X-Ray Rounds

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X-Ray Rounds

• Cass Djurfors
• Feb 20, 2003

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10 y.o. boy with leg pain

• Obese 10-year old male presents with a two week
  history of right thigh and knee pain.
• He states that the pain is mainly in his thigh
  (points to his upper thigh) but radiates down to
  his knee.

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10 y.o. boy with leg pain

• He was playing basketball when he collided with
  another player and fell. He noted severe pain in
  his thigh and had to limp home, mostly on his
  left leg.
• The pain is worse with weight-bearing and much
  better when lying in bed.
• No history of fever, rash, chest discomfort, or
  pains in other joints.

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On Exam

• Vitals
• T37.0 (oral)
• P66
• R20
• BP 112/65
• weight 69.3 kg (gtgt95th percentile)
• height 152 cm (gt95th percentile)
• Alert, cooperative, in no distress
• Head and neck, CVS, Respiratory and Abdominal
  exam all normal

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On Exam

• Right lower extremity
• Moderate tenderness in the upper anterior thigh
• Severely tender in the hip, ROM not done
• Pubic symphysis, mid thigh, knee, tibia/fibula
  all non tender
• No joint swelling
• ROM knee normal
• Left lower extremity
• Non-tender, normal exam

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And the answer isSCFE!

• Hip radiographs show a slipped capital femoral
  epiphysis on the right
• Left hip appears normal (but difficult to rule
  out an early slip)

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SCFE

• The radiographic diagnosis of slipped capital
  femoral epiphysis (SCFE) can be subtle
• In this case, the physis appears to be wider and
  more lucent in the patient's right hip compared
  to his left
• The position of the femoral head epiphysis should
  resemble a cap over the physis
• Subtle cases may just show a slight
  malpositioning of the epiphysis

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• Klein line a line drawn along the superior
  border of the proximal femoral metaphysis should
  intersect part of the proximal femoral epiphysis
• In this patient, right hip shows the line just
  touching the lateral margin of the epiphysis
  this is abnormal and indicates that the femoral
  capital epiphysis has slipped inferiorly and
  medially
• The patient's normal left hip shows the line
  intersecting the lateral part of the femoral
  epiphysis

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Management

• Patient is hospitalized and put on bedrest
• He is taken to the operating room for internal
  fixation of his right capital femoral epiphysis.

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Much more obvious
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• Severe left slipped capital femoral epiphysis
• The slipped capital femoral epiphysis on the
  right is not as obvious
• This patient has bilateral SCFE, severe on the
  left, and moderate on the right

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SCFE

• Presents with acute, subacute, or chronic pain in
  the hip, thigh, or knee
• Ambulatory ability may range from non-weight
  bearing to a normal gait
• Most comfortable with hip externally rotated
• Unable to fully internally rotate affected hip

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SCFE

• Occurs during adolescent growth spurt
• Most frequent in obese children
• 40-80 are bilateral
• Classification emphasizes epiphyseal stability
• Stableambulation possible
• Unstableambulation impossibledo not attempt
  passive ROM on exam for fear of further slip
• Mild/Mod/Severe 1/3, ½, gt1/2
• 90 are stable good prognosis if diagnosed early
• Unstable SCFE has a much poorer prognosis due to
  high risk of avascular necrosis

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Diagnosis

• SCFE can be detected radiographically in most
  instances
• AP views show only inferior and medial slips
• Early slips tend to be posteriorbest seen on
  lateral x-ray
• CT scanning can be helpful, but is not usually
  needed in the emergency department
• Obvious cases are hard to miss

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Diagnosis

• Subtle cases
• Widened or irregular epiphyseal plate (compare to
  opposite side)
• The physis may alternatively appear thinner than
  the normal side (esp with posterior slips)
• A line drawn along the superior border of the
  metaphysis (the Klein line) will intersect less
  of the epiphysis compared to the normal side
• The blanch sign of Steel (AP view)
  crescent-shaped area of increased density
  represents superimposition of the posteriorly
  displaced epiphysis on the femoral neck

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Treatment

• Ensure child is non weight-bearing
• Orthopedic referral
• Most are fixed with a single central screw

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