Image Quiz
Flexion Contracture and Cyclic Hip Pain in a Twenty-Three-Year-Old Woman1
A twenty-three-year-old woman was seen because of a twenty-month history of
stiffness and pain in the right hip. The first symptom was stiffness in the
hip, followed by the onset of pain in the right groin approximately two months
later. The pain was cyclical in nature and always occurred twenty-four to
forty-eight hours after the onset of her menstrual period. It lasted for ten to
twelve days and then gradually subsided until her next monthly period. The pain
and stiffness progressively worsened, resulting in marked external rotation and
flexion of the extremity and a limp during walking. The pain was exacerbated by
activity but was also present at rest and had been unresponsive to several
trials of nonsteroidal anti-inflammatory medications. The patient had no
history of trauma. She worked as a radiographic technician and was otherwise
healthy, with her only medications being oral contraceptives for the treatment
of dysmenorrhea. She had a smoking history of eight cigarettes per day for the
past six years.
She was seen by an orthopaedic surgeon approximately one
year after the onset of symptoms. She was noted to have marked limitation of
internal rotation of the hip. Radiographs were suggestive of an old slipped
capital femoral epiphysis, which was thought to explain the external rotation
and flexion contracture. She was referred to a gynecologist for further
evaluation of the pain. The findings of the pelvic examination were unremarkable.
A pelvic ultrasound study revealed normal findings. An intravenous pyelogram
did not reveal any abnormalities of the kidneys or ureters. An exploratory
laparoscopy revealed papillary lesions on the surface of the right ovary. These
lesions were biopsied, and the pathologic diagnosis was consistent with
reactive fibrosis.
Three months later, the patient consulted another
orthopaedic surgeon, who noted tenderness at the posterior-superior iliac spine
and the adductor origins from the pubis as well as a fixed external rotation
contracture of the hip. Magnetic resonance imaging revealed diffuse hypertrophy
of the right obturator internus muscle and signal changes consistent with
hemorrhage. A variety of nonsteroidal anti-inflammatory medications did not relieve
the symptoms. Two months later, the patient was evaluated by a third
orthopaedist, who noted that the patient stood and walked comfortably with the
hip externally rotated approximately 90° during gait and that she had an
external rotation contracture of 30° when lying in the supine position.
Abduction was limited to 20° on the right, compared with 70° on the left. The
right hip had a 30° flexion contracture, with flexion to 80°. The range of
motion of the right knee was normal. A repeat gynecologic examination and Pap
smear were negative.
The patient was then referred to our institution for further
evaluation and treatment. At that time, she was found to walk with the right
lower extremity externally rotated approximately 45°. The hip was fixed in 45° of
external rotation and 5° of abduction with no internal rotation, external
rotation, abduction, or adduction from this position. The right hip had a
flexion arc of 30° to 70°. Straight-leg raising did not
elicit pain. The girth of the right thigh was 2 cm smaller than that of the
left thigh when measured 5 cm proximal to the superior pole of the patella.
Sensory and vascular examinations of the lower extremities revealed normal
findings. The motor examination revealed normal findings except for mild weakness
of hip flexion, which was classified as grade 4 (of 5). No palpable masses or
lymphadenopathy was detected.
Radiographs showed demineralization of the right femoral
head and neck and external rotation of the right hip (Fig. 1). Laboratory studies
revealed a hemoglobin level of 13.1 g/dL, a white blood-cell count of 7.9 × 109/L, a platelet count of 254 × 109/L, an erythrocyte sedimentation
rate of 11 mm/hr, a negative test for antinuclear antibodies, a C-reactive
protein level of 1.9 mg/dL, a rheumatoid factor level of <20 IU/mL, and an
anti-DS-DNA level of 4 IU/mL. A triple-phase technetium-99 bone scan revealed hyperemia of the soft tissues of the medial
aspect of the proximal part of the right thigh, and the bone images showed focal
areas of uptake in the right ilium, the right ischium, and the inferior part of
the right acetabulum. These findings were interpreted as being consistent with
infiltrative disease or increased bone-remodeling secondary to bone stress.
Fig. 1 |
Fig. 2 |
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