E4: Hip Pain x 2 weeks*

History of Present Illness:

A 40-ish-year-old male with a history of type 1 diabetes presents to the ED for 2 weeks of waxing and waning constant right groin & inner thigh pain that is aggravated by activity.  Even it rest it is bad and he cannot sleep due to the pain and also started using a cane for the first time in his life.    He has had chills but denies any injury, fever or other complaints.  He has no other past medical history and denies drug use.

Vital Signs & Physical Exam:

Vital signs are normal except for a temperature of 99.3.  Physical exam is otherwise normal except for limping and severe pain with forced internal rotation of the hip.

Initial Diagnostic Testing:

  • UA: shows hematuria w/o pyuria
  • CBC: WBC = 9.4, Hb = 12.9, plt = 519.  CRP moderately elevated
  • BMP: glucose 316, sodium 131.  Everything else normal.  No anion gap
  • Imaging: see below

What does the ultrasound image show?

  • A) Hip fracture
  • B) Hip effusion
  • C) Hydronephrosis
  • D) DVT

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ANSWERS: What does the ultrasound image show?

  • A) Hip fracture
  • B) Hip effusion – CORRECT – this is an ultrasound image showing a hip effusion (black curved stripe)
  • C) Hydronephrosis
  • D) DVT

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CASE CONCLUSION: Orthopedics and IR was consulted.  The arthrocentesis showed ~200,000 WBC/hpf with 87% PMN’s.  It eventually grew 4+ staph aureus (not MRSA).   He went to the OR for a washout then was treated with 6 weeks of Ancef via a PICC line and did well.

Pearls:

  1. Pain with internal rotation of the leg suggest hip pathology rather than sciatica or vascular cause of leg pain
  2. Even if the WBC is normal, there can be a severe infection.  Other clues are elevated CRP, elevated platelets and any temp >98.6
  3. Low sodium is often due to a diuretic but is also common with bad infections (especially CNS and pulmonary)