Question

Difficulty: MediumPediatric Musculoskeletal Disorders

During a health maintenance visit, a 1313-year-old adolescent male reports a 44-week history of a constant, dull ache in his left anterior thigh and knee. He has no history of recent trauma, fever, or prior medical conditions. His body mass index is 32 kg/m232 \text{ kg/m}^2. Vital signs are within normal limits, with a temperature of 36.8∘C36.8^\circ\text{C} (98.2∘F98.2^\circ\text{F}), heart rate of 78/min78/\text{min}, and blood pressure of 112/72 mm Hg112/72 \text{ mm Hg}. On physical examination, the left knee has no effusion, erythema, or joint line tenderness, and range of motion is full and painless. However, his gait is noticeably antalgic, and his left foot rests in an externally rotated position while standing. Passive internal rotation of the left hip is restricted and elicits pain. Laboratory evaluation reveals an erythrocyte sedimentation rate of 9 mm/h9 \text{ mm/h}, a C-reactive protein level of 0.4 mg/dL0.4 \text{ mg/dL}, and a leukocyte count of 7,100/mm37,100/\text{mm}^3. Which of the following is the most appropriate next step in management?

  1. Anteroposterior and frog-leg lateral radiographs of the bilateral hipsAnswer
  2. B
    Anteroposterior and lateral radiographs of the left knee
  3. C
    Magnetic resonance imaging of the left knee
  4. D
    Ultrasound-guided arthrocentesis of the left hip
  5. E
    Discharge with nonsteroidal anti-inflammatory drugs and instructions for rest

Answer

Anteroposterior and frog-leg lateral radiographs of the bilateral hips
The correct answer is bilateral hip radiography because the patient's clinical presentation is highly suspicious for Slipped Capital Femoral Epiphysis (SCFE). SCFE typically occurs in obese adolescents undergoing rapid growth. The displacement of the proximal femoral epiphysis leads to hip pain, an antalgic gait, and obligate external rotation of the hip. Crucially, up to 15%15\% of patients present solely with referred pain to the thigh or knee due to the shared innervation by the obturator nerve. A completely normal knee examination in the setting of thigh or knee pain should immediately prompt evaluation of the hip. Anteroposterior and frog-leg lateral radiographs of both hips are required to confirm the diagnosis, as posterior displacement may only be visible on the lateral view, and the condition is bilateral in 20%20\% to 40%40\% of cases.

Step-by-Step Solution

1
Analyze the patient's demographic and clinical risk factors.
The patient is a 1313-year-old obese male, which is the classic demographic for Slipped Capital Femoral Epiphysis (SCFE).
SCFE is most common in obese adolescents undergoing rapid growth spurts due to increased shear stress on the physis.
2
Evaluate the physical examination findings in the context of the reported symptoms.
The patient reports knee/thigh pain, but the knee exam is completely normal. Conversely, the hip shows restricted internal rotation and obligate external rotation.
Hip pathology frequently presents as referred pain to the anterior thigh or knee via the obturator nerve. A normal knee exam with an abnormal hip exam localizes the lesion to the hip.
3
Review the laboratory results to rule out competing diagnoses.
Normal ESR, CRP, WBC, and afebrile status.
Normal inflammatory markers reliably rule out infectious causes like septic arthritis or osteomyelitis, pointing toward a biomechanical issue.
4
Determine the most appropriate diagnostic modality.
Bilateral anteroposterior and frog-leg lateral hip radiographs are selected.
Both AP and lateral views are required because early SCFE slippage is often posterior and may only be visible on the lateral projection. Bilateral imaging is standard as the condition is bilateral in up to 40%40\% of patients.

Key Concept

Slipped Capital Femoral Epiphysis (SCFE) often presents with referred knee pain and requires bilateral hip radiographs (AP and frog-leg lateral views) for diagnosis.
Rate this question