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Thigh and knee pain in an obese 10 year old Pediatric Case Presentation By Annerie Hattingh 28 October 2009.

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Presentation on theme: "Thigh and knee pain in an obese 10 year old Pediatric Case Presentation By Annerie Hattingh 28 October 2009."— Presentation transcript:

1 Thigh and knee pain in an obese 10 year old Pediatric Case Presentation By Annerie Hattingh 28 October 2009

2 History  10 yr old boy presents to ED with 1 week history of ® thigh + knee pain.  He states that the pain is mainly in the thigh, but radiates down to his knee.  He was playing soccer when he collided with another player + fell.  Noted severe pain in his thigh + had to limp home on his left leg.  Since then, he has been complaining of pain in his ® thigh when bearing weight.

3 History  The pain would subside when lying down.  He did not improve much + was brought to ED.  He had no history of fever, rash, chest discomfort or pains in other joints.

4 Examination  Vitals: Temp 37’C (oral) PR 66 RR 20 BP 112/65  Weight: 59.3kg (>>95 th percentile)  Height: 152cm (> 95 th percentile)  Alert, cooperative + in no distress when lying down.  Obese + large for age.

5 Examination  CVS: HR regular (-) murmurs  Lungs: clear  Abdo: Round contour Soft Non-tender

6 Examination  Musculoskeletal:  ® lower extremity: - Moderate tenderness in the upper ant. thigh - Severely tender hip, restricted ROM - Pubic symphysis non tender - Knee, tib-fib + foot non tender, normal ROM - No joint swelling noted

7 Examination  Musculoskeletal:  (L) lower extremity: - Mild tenderness of the hip on palpation - Mild tenderness on ROM testing - Rest unremarkable NOTE: Although his chief complaint is thigh pain, the hip and knee joints should also be examined. Hip injuries often present with knee pain.

8 Special investigations  X-rays of the hips are ordered.

9 Diagnosis  History of collision + fall suggests an acute injury such as a non-displaced #.  An obese child with hip pain in this age group should always raise the possibility of a SLIPPED FEMORAL EPIPHYSIS.  The X-ray shows a slipped capital femoral epiphysis on the ®.  The left hip appears to be normal, however an early slip on the left is difficult to rule out.

10 Management  He is hospitalized and bed rest ordered.  After a few hours of bed rest, his left hip is no longer tender.  He is referred to the orthopedic surgeon + taken to the OR for internal fixation of his ® femoral epiphysis.

11 Discussion  Radiographic dx of slipped femoral epiphysis can be subtle.  Clinical suspicion very important.

12 Discussion  In this case, the physis appears to be wider + more lucent in the ® hip, compared to the left.

13 Discussion  The position of the femoral head epiphysis should resemble a cap over the physis.  Subtle cases may just show a slight malpositioning of the epiphysis.

14 Discussion  Examine the following diagram of the pt’s hips:

15 Discussion  The lines drawn along the superior border of the prox. femur metaphysis (the Klein line) should intersect part of the prox. femoral epiphysis.

16 Discussion  The pt’s ® hip ( left on the screen ) shows the line just touching the lateral margin of the epiphysis.

17 Discussion  This is abnormal, indicating that the femoral epiphysis has slipped inferiorly + medially.

18 Discussion  The normal left hip (right on the screen) shows the line intersecting the lateral part of the femoral epiphysis.

19 Discussion  View this obvious case :

20 Discussion  No line needs to be drawn here to appreciate that the pt’s left hip is abnormal.  Severe left slipped femoral epiphysis.

21 Discussion  The slipped epiphysis on the ® may not be so obvious.  Bilat. SFE is present, severe on the L + moderately severe on the R.

22 Discussion  SCFE is a Dx that will occasionally present to the ED with an acute, sub acute or chronic pain in the hip, thigh or knee.  The Dx is not difficult if it is considered!!  Vague symptoms may be present  Degree of pain may range from severe to non-existent.  Ambulatory ability may range from non-weight bearing to normal gait.

23 Discussion  Often wrongly diagnosed as: - pulled muscle - hip bruise - hip/knee sprain  Patients tend to keep their hip externally rotated with inability to fully internally rotate the hip.

24 Discussion  Risk factors:  Cause is unknown.  3-4 x more common in males than females.  Average age 10 – 16 years.  Pt’s are overweight for height/obese.  Associated with endocrine disorders like hypothyroidism, pituitary tumors + low growth hormone levels.  May be associated with minor fall or trauma

25 Discussion  Radiographic diagnosis:  Obvious cases - epiphysis obviously displaced  Subtle cases - epiphyseal plate (physis) may be widened / irregular compared to the other side.  A line drawn along the sup. border of the metaphysis ( the Klein line ) may intersect less of the epiphysis compared to the normal side.  The epiphysis may appear to be thinner + occur if the slip is posteriorly.

26 Discussion  Radiographic diagnosis:  Early slips difficult to detect on XR.  AP views only detect inferior + medial slips.  Posterior slips seen on lateral views ( but difficult to obtain ).  CT scans helpful to orthopedic surgeon - rarely done in Emergency Department.  MRI scanning not useful.

27 Discussion  Treatment:  Responsibility of Orthopedic surgeon.  Prevent further slipping with internal fixation.  Important to make diagnosis on initial presentation!  Missed diagnosis may worsen slip and the future outcome.

28 Discussion  Complications: 1. Avascular necrosis - most NB! 2. Premature osteoarthritis 3. Chondrolysis - loss of articular cartilage of the hip joint - causes hip to stifffen with permanent loss of motion, flexion contracture + pain.

29 The End

30 References 1. MEDSCAPE pediatric trauma case studies 2. Online CME: Pediatrics 3. Rosen’s Emergency Medicine Online: Pediatric Trauma

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