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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
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318
RECURRENT HIP AREA
PAIN IN AN ADULT
The GP overview
Hip area pain is a common presentation in the middle-aged and elderly, and the patient will
oen attribute it to osteoarthritis. is diagnosis may well be correct, although the dierential
is wide – besides, the patient’s view of what actually constitutes the ‘hip’ may be at odds with
the anatomical truth. e dierential for the child with hip pain is very dierent – see Limp in
a child, p. 307.
Differential diagnosis
COMMON
muscular/ligamentous strain
osteoarthritis
trochanteric bursitis
referred from back
meralgia paraesthetica
OCCASIONAL
inammatory arthritis
avascular necrosis
hernia
complications of a total hip replacement (e.g. loosening, infection)
spinal stenosis
iliotibial band syndrome
acetabular labral tear
RARE
impacted fracture
dislocation
bony pathology (e.g. secondaries, Paget’s)
https://t.me/med1917
RECURRENT HIP AREA PAIN IN AN ADULT 319
Ready reckoner
Muscular/
ligament
Osteoarthritis Trochanteric
bursitis
Referred
from back
Meralgia
paraesthetica
Pain lying on affected side Possible No Ye s No No
Leg numbness No No No Possible Ye s
Painful hip movement Ye s Yes Possible No No
Pain mainly in groin Possible Ye s No Possible No
Coexisting back pain No Possible No Ye s No
Possible investigations
LI KE LY: X-ray.
POSSIBLE: FBC, CRP, autoantibodies, HLA-B27, alkaline phosphatase, urinalysis.
SMALL PRINT: Arthroscopy, bone scan, lumbar spine MRI (all in hospital).
X-ray: May show evidence of osteoarthritis, avascular necrosis, fracture, dislocation, hip
replacement loosening and bony pathology. Spinal X-ray may reveal spinal pathology as a
cause.
FBC, CRP: CRP may be elevated and Hb reduced in inammatory arthritis. CRP and
WCC raised in infection of joint prosthesis.
Autoantibodies: For clues about the aetiology of inammatory arthritis.
HLA-B27: A high prevalence in spondoarthritides.
Alkaline phosphatase: Raised in Paget’s disease.
Urinalysis: May reveal proteinuria or haemat uria if there is renal involvement in inammator y
arthritis.
Arthroscopy: Diagnostic and potentially therapeutic in labral tear.
Bone scan: May reveal bony secondaries.
Lumbar spine MR I: For evidence of spinal stenosis; might reveal other causes of pain referred
from spine.
TOP TIPS
Check what the patient means by ‘hip’. Most don’t realise that the hip joint is actually in
the groin.
An X-ray may not be necessary, even if the clinical picture suggests hip arthritis – but the
patient may well expect one, so ensure it is at least discussed.
Examine the patient standing up – this may reveal a hernia as the cause.
Localised lateral pain aggravated by lying on the aected side is likely to be caused by
trochanteric bursitis.
https://t.me/med1917
320 SYMPTOM SORTER
Remember the possibility of loosening or infection in joint replacements.
Consider avascular necrosis if a patient on long-term steroids develops severe hip pain.
Beware that the elderly can sometimes remain weight bearing – albeit with pain and a limp –
aer an impacted hip fracture.
Signicant depression may aggravate or result from hip arthritis pain – consider a trial of
antidepressants.
NOTES:
https://t.me/med1917
321
RECURRENT KNEE PAIN
The GP overview
Recurrent knee pain is a very common presentation with a wide dierential. Classication of
causes isn’t helped by changing and conf using nomenclature. A s ever in general practice, a carefu l
history and examination will provide useful clues – but management will oen be dictated more
by degree of disability and the patient’s wishes than by making a precise diagnosis.
Differential diagnosis
COMMON
ligament sprain/minor so tissue injury
osteoarthritis
cartilage injury
chondromalacia patellae/patellofemoral pain
Osgood–Schlatter’s disease
OCCASIONAL
recurrent monoarthritis (e.g. gout, pseudogout, Reiter’s)
as part of polyarthritis (e.g. rheumatoid, ankylosing spondylitis, psoriatic arthritis)
iliotibial tract syndrome
bursitis
referred from hip or back
ligament rupture
patellar tendonitis
Baker’s cyst
loose body
bone disease (e.g. Paget’s)
recurrent dislocation of the patella
medial shelf syndrome
osteochondritis dissecans
RARE
haemochromatosis
recurrent haemarthroses (e.g. coagulation disorder)
osteosarcoma
https://t.me/med1917
322 SYMPTOM SORTER
Ready reckoner
Ligament sprain/
soft tissue
Osteoarthritis Cartilage
injury
Chondromalacia
patellae/patellofemoral
pain
Osgood–
Schlatter’s
Effusion No Possible Possible Possible No
Specic injury Yes No Yes No No
Locking No Possible Possible No No
Both knees affected No Possible No Possible Possible
More common in women No No No Ye s No
Possible investigations
LI KE LY: X-ray.
POSSIBLE: FBC, CRP, uric acid, MRI, autoantibodies.
SMALL PRINT: HLA-B27, joint aspiration, hip or back investigations if referred pain suspected,
alkaline phosphatase, serum ferritin, coagulation screen.
X-ray: May give clues to many of the possible causes, or conrmatory evidence when clinical
suspicion is high – for example, with osteoarthritis, bony loose body, Paget’s, osteochondritis
dissecans.
FBC, CRP: CRP elevated and Hb may be reduced in inammatory polyarthritis.
Uric acid: Typically elevated in gout.
MRI: Useful to assess so tissue such as cartilage, especially if surgery is being considered.
Autoantibodies: If inammatory polyarthritis suspected.
HLA-B27: A high prevalence in spondoarthritides.
Joint aspiration: May be diagnostica lly useful if an eusion is present – for example, revealing
positively birefringent crystals in pseudogout. In practice, usually performed aer specialist
referral.
Hip or back investigations: Appropriate radiology may be necessary if it is thought the knee
pain is referred from these areas.
Alkaline phosphatase: Elevated in Paget’s.
Serum ferritin: Elevated in haemochromatosis.
Coagulation screen: If coagulopathy suspected.
TOP TIPS
Patients place great value on X-rays whereas, in practice, they may contribute little to
management of straightforward recurrent knee pain. To prevent an unsatisfactory outcome,
consider proactively broaching the fact that an X-ray may be unnecessary.
Insisting that the patient accurately localises the pain – if possible – may usefully limit the
diagnostic possibilities.
https://t.me/med1917
RECURRENT KNEE PAIN 323
‘Straightforward’ osteoarthritis can become quite suddenly more painful, oen for no
obvious reason – exacerbations and remissions are part of the natural history of the disease.
Keen sports people oen present with recurrent knee pain and are unlikely to indulge in
the GP’s time-honoured ‘wait and see’ approach. Earlier investigation or intervention may
prove necessary.
Do not forget that knee pain may be referred – if the cause isn’t immediately apparent,
examine the hip, especially in children.
Anterior cruciate ligament injury is quite easily missed in casualty in the acute stage. It may
only present later with an unstable knee.
Osteosarcomas are rare: But most commonly occur near the knee. Beware of unexplained
constant, increasing pain waking the patient at night. Swelling and inammation will only
appear later.
NOTES:
https://t.me/med1917
324
SWOLLEN ANKLES
The GP overview
is is one of the commonest presenting complaints in the elderly and, in this age group, may be
linked to recurrent falls. As a result, it is frequently the reason for a home visit request. In younger
age groups, it is much rarer, but much more likely to signify serious pathology.
Differential diagnosis
COMMON
congestive cardiac failure (CCF)
drug reaction: especially calcium antagonists
gravitational (venous insuciency, oen with poor mobility)
obesity
pelvic mass (including pregnancy)
OCCASIONAL
cirrhosis
premenstrual syndrome
anaemia
renal: acute or chronic nephritis, nephrotic syndrome
protein-losing enteropathy (e.g. coeliac disease, inammatory bowel disease)
RARE
malnutrition
inferior vena cava thrombosis
lariasis
Milroy’s disease (hereditary lymphoedema)
ancylostomiasis (hookworm)
https://t.me/med1917
SWOLLEN ANKLES 325
Ready reckoner
CCF Drug reaction Gravitational Obesity Pelvic mass
Shortness of breath on exertion Ye s No No Possible Possible
Altered breath sounds Ye s No No No No
Less swollen in the morning Possible Possible Ye s Possible Possible
Taking oedema-genic drug Possible Yes No No No
Other symptoms or signs Ye s No No No Yes
Possible investigations
LI KE LY: Urinalysis, FBC, U&E, LFT, BNP.
POSSIBLE: ECG, TFT, echocardiography.
SMALL PRINT: CXR, pelvic ultrasound, further investigation of underlying cause.
Urinalysis: For proteinuria.
FBC: Look for anaemia of chronic disorder, raised MCV (alcohol abuse).
U&E: Will reveal underlying renal failure; sodium low in CCF and cirrhosis.
LFT: May reveal hypoproteinaemia (e.g. in cirrhosis, protein-losing enteropathy and
nephrotic syndrome).
BNP: Likely to be elevated in heart failure.
ECG: In heart failure, may show signs of le ventricular hypertrophy, ischaemia or
arrhythmia.
Echocardiography: To conrm suspected heart failure.
CXR: Pulmonary oedema and pleural eusion in CCF.
Pelvic ultrasound: For pelvic mass.
Further investigation of underlying cause: is might involve CT scan (pelvic mass), renal
biopsy (nephritis) and bowel investigations (enteropathy).
TOP TIPS
In the elderly, the cause is oen multifactorial, with immobility playing a major role.
Proper assessment can take time – consider spreading the work over a couple of consultations,
using the intervening time to arrange and assess investigations.
Ankle swelling is usually symmetrical, though venous insuciency in particular can aect
one side much more than the other. But if only one ankle is swollen, consider deep vein
thrombosis, a ruptured Baker’s cyst or cellulitis.
Don’t forget that many drugs (such as calcium antagonists and NSAIDs) can cause marked
ankle swelling.
https://t.me/med1917
326 SYMPTOM SORTER
If no cause is obvious in an elderly person, examine the abdomen and also consider a rectal
examination.
e younger the patient, the greater the chance of signicant pathology – especially renal.
Marked swelling of recent and sudden onset is likely to be signicant regardless of age.
NOTES:
https://t.me/med1917
327
SWOLLEN CALF
The GP overview
Such has been the publicity about ‘economy class syndrome’ that this presentation – and the
closely related symptom, ‘calf pain’ (see p. 292) – has become quite common. e worry the
patient has about a possible DVT can prove quite ‘infectious’, with the GP anxious not to miss
this signicant problem. In most cases, a careful history, backed up by appropriate examination,
should reveal the true cause.
Differential diagnosis
COMMON
cellulitis
most causes of swollen ankles (see p. 322)
muscle strain/rupture (especially rupture of plantaris tendon)
ruptured Baker’s cyst
DVT
OCCASIONAL
ruptured Achilles tendon
varicose eczema
phlebitis
RARE
muscle herniation through fascia (especially tibialis anterior)
muscular neoplasm
pseudohypertrophy (as in muscular dystrophy)
https://t.me/med1917
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