Femoral Head Avascular Necrosis Clinical Presentation

Author: John D Kelly IV, MD; Chief Editor: Sherwin SW Ho, MD more...

Updated: Feb 28, 2010

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History
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History

AVN may present with nonspecific signs and symptoms.
Early in the disease process, the condition is painless; however, patients ultimately present with pain and limitation of motion.
- The pain is most commonly localized to the groin area, but it may also manifest in the ipsilateral buttock, knee, or greater trochanteric region.
- Painful symptoms are usually exacerbated with weight bearing but are relieved by rest.

Passive range of motion of the hip is limited and painful, especially forced internal rotation.
A distinct limitation of passive abduction is usually noted.
A straight-leg raise against resistance provokes pain in most symptomatic cases.
Passive internal and external rotation of the extended leg ("log roll test") may elicit pain that is consistent with an active capsular synovitis.

Traumatic AVN is simply a result of mechanical disruption of blood flow to the femoral head. During sports endeavors, hip dislocation or subluxation is the most frequently reported traumatic means of AVN. A tackle from behind may cause an anterior hip subluxation in a ball carrier. Likewise, extreme abduction or external rotation may result in an anterior dislocation in a fallen water-skier.
Similarly, a displaced femoral neck fracture can damage the fragile retinacular vessels, which supply the femoral head and result in femoral head necrosis. (See also the eMedicine articles Femoral Neck, Fractures [in the Radiology section], Femoral Neck Stress and Insufficiency Fractures [in the Orthopedic Surgery section], and Femoral Neck Fracture [in the Sports Medicine section].)
Most cases of AVN are atraumatic and include the following^[3]:
- Excessive corticosteroid usage and alcohol abuse account for as many as 90% of new cases.
- Intravascular coagulation appears to be the central event associated with nontraumatic AVN. (See also the eMedicine articles Disseminated Intravascular Coagulation [in the Emergency Medicine section] and Disseminated Intravascular Coagulation [in the Hematology section].)
- Coagulation may occur secondary to extravascular compression (eg, marrow fat enlargement), vessel wall injury (eg, chemotherapy, radiation), or a thromboembolic event (eg, fat emboli).
- Ischemic insult to the femoral head results in infarcted subchondral bone. In this situation, weakened and unrepaired necrotic bony trabeculae fail under a compressive load, leading to subchondral collapse (ie, crescent sign) and, ultimately, articular collapse.
Traumatic causes of femoral head AVN include the following:
- Femoral neck fractures
- Hip dislocation (See also the eMedicine articles Hip Dislocation [in the Sports Medicine section] and Dislocations, Hip [in the Emergency Medicine section].)
- Slipped capital femoral epiphysis (See also the eMedicine articles Slipped Capital Femoral Epiphysis [in the Orthopedic Surgery section] and Slipped Capital Femoral Epiphysis [in the Sports Medicine section].)
Atraumatic osteonecrosis causes include the following:
- Alcohol abuse – Patients who consume less than 400 mL of alcohol per week have a 3-fold higher risk for AVN than individuals who do not drink. The risk rises to an 11-fold risk if more than 400 mL per week is consumed. (See also Alcohol Disorders Common, Largely Untreated Among American Adults and Youth Exposure to Alcohol Advertising in Magazines --- United States, 2001--2005 on Medscape.)
- Coagulopathies
- Chemotherapy
- Chronic liver disease (See also the eMedicine articles Cirrhosis, Primary Sclerosing Cholangitis, and Hepatitis B [in the Gastroenterology section], as well as Health-related Quality of Life of Chronic Liver Disease Patients With and Without Hepatocellular Carcinoma, Nutritional Support in Chronic Liver Disease, and Health-related Quality of Life of Chronic Liver Disease Patients With and Without Hepatocellular Carcinoma on Medscape.)
- Corticosteroids^[4](See also Corticosteroids Influence the Mortality and Morbidity of Acute Critical Illness on Medscape.)
- Decompression sickness (See also the eMedicine article Decompression Sickness, as well as Magnetic Resonance Imaging in Spinal Cord Decompression Sickness on Medscape.)
- Gaucher disease (See also the eMedicine article Gaucher Disease, as well as Treatment Interruption in Gaucher Disease Can Cause Irreversible Complications and High-Dose Enzyme Therapy Speeds Response of Type 1 Gaucher Disease on Medscape.)
- Gout (See also the eMedicine articles Gout [in the Radiology section], Gout [in the Rheumatology section], Gout [in the Orthopedic Surgery section], and Gout and Pseudogout [in the Emergency Medicine section].)
- Hemoglobinopathy (eg, sickle cell disease)
- Idiopathic hyperlipidemia (See also the Hyperlipidemia Resource Center on Medscape.)
- Idiopathic atraumatic osteonecrosis
- Metabolic bone disease (see also Diseases of Calcium Metabolism and Metabolic Bone Disease on Medscape.)
- Pregnancy
- Radiation
- Smoking
- Systemic lupus erythematosus (See also the eMedicine articles Systemic Lupus Erythematosus [in the Rheumatology section], Systemic Lupus Erythematosus [in the Physical Medicine and Rehabilitation section], and Systemic Lupus Erythematosus [in the Pediatrics section], as well as the Lupus Resource Center, on Medscape.)
- Vasculitis (See also the eMedicine article Vasculitis and Thrombophlebitis, as well as Controversies in Small Vessel Vasculitis - Comparing the Rheumatology and Nephrology Views and Systemic Vasculitis: State of the Art and Emerging Concepts on Medscape.)

Proceed to Differential Diagnoses

Contributor Information and Disclosures

Author

John D Kelly IV, MD Associate Professor, Department of Orthopedic Surgery, University of Pennsylvania, Consulting Surgeon Shriner's Hospital for Surgery

John D Kelly IV, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Eastern Orthopaedic Association, Pennsylvania Orthopaedic Society, and Philadelphia County Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

David Wald, DO, FACOEP Assistant Program Director, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Temple University School of Medicine

David Wald, DO, FACOEP is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Gerard A Malanga, MD Director of Pain Management, Overlook Hospital; Director of PM&R Sports Medicine Fellowship, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey Medical School; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Cephalon Honoraria Speaking and teaching; Endo Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Jon B Whitehurst, MD Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital

Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Nothing to disclose.

References

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Vail TP, Covington DB. The incidence of osteonecrosis. In: Urbaniak JR, Jones JR, eds. Osteonecrosis: Etiology, Diagnosis, Treatment. Rosemont, Ill: American Academy of Orthopedic Surgeons; 1997:43-9.
Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am. Mar 1995;77(3):459-74. [Medline].
Pritchett JW. Statin therapy decreases the risk of osteonecrosis in patients receiving steroids. Clin Orthop Relat Res. May 2001;386:173-8. [Medline].
Arlet J, Ficat P. [Non-traumatic avascular femur head necrosis. New methods of examination and new concepts] [Polish]. Chir Narzadow Ruchu Ortop Pol. 1977;42(3):269-76. [Medline].
Steinberg ME. Avascular necrosis: diagnosis, staging, and management. J Musculoskel Med. 1997;14(11):13-25.
Steinberg ME. Diagnostic imaging and the role of stage and lesion size in determining outcome in osteonecrosis of the femoral head. Techniques in Orthopaedics. Mar 2001;16(1):6-15. [Full Text].
McGrory BJ, York SC, Iorio R, et al. Current practices of AAHKS members in the treatment of adult osteonecrosis of the femoral head. J Bone Joint Surg Am. Jun 2007;89(6):1194-204. [Medline].
Ciombor DM, Aaron RK. Biologically augmented core decompression for the treatment of osteonecrosis of the femoral head. Techniques in Orthopaedics. Mar 2001;16(1):32-8. [Full Text].
Katz MA, Urbaniak JR. Free vascularized fibular grafting of the femoral head for the treatment of osteonecrosis. Techniques in Orthopaedics. Mar 2001;16(1):44-60. [Full Text].
McCarthy J, Puri L, Barsoum W, et al. Articular cartilage changes in avascular necrosis: an arthroscopic evaluation. Clin Orthop Relat Res. Jan 2003;406:64-70. [Medline].
Ivankovich DA, Rosenberg AG, Malamis A. Reconstructive options for osteonecrosis of the femoral head. Techniques in Orthopaedics. Mar 2001;16(1):66-79. [Full Text].
Squire M, Fehring TK, Odum S, Griffin WL, Bohannon Mason J. Failure of femoral surface replacement for femoral head avascular necrosis. J Arthroplasty. Oct 2005;20(7 suppl 3):108-14. [Medline].
Glueck CJ, Freiberg RA, Sieve L, Wang P. Enoxaparin prevents progression of stages I and II osteonecrosis of the hip. Clin Orthop Relat Res. Jun 2005;435:164-70. [Medline].
[Best Evidence] Lai KA, Shen WJ, Yang CY, et al. The use of alendronate to prevent early collapse of the femoral head in patients with nontraumatic osteonecrosis. A randomized clinical study. J Bone Joint Surg Am. Oct 2005;87(10):2155-9. [Medline].
DeLee JC. Fractures and dislocations of the hip. In: Rockwood CA, Green DP, Bucholz RW, eds. Rockwood and Green's Fractures in Adults. 4^th ed. Philadelphia, Pa: Lippincott-Raven; 1996:1661-9.
Etienne G, Mont MA, Khanuja HS, Hungerford DS. Nonvascularized bone grafts for osteonecrosis of the femoral head: current concepts and techniques. Techniques in Orthopaedics. Mar 2001;16(1):39-43. [Full Text].
Kim SY, Kim YG, Kim PT, et al. Vascularized compared with nonvascularized fibular grafts for large osteonecrotic lesions of the femoral head. J Bone Joint Surg Am. Sep 2005;87(9):2012-8. [Medline].
Urbaniak JR, Barnes CJ. Meeting the challenge of osteonecrosis in adults. J Musculoskel Med. 2001;18:395-403.

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Femoral Head Avascular Necrosis Clinical Presentation

History

Physical

Causes