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A 40-year-old female presents to your office complaining of the pain in her right hip. She denies trauma and says that the pain began two weeks ago and gradually increased. Her past medical history is significant for systemic lupus erythematosus diagnosed seven years ago. Her current medications include prednisone, hydroxychloroquine, and lansoprazole. There is no local tenderness on physical examination and the range of motion of the right hip is normal. Hip radiograph is normal. What is the next best step in the management of this patient?
A. Joint aspiration
B. Low-dose NSAIDs
C. Increase the dose of prednisone
D. MRI of the hip
E. Observation
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dd R/O avascular necrosis
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dd ( for avascular necrosis )
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D. MRI of the hip
agreed..AVN
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D is correct.
expl:
The most probable cause of this patient™s complaints is avascular necrosis of the femoral head. It represents an ischemic necrosis of the bone with eventual collapse of the periarticular bone and cartilage. Ischemic bone necrosis is due to compromised blood flow to the femoral head that can be traumatic or non-traumatic. The well-known causes of non-traumatic avascular (aseptic) necrosis are chronic corticosteroid therapy, alcoholism, and hemoglobinopathies. The clinical scenario described is typical (progressive hip pain without restriction of motion range and normal radiograph on early stages). A high index of suspicion is required, because early diagnosis is desirable whether nonoperative or operative treatment is considered (Choice E is incorrect); therefore, knowing the predisposing factors is important. MRI and scintigraphy are used to confirm the diagnosis (Choice D).
