Emergency Medicine, Georgetown University Hospital, Washington, DC 20007, USA.
Am J Emerg Med. 2011 Mar;29(3):356.e1-3. doi: 10.1016/j.ajem.2010.03.033.
A patient with acute hip pain out of proportion to physical findings and inability to weight bear despite negative plain films warrants further in-depth evaluation. Correctly diagnosing the cause of hip pain, a common emergency department (ED) complaint, may be a challenge in the geriatric population (Perron A, Miller M, Brady W. Orthopedic pitfalls in the ED: radiographically occult hip fracture. Am J Emerg Med 2002; 20: 234-7; Cannon J, Silvestri S, Munro M. Imaging choices in occult hip fracture. J Emerg Med 2009; 37: 144-52; Kiu A, Khan S. Radiology of acute hip and femoral injuries. Br J Hosp Med (London) 2010; 71: M22-M24; Zacher J, Gursche A. Regional musculoskeletal conditions: hip pain. Best Pract Res Clin Rheumatol 2003; 17: 71-85). A perirectal abscess as a cause of acute hip pain and inability to ambulate, with gluteus muscle inflammation but no evidence for bone or joint infection, has not been described, to the authors' knowledge. An 82-year-old woman with a history of diabetes, previously ambulatory, presented to the ED after being found on her apartment floor by a visiting health aide, complaining of acute pain in her left hip. Pain was exacerbated by palpation and range of motion testing, and she was unable to bear weight. There was no report of fever, rectal or abdominal pain, bleeding, or painful defecation. Plain films were negative for fracture or lytic lesion. Computerized tomography (CT) of the hip and pelvis was then obtained, which was negative for boney abnormality but revealed a 5-cm ischiorectal abscess with inflammation of the adjacent gluteus muscle. This case illustrates the potentially subtle nature of a deep perirectal abscess in an elderly patient. The CT imaging, useful for investigating the possibility of occult femoral neck fracture, was fortuitous in leading to the diagnosis. One must consider the possibility of visceral processes causing referred pain, when evaluating the patient with an acutely painful hip (Perron A, Miller M, Brady W. Orthopedic pitfalls in the ED: radiographically occult hip fracture. Am J Emerg Med 2002; 20: 234-7; Zacher J, Gursche A. Regional musculoskeletal conditions: hip pain. Best Pract Res Clin Rheumatol 2003; 17: 71-85).
一位急性髋痛患者，其疼痛程度与体格检查结果不成比例，且尽管 X 线平片阴性仍无法负重，需要进一步深入评估。在老年人群中，正确诊断髋痛的原因（这是急诊科常见的主诉）可能具有挑战性（Perron A、Miller M、Brady W. 急诊科的骨科陷阱：影像学隐匿性股骨颈骨折。美国急诊医学杂志 2002 年；20:234-7；Cannon J、Silvestri S、Munro M. 隐匿性髋部骨折的影像学选择。急诊医学杂志 2009 年；37:144-52；Kiu A、Khan S. 急性髋部和股骨损伤的放射学。英国医院医学杂志（伦敦）2010 年；71:M22-M24；Zacher J、Gursche A. 局部肌肉骨骼疾病：髋痛。临床风湿病最佳实践研究 2003 年；17:71-85）。据作者所知，直肠周围脓肿作为急性髋痛和无法行走的原因，伴有臀肌炎症，但没有骨或关节感染的证据，尚未被描述。一位 82 岁的女性，有糖尿病病史，以前能走动，被一位来访的健康助手发现在她的公寓地板上，抱怨左髋部急性疼痛，到急诊科就诊。触诊和运动范围测试使疼痛加剧，她无法负重。没有发热、直肠或腹痛、出血或疼痛性排便的报告。X 线平片未见骨折或溶骨性病变。随后进行了髋关节和骨盆 CT 检查，未见骨异常，但发现 5cm 坐骨直肠脓肿，相邻臀肌炎症。本例说明了老年患者深部直肠周围脓肿的潜在隐匿性。CT 成像有助于探索隐匿性股骨颈骨折的可能性，因此偶然导致了诊断。在评估急性髋痛患者时，必须考虑内脏过程引起牵涉痛的可能性（Perron A、Miller M、Brady W. 急诊科的骨科陷阱：影像学隐匿性股骨颈骨折。美国急诊医学杂志 2002 年；20:234-7；Zacher J、Gursche A. 局部肌肉骨骼疾病：髋痛。临床风湿病最佳实践研究 2003 年；17:71-85）。
