A 15yo boy presents with a limp and pain in the knee. Exam: leg is externally rotated and 2cm
shorter. There is limitation of flexion, abduction and medial rotation. As the hip is flexed
external rotation is increased. Choose the most likely dx?
a. Juvenile rheumatoid arthritis
b. Osgood-schlatter disease
c. Reactive arthritis
d. Slipped femoral epiphysis
e. Transient synovitis of the hip
answer: D
Slipped Femoral Epiphysis
• type I Salter-Harris epiphyseal injury at proximal hip
• most common adolescent hip disorder, peak incidence at pubertal growth spurt
• risk factors: male, obese (#1 factor), hypothyroid (risk of bilateral involvement)
Ages 10-14, below associated with hypothyroidism
Clinical Features
• acute: sudden, severe pain with limp
• chronic (typically): groin and anterior thigh pain, may present with knee pain
positive Trendelenburg sign on affected side, due to weakened gluteal muscles
• tender over joint capsule
• restricted internal rotation, abduction, flexion
Whitman’s sign: obligatory external rotation during passive flexion of hip
Investigations
• x-rays: AP, frog-leg, lateral radiographs both hips
posterior and medial slip
disruption of Klein's line
AP view may be normal or show widened/lucent growth plate compared with opposite side
Treatment and Complications
• mild/moderate slip: stabilize physis with pins in current position
• severe slip: ORIF or pin physis without reduction and osteotomy after epiphyseal fusion
• complications: AVN (roughly half of unstable hips), chondrolysis (loss of articular cartilage, resulting in narrowing of joint space), pin penetration, premature OA, loss of ROM
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