Diagnósticos Diferenciais de Dor da Art. Coxofemoral

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Diagnósticos Diferenciais de Dor da Art. Coxofemoral

Mensagem  Bernardokm em Seg Mar 11, 2013 10:51 pm

Femoral neck fractures

The number of individuals participating in athletic activities is continually increasing, whether these individuals are highly competitive athletes or weekend sports enthusiasts.[1, 2] Stress fractures of the femoral neck are uncommon injuries (see image depicted below). In general, these injuries occur in 2 distinct populations, (1) young, active individuals with unaccustomed strenuous activity or changes in activity, such as runners or endurance athletes, and (2) elderly individuals with osteoporosis. Elderly individuals may also sustain femoral neck stress fractures; however, hip fractures are much more common and are often devastating injuries. Femoral neck fractures in young patients are usually caused by high-energy trauma. These fractures are often associated with multiple injuries and high rates of avascular necrosis and nonunion. Results of this injury depend on (1) the extent of injury (ie, amount of displacement, amount of comminution, whether circulation has been disturbed), (2) the adequacy of the reduction, and (3) the adequacy of fixation. Recognition of the disabling complications of femoral neck fractures requires meticulous attention to detail in their management.

Femoral neck stress fractures

Stress fractures are a problem in various populations including runners and military trainees.[1, 2, 3] These fractures can occur with as little as 2-3 weeks of training, be very mild, causing only minimal changes to the bone which eventually heals, or they may progress to a complete fracture that requires surgical fixation. Although rare, poor outcomes may occur in the form of nonunions or avascular necrosis. Certain stress fractures have a higher risk of poor outcome, including anterior tibial and femoral neck stress fractures (FNSFs). FNSFs are some of the most difficult injuries to diagnose. The pain associated with such an injury may be poorly localized in the hip and may be referred to the thigh or back. Physical examination findings are not very specific for this injury, and diagnostic radiographs in the form of x-ray films, bone scans, and/or magnetic resonance images (MRIs) are often necessary.[4] Failure to diagnose FSNFs may lead to catastrophic consequences, including avascular necrosis of the femoral head and the need for a hip replacement in otherwise healthy young individuals. A high index of suspicion in the appropriate risk populations is the key to diagnosing and treating FNSFs.

Hip Tendonitis and Bursitis

Hip overuse injuries such as tendinitis and bursitis occur commonly in active individuals who participate in running, cycling, and cutting sports such as football, hockey, soccer, etc. These injuries can occur after an acute injury, such as an adductor strain from soccer, or present as a chronic pain, such as a hamstring tendinopathy from repetitive activities such as running. Training errors, biomechanical issues, and sudden increases in activity levels are also risk factors. In the adolescent age group, traction injuries such as avulsion fracture and apophysitis can occur and cause difficulties with training and performance. The investigation into the cause and treatment of hip overuse injuries can often be frustrating for clinicians and patients alike. Many musculoskeletal injuries can cause referred pain into the hip area, but so can intra-abdominal, gynecologic, urologic, and spinal disorders.

Groin Injury

Groin injuries are commonly encountered by physicians and clinicians who treat athletes of all ages at all levels of competition. Groin injuries are particularly common in activities in which forceful adduction of the hip occurs; examples include skating, ice hockey, swimming, and soccer. In fact, as many as 10% of ice hockey–related injuries and 5% of soccer-related injuries are groin injuries.[1, 2] This article focuses on acute and chronic groin injuries related to sporting activities. Groin injuries resulting from major trauma (eg, multiple trauma, penetrating injuries) are not addressed, except to note that they require emergent medical evaluation. Give special consideration to children, adolescents, and females with groin pain, because these conditions in this patient population may be erroneously attributed to minor trauma when they are, in fact, serious and require medical or surgical intervention. Evaluate any child aged 2-15 years with groin pain and an antalgic gait, especially if he or she has a fever. Avascular necrosis (AVN) of the hip, Legg-Calve-Perthes disease, septic arthritis, and slipped capital femoral epiphysis must be ruled out. Consider early orthopedic consultation in any such case. Hip pain in the adolescent athlete must take into consideration the relatively weaker growth plate of certain bony structures in the hip, and it should prompt the clinician to consider the diagnosis of apophyseal avulsion fractures. Apophysitis and apophyseal fractures are more common in skeletally immature athletes, in whom the physis is the weakest link in the muscle – tendon – bone complex. Moreover, remember that children and adolescents may report knee pain that is actually referred from pathology in the hip, or vice versa. That is, complaints of both hip and lower-extremity pain in children and adolescents merit a detailed physical examination of the affected joint and surrounding structures.
The initial evaluation and conservative treatment for adult female athletes may be similar to that of male athletes. However, epidemiologic findings suggest that differences in female body mechanics may lead to subtly different injury patterns and a need for specialized rehabilitation services. Although anatomic differences are obvious, several factors play important roles in determining injury patterns in female athletes. These factors include (1) differences in metabolism, circulation, and cardiorespiratory capacity; and (2) differences in body shape, size, and composition. An example of such is the higher rate of patellofemoral disorders in female athletes, possibly accounted for by an increased quadriceps angle, less developed vastus medialis, and greater degree of genu valgum.

Hip Dislocation

Hip dislocations are relatively uncommon during athletic events. Injuries to small joints (eg, finger, wrist, ankle, knee) are much more common. However, serious morbidity can be associated with hip dislocations, making careful and expedient diagnosis and treatment important for the sports medicine physician.Large-force trauma (eg, motor vehicle accidents, pedestrians struck by automobiles) are the most common causes of hip dislocations. This type of injury is also associated with high-energy impact athletic events (eg, American football, rugby, water skiing, alpine skiing/snowboarding, gymnastics, running, basketball, race car driving, equestrian sports). Diagnosing and correctly treating these injuries to avoid long-term sequelae of avascular necrosis and osteoarthritis is imperative.
Hip dislocations are either anterior or posterior, with posterior hip dislocations comprising the majority of traumatic dislocations.

Several classification systems are used to describe posterior hip dislocations.
The Thompson-Epstein classification is based on radiographic findings.
Type 1 – With or without minor fracture
Type 2 – With large, single fracture of posterior acetabular rim
Type 3 – With comminution of rim of acetabulum, with or without major fragments
Type 4 – With fracture of the acetabular floor
Type 5 – With fracture of the femoral head

The Steward and Milford classification is based on functional hip stability.
Type 1 – No fracture or insignificant fracture
Type 2 – Associated with a single or comminuted posterior wall fragment, but the hip remains stable through a functional range of motion
Type 3 – Associated with gross instability of the hip joint secondary to loss of structural support
Type 4 – Associated with femoral head fracture

Hip Fracture

Although sports injuries to the knee, ankle, and shoulder have been well documented, injuries to the pelvis, hip, and thigh get little attention because of their low prevalence. Unfortunately, severe consequences may result if these injuries are improperly managed. Femoral neck stress fractures were mainly seen in military recruits due to a triad of activity that is new, strenuous, and highly repetitive. However, as a result of self-imposed fitness regimens of recreational athletes, over the last 20 years the number of these injuries has been increasing in nonmilitary populations. In contrast, contact sports such as football, rugby, and soccer are usually the cause of most fractures of the hip. Stress fractures occur in normal bone undergoing repeated submaximal stress. As the bone attempts to remodel, osteoclastic activity occurs at a greater rate than osteoblastic activity. When these cumulative forces exceed the structural strength of bone, stress fractures occur. Stress fractures occur mainly at the femoral neck and are classified as either tension (at the superior aspect of the femoral neck) or compression (at the inferior aspect of the femoral neck).

Acetabulum Fractures

Fractures of the acetabulum occur primarily in young adults as a result of high-velocity trauma. These fractures are often associated with other life-threatening injuries. Displacement of the fracture fragments leads to articular incongruity of the hip joint that results in abnormal pressure distribution on the articular cartilage surface. This can lead to rapid breakdown of the cartilage surface, resulting in disabling arthritis of the hip joint. Anatomic reduction and stable fixation of the fracture, such that the femoral head is concentrically reduced under an adequate portion of the weightbearing dome of the acetabulum, is the treatment goal in these difficult fractures.

Recent studies
In one study of patients with posterior wall fractures and late revision surgery with the Kocher-Langenbeck approach, 3 of the 4 patients eventually required total hip arthroplasty. According to Dean et al, if salvage procedures are delayed more than 3 weeks, total hip arthroplasty is more likely to be ultimately required, especially in older patients. Collinge et al concluded that acetabular fractures reduced and stabilized using the Kocher-Langenbeck approach had a higher rate of radiographic residual fracture displacement if treated in the lateral as compared with the prone position. Mehin et al, in a study of 5 cadaveric acetabula with transverse acetabular fractures, found that the locking plate construct was as strong as plate plus interfragmentary lag screw for repair of transverse acetabular fractures. The authors feel locking plates my provide an advantage in that fractures may be displaced during lag-screw tightening. Boraiah et al found that in 18 patients (mean age, 71 years) who underwent combined open reduction/internal fixation (ORIF) and total hip arthroplasty (THA) for acetabular fractures (1 transverse; 1 anterior-column posterior hemitransverse; 1 both-column; 15 posterior wall), only 1 patient required revision surgery, because of failure of the acetabular component. The authors concluded that in appropriately selected patients, ORIF/THA can be an acceptable treatment approach.

Referencia: MedScape



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