A 10-year-old girl is brought to the clinic for evaluation of a limp. She first noticed mild pain in the right groin 2 weeks ago and took ibuprofen, which initially helped. The pain acutely worsened 2 days ago after the patient fell while ice skating. Since then, she has been unable to fully bear weight on her right leg due to pain, which is now minimally relieved with ibuprofen and rest. The patient has autoimmune hypothyroidism for which she takes levothyroxine. Temperature is 37.2 C (99 F). Height and weight are at the 10th and 25th percentiles for age, respectively. When the right hip is flexed, there is external rotation of the hip. When the left hip is flexed, the hip remains in a neutral position. There is normal range of motion in both knees and no redness or edema overlying the hips and knees. The patient has a limp and bears little weight on her right side when walking. Bilateral hip radiograph with frog-leg lateral view reveals the following: Which of the following is the best next step in management of this patient?

Question

A 10-year-old girl is brought to the clinic for evaluation of a limp.  She first noticed mild pain in the right groin 2 weeks ago and took ibuprofen, which initially helped.  The pain acutely worsened 2 days ago after the patient fell while ice skating.  Since then, she has been unable to fully bear weight on her right leg due to pain, which is now minimally relieved with ibuprofen and rest.  The patient has autoimmune hypothyroidism for which she takes levothyroxine.  Temperature is 37.2 C (99 F).  Height and weight are at the 10th and 25th percentiles for age, respectively.  When the right hip is flexed, there is external rotation of the hip.  When the left hip is flexed, the hip remains in a neutral position.  There is normal range of motion in both knees and no redness or edema overlying the hips and knees.  The patient has a limp and bears little weight on her right side when walking.  Bilateral hip radiograph with frog-leg lateral view reveals the following:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d745_69f0_bc81_ef4fac82c2c8_MD0003_00 This patient has slipped capital femoral epiphysis (SCFE), which is characterized by displacement of the proximal femur relative to the femoral head due to weakening of the femoral growth plate (ie, physis). It is most commonly seen in obese, adolescent (age 10-14) boys. Because thyroid hormone promotes ossification of the growth plate, patients with hypothyroidism (such as this patient) are also at increased risk. Children with endocrinopathies often have SCFE at an earlier age (<10) and are more likely to develop bilateral disease. displacement of the proximal femur SCFE typically presents with insidious onset of hip, thigh, or knee pain that leads to limping. Minor trauma, as in this patient, can sometimes exacerbate the pain and prompt the patient to seek medical attention. Examination shows limited internal rotation of the hip, and the thigh externally rotates during passive hip flexion. A posteriorly displaced femoral head on frog-leg lateral hip radiograph is diagnostic (blue outline). Patients should be prescribed non-weight-bearing status and may require bedrest if SCFE is bilateral. Definitive treatment is prompt surgical screw fixation to stabilize the physis and prevent further slippage. Closed reduction is not typically recommended because it can cause damage to the tenuous blood supply of the femoral head and lead to avascular necrosis, an uncommon but serious complication of SCFE (Choice A). (Choice B) Oral methotrexate is often prescribed for juvenile idiopathic arthritis, which is characterized by chronic joint pain and stiffness. It rarely presents in the hip, and radiographs may be normal or show bony erosion with prolonged disease. A posteriorly displaced femoral head would not be seen. (Choice D) Conservative management with rest and analgesics is the treatment for transient synovitis, an inflammatory hip condition that presents in children age 3-8 with hip pain and limp following a viral illness. X-ray may be normal or show joint effusion. (Choice E) Total hip replacement may be considered in patients with avascular necrosis (a potential complication of SCFE) and chronic pain despite surgical screw fixation. Educational objective: Slipped capital femoral epiphysis is characterized by proximal femoral displacement relative to the femoral head along the growth plate. Patients with hypothyroidism are at increased risk due to impaired ossification of the growth plate. Treatment is surgical stabilization of the physis to prevent further slippage. References: Slipped capital femoral epiphysis and associated hypothyroidism. A review of the literature with two classic case examples. (http://www.ncbi.nlm.nih.gov/pubmed/26812778) Prepubertal onset of slipped capital femoral epiphysis associated with hypothyroidism: a case report and literature review. (http://www.ncbi.nlm.nih.gov/pubmed/28923047)

A 10-Year-Old Girl Is Brought to the Clinic for Evaluation