Xray Vision: Limping Answer

Here’s the image again:

good job, Dr. Berkowitz! The image shows SCFE of the right hip.

SCFE

Slipped capital femoral epiphysis results from a Salter-Harris physeal fracture. Mainly occurs between ages of 10 -16 years. Incidence is higher in boys than girls. 20% of patients will have bilateral involvement at the time of presentation. 20-40% more will progress to BL slips, and the second hip will usually slip within 18 months of the first SCFE. Increase risk in obese children or children with hypothyroidism, low growth hormone level, pituitary tumor, and Down syndrome. Typically left hip is affected more than the right. Patient can present with knee pain instead of hip pain. Often the patients hold their affected hip in passive external rotation

Physical:

• Examine passive range of motion in both hips
• SCFE is suspected if lower extremity is externally rotated and abducted with gentle passive hip flexion
• Patient will have painful internal rotation.

Workup:

• For atypical presentations (patient <10yo or >16 yo) consider endocrine workup for hypothyroidism, low growth hormone level, pituitary tumors, and Down syndrome
• Xray: obtain AP and frog-lateral views of pelvis and BL hips.
• Klein line: line drawn straight up the superior aspect of the femoral neck. This line should intersect the epiphysis. If not, likely SCFE.
• Frog leg view: a straight line through the center of the femoral neck proximally should be at the center of the epiphysis. If not, likely SCF

Treatment:

• SCFE is an emergent diagnosis
• Ortho consult for immediate internal fixation in-situ
• Prophylactic fixation of the unaffected hip is controversial
• Parents should be informed about possible bilateral involvement

Follow up:

• Repeat xray is continued until physeal closure is achieved to ensure the slippage has not progressed
• Xray of contralateral hip to ensure no bilateral involvement.

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jwang

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