Secondary arthritis of hip most likely due to avascular

necrosis of head of femur

1) History and examination of a typical case (pic):-

 History-
- I am presenting a case of Mr. Ramlal 55 yrs old man, resident of delhi, labourer
by occupation , presented with chief complaint of
 Pain right hip since 2 years
 Limp in right lower limb since 6 months.
- HOPI: Patient was apparently normal 2 years back when he developed pain in
his right hip which was of insidious in onset, mild in intensity, dull aching in
nature, progressive, localized to right hip, aggravated by movement & exertion
and relieved by rest and analgesics. For this he visited a local doctor and was
given treatment in form of pain relieving medicine for one and half year. With
this treatment his pain was partially reduced in intensity but not completely
relieved. From last six month he developed limp which was associated with pain
and limp was progressive and he continued his activity with limp and pain in
right hip. He came to this hospital with complaints of limp and pain which is
moderate in intensity. He is able to do squatting and can sit cross-legged with
difficulty. There is no history of any constitutional symptom, morning stiffness,
multiple joint pain, redness of eyes and burning micturition, no history of skin
disease.

- Past history:-there is history of asthma and he is taking medicine for the same
since last 2 years there is no history of diabetes, hypertension, tuberculosis or
other chronic illness or prior hospitalization.
- Family history: no significant family history.
- Personal history: patient is married, non-vegeterian, alcoholic, Smoker, non-
tobacco chewer with normal bowel habits and normal sleeping pattern.
 General physical examination –
- Patient is conscious, cooperative and well oriented to time place and person, of
average built and average nourished.
- Vitals: Pulse rate-80 per minute, blood pressure-120/80 mmHg, respiratory rate-
14 per minute and afebrile.
- There is no pallor, icterus, clubbing, cyanosis, pedal oedema ,generalized
lymphadenopathy.
- Systemic examination:
Chest- bilateral air entry equal without any adventitious sound.
Cardiovascular system- both heart sound S1and S2 heard without any murmer,
Abdomen-soft, nontender without any palpable organomegaly.
Central nervous system – higher functions are normal and cranial nerves
examination within normal limit.
 Local examination of right hip:
- I have examined my Patient in walking, standing and lying down position from
front side and back.
- Gait: patient walks with bipedal, unassited with swaying of trunk to opposite
side with short stance phase, appears to be antalgic gait.
- Attitude: patient is lying comfortably on bed with right lower limb is neutral
rotation position, patella is facing toward ceiling. Right lower limb also appears
to be shortened so much so that patella and medial malleolus lies higher level
in comparison to left side.
- Inspection
 From the front: Both shoulders at same level, right ASIS at lower level in
relation to left side, no fullness in iliac fossa and Scarpa’s triangle, thigh
wasting present.
 From the side: There is exaggeration of lumbar lordosis, GT prominent.
 From the back: lateral deviation of spine towards right side, right PSIS at
lower level in relation to left side, buttock appear to be wasted and right
side gluteal fold at higher level.
- Palpation –
 No local rise of temperature, tenderness present over anterior joint line.
 I have confirmed my findings of inspection by palpation and all bony
landmarks are marked.
 Bony points:
 ASIS: at lower level,
 GT at higher level, without any thickening, broadening or surface
irregularity and non-tender.
 Soft regions:
 Bilateral femoral pulses comparable
 Pelvic lymph node not palpable
- Deformity and movement:
 Fixed flexion deformity of 200 active flexion possible upto 600 and further
passive flexion possible upto 1000
 Fixed Abduction deformity of 100 and further abduction possible upto 200
,External rotation (00-300) and Internal rotation (00-200) in extension and
there is discrepancy in rotation of limb in extension and flexion. Internal
rotation is decreased in flexion.
 All these movements are painful throughout the range of movement.
- Measurements:
 Apparent shortening – 2 cm
 True shortening – 3 cm which is suprastrochanteric and confirmed by
Bryant’s triangle
 Thigh wasting – 2 cm
- Special test:
 Active straight leg raising possible upto 600
 Trendelenburg test positive
 Axis deviation present
- Other joint examination: opposite hip, spine, sacroiliac joint and knee are
normal
- distal neurovascular deficit:-absent