Julia Rawlings, MD 23 March 2012

Presentation
Clinic visit: 13 year old male with 4 weeks of left hip &

groin pain 4 weeks ago while playing football was hit laterally just above the left knee Pain started after that and worsened after he fell riding his bike 3 days ago Seen by physical therapist for 3 weeks who diagnosed a muscle strain

Presentation
Last 24 hours can no longer ambulate and is using

crutches Feels popping in his groin Hurts when he tries to stretch No decrease in sensation in his leg or foot Has been using ice and NSAIDs without much relief

Past Medical History

Mild asthma and eczema
No previous injuries to his lower extremities No surgeries

Medications: Albuterol prn

Vaccinations are up to date No known allergies Social History: Lives with parents; he plays football

and baseball Family History: Mom has asthma

Physical Exam

Weight 40.8 kg (19th percentile) Vital Signs: T 37.4, HR 88, RR 18, BP 129/80, SaO2 98% Well-developed, well-nourished male in no distress. HEENT: WNL Neck: Supple without adenopathy Lungs: CTAB Cardiovascular: RRR, no murmurs Abdomen: Soft, NT, no HSM/masses. Musculoskeletal: Left hip held in slight external rotation and flexion with limited ROM in all directions, pain with internal rotation and abduction; Right hip normal, left knee & lower leg normal

Differential Diagnosis of Acute Limp Pain

Differential Diagnosis
Trauma Fracture Contusion Ligament Sprain Muscle Strain Infectious Septic arthritis Osteomyelitis Myositis Reactive arthritis Toxic synovitis
Lyme disease
Rheumatic fever

Malignancy Leukemia Bone tumor Juvenile idiopathic arthritis Slipped capital femoral

epiphysis Legg-Calve-Perthes Growing pains

Laboratory Results
Growth hormone 2.89
Free T4 1.62, TSH 0.48 (nl 0.6-4.9) Vit D 1,25 Dihydroxy 37

Prolactin 22.5 (nl 2-14)

X-ray
Slipped capital femoral epiphysis with moderate

displacement Mild necrosis of head of femur

Disposition
Sent to Primary Childrens Medical Center via

ambulance Orthopedic surgery: Open reduction & fixation because of severe/acute nature (instead of percutaneous pinning in situ) Touchdown weight bearing x 8 weeks ~ 6 months later developed right-sided SCFE

Slipped Capital Femoral Epiphysis

Incidence: 1/1,000 to 1/10,000 children
Mean age: 12 girls, 13.5 boys Multicenter study: >60% of patients w/ SCFE have BMI >

90%ile 30-60% will eventually have SCFE in contralateral leg Classic patient:
Obese child

Early adolescence near peak linear growth

Non-radiating, dull, aching pain in hip, groin, thigh, or knee No history of trauma

Slipped Capital Femoral Epiphysis

Risk factors (things that weaken physis): Obesity Peak linear growth (early adolescence) Renal failure (osteodystrophy) History of radiation therapy Endocrine abnormalities (Hypothyroid, growth hormone deficiency) Down Syndrome Atypical SCFE: age <10 or >16, weight < 50%ile, height

<10%ile

Clinical Manifestations
15% have isolated knee or thigh pain
Altered gait Affected leg shorter and externally rotated

When hip is passively flexed from an extended

position, the thigh with abduct and externally rotate Patterns: Pre-slip, acute, acute on chronic, chronic Classified as stable vs. unstable
Stable: weight bearing possible Unstable: epiphysis is displaced or cannot bear weight

Evaluation
Evaluation: AP Pelvic x-ray best to view both hips; may

attempt to get lateral w/ frog-leg or cross-table Early slip:

Blurring of junction between metaphysis & growth plate

Widening, lucency, irregularity of physis

Blanch sign of Steel Kleins line

MRI can detect preslips, widening of physis Tests: If atypical SCFE, should evaluate for renal failure &

endocrine disorders (TSH, Free T4, bone age)

Treatment
Refer promptly to orthopedic surgery
Make non-weight bearing and stabilize

until surgery to avoid complications Hospitalize for acute SCFE or bilateral SCFE Surgery: goal is to prevent further slippage
Pinning in situ without reduction Open reduction and fixation

Post-op: Touchdown weight bearing for

6-8 weeks

Complications

Most severe Damage to lateral epiphyseal

Narrowing of joint space &

artery

cartilage loss Stabilizing pins penetrate joint

Take Home Points

Suspect SCFE in teen w/ hip,

groin, or leg pain Get x-rays Immobilize and non-weight bearing to prevent complications Refer immediately to orthopedic surgery

References
Ortho Pediatrics, 22 March 2012

http://www.orthopediatrics.com/docs/Guides/slipped _CFE.html Slipped Capital Femoral Epiphysis Up To Date. 22 March 2012. Tse SM. Acute Limb Pain. Pediatrics in Review 27:2006;170-179.