Avascular Necrosis Clinical Presentation

Updated: Oct 10, 2017
  • Author: Sunny B Patel, MD; Chief Editor: Herbert S Diamond, MD  more...
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Presentation

History

Avascular necrosis (AVN) may be asymptomatic and is occasionally discovered incidentally on radiographs. Symptoms depend on the affected joint. Medullary infarcts are usually silent, and infarcts of the small bones of the hands and feet are often symptomatic.

Pain in the affected joint is typically the presenting symptom of AVN, regardless of the location. Patients with AVN of the femoral head often report groin or anterior thigh pain that is exacerbated by weight bearing. The pain may initially be mild but progressively worsens over time and subsequently may be present at rest or at night.

Large infarcts, such as those due to Gaucher disease and hemoglobinopathies, are associated with very severe pain.

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Causes

AVN may be primary or idiopathic. For AVN that is secondary or associated with an underlying condition or exposure, the following factors have been identified:

  • Systemic corticosteroid use or Cushing disease [12]

  • Trauma

  • Alcohol abuse

  • Systemic lupus erythematosus (with or without antiphospholipid syndrome), as well as other connective-tissue diseases

  • Hemoglobinopathies or hemophilic disorders (eg, sickle cell disease, hemophilia A or B)

  • Osteoporosis medications (ie, bisphosphonates, denosumab)

  • Hyperlipidemia

  • Bone disorders (slipped capital femoral epiphysis, congenital dysplasia of the hip, Legg-Calve-Perthes disease)

  • Allogeneic bone marrow transplantation [15, 16]

  • Radiation therapy

  • Gaucher disease

  • Malignancy (marrow infiltration, malignant fibrous histiocytoma)

  • Caisson disease (uncommon diving-related decompression illness)

  • Pregnancy

  • Psoriasis [11]

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Physical Examination

Initially, the physical examination findings of AVN may be unrevealing. Abnormal physical findings depend on the location and severity of disease. With progression of AVN of the hip, joint function deteriorates and the patient may walk with a limp. AVN of smaller, non–weight-bearing joints typically does not cause significant disability. Findings may include the following:

  • Patients with AVN may have tenderness around the affected bone.

  • Both active and passive joint movements may be restricted and painful.

  • A neurologic deficit may be present if a nerve is affected (compressed) because of necrosis and compression deformity of affected bones.

  • Advanced AVN can result in joint deformity and muscle wasting.

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