Neck of femur fracture differential diagnosis: Difference between revisions

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[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Neck_of_femur_fracture]]
{{CMG}}; {{AE}} {{Rohan}}
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==Differentiating Neck of Femur Fracture from other Diseases==
==Differentiating Neck of Femur Fracture from other Diseases==
* Neck of femur fracture must be differentiated from other causes of acute [[hip]] pain, [[restriction of movements]], and [[deformity]] such as [[intertorchanteric hip fracture]], [[osteoarthritis]], [[avascular necrosis]], [[septic arthritis]],  [[Trochanteric bursitis|trochanteric]] [[bursitis]], [[slipped capital femoral epiphysis]] and acute [[synovitis]].<ref>{{cite book | last = Rockwood | first = Charles | title = Rockwood and Green's fractures in adults | publisher = Wolters Kluwer Health/Lippincott Williams & Wilkins | location = Philadelphia, PA | year = 2010 | isbn = 9781605476773 }}</ref><ref>{{cite book | last = Azar | first = Frederick | title = Campbell's operative orthopaedics | publisher = Elsevier | location = Philadelphia, PA | year = 2017 | isbn = 9780323374620 }}</ref>
* Neck of femur fracture must be differentiated from other causes of acute [[hip]] pain, [[restriction of movements]], and [[deformity]] such as [[intertorchanteric hip fracture]], [[osteoarthritis]], [[avascular necrosis]], [[septic arthritis]],  [[Trochanteric bursitis|trochanteric]] [[bursitis]], [[slipped capital femoral epiphysis]] and acute [[synovitis]].<ref>{{cite book | last = Rockwood | first = Charles | title = Rockwood and Green's fractures in adults | publisher = Wolters Kluwer Health/Lippincott Williams & Wilkins | location = Philadelphia, PA | year = 2010 | isbn = 9781605476773 }}</ref><ref>{{cite book | last = Azar | first = Frederick | title = Campbell's operative orthopaedics | publisher = Elsevier | location = Philadelphia, PA | year = 2017 | isbn = 9780323374620 }}</ref><ref name="pmid23522513">{{cite journal| author=Hall M, Anderson J| title=Hip pointers. | journal=Clin Sports Med | year= 2013 | volume= 32 | issue= 2 | pages= 325-30 | pmid=23522513 | doi=10.1016/j.csm.2012.12.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23522513  }} </ref><ref name="pmid23395055">{{cite journal| author=Kelly BT, Maak TG, Larson CM, Bedi A, Zaltz I| title=Sports hip injuries: assessment and management. | journal=Instr Course Lect | year= 2013 | volume= 62 | issue=  | pages= 515-31 | pmid=23395055 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23395055  }} </ref><ref name="pmid24082863">{{cite journal| author=Poultsides LA, Bedi A, Kelly BT| title=An algorithmic approach to mechanical hip pain. | journal=HSS J | year= 2012 | volume= 8 | issue= 3 | pages= 213-24 | pmid=24082863 | doi=10.1007/s11420-012-9304-x | pmc=3470663 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24082863  }} </ref><ref name="pmid27857636">{{cite journal| author=Battaglia PJ, D'Angelo K, Kettner NW| title=Posterior, Lateral, and Anterior Hip Pain Due to Musculoskeletal Origin: A Narrative Literature Review of History, Physical Examination, and Diagnostic Imaging. | journal=J Chiropr Med | year= 2016 | volume= 15 | issue= 4 | pages= 281-293 | pmid=27857636 | doi=10.1016/j.jcm.2016.08.004 | pmc=5106442 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27857636  }} </ref><ref name="pmid19038713">{{cite journal| author=Tibor LM, Sekiya JK| title=Differential diagnosis of pain around the hip joint. | journal=Arthroscopy | year= 2008 | volume= 24 | issue= 12 | pages= 1407-21 | pmid=19038713 | doi=10.1016/j.arthro.2008.06.019 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038713  }} </ref>
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* Shortening
*[[Shortening]]
* Externally rotated leg
*[[External rotation|Externally rotated]] leg
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* [[Fracture]] fragment displacement
*[[Fracture]] fragment displacement
* [[Fracture]] fragment angulation
*[[Fracture]] fragment angulation
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* Accurate diagnosis of [[Fracture|fractur]]<nowiki/>e pattern ans aids in [[classification]].
*Accurate [[diagnosis]] of [[Fracture|fractur]]<nowiki/>e pattern ans aids in [[classification]].
* Useful for preoperative surgical planning for patients with complex, multifragmentary fractures.
*Useful for [[Pre-operative clearance|preoperative]] [[Surgery|surgical planning]] for patients with complex, multifragmentary [[Bone fracture|fractures]].
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* Useful in diagnosing occult [[Bone fracture|fractures]].
* Useful in diagnosing [[Bone fracture|occult fractures]].
| style="background: #F5F5F5; padding: 5px;" |X-ray
| style="background: #F5F5F5; padding: 5px;" |[[X-rays|X-ray]]
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* Bone scan shows increased uptake of radioactivity in region of fracture.
*[[Bone scan]] shows increased uptake of [[radioactivity]] in region of [[fracture]].
|-
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Intertrochanteric Hip [[Fracture]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Hip fracture|Intertrochanteric Hip Fracture]]
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* Shortening
*[[Shortening]]
* Externally rotated leg
*[[External rotation|Externally rotated]] leg
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| style="background: #F5F5F5; padding: 5px; text-align: center;" | -
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* [[Fracture]] fragment displacement
*[[Fracture]] fragment displacement
* [[Fracture]] fragment angulation
*[[Fracture]] fragment angulation
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* Accurate diagnosis of [[Fracture|fractur]]<nowiki/>e pattern ans aids in [[classification]].
*
* Useful for preoperative surgical planning for patients with complex, multifragmentary fractures.
**Accurate [[diagnosis]] of [[Fracture|fractur]]<nowiki/>e pattern ans aids in [[classification]].  
**Useful for [[Pre-operative clearance|preoperative]] [[Surgery|surgical planning]] for patients with complex, multifragmentary [[Bone fracture|fractures]].
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| style="background: #F5F5F5; padding: 5px;" |
* Useful in diagnosing occult [[Bone fracture|fractures]].
** Useful in diagnosin<nowiki/>g [[Bone fracture|occult fractures]].
| style="background: #F5F5F5; padding: 5px;" |X-ray
| style="background: #F5F5F5; padding: 5px;" |[[X-rays|X-ray]]
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* Trochanteric Thump test is positive.
*[[Trochanteric fossa|Trochanteric]] Thump test is positive.
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Subtrochanteric Femur Fracture
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Hip fracture|Subtrochanteric Femur Fracture]]
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* Thigh is deformed
*[[Thigh]] is deformed
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| style="background: #F5F5F5; padding: 5px; text-align: center;" | -
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* [[Fracture]] fragment displacement
*[[Fracture]] fragment displacement
* [[Fracture]] fragment angulation
*[[Fracture]] fragment angulation
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| style="background: #F5F5F5; padding: 5px; text-align: center;" |
* Accurate diagnosis of [[Fracture|fractur]]<nowiki/>e pattern ans aids in [[classification]].  
*<nowiki/><nowiki/> Accurate [[diagnosis]] of [[Fracture|fractur]]<nowiki/>e pattern ans aids in [[classification]].
* Useful for preoperative surgical planning for patients with complex, multifragmentary fractures.
*Useful for [[Pre-operative clearance|preoperative]] [[Surgery|surgical planning]] for patients with complex, multifragmentary [[Bone fracture|fractures]].
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| style="background: #F5F5F5; padding: 5px; text-align: center;" |
* Useful in diagnosing occult [[Bone fracture|fractures]].
*Useful in diagnosing [[Occult fracture|occult fractures]].
| style="background: #F5F5F5; padding: 5px; text-align: center;" |X-ray
| style="background: #F5F5F5; padding: 5px; text-align: center;" |[[X-rays|X-ray]]
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|-
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Acetabular Fracture
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Acetabular labrum|Acetabular]] [[Fracture]]
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| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/-
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* [[Fracture]] fragment displacement
*[[Fracture]] fragment displacement
* [[Fracture]] fragment angulation
*[[Fracture]] fragment angulation
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* Accurate diagnosis of [[Fracture|fractur]]<nowiki/>e pattern ans aids in [[classification]].  
*Accurate [[diagnosis]] of [[Fracture|fractur]]<nowiki/>e pattern ans aids in [[classification]].  
* Useful for preoperative surgical planning for patients with complex, multifragmentary fractures.
*<nowiki/>Useful for [[Pre-operative clearance|preoperative]] [[Surgery|surgical planning]] for patients with complex, multifragmentary [[Bone fracture|fractures.]]
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* Useful in diagnosing occult [[Bone fracture|fractures]].
*Useful in diagnosing [[Occult fracture|occult fractures]].
| style="background: #F5F5F5; padding: 5px; text-align: center;" |CT
| style="background: #F5F5F5; padding: 5px; text-align: center;" |[[CT-scans|CT]]
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* It is a medical emergency as there largee amount of blood loss
*It is a [[medical emergency]] as there is a large amount of [[blood loss]].
* Per urethral blood may be present
*Per [[urethral]] [[blood]] may be present.
* Sweeling may be prsent in the scrotal or perineal area.
*[[Swelling]] may be present in the [[Scrotal examination|scrotal]] or [[perineal]] area.
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Pubic Rami Fracture
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pubic bone|Pubic Rami]] [[Bone fracture|Fracture]]
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* [[Fracture]] fragment displacement
*[[Fracture]] fragment displacement
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| style="background: #F5F5F5; padding: 5px; text-align: center;" |
* Accurate diagnosis of [[Fracture|fractur]]<nowiki/>e pattern ans aids in [[classification]].
*Accurate [[diagnosis]] of [[Fracture|fractur]]<nowiki/>e pattern ans aids in [[classification]].
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* Useful in diagnosing occult [[Bone fracture|fractures]].
*Useful in [[Diagnosis|diagnosing]] occult [[Bone fracture|fractures]].
| style="background: #F5F5F5; padding: 5px; text-align: center;" |MRI
| style="background: #F5F5F5; padding: 5px; text-align: center;" |[[MRI]]
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Femoral Head Fracture
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Femur|Femoral Head]] [[Fracture]]
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* May be associated with flexion, adduction and internal rotation deformity.
*May be associated with [[flexion]], [[adduction]] and [[internal rotation]] deformity.
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* [[Fracture]] fragment angulation
* [[Fracture]] fragment angulation
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* Accurate diagnosis of [[Fracture|fractur]]<nowiki/>e pattern ans aids in [[classification]].  
*
* Useful for preoperative surgical planning for patients with complex, multifragmentary fractures.
**Accurate [[diagnosis]] of [[Fracture|fractur]]<nowiki/>e pattern ans aids in [[classification]].  
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Useful in diagnosing occult [[Bone fracture|fractures]].
**Useful for [[Pre-operative clearance|preoperative]] [[Surgery|surgical planning]] for patients with complex, multifragmentary [[Bone fracture|fractures]].
| style="background: #F5F5F5; padding: 5px; text-align: center;" |CT
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Useful in diagnosing [[Occult fracture|oc]]<nowiki/>[[Occult fracture|cult fractures]].
| style="background: #F5F5F5; padding: 5px; text-align: center;" |[[CT]]
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* It may be associated with dislocation.
*It may be associated with [[Joint dislocation|dislocation]].
* It may be associated with foot drop due to compression of the sciatic nerve.
*It may be associated with [[foot drop]] due to compression of the [[sciatic nerve]].
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Osteoarthritis
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Osteoarthritis]]
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*[[Flexion]] and [[external rotation]] deformity
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| style="background: #F5F5F5; padding: 5px; text-align: center;" | -
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* [[Fracture]] fragment displacement
*[[Joint]] space narrowing, [[osteophytes]], subchondral [[sclerosis]] and subchondral [[Cyst|cysts]].
* [[Fracture]] fragment angulation
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* [[CT]] confirms the [[x-ray]] finding.
*Normal
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* [[Swelling]] and [[tear]] of the [[patellar tendon]] and the [[retinaculum]] may be seen
*[[MRI]] shows [[Cartilage injuries|cartilage defects]] and [[bone marrow]] lesions.
* Also helps to identify osteochondral fragments
| style="background: #F5F5F5; padding: 5px;" |[[X-ray]]
| style="background: #F5F5F5; padding: 5px;" |[[X-ray]]
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* Inability to do [[Straight leg raise|straight leg raising]] test.
*[[Hip]] locking, [[instability]] and catching [[sensation]].
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Trochanteric Bursitis
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Bursitis|Trochanteric Bursitis]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | -
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| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | -
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* [[Tubercle (anatomy)|Tuberosity avulsion]] and displacement is seen
*Normal
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* [[CT]] confirms the [[x-ray]] finding
*Normal
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* Helps to identify accompanying [[Patellar tendon rupture|patellar tendon injury]]
*Increased signal in [[Bursa (anatomy)|bursa]] due to [[inflammation]] on T2 [[images]].
| style="background: #F5F5F5; padding: 5px;" |[[X-ray]]
| style="background: #F5F5F5; padding: 5px;" |[[MRI]]  
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* Inability to do [[Straight leg raise|straight leg raising]] test.
*Lateral [[hip]] [[pain]] near the [[greater trochanter]] and patients points to [[greater trochanter]].
*Patient may have [[trendelenburg gait]].
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Septic Arthritis
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Septic arthritis|Septic Arthritis]]
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* Normal
*Normal
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* Normal
*Normal
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* MRI  shows joint fullness and capsular dilation.
*[[Joint (anatomy)|Joint]] fullness and [[Capsular ligament|capsular]] [[dilation]].
* It also demonstrates damage to the articular cartilage.
*It also demonstrates damage to the [[articular cartilage]].
| style="background: #F5F5F5; padding: 5px; text-align: center;" |[[MRI]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |[[MRI]]
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* Fever and chills may be present.
*[[Fever]] and [[chills]] may be present.
* Hip aspiration may reveal frank pus or a turbid fluid.
*[[Arthrocentesis|Hip aspiration]] may reveal frank [[pus]] or a [[Turbid|turbid fluid]].
* Culture of the infecting organisms in the fluid is confirmatory.
*[[Culture collection|Culture]] of the [[Infection|infecting]] [[Organism|organisms]] in the fluid is confirmatory.
* Leukocytosis.
*[[Leukocytosis]].
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Avascular Necrosis of Head of Femur
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Avascular necrosis|Avascular Necrosis of Head of Femur]]
(Osteonecrosis)
([[Osteonecrosis]])
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*[[Adduction]] deformity
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| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/-
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* Type of [[knee dislocation]]
*Early [[X-rays|x-ray]] findings include lucency of the [[Femoral|femoral head]]  and subchondral [[sclerosis]].
* Associated [[fractures]]
*In advanced stage, subchondral [[collapse]] (ie, [[Crescent Rising|crescent sign]]), [[Femoral|femoral head]] flattening and [[joint]] space narrowing is seen.
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* [[CT]] confirms the [[x-ray]] findings and shows any osteochondral injury
* [[CT]] shows subchondral [[collapse]].
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* [[MRI]] shows damage to internal structures such as [[muscles]], [[ligaments]] and [[Neurovascular bundle|neurovascular]] bundle.
*[[MRI]] shows [[bone marrow]] [[edema]] and rail track sign.
| style="background: #F5F5F5; padding: 5px; text-align: center;" |[[MRI]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |[[MRI]]
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* [[Angiography]] of the [[lower limb]] is mandatory to check [[blood flow]] to the [[lower limb]] and decrease the chances of [[Vascular injury|vascular insult]]
*Patient may have  trendelenburg gait.
*Passive internal and external rotation of the extended leg  may elicit pain due to synovitis.
*Ficart and Arlet as well as Steinberg classification of avascular necrosis is done radiologically.
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! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Additional findings
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Additional findings
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Acute Synovitis
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Femoroacetabular Impingement]]
 
(FAI)
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*External rotation deformity
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* Normal
* '''Pistol grip deformity:''' It is asphericity and contour of femoral head and neck indicating Cam impingement.
*'''Crossover sign:''' It is a sign of acetabular retroversion seen in Pincer impingement.
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* Normal
* Confirms X-ray findings.
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* It helps identify the type of tear and classify the [[tear]].
*Evaluates articular cartilage damage, and labral degeneration and tears.
* It also aids in management plan for [[Tear of meniscus|meniscal injury]].
| style="background: #F5F5F5; padding: 5px; text-align: center;" |MRI
| style="background: #F5F5F5; padding: 5px; text-align: center;" |[[MRI scan|MRI]]
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* [[McMurray's test|McMurray's est]] positive for [[Tear of meniscus|meniscal injury]]
*Anterior impingement test: On flexion, adduction, internal rotation of the hip produces pain.
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Slipped Capital Femoral Epiphysis
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Idiopathic Transient Osteoporosis of the Hip]] (ITOH)
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* Usually Normal
* Subchondral cortical loss.
* It may show associated avulsion [[Bone fracture|fracture]]
*Diffuse osteopenia of femoral head and neck.
*Joint effusion
*Joint space is always preserved
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* Normal
*Confirms X-ray findings.
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* It helps to identify partial or complete [[tear]]
*Marrow edema of femoral head and neck
* It also aids in distinguishing acute versus chronic [[tears]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |MRI
* It may show signs of early [[degeneration]] and [[Cartilage injuries|cartilage wear]] due  to [[ligament]] injury
| style="background: #F5F5F5; padding: 5px; text-align: center;" |[[MRI]]
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* [[Lachman test]] and [[Drawer test|Anterior Drawer test]] positive in [[Anterior cruciate ligament injury|Anterior cruciate ligament tear]] (ACL)
*Commonly seen among women in 3rd trimester of pregnancy and middle aged men.
* [[Posterior drawer test]] and Dial test positive for [[posterior cruciate ligament]] (PCL)
*Bone scan shows increased uptake in the femoral head.
* [[Valgus]] stress test is positive for [[MCL|Medial Collateral Ligament]] (MCL)
* [[Varus]] stress test is positive for [[Lateral collateral ligament|Lateral Collateral Ligament]] (LCL)
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Iliospoas Tendinitis
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Transient synovitis|Transient Synovitis of the Hip]]
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*Flexion, abduction and external rotation deformity
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* Usually Normal
*Normal
* It may show associated avulsion [[fracture]]
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* Normal
*Normal
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* It shows degree of [[tear]]
*Joint space effusion
* It also aids in [[Surgery|surgical]] planning
| style="background: #F5F5F5; padding: 5px; text-align: center;" |USG
| style="background: #F5F5F5; padding: 5px; text-align: center;" |[[MRI]]
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* Defect present superior to superior pole of [[patella]]
*History of recent upper respiratory tract infection or trauma to the hip.
*Fever may be present.
*Involuntary muscle guarding on log rolling of the leg.
*Ultrasound shows intracapsular effusion and synovial membrane thickening.
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Hip Pointer
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Slipped capital femoral epiphysis|Slipped Capital Femoral Epiphysis]]
(SCFE)
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*Adduction and external rotation defromity
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* [[Bone fracture|Fracture]] of [[Tuberosity of the tibia|tibial tuberosity]] apophysis is seen
* '''Klein's line''': A line drawn along superior border femoral neck will intersect less of the femoral head or not at all in a child with SCFE.
*Epiphysiolysis
*'''Blanch sign of Steel''': Proximal femoral metaphyseal blurring
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* [[CT]] confirms [[x-ray]] findings  
* Confirms X-ray findings.
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* [[Swelling]] and effusion of the [[Joint (anatomy)|joint]] may be seen
*Growth plate widening
| style="background: #F5F5F5; padding: 5px; text-align: center;" |[[X-ray]]
*Edema in metaphysis
| style="background: #F5F5F5; padding: 5px; text-align: center;" |[[MRI]]
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* [[Adolescent|Adolescents]] are commonly affected by the disease.
*Antalgic gait
*'''Drehmann sign''': External rotation during passive flexion of the hip.
*Externally rotated foot progression angle.
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Snapping Hip Syndrome
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Adult Dysplasia of the Hip
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*Increased internal rotation due to increased femoral anteversion
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*External rotation deformity may be present in the late stages.
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*Decreased femoral head sphericity.
*Crossover sign results from increased retroversion.
*Acetabular protrusio: Decreased lateral center-edge angle < 20°.
*Increased '''Tonnis angle''' ( angle between the horizontal line and line along the superior acetabulum)        > 10°.
*Decreased head-neck offset ratio.
*Increased femoral neck-shaft angle.
*Decreased vertical center anterior margin angle.
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*Structural abnormalities of the femoral head and neck is seen.
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| style="background: #F5F5F5; padding: 5px; text-align: center;" |X-Ray
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*Positive anterior impingement test may be seen.
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! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Diseases
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Pain
! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Restriction of Movements
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Deformity
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Tenderness
! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Acitve Straight Leg Raising
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Distal Pulses
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |X-ray
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |CT scan
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |MRI
| style="background: #4479BA; color: #FFFFFF; text-align: center;" |'''Gold standard'''
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Additional findings
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Iliospoas [[Tendinitis]]
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*Flexion and external rotation deformity
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* Normal
*Normal
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* Normal
*Normal
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* Normal
*T2 images show an increased signal intensity associated with swelling and inflammation.
| style="background: #F5F5F5; padding: 5px; text-align: center;" |[[Doppler ultrasound]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |[[MRI]]
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* [[Doppler ultrasound]] and [[angiography]] of the [[lower limb]] confirms the [[disease]]
*Anterior pelvic tilt due to tightening of the iliopsoas muscle.
*'''Ludloff sign:''' Patient asked to sit with knees extended and subsequent elevation of the heel on the affected side causes pain.
*Ultrasound demonstrates thickened band and fluid in the iliospoas bursa.
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Maisonneuve fracture|Osteitis Pubis]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Hip pointer|Hip Pointer]]
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(Contusion of the Iliac Crest)
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| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/-
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*Adduction and internal rotation deformity may be present.
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* [[Bone fracture|Fracture]] fragment displacement
* Normal
* [[Bone fracture|Fracture]] fragment angulation
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| style="background: #F5F5F5; padding: 5px; text-align: center;" |[[CT]] confirms [[x-ray]] findings
*Normal
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* Useful in diagnosing occult [[Bone fracture|fractures]], [[Ligamentous laxity|ligamentous]] and [[soft tissue]] injuries
*[[Swelling]] of the surrounding soft tissues may be seen.
| style="background: #F5F5F5; padding: 5px; text-align: center;" |[[X-ray]]
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* [[Foot drop]] may be present in few patients
*Contusion or swelling may be present.
* [[Electromyography]] and [[Nerve conduction study|Nerve conduction studies]] done to check for any damage to [[Common fibular nerve|commom peroneal nerve]]
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |Referred Pain from Lumbosacral Plexus
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Snapping Hip Syndrome]]
(Coxa Saltans)
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | -
| style="background: #F5F5F5; padding: 5px; text-align: center;" | -
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
*Normal
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
*Normal
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
*May show inflamed bursa.
| style="background: #F5F5F5; padding: 5px; text-align: center;" |Ultrasound
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
*'''External snapping hip:'''  Palpate the greater trochanter as hip is actively flexed and applying pressure will likely stop snapping if external band present.
*'''Ober's Test:''' Limited hip adduction when hip held in extension indicate tightness of tensor fascia lata.
*'''Internal snapping hip:''' Snapping is reproduced by passively moving hip from a flexed and externally rotated position to an extended and internally rotated position.
*Ultrasound shows the snapping band in either internal or external snapping.
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Osteitis pubis|Osteitis Pubis]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | -
| style="background: #F5F5F5; padding: 5px; text-align: center;" | -
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
*Osteolytic pubis with bony erosions
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
*[[CT]] confirms [[x-ray]] findings
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
*Bone marrow edema is seen.
| style="background: #F5F5F5; padding: 5px; text-align: center;" |MRI
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
*Bone scan shows increased activity in area of pubic symphysis.
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Referred pain|Referred Pain]] from [[Lumbosacral plexus|Lumbosacral Plexus]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | -
| style="background: #F5F5F5; padding: 5px; text-align: center;" | -
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
*Narrowing of the disc space
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
*Normal
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
*Compression of the nerve root and disc bulge
*Osteophytes may be seen.
| style="background: #F5F5F5; padding: 5px; text-align: center;" |MRI
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
*Pain on passive straight leg raising.
|}
|}


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[[Category:Orthopedics]]
[[Category:Orthopedics]]
[[Category:Orthopedic surgery]]
[[Category:Orthopedic surgery]]
[[Category:Primary care]]
[[Category:Fractures]]
[[Category:Fractures]]
[[Category:Bone fractures]]
[[Category:Bone fractures]]

Latest revision as of 22:55, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

Overview

Neck of femur fracture must be differentiated from other causes of acute hip pain, restriction of movements, and deformity such as intertorchanteric hip fracture, osteoarthritis, avascular necrosis, septic arthritis, trochanteric bursitis, slipped capital femoral epiphysis and acute synovitis.

Differentiating Neck of Femur Fracture from other Diseases

Diseases Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Imaging
Pain Restriction of Movements Deformity Tenderness Active Straight Leg Raising Distal Pulses X-ray CT scan MRI
Neck of Femur Fracture + + + - + X-ray
Intertrochanteric Hip Fracture + + + - + X-ray
Subtrochanteric Femur Fracture + + + - + X-ray
Acetabular Fracture + + - + +/- +/- CT
Pubic Rami Fracture + + - + +/- + MRI
Femoral Head Fracture + + + - + Useful in diagnosing occult fractures. CT
Osteoarthritis + + + + +
  • Normal
X-ray
Trochanteric Bursitis + +/- - + + +
  • Normal
  • Normal
MRI
Septic Arthritis + + +/- + + +
  • Normal
  • Normal
MRI
Avascular Necrosis of Head of Femur

(Osteonecrosis)

+ + + + + MRI
  • Patient may have trendelenburg gait.
  • Passive internal and external rotation of the extended leg may elicit pain due to synovitis.
  • Ficart and Arlet as well as Steinberg classification of avascular necrosis is done radiologically.
Diseases Pain Restriction of Movements Deformity Tenderness Acitve Straight Leg Raising Distal Pulses X-ray CT scan MRI Gold standard Additional findings
Femoroacetabular Impingement

(FAI)

+ +
  • External rotation deformity
+ + +
  • Pistol grip deformity: It is asphericity and contour of femoral head and neck indicating Cam impingement.
  • Crossover sign: It is a sign of acetabular retroversion seen in Pincer impingement.
  • Confirms X-ray findings.
  • Evaluates articular cartilage damage, and labral degeneration and tears.
MRI
  • Anterior impingement test: On flexion, adduction, internal rotation of the hip produces pain.
Idiopathic Transient Osteoporosis of the Hip (ITOH) + + - + + +
  • Subchondral cortical loss.
  • Diffuse osteopenia of femoral head and neck.
  • Joint effusion
  • Joint space is always preserved
  • Confirms X-ray findings.
  • Marrow edema of femoral head and neck
MRI
  • Commonly seen among women in 3rd trimester of pregnancy and middle aged men.
  • Bone scan shows increased uptake in the femoral head.
Transient Synovitis of the Hip + +
  • Flexion, abduction and external rotation deformity
+ + +
  • Normal
  • Normal
  • Joint space effusion
USG
  • History of recent upper respiratory tract infection or trauma to the hip.
  • Fever may be present.
  • Involuntary muscle guarding on log rolling of the leg.
  • Ultrasound shows intracapsular effusion and synovial membrane thickening.
Slipped Capital Femoral Epiphysis

(SCFE)

+ +
  • Adduction and external rotation defromity
+ + +
  • Klein's line: A line drawn along superior border femoral neck will intersect less of the femoral head or not at all in a child with SCFE.
  • Epiphysiolysis
  • Blanch sign of Steel: Proximal femoral metaphyseal blurring
  • Confirms X-ray findings.
  • Growth plate widening
  • Edema in metaphysis
MRI
  • Antalgic gait
  • Drehmann sign: External rotation during passive flexion of the hip.
  • Externally rotated foot progression angle.
Adult Dysplasia of the Hip +
  • Increased internal rotation due to increased femoral anteversion
  • External rotation deformity may be present in the late stages.
+ + +
  • Decreased femoral head sphericity.
  • Crossover sign results from increased retroversion.
  • Acetabular protrusio: Decreased lateral center-edge angle < 20°.
  • Increased Tonnis angle ( angle between the horizontal line and line along the superior acetabulum) > 10°.
  • Decreased head-neck offset ratio.
  • Increased femoral neck-shaft angle.
  • Decreased vertical center anterior margin angle.
  • Structural abnormalities of the femoral head and neck is seen.
- X-Ray
  • Positive anterior impingement test may be seen.
Diseases Pain Restriction of Movements Deformity Tenderness Acitve Straight Leg Raising Distal Pulses X-ray CT scan MRI Gold standard Additional findings
Iliospoas Tendinitis + -
  • Flexion and external rotation deformity
+ + +
  • Normal
  • Normal
  • T2 images show an increased signal intensity associated with swelling and inflammation.
MRI
  • Anterior pelvic tilt due to tightening of the iliopsoas muscle.
  • Ludloff sign: Patient asked to sit with knees extended and subsequent elevation of the heel on the affected side causes pain.
  • Ultrasound demonstrates thickened band and fluid in the iliospoas bursa.
Hip Pointer

(Contusion of the Iliac Crest)

+ +/-
  • Adduction and internal rotation deformity may be present.
+ + +
  • Normal
  • Normal
  • Swelling of the surrounding soft tissues may be seen.
-
  • Contusion or swelling may be present.
Snapping Hip Syndrome

(Coxa Saltans)

+/- - - +/- + +
  • Normal
  • Normal
  • May show inflamed bursa.
Ultrasound
  • External snapping hip: Palpate the greater trochanter as hip is actively flexed and applying pressure will likely stop snapping if external band present.
  • Ober's Test: Limited hip adduction when hip held in extension indicate tightness of tensor fascia lata.
  • Internal snapping hip: Snapping is reproduced by passively moving hip from a flexed and externally rotated position to an extended and internally rotated position.
  • Ultrasound shows the snapping band in either internal or external snapping.
Osteitis Pubis + - - + + +
  • Osteolytic pubis with bony erosions
  • Bone marrow edema is seen.
MRI
  • Bone scan shows increased activity in area of pubic symphysis.
Referred Pain from Lumbosacral Plexus + - - + + +
  • Narrowing of the disc space
  • Normal
  • Compression of the nerve root and disc bulge
  • Osteophytes may be seen.
MRI
  • Pain on passive straight leg raising.

References

  1. Rockwood, Charles (2010). Rockwood and Green's fractures in adults. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. ISBN 9781605476773.
  2. Azar, Frederick (2017). Campbell's operative orthopaedics. Philadelphia, PA: Elsevier. ISBN 9780323374620.
  3. Hall M, Anderson J (2013). "Hip pointers". Clin Sports Med. 32 (2): 325–30. doi:10.1016/j.csm.2012.12.010. PMID 23522513.
  4. Kelly BT, Maak TG, Larson CM, Bedi A, Zaltz I (2013). "Sports hip injuries: assessment and management". Instr Course Lect. 62: 515–31. PMID 23395055.
  5. Poultsides LA, Bedi A, Kelly BT (2012). "An algorithmic approach to mechanical hip pain". HSS J. 8 (3): 213–24. doi:10.1007/s11420-012-9304-x. PMC 3470663. PMID 24082863.
  6. Battaglia PJ, D'Angelo K, Kettner NW (2016). "Posterior, Lateral, and Anterior Hip Pain Due to Musculoskeletal Origin: A Narrative Literature Review of History, Physical Examination, and Diagnostic Imaging". J Chiropr Med. 15 (4): 281–293. doi:10.1016/j.jcm.2016.08.004. PMC 5106442. PMID 27857636.
  7. Tibor LM, Sekiya JK (2008). "Differential diagnosis of pain around the hip joint". Arthroscopy. 24 (12): 1407–21. doi:10.1016/j.arthro.2008.06.019. PMID 19038713.

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