Hip Pain- When A Fall Is Not Just A Fall

HISTORY: A 17-year-old African American female with Sickle Cell Disease presents to the clinic for right hip pain after a fall she had 1 week ago. Patient says she was pushed, doesn’t remember how she landed, but after falling, another individual then stepped on her right thigh. She states that immediately after the incident she had pain to her right hip and had difficulty bearing weight. She had been seen at the local urgent care and x-rays were done that were reportedly normal, and she had been sent home. PHYSICAL EXAM: Normal knee exam but significantly limited right hip flexion, extension, internal rotation and external rotation. Patient also had a positive Drehman sign, FADIR and FABER. She did not exhibit edema, ecchymosis or palpable abnormalities in the hip region. She was not able to actively bear weight in the office due to hip pain. DIFFERENTIAL DIAGNOSIS: 1.Avascular Necrosis2.Femoral Neck/Head Fracture3.Sickle cell crisis4.Slipped capital femoral epiphysis (SCFE)5.Femoroacetabular impingement (FAI)6.Labral tear7.Deep hematoma TESTS/RESULTS: Right hip anterior-posterior and frog leg radiographs- Subtle evidence of flattening of the right femoral head compared to the left femoral head. Right Hip MRI without Contrast-Avascular necrosis of the right femoral head with mild flattening and irregularity but no collapse or fragmentation.-Bone infarcts in the right acetabulum and right proximal femoral diaphysis. -Moderate joint effusion which is likely reactive. FINAL WORKING DIAGNOSIS: Avascular Necrosis of the right femoral head TREATMENT AND OUTCOME: Patient was made non-weight bearing status with bedrest. A wheelchair was ordered for her and naproxen was prescribed for pain. After 2 weeks, patient still had no improvement in her pain and was unable to weight bear and so she was referred to orthopedic surgery.