A 69-year-old woman presents with pain in her hip and groin. The pain is present in the morning but is nearly unbearable by the end of the day. Her medical history is notable for a treated episode of acute renal failure, diabetes mellitus, obesity, and hypertension. Her current medications include losartan, metformin, insulin, and ibuprofen. The patient recently started taking high doses of vitamin D as she believes that it could help her symptoms. She also recently fell off the treadmill while exercising at the gym. Her temperature is 98.6°F (37°C), blood pressure is 135/91 mmHg, pulse is 72/min, and respirations are 12/min. On exam, an obese woman in no distress is noted. There is pain, decreased range of motion, and crepitus on exam of her right hip. The patient points to the areas that cause her pain stating that it is mostly over the groin. Which of the following is most likely to be found on plain radiographic imaging of this patient?
Femoral neck fracture
Posterior displacement of the femoral head
Loss of joint space and osteophytes
Hyperdense foci in the ureters
Loss of joint space and osteophytes
This patient is presenting with pain worse on exertion, decreased range of motion, and crepitus in her hip, suggesting a diagnosis of osteoarthritis. A loss of joint space and osteophytes (reactive bone formation) would be seen on radiography.

Osteoarthritis occurs due to wear and tear of the joint typically from repeat trauma in the setting of risk factors such as obesity. Pain can be located in the hip, and can be referred to the groin or knee. The classic presentation is pain that worsens with activity. Crepitus and decreased range of motion can be found on physical exam. Common radiological findings include a loss of joint space and osteophytes. Treatment should start with conservative measures such as activity modification, weight loss, and an unloading brace. A corticosteroid injection may be appropriate as a second-line measure. Refractory cases can be treated with a total joint replacement.

Glyn-Jones et al. review the evidence regarding the diagnosis and treatment of osteoarthritis. They discuss how total joint arthroplasty operations can be limited by the lifestyle of the prosthesis and other complications. They recommend considering joint preserving options such as lifestyle modification.

Incorrect Answers:
Answer A: Femoral neck fracture would present acutely with pain in the hip and a shortened and externally rotated leg. This diagnosis is possible given the patient's recent fall; however, her other symptoms and less acute presentation suggest a diagnosis of osteoarthritis. Treatment is with a hemiarthroplasty.

Answer B: Hyperdense foci in the ureters suggest a diagnosis of renal calculi. Though this patient's referred pain to the groin, history of renal failure, and possible hypercalcemia (due to increased vitamin D intake) could suggest this diagnosis, her other symptoms are more suggestive of osteoarthritis. Treatment is lithotripsy or stone removal for larger kidney stones.

Answer D: Normal radiography would be found with a minor sprain/muscular injury which presents with a self-limited course of pain and tenderness over the affected muscle. Treatment is with rest, ice, compression, and elevation.

Answer E: Posterior displacement of the femoral head suggests a diagnosis of posterior hip dislocation. Posterior hip dislocation would present with a shortened and internally rotated leg and a more acute presentation. Treatment is with closed reduction of the hip under sedation.

Bullet Summary:
Osteoarthritis presents with joint pain that is worse with exertion and radiographical findings of decreased joint space and osteophytes.