A 13-year-old girl is brought to the clinic by her mother due to difficulty walking. The patient noticed a mild ache in both hips 2 months ago that occurred most days after walking home from school. The aches usually resolved after rest but this week, the aches have worsened to the point where she has difficulty walking, and ibuprofen only minimally relieves the symptoms. Her mother attributed the symptoms to muscle soreness related to deconditioning because the patient gained noticeable weight over the past year. The patient has no chronic medical conditions and takes no other medications. Height is at the 75th percentile, and weight is at the 97th percentile. Temperature is 37.4 C (99.3 F). The patient has a waddling gait with both feet turned laterally. Bilateral knees have full range of motion. Both hips externally rotate during hip flexion, and there are no palpable clicks when the hips are brought back to extension. There is limited internal rotation bilaterally. There is mild tenderness to palpation at the bilateral anterior groin. Which of the following is the most likely diagnosis in this patient?

Question

A 13-year-old girl is brought to the clinic by her mother due to difficulty walking.  The patient noticed a mild ache in both hips 2 months ago that occurred most days after walking home from school.  The aches usually resolved after rest but this week, the aches have worsened to the point where she has difficulty walking, and ibuprofen only minimally relieves the symptoms.  Her mother attributed the symptoms to muscle soreness related to deconditioning because the patient gained noticeable weight over the past year.  The patient has no chronic medical conditions and takes no other medications.  Height is at the 75th percentile, and weight is at the 97th percentile.  Temperature is 37.4 C (99.3 F).  The patient has a waddling gait with both feet turned laterally.  Bilateral knees have full range of motion.  Both hips externally rotate during hip flexion, and there are no palpable clicks when the hips are brought back to extension.  There is limited internal rotation bilaterally.  There is mild tenderness to palpation at the bilateral anterior groin.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d746_0631_bc81_9d802c52a853_MD0003_00 This adolescent girl has chronic aching and limited internal rotation of the hips consistent with slipped capital femoral epiphysis (SCFE). Weakening of the femoral physis (ie, growth plate) causes anterior displacement of the proximal femoral diaphysis with posterior slippage of the femoral head. Both hips are affected in <40% of cases, and many patients with unilateral SCFE will develop slip in the contralateral hip in the future. displacement of the proximal femoral diaphysis SCFE most commonly presents in obese adolescents (age 10-16) with limp and chronic pain/ache of the hip, thigh, or knee that worsens with activity. Patients with unilateral SCFE may have an antalgic gait to avoid bearing weight on the affected leg whereas patients with bilateral SCFE often develop a waddling gait, as seen here. Feet are pointed laterally due to limited internal rotation of the affected hip, and external rotation of the thigh during passive hip flexion is a characteristic examination finding. Radiographs are diagnostic and show displacement of the femoral epiphysis, which resembles ice cream slipping off a cone. Management involves stabilization of the physis with surgical screw fixation. Radiographs (Choice A) Iliopsoas bursitis is inflammation within the bursa posterior to the iliopsoas muscle due to overuse or trauma. Patients have hip pain and limited range of motion, but a palpable click with manipulation of the hip is typically present (not seen in this patient). (Choice B) Osteosarcoma is a bony malignancy that most commonly presents in adolescent boys with localized bone pain and swelling, usually at the distal femur. A soft tissue mass is typically present, and bilateral disease is unlikely. (Choice C) Physiologic genu valgum ("knock-knee") refers to the developmentally normal leg alignment in children age 2-5. Affected children typically have no symptoms, unlike this adolescent with chronic pain and an abnormal gait. Physiologic genu valgum (Choice E) Transient synovitis, which can cause a limp and pain in one or both hips, presents in children age 3-8 and usually follows a mild viral illness. Symptoms typically resolve within weeks. This patient's age and chronic symptoms make SCFE more likely. Educational objective: Slipped capital femoral epiphysis, which occurs most commonly among obese adolescents, is characterized by proximal femoral displacement relative to the femoral head along the growth plate. Bilateral involvement is common and may present with chronic hip, thigh, or knee pain and a waddling gait. References: Review for the generalist: evaluation of pediatric hip pain. (http://www.ncbi.nlm.nih.gov/pubmed/19450281) Pediatric hip: pearls and pitfalls. (http://www.ncbi.nlm.nih.gov/pubmed/23787987)

A 13-Year-Old Girl Is Brought to the Clinic by Her