【双语病例】肌骨|女性?33岁?左髋疼痛并活动时可闻及弹响

【病例学习】

History

A 33-year-old woman presents with left hip pain and audible snapping sensations during hip movements.【女性 33岁 左髋疼痛并活动时可闻及弹响】

Question

1.1 Which of the following is present in these hip radiographs?

•  A Disrupted Shenton line股骨颈闭孔线中断

•  B Hip joint-space narrowing and osteophytes髋关节间隙变窄，骨赘

•  C Widening of pubic symphysis

•  [ ] D No significant abnormality involving the left hip左髋关节无明显异常

•  E Vertical fracture line through the left sacral ala左侧骶骨翼见垂直骨折线通过

2.1 Which of the following is present on the hip MRI?

•  A Femoral head bone marrow edema股骨头骨髓水肿

•  B Evidence of muscle edema肌肉水肿的征象

•  C Fracture through the femoral neck股骨颈骨折

•  D Subchondral cyst formation软骨下囊肿形成

•  E Soft-tissue edema superficial to the greater trochanter股骨大转子表面软组织水肿

3.1 Which of the following is the most likely diagnosis?

•  A Pelvic insufficiency fracture骨盆不全骨折

•  B Hip osteoarthrosis髋关节骨关节病

•  C Snapping hip syndrome弹响髋综合症

•  D Myositis肌炎

•  E Femoral neck fracture股骨颈骨折

3.2 Snapping hip syndrome should initially be managed by which of the following?

•  A Physical therapy and NSAIDs物理治疗和非甾体抗炎药

•  B Resection of the iliotibial band对髂胫束切除

•  C Bisphosphonates二膦酸盐

•  D Opioids类罂粟碱

•  E Steroid injections类固醇注射

Axial T2-weighted MR image of the hip demonstrates soft-tissue edema at the lateral aspect of the greater trochanter of the femur, underlying the iliotibial band (white circle).髋关节轴向T2加权MR图像显示 在股骨大粗隆外侧的软组织水肿，髂胫束的深层（白圈）

Coronal T2-weighted MR image of the hip demonstrates soft-tissue edema interposed between the greater trochanter and iliotibial band (white circle). Note the lack of abnormal bone marrow or muscle edema.髋关节冠状位T2加权MR图像显示 股骨大转子和髂胫束之间的软组织水肿（白圈）。注意骨髓或肌肉无水肿。

Coronal proton density MR image of the hip again demonstrates soft-tissue edema (white circle) adjacent to the greater trochanter, which is characteristic for snapping hip syndrome.髋关节冠状位质子密度MR图像再次显示靠近大转子旁软组织水肿（白色圆圈），这是髋关节弹响症状特点。

Diagnosis

Snapping hip syndrome弹响髋综合症

Differential Diagnosis

1. Iliopsoas bursitis髂腰肌滑囊炎

2. Greater trochanteric bursitis大转子滑囊炎

3. Intra-articular bodies 关节内游离体

Case Points

1. Snapping hip syndrome is a common disease characterized by an audible snapping during hip movement.弹响髋综合征是一种常见的疾病，其特征表现为在髋关节运动过程中可闻及弹响

2. Dynamic ultrasound and MRI findings can help make the diagnosis by detecting abnormal tendon movements and soft-tissue edematous changes.动态超声和MRI检查有助于作出诊断，通过检测异常肌腱运动和软组织水肿改变。

3. Snapping hip syndrome usually responds well to conservative treatment and has an excellent prognosis. 弹响髋综合征通常保守治疗效果很好，预后良好

Discussion

1. Snapping hip syndrome, also known as coxa saltans, is a relatively common disease affecting 5-10% of the population. It is characterized by an audible snapping sensation during a hip movement and can be associated with hip pain. The disease is more commonly seen in athletes and dancers who perform an extreme range of hip motions. A history of trauma and surgery of the hip also predisposes snapping hip syndrome, and females are more likely to be affected by the disease than males.弹响髋综合症，又称coxa saltans，是影响5-10%的人群的常见病。它的特点是在髋关节运动过程中可闻及声响，与髋关节疼痛相关。在进行极端的髋关节运动的运动员和舞者中，这种疾病是最常见。髋关节创伤和手术史也容易导致弹响髋综合症，女性较男性更容易受此病影响。

2. There are three distinct types of snapping hip syndrome: external extra-articular type, internal extra-articular type, and intra-articular type. The external extra-articular type is the most common form of snapping hip syndrome. It is caused by the abnormal snapping motion of the iliotibial band or gluteus maximus muscle over the greater trochanter. Inflammation of the affected tendons and underlying greater trochanteric bursa can often cause hip pain. The internal extra-articular type is a result of abnormal snapping motions of the iliopsoas tendon over the iliopectineal eminence or the lesser trochanter. The iliopsoas bursa and the affected tendons can become inflamed and cause groin pain. Lastly, the intra-articular type is caused by abnormalities involving the hip joint, such as a torn acetabular labrum, hyaline cartilage flaps, and intra-articular bodies, and may result in a clicking sensation with movement in the hips.弹响髋综合征有三种不同类型的：外关节外型、内关节外型、关节内型。外关节外型是弹响髋综合症最常见的一种形式。它是由髂胫束或臀大肌在大粗隆处异常猛烈运动造成的。受影响的肌腱和潜在大转子囊的炎症常可引起髋关节疼痛。内关节外型是有髂腰肌肌腱在髂耻隆起或小转子处异常猛烈运动引起的。髂腰肌囊及受影响肌腱发炎而导致腹股沟疼痛。最后，关节内型是由涉及髋关节异常造成的，如髋臼唇的撕裂，透明软骨损伤，和关节内游离体，并可能导致髋关节活动时发出咔嚓的声响。

3. Diagnosis is usually made based on physical examination. However, further imaging studies may be obtained to assess the underlying anatomical abnormalities or rule out other causes of hip pain. Radiographs of patients with snapping hip syndrome are usually normal. Consequently, dynamic ultrasound examination can be helpful in detecting the abnormal snapping movement of the affected tendons over the bony eminences. For a suspected external extra-articular type case, a linear transducer can be placed directly over the greater trochanter. In the case of the internal extra-articular type, the transducer is placed over the anterior hip joint. Additionally, ultrasound can also detect abnormal thickening of the affected tendons and hyperemia on the Doppler examination. Alternately, MRI of the hip can more readily demonstrate abnormal thickening and soft-tissue edema secondary to repetitive friction trauma of the tendons over the bony prominences. T1 hypointense and T2 hyperintense signals of the tendons and surrounding bursae are characteristic. MR arthrography is especially valuable in detection of intra-articular abnormalities causing the intra-articular type of snapping hip syndrome. Treatment of snapping hip syndrome is generally conservative, utilizing physical therapy and NSAIDs. Corticosteroid injections can help minimize pain when there is surrounding bursitis. Surgical treatment is only reserved for refractory cases that do not respond to the conservative treatments listed above。诊断通常是根据身体检查。然而，进一步的影像学研究，可获得评估潜在的解剖异常或排除其他原因引起的髋关节疼痛。声响髋综合征的患者X线检查通常是正常的。因此，动态超声检查有助于检测骨隆起处受影响肌腱的异常捕捉运动。对于疑似外关节外型的情况下，线性探头可以直接放在大转子处。在内关节外型的情况下，探头放置在髋关节前侧。此外，超声可以检测受影响肌腱的异常增厚及多普勒超声可以显示血流。另外，髋关节MRI能更容易显示出肌腱在骨隆起处反复摩擦损伤而继发的异常增厚、软组织水肿。肌腱和周围滑囊的特征是T1低信号、T2高信号。MR关节造影对于引起关节内型弹响髋综合征的关节内异常的检测特别有价值。声响髋关节综合症的治疗通常是保守治疗，利用物理治疗和非甾体类抗炎药。在周围有滑囊炎时，激素注射可以帮助减少疼痛。手术治疗只是用于上述保守治疗无效的情况下。