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Case 82

Avascular necrosis of the femoral head

A 50 year old man with hip pain

This 50 year old man was referred by his general practitioner with pain in the right hip on walking, for a plain film of his hips and pelvis.

Some minor degenerative changes were noted on the previous film, but no further diagnosis was made. The patient's pain persisted, and a further film was obtained a few months later.

Findings

On the initial film there is patchy sclerosis of the femoral head, and a step is visible in the contour of the femoral head consistent with a fracture secondary to ischaemic necrosis. On the subsequent film the sclerosis and abnormal femoral head contour are more obvious.

Diagnosis

Avascular necrosis of the femoral head

Discussion

No cause was evident in this patient. In cases of doubt, MRI is the investigation of choice and demonstrates abnormalities much earlier than plain films (the sclerosis occurs as a response to the initial insult and takes time to develop.

Chapman and Nakielny give a useful and thorough differential for the causes:

1. Toxic
   Steroids, Anti-inflammatory drugs, Alcohol, Immunosuppressives, Traumatic, Idiopathic, Fractures (femoral neck, talus, scaphoid), Radiotherapy, Heat (burns), Fat embolism
2. Inflammatory
   Rheumatoid arthritis, SLE, Scleroderma, Infection - eg. pyogenic arthritis, Pancreatitis
3. Metabolic and endocrine
   Pregnancy, Diabetes, Cushing's syndrome, Hyperlipidaemias, Gout
4. Haemopoetic disorders
   Haemoglobinopathies, Polycythaemia rubra vera, Haemophilia
5. Thrombotic and embolic
   Dysbaric osteonecrosis (divers), Arteritis

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