A 12-year-old boy is brought to the office by his father for an urgent care visit due to right hip pain that has worsened over the past 3 weeks. The patient initially had "a little bit" of hip pain, but now the pain has spread to his thigh and knee. He says, "It is so bad that I can barely walk." The boy has had no recent injuries, fever, or sore throat. Aside from the pain in the right lower extremity, he feels well. He has mild eczema that is managed with emollients. He is allergic to dust and cats. The patient's only hospitalization was for an appendectomy at age 7. Temperature is 37 C (98.6 F), blood pressure is 114/74 mm Hg, and pulse is 90/min. He is at the 95th percentile for weight and the 50th percentile for height. Physical examination reveals an obese boy in moderate pain, with the right hip in an externally rotated position. There is no warmth, swelling, or tenderness of the right knee or thigh. The patient has normal Tanner 3 male external genitalia; the testes are descended bilaterally. Sensation is intact in the lower extremities, and peripheral pulses are 2+ bilaterally. Dry, red patches are present on the right knee and left elbow. The remainder of the physical examination is normal. X-ray of the hips is shown below. Which of the following is the most appropriate next step in management of this patient's condition?

Question

A 12-year-old boy is brought to the office by his father for an urgent care visit due to right hip pain that has worsened over the past 3 weeks.  The patient initially had "a little bit" of hip pain, but now the pain has spread to his thigh and knee.  He says, "It is so bad that I can barely walk."  The boy has had no recent injuries, fever, or sore throat.  Aside from the pain in the right lower extremity, he feels well.  He has mild eczema that is managed with emollients.  He is allergic to dust and cats.  The patient's only hospitalization was for an appendectomy at age 7.  Temperature is 37 C (98.6 F), blood pressure is 114/74 mm Hg, and pulse is 90/min.  He is at the 95th percentile for weight and the 50th percentile for height.  Physical examination reveals an obese boy in moderate pain, with the right hip in an externally rotated position.  There is no warmth, swelling, or tenderness of the right knee or thigh.  The patient has normal Tanner 3 male external genitalia; the testes are descended bilaterally.  Sensation is intact in the lower extremities, and peripheral pulses are 2+ bilaterally.  Dry, red patches are present on the right knee and left elbow.  The remainder of the physical examination is normal.  X-ray of the hips is shown below.  Which of the following is the most appropriate next step in management of this patient's condition?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0ca_d03d_8f63_93113222a542_MD0005_00 The child has a slipped capital femoral epiphysis (SCFE) that is progressing from stable (able to bear weight) to unstable (unable to bear weight). SCFE typically presents in an obese adolescent (age 10-16). Widening of the epiphyseal growth plate due to abnormal cartilage maturation results in progressive dull hip (or referred knee/thigh) pain, altered gait, and impaired internal rotation of the hip. (SCFE) SCFE is diagnosed by x-ray (anteroposterior and frog-leg lateral views) of the bilateral hips. Radiographs reveal posterior and inferior displacement of the femoral head along the plane of the physis, giving the appearance of "ice cream slipping off a cone." Up to 20% of those affected have bilateral involvement at presentation; an additional 20%-40% have bilateral involvement within 18 months of the initial SCFE. Radiographs The treatment is immediate surgical pinning. Delay in treatment (>24 hours in unstable SCFE) can lead to avascular necrosis and femoroacetabular impingement, which increase the risk of future degenerative arthritis. (Choice A) Septic arthritis, diagnosed with arthrocentesis, presents with fever and acute-onset hip pain. Imaging shows an effusion. (Choice B) Bone scintigraphy (bone scan) is generally avoided in children due to high radiation exposure. Although it may identify long-term complications, such as poor femoral head perfusion and osteonecrosis, it should not delay treatment once a diagnosis is made on radiograph. (Choice C) External reduction and fixation with a cast is the treatment for a fracture, which generally presents as acute pain following trauma. Reduction correlates with worse outcomes in patients with SCFE. (Choice E) Weight loss helps to prevent SCFE but is not the treatment once it has occurred. Analgesics may provide symptomatic relief but do not address the underlying structural instability. Once a diagnosis of SCFE is made, the patient should be made non-weight bearing and referred immediately for surgery to prevent further slippage. Educational objective: Slipped capital femoral epiphysis is a common cause of progressive hip pain and altered gait in obese adolescents. It is diagnosed on x-ray with a posteriorly displaced femoral head, and immediate surgical pinning is the treatment of choice. References: Slipped capital femoral epiphysis: how to evaluate with a review and update of treatment. (http://www.ncbi.nlm.nih.gov/pubmed/25439015) Long-term outcomes of slipped capital femoral epiphysis treated with in situ pinning. (http://www.ncbi.nlm.nih.gov/pubmed/27438268)

A 12-Year-Old Boy Is Brought to the Office by His