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Radiology Quiz
This 65 year old farmer complained of
increasing pain and stiffness in his
right hip on walking, with the pain
now interfering with his sleep. His wife also
mentioned that he now seems to limp on the
right hand side. He also complained of
restricted movement in the right leg that was
confirmed on examination of the hip.
Questions
(1) What abnormalities does this radiograph show?
Bone cysts, subchondralsclerosis, narrowing of the joint space. The other main radiographic feature of osteoarthritis hip is osteophytes . These are not readily apparent on this film. You should compare the diseased right hip with the normal left hip to appreciate the radiographic changes.
(2) What further questions would you like to ask or what examinations would you like to do?
Take a thorough history including attention to any factors that may have led
to secondary osteoarthritis: injury, infection (see answer to question 5).
- A complete examination of both hips should be undertaken with attention to the following parts.
Do the Trendelenburg's test (for gluteal muscle strength). Undertake Thomas' test
(for a fixed flexion de formity, which is common in aosteoarthritic hip). Measure the
real and apparent lengths of both legs
(apparent length is often shorter in a
osteoarthritic hip). It is also good practice
to examine the neighbouring joint, in this
case the knee.
- Examine for Herbeden's and
Bouchard's nodes at the distalinterphalangeal joint and proximal interphalangeal
joints respectively and carpo metacarpal joint involvement giving squaring of the hand . These are characteristic of some primary forms of a osteoarthritic hip.
- How have the problems affected his
activities of daily living, which indicate the
degree of disability in the individual?
(3) Indicate exactly where you would find the specific radiograph changes characteristic of this disease
Bone cysts - in subchondralareas only. Osteophytes - at joint margin only. Sclerosis - subchondral only. Subchondral means beneath the bone lined by articular cartilage.
(4) What is your exact diagnosis?
Osteoarthritis of the right hip.
(5) Give the potential causes of this disease.
A neat reminder of most causes of osteoarthritis is the "eight I's":
- Idiopathic - for example , generalised nodal osteoarthritis.
- Injury - for example, intra-articular fracture.
- Inflammation - for example, rheumatoid arthritis, gout.
- Incongruency - for example , slipped upper femoral epiphysis, developmental dysplasia of the hip.
- Infection - for example, osteomyelitis.
- Ischaemia - for example, Perthes' disease.
- Iatrogenic - for example, menisectomy.
- Interesting others - for example, acromegaly, Paget's disease.
The quiz is compiled by Barry Kelly, consultant radiologist,
Royal Victoria Hospital, Belfast, and
Ian C Bickle, fourth year medical student, Queen's University, Belfast.
We would like to thank James Nixon, professor of orthopaedic surgery, Musgrave Park Hospital, Belfast, for his help.
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