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Endgames Case Review

Bilateral groin pain in a young man

BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i5025 (Published 11 October 2016) Cite this as: BMJ 2016;355:i5025
  1. Raju Vaishya, senior consultant1,
  2. Amit Kumar Agarwal, consultant,1,
  3. Vipul Vijay, consultant1
  1. 1Department of Orthopaedics and joint replacemennt surgery, Indraprastha Apollo Hospitals, New Delhi, India
  2. Correspondence to: A K Agarwal amitorthopgi@yahoo.co.in

A 23 year old black man with sickle cell disease presented to hospital with a two year history of worsening groin pain and stiffness in both hips. He was admitted under orthopaedics after being referred by his general practitioner. No other joints were involved. The patient had no history of comorbidities associated with sickle cell disease and had restricted range of movement in both hips. A plain radiograph of the pelvis was obtained (fig 1⇓). Results of a full blood count test showed a haemoglobin level of 90 g/L (reference range 135-180 g/L and a peripheral blood film showed sickle shaped cells, nucleated red blood cells, and cell fragments. Haemoglobin electrophoresis showed high levels of haemoglobin S (65%), and serum bilirubin was 17.1 μmol/L. (reference range- 3-25 μmol/L) Other laboratory tests were unremarkable.

Fig 1 Plain radiograph of pelvis showing both hips

Questions

  • 1. What is the diagnosis and what are the differential diagnoses?

  • 2. How is this condition assessed radiologically?

  • 3. How is the condition managed?

Answers

1. What is the diagnosis and what are the differential diagnoses?

Short answer

The diagnosis is osteonecrosis of both femoral heads with secondary osteoarthritis of the hips. The differential diagnoses are primary osteoarthritis, inflammatory arthritides, rapidly progressive osteoarthritis, subchondral insufficiency fractures, and transient osteoporosis of the hip.

Discussion

Osteonecrosis of the femoral head results from an inadequate blood supply, which causes death of the osteocytes. It can be idiopathic, but known causes include:

  • Steroid use

  • Alcohol consumption

  • Disruption of arterial supply—for example, from pelvic trauma

  • Pelvic surgery

  • Lipid metabolism disorders

  • Coagulation disorders

  • Embolism—for example, due to sickle cell disease, Gaucher’s disease, or dysbarism

  • Autoimmune disease

  • Ionising radiation

  • Cytotoxic agents.

Osteonecrosis of the femoral head typically affects people aged 20 to 40 …

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