuesday, January 17, 2012

Case 5

15 years old male patient
Chief complaints:
   pain in the left hip since 8 months.
   limp since 6 months.
History of present illness:
Pateint asymptomatic before,correlate his history to a trivial trauma while playing as he sustained left hip injury due to fall and able to continue game after that,had little discomfort while performing routene activity and started message therapy almost 2 weeks after injury and continuedfor a month.
He developed swelling around the hip and there increase in the intensity of the pain.he was completely bed ridden due to pain. He had high grade fever with chills and rigours.
The swelling increased slowly around the anterior aspect of the left hip and the left iliac region(patient is localizing the site by his finger)patient hospitalized during that course and the surgery done over the left iliac region(scar sugesting of the incision ovr left iliac region)
The pus was drained and further medication given and patient discharged.
The pain subsided after the surgeryto little extent  with limp and then it increased gradually to the present situation,as patient unable to walk to his working place at present
Patient unable to squat and sit crossed leg.
Patient using support while walking or standing from bed since one month.
No history of night fever,weight loss,cough or other contitutional symptoms.
No history of any previous medications.
No history of pain in other joints.
Past history:
history of surgery around 7 months back, as mentioned in present illness.
No history of other illness.
No history of any medications in past.
Personal history:
Diet: mixed
Appetite: normal
Bowel bladder : regular.
Sleep: disturb due to pain.
Addiction: nil.
Family history:
Nothing contributory.
General examination:
Noting contributory.
local examination:
patient lying comfortabily,head central, both shoulder at same level,umblicus central,
Both ASIS at same level, hip in external rotation (L),patella facing laterally(L),foot lateral border touching bed.no exagrated lumbar lordosis.
Scarpa’s triangle free,greater trochanter more prominent than rt side,thigh muscle wasting,
Gluteal muscle wasting,scar over the left iliac fossa(primary intension healing),no sinuses,visible swelling,pulstionsor dilated veins.
No apparent limb length difference.
No local rise of temperature,ASIS at same level,anterior left hip joint line tenderness present,greater trocanter tender,broadened and irregular with no proximal migration.
No palpable mass around hip ant/pos/laterally.
Femoral pulse palpable and symetrical both sides.
Scar over the left iliac fossa is healthy non tender and not adherent to deeper tissue.
Left hip:
Flexion: pain free 0 to 60 degrees and further pain full 60 to 100 degrees with axial deviation while flexion.
Extension:0 to 5 degrees of extension pain full
Adduction: 0 to 10 degrees painless and further 10 to 20 degree pain full .
Abduction: 0 to 15 degrees pain less and further 15 to 25 degrees painfull
External rotation : fixed external rotation deformity of 5 degrees with further external rotation of 15 degrees.
Note:pain while terminal range of all movement with palpable crepitus.
Apparent length equall both sides.
True length equal both sides.
Byrants triangle symetrical both sides.
Shoe maker line: symetrical meeting at umblicus.
Neletons line: no abnormality.
Chienes parellelogram: normal.
Thomas test: no fixed flexion deformity.
Telescopic test: negative.
Trendelenberg test: positive.
Gait: stable/painfull gait-short limb gait.

ESR 20mm@ 2ND HR
Montoux Neg
septic arthritis of left hip.
Tuberculous  arthritis of left hip.

Whats Your DDX?????
How would you proceed further..
Whats your plan of management

1 comment:

  1. Movements appear quite better compared to the radiological appearance. Radiologically the trochanter appears migrated up and unusually the real and apparent lengths are equal to normal side! The history and involvement of acetabulum as well along with the head of femur indicate post septic sequelae. Further imaging studies might help in diagnosis. Once the inflammation subsides, Hip manipulatoin followed by physiotherapy might help to improve the movements!