Avascular Necrosis

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Information for medical professionals (especially Physical Therapists) about avascular necrosis and how to recognize the signs and symptoms in the clinic.

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Diagnostic Imaging and Avascular Necrosis:

Diagnostic Imaging and Avascular Necrosis October 16 th , 2013 Emily Hillison, Meghan Shaw, Geoff Miller, Dara Sandifer , Caleb Kauffman, Ryan Eastridge , and Kurtise Wilkes

AVN1-4:

AVN 1-4 Death of a bone and marrow as a result of loss of blood supply Permanent damage can occur with only 2 hours of complete ischemia 10,000-20,000 cases annually in the US 200,000 cases in the US Underlying cause of 10% of total hip replacements

Etiology3:

Etiology 3 Traumatic Causes FOOSH Jumping from high ledge J oint subluxation Atraumatic causes Sickle cell anemia Legg-Calve- Perthes T hrombosis

Risk Factors1:

Risk Factors 1 Lifestyle Alcohol Obesity Pregnancy Medications Steroids Osteoporosis drugs Oral Contraceptives Medical Conditions Medical Procedures Medical Conditions HIV/AIDS Lupus Diabetes Mellitus Gout Medical Procedures Dialysis Organ Transplant Cancer treatment

What does a patient with AVN present with during physical therapy?5-7:

What does a patient with AVN present with during physical therapy? 5-7 Can be asymptomatic Pain L oss of motion Other symptoms will depend on the location of the infarct Femoral head 8 (Legg-Calve- Perthes – children) Scaphoid 9 Humeral head 10 Neck of the Talus 11

Imaging for Avascular Necrosis13 :

Imaging for Avascular Necrosis 13 X-Ray Not sensitive enough to detect early changes Used to monitor progression in later stages MRI Most sensitive method for early diagnosis Can detect chemical changes in bone marrow CT Scan - Provides a 3D image of the bone - Clearer image than bone scan and X-Ray - Less sensitive than MRI

AVN of the Femoral Head13:

AVN of the Femoral Head 13 CT Scans: show thickening of trabeculae in center of femoral head: asterisk sign -Show extent of sclerotic branches MRI: most sensitive imaging for early detection T1: proximal femoral neck and intertrochanteric regions “ hypointense ” T2: fatty marrow as a high intensity signal X-Ray: frogleg lateral view can show crescent sign: indicates a subchondral fracture

PT’s Role with AVN14-15:

PT’s Role with AVN 14-15 Teach patients non- weightbearing methods, to slow progression of disease Provide exercises to maintain range of motion Provide strengthening exercises for muscles surrounding joint with AVN Exercises to areas with AVN will help increase blood circulation to improve healing and relieve pain

Avascular Necrosis of Humeral Head16-17:

Avascular Necrosis of Humeral Head 16-17

Avascular Necrosis of Talus18-19:

Avascular Necrosis of Talus 18-19

Avascular Necrosis of Lunate (Kienbock’s)20-21:

Avascular Necrosis of Lunate (Kienbock’s ) 20-21

Avascular Necrosis of Femoral Head22:

Avascular Necrosis of Femoral Head 22 Hip/Femoral head Coronal T1 weighted MRI Stage 3 AVN Reference: http://www.centenoschultz.com/2009/early-detection-of-avascular-necrosis-of-femoral-head/

Radiographic ABC:

Radiographic ABC Avascular Necrosis of Femoral Head http://www.wheelessonline.com/ortho/avascular_necrosis_of_femoral_head

References:

References http:// www.niams.nih.gov/Health_Info/Osteonecrosis/default.asp Rubin RR. Bones and Joints : Rubin’s Pathology. 6 th Edition. Baltimore, MD. Lippincott Williams & Wilkin. 2012. 1217-1218. Goodman CC . Soft Tissue, Joint, and Bone Disorders: Pathology: Implications for the Physical Therapist . 3 rd Edition. St. Loius , MO. Saunders Elsevier. 2009. 1310-1311. Goodman CC. Screening the Lower Quadrant : Differential Diagnosis for the Physical Therapist. 5 th Edition. St. Louis, MO, Saunders Else http://emedicine.medscape.com/article/333364-clinical http://www.mayoclinic.com/health/avascular-necrosis/DS00650/DSECTION=symptoms http://my.clevelandclinic.org/orthopaedics-rheumatology/diseases-conditions/hic-avascular-necrosis.aspx Mont MA, Jones LC, Hungerford DS. Non-traumatic osteonecrosis of the femoral head: Ten years later- current concepts review. J Bone Joint Surg Am . 2006;88:1107–29. Grover R. Clinical assessment of scaphoid injuries and the detection of fractures. J Hand Surg [Br] 1996;21:341–3. Hollis R., Yamaguchi K. Avascular Necrosis of the Shoulder. Seminars in Arthroplasty . 2008;19(1) 19-22 Foot & Ankle Surgery (Elsevier Science) [serial online]. October 2004;10(4):213-215. Available from: Academic Search Complete, Ipswich, MA. Accessed October 6, 2013

References :

References Gruson K, Kwon Y. Atraumatic Osteonecrosis of the Humeral Head. Bulletin Of The NYU Hospital For Joint Diseases . January 2009;67(1):6-14. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed October 6, 2013. Imaging in Avascular Necrosis of the Femoral Head. Author: Michael R Aiello, MD; Chief Editor: Felix S Chew, MD, MBA, EdM March 8, 2013 http://emedicine.medscape.com/article/386808-overview Rienecke , Kimberly. Exercises for a person with Avascular Necrosis . December 23, 2010. ( http://www.livestrong.com/article/341336-exercises-for-a-person-with-avascular-necrosis/ ) Shiel , William (author). Balentine , Jerry (editor). Medicinehealth . Avascular Necrosis (Aseptic Necrosis or Osteonecrosis . ( http://www.emedicinehealth.com/avascular_necrosis/article_em.htm ) http://www.mridoc.com/mskatlas/Vascular/AVN_Talus/ http://www.nwhealth.edu/conted/distlear/avn/avnhumer.html http://www.assh.org/Public/HandConditions/Pages/KienbocksDisease.aspx http://www.mridoc.com/mskatlas/Vascular/AVN_Talus/

References:

References http://www.assh.org/Public/HandConditions/Pages/KienbocksDisease.aspx http://www.elbowandhand.com/Kienbocks_Disease.html http://www.cedars-sinai.edu/Patients/Health-Conditions/Avascular-Necrosis.aspx

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