Femoral head avascular necrosis - bilateral

Case contributed by Dr Mahmoud Ibrahim Mekhaimar


Presents to the ER with severe pain of both hips and inability to walk.

Patient Data

Age: 20
Gender: Female

Irregular shaped subchondral areas of abnormal signal intensity are seen at the superior aspect of both femoral heads appearing of dark signal on all pulse sequences, associated with adjacent patchy areas of marrow edema at the femoral head, neck, greater trochanter and both inter-trochanteric region on both sides appearing of low T1, high T2 and STIR signal.

 A superadded non displaced fracture is noted at the right femur head.

Patchy areas of marrow edema signal are also seen at both acetabulae associated with bony remodeling and thinned acetabular sockets and protrusion acetabuli.

 Multiple bizarre shaped intra-osseous and subchondral areas of geographic appearance and heterogenous MR signal are seen scattered within the upper aspect of both proximal femoral shafts as well as at the iliac side of both SIJs (iliac wings).

The right pectineus muscle as well as the adductor longus and brevis muscles appear swollen and show interstitial high T2/STIR signal with a small encysted collection (of low T1 and high T2/STIR signal) seen at the lateral aspect of the aforementioned muscle near its femoral insertion.

A small focal area of a similar signal is seen at the distal end of the left gluteus maximus muscle.

Increased girth of the right thigh is noted.

Bilateral hip joint effusion is noted, more on the left, associated with synovial thickening and debris.

Case Discussion

MR appearance is highly suggestive of bilateral femoral heads avascular necrosis (stage IV) associated with multiple areas of osteonecrosis (bone infarctions) at both proximal femoral shafts as well as both iliac wings. Right femur head non displaced fracture. Right pectineus, adductors as well as left gluteus maximus muscles interstitial high signal (myositis).

This patient had a known history of sickle cell anemia. 


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