CASE CONFERENCE Qadeer Ahmed PEM Fellow 03/05/2015

CASE PRESENTATION Presenting complaints: Presenting complaints: 14 y/o with abdominal pain for one day 14 y/o with abdominal pain for one day HPI HPI He started with abdominal pain with bowel movement since yesterday, normally he goes once a day but for last few days its twice a day, pain is only with stooling He started with abdominal pain with bowel movement since yesterday, normally he goes once a day but for last few days its twice a day, pain is only with stooling Today he noticed red areas on scrotum, no testicular pain or swelling Today he noticed red areas on scrotum, no testicular pain or swelling He felt nausea but no vomiting He felt nausea but no vomiting

CASE PRESENTATION Review of systems: Review of systems: No constipation, no fever, no weight loss, no abdominal injury, no urinary complaints No constipation, no fever, no weight loss, no abdominal injury, no urinary complaints Past History: Past History: Insignificant other then a fracture of distal radius Insignificant other then a fracture of distal radius Examination: Examination: Alert, ambulatory Alert, ambulatory CVS: S1, S2 no murmur CVS: S1, S2 no murmur Lungs: CTA Lungs: CTA Neuro: Intact Neuro: Intact Abdomen: Soft, NT, ND, normal bowel sounds Abdomen: Soft, NT, ND, normal bowel sounds

DIFFERENTIAL DIAGNOSIS Constipation Constipation UTI UTI Renal stone Renal stone Appendicitis Appendicitis IBS IBS

INVESTIGATIONS Urine Dip stick: WNL Abdominal X-Ray: No constipation or obstruction B/L Slipped capital femoral epiphysis AP and Frog-Leg views of pelvis confirmed the diagnosis Seen by Orthopedics and admitted

SLIPPED CAPITAL FEMORAL EPIPHYSIS Slipped capital femoral epiphysis (SCFE) is the most common hip disorder in adolescents. Slipped capital femoral epiphysis (SCFE) is the most common hip disorder in adolescents. It is twice as common in males as females, and more common in African–Americans. It is twice as common in males as females, and more common in African–Americans. Over 80% of patients with SCFE have body mass index above the 95th percentile. Over 80% of patients with SCFE have body mass index above the 95th percentile. Boys are most commonly affected between13 and 15 years of age, and girls between 11 and 13 years of age because of their earlier pubertal development. Boys are most commonly affected between13 and 15 years of age, and girls between 11 and 13 years of age because of their earlier pubertal development. Slippage of capital femoral epiphysis is almost always posterior and inferior relative to the proximal femoral metaphysis, however, displacement anteriorly or superiorly has been reported. The epiphysis maintains a normal relationship with the acetabulum. Slippage of capital femoral epiphysis is almost always posterior and inferior relative to the proximal femoral metaphysis, however, displacement anteriorly or superiorly has been reported. The epiphysis maintains a normal relationship with the acetabulum. The left hip is affected more often than the right. Although symptoms are usually unilateral, plain radiographs document bilateral slippage in about 25% of cases, computed tomographic (CT) scans and MRI in up to 50%. The left hip is affected more often than the right. Although symptoms are usually unilateral, plain radiographs document bilateral slippage in about 25% of cases, computed tomographic (CT) scans and MRI in up to 50%.

SLIPPED CAPITAL FEMORAL EPIPHYSIS The term SCFE is a misnomer. It is actually the portion of the proximal femur distal to the physis (growth plate) that is displaced anterolaterally and superiorly. This displacement gives the appearance of posterior and inferior displacement of the epiphysis, which in fact remains in normal position in the acetabulum The term SCFE is a misnomer. It is actually the portion of the proximal femur distal to the physis (growth plate) that is displaced anterolaterally and superiorly. This displacement gives the appearance of posterior and inferior displacement of the epiphysis, which in fact remains in normal position in the acetabulum The perichondrium is primarily responsible for the strength of the proximal femoral physis. The perichondrium is primarily responsible for the strength of the proximal femoral physis. SCFE differs from a displaced Salter I fracture in that the perichondrium remains intact in most cases of SCFE and is disrupted with acute Salter I fractures. SCFE differs from a displaced Salter I fracture in that the perichondrium remains intact in most cases of SCFE and is disrupted with acute Salter I fractures.

PATHOPHYSIOLOGY SCFE occurs when shearing forces applied to the femoral head exceed the strength of the capital femoral physis. The factors that weaken the physeal plate are not fully clarified but are thought to include: SCFE occurs when shearing forces applied to the femoral head exceed the strength of the capital femoral physis. The factors that weaken the physeal plate are not fully clarified but are thought to include: Normal periosteal thinning and widening of the physis, which occurs during physiologic hormonal changes associated with adolescence and other periods of rapid growth acceleration. Normal periosteal thinning and widening of the physis, which occurs during physiologic hormonal changes associated with adolescence and other periods of rapid growth acceleration. Trauma (particularly in acute and acute-on-chronic slips). Trauma (particularly in acute and acute-on-chronic slips). Obesity, which increases mechanical strain on the physis. Obesity, which increases mechanical strain on the physis. Inflammatory changes. Inflammatory changes. Genetic predisposition. Genetic predisposition. Endocrine and metabolic disorders (e.g., hypothyroidism and growth hormone deficiency, which can cause abnormal growth and mineralization of cartilage). Endocrine and metabolic disorders (e.g., hypothyroidism and growth hormone deficiency, which can cause abnormal growth and mineralization of cartilage). Total body irradiation used in pediatric cancer patients. Total body irradiation used in pediatric cancer patients.

CLINICAL PRESENTATION Pain and/or limp are the most common chief complaints in patients with SCFE. Pain is referred to the thigh, knee, or groin. It is often dull, vague, intermittent, and chronic in nature. Pain and/or limp are the most common chief complaints in patients with SCFE. Pain is referred to the thigh, knee, or groin. It is often dull, vague, intermittent, and chronic in nature. The average duration of symptoms prior to diagnosis of SCFE is 2 months. The average duration of symptoms prior to diagnosis of SCFE is 2 months. A history of trivial injury is sometimes obtained, causing the additional slippage that precipitates a medical evaluation. A history of trivial injury is sometimes obtained, causing the additional slippage that precipitates a medical evaluation. Acute onset of severe symptoms suggests acute or acute-on-chronic slippage, sometimes referred to as “unstable” SCFE. These patients are often unable to bear weight and may be in signi fi cant pain. Acute onset of severe symptoms suggests acute or acute-on-chronic slippage, sometimes referred to as “unstable” SCFE. These patients are often unable to bear weight and may be in signi fi cant pain.

EXAMINATION Examination findings in patients with SCFE include a resting position with hip flexion and some external rotation. Examination findings in patients with SCFE include a resting position with hip flexion and some external rotation. Range of motion of the hip, especially full flexion, medial rotation, and abduction, is decreased and painful. Range of motion of the hip, especially full flexion, medial rotation, and abduction, is decreased and painful. Patients with signicant displacement may have evidence of limb shortening. Patients with signicant displacement may have evidence of limb shortening.

DIAGNOSIS Radiographs of the hip should include two views because SCFE is in-apparent in one third of cases in which a single anteroposterior (AP) view is obtained. On the AP view, widening of the physis is usually seen, even if the displacement is in-apparent. Radiographs of the hip should include two views because SCFE is in-apparent in one third of cases in which a single anteroposterior (AP) view is obtained. On the AP view, widening of the physis is usually seen, even if the displacement is in-apparent. A line drawn along the lateral aspect of the femoral neck on the AP view (Klein’s line) should intersect a small portion of the femoral epiphysis in a normal hip, but will not in cases of SCFE. The epiphysis in SCFE is almost always displaced posteriorly. A line drawn along the lateral aspect of the femoral neck on the AP view (Klein’s line) should intersect a small portion of the femoral epiphysis in a normal hip, but will not in cases of SCFE. The epiphysis in SCFE is almost always displaced posteriorly. Two radiographic views of the hip are 80% sensitive for SCFE. Those with suspicious clinical presentations but normal radiographs may have early SCFE or a “pre slip” that may be detected by MRI. Two radiographic views of the hip are 80% sensitive for SCFE. Those with suspicious clinical presentations but normal radiographs may have early SCFE or a “pre slip” that may be detected by MRI.

CLASSIFICATION SCFE is classified by symptom duration, stability, and degree of displacement. SCFE is classified by symptom duration, stability, and degree of displacement. Patients with acute SCFE have symptoms for less than 3 weeks; with chronic SCFE, symptoms are present for more than 3 weeks. Acute-on-chronic SCFE describes patients with symptoms for more than 3 weeks with a recent exacerbation. Patients with acute SCFE have symptoms for less than 3 weeks; with chronic SCFE, symptoms are present for more than 3 weeks. Acute-on-chronic SCFE describes patients with symptoms for more than 3 weeks with a recent exacerbation. An acute slip with severe symptoms is unstable. Acute or chronic slips with mild symptoms are stable and have a more favorable prognosis. An acute slip with severe symptoms is unstable. Acute or chronic slips with mild symptoms are stable and have a more favorable prognosis. The degree of slippage is expressed with a grading system: grade I or pre slip with possible widening of the physis but no displacement, grade II with displacement less than one-third of the width of the metaphysis, grade III with displacement of one-third to half of the metaphyseal width, and grade IV with displacement of greater than half the metaphyseal width. The degree of slippage is expressed with a grading system: grade I or pre slip with possible widening of the physis but no displacement, grade II with displacement less than one-third of the width of the metaphysis, grade III with displacement of one-third to half of the metaphyseal width, and grade IV with displacement of greater than half the metaphyseal width.

MANAGEMENT Children with SCFE who present with severe symptoms and/or acute onset should be admitted and promptly evaluated by an orthopedic surgeon. Children with SCFE who present with severe symptoms and/or acute onset should be admitted and promptly evaluated by an orthopedic surgeon. Those with milder symptoms may be sent home on crutches, assuming timely orthopedic follow up has been arranged. Those with milder symptoms may be sent home on crutches, assuming timely orthopedic follow up has been arranged. Treatment of SCFE is primarily surgical. Screws are usually placed through the femoral neck into the epiphysis. Treatment of SCFE is primarily surgical. Screws are usually placed through the femoral neck into the epiphysis. Chondrolysis is the most common complication of SCFE, occurring in about 8% of patients. Pain and persistent decreased range of motion after pinning are the usual presenting symptoms. Chondrolysis is the most common complication of SCFE, occurring in about 8% of patients. Pain and persistent decreased range of motion after pinning are the usual presenting symptoms.

MANAGEMENT Some pediatric orthopedists advocate prophylactic pinning of the contralateral hip after unilateral SCFE if the risk for subsequent slippage is high. Some pediatric orthopedists advocate prophylactic pinning of the contralateral hip after unilateral SCFE if the risk for subsequent slippage is high. Younger chronological age (girls younger than 10 years, boys younger than 12 years) is a very signi fi cant predictor for development of a contralateral slip. Younger chronological age (girls younger than 10 years, boys younger than 12 years) is a very signi fi cant predictor for development of a contralateral slip.

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