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Difficulty: MediumOrthopedic Surgery

A 13-year-old boy is brought to the clinic by his parents due to a 4-week history of dull, aching pain in his right anterior thigh and knee. He has no history of recent trauma, and he has been afebrile. His body mass index (BMI) is 34 kg/m². He walks with a noticeable limp, keeping his right foot externally rotated. On physical examination, internal rotation of the right hip is significantly limited and elicits pain. When the physician passively flexes the patient's right hip, the thigh obligatorily rotates outward. Radiographs of the pelvis demonstrate widening of the right proximal femoral physis with posterior and inferior displacement of the epiphysis relative to the femoral neck. Which of the following is the most appropriate next step in management?

  1. Immediate non-weight bearing and surgical pinning in situAnswer
  2. B
    Recommendation for weight loss, physical therapy, and NSAIDs
  3. C
    Closed reduction of the right hip followed by spica casting
  4. D
    Reassurance and observation as this represents a benign developmental variant
  5. E
    Aspiration of the right hip joint under ultrasound guidance

Answer

Immediate non-weight bearing and surgical pinning in situ
The clinical presentation of an obese adolescent with hip or referred knee pain, an antalgic gait, and obligatory external rotation with hip flexion is classic for Slipped Capital Femoral Epiphysis (SCFE). The described radiographic findings confirm the diagnosis. The immediate and most appropriate management for SCFE is to place the patient on crutches or in a wheelchair (strictly non-weight bearing) to prevent further slippage. This must be followed promptly by surgical stabilization, typically via single-screw percutaneous pinning in situ.

Step-by-Step Solution

1
Analyze the clinical presentation and physical exam findings.
The patient is an obese adolescent boy presenting with chronic progressive hip/knee pain, limited internal rotation, and obligatory external rotation upon hip flexion.
These demographic factors and pathognomonic physical exam signs point strongly toward Slipped Capital Femoral Epiphysis (SCFE).
2
Interpret the described radiographic findings.
Radiographs confirm widening of the physis and posterior-inferior displacement of the proximal femoral epiphysis.
Imaging definitively establishes the diagnosis of SCFE, ruling out other etiologies like Legg-Calvé-Perthes disease or osteosarcoma.
3
Determine the appropriate management strategy based on the diagnosis.
The patient must immediately cease weight-bearing activities and undergo surgical pinning in situ.
Continued weight bearing risks further catastrophic epiphyseal displacement. Prompt surgical stabilization is required to minimize the risk of osteoarthritis and avascular necrosis.

Key Concept

Slipped Capital Femoral Epiphysis (SCFE) presents in obese adolescents with hip/knee pain and obligatory external rotation upon hip flexion. It requires immediate non-weight bearing status and surgical stabilization (pinning in situ).
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Orthopedic Surgery

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