Examkin

Soru

Zorluk: OrtaOrthopedic Surgery

An obese 13-year-old adolescent is brought to the clinic by his parents due to a four-week history of a right-sided limp and intermittent right knee pain. The pain is exacerbated by physical activity and relieved by rest. There is no history of trauma, fever, or weight loss. His body mass index is 33 kg/m233 \text{ kg/m}^2. Vital signs are within normal limits. On physical examination, there is no swelling, erythema, or localized tenderness over the right knee. Ligamentous testing of the knee is normal. However, when the patient's right hip is passively flexed, the thigh obligately deviates into external rotation. Internal rotation of the right hip is significantly limited compared to the left. Which of the following is the most appropriate next step in management?

  1. A
    Magnetic resonance imaging of the right knee
  2. B
    Reassurance, rest, and oral nonsteroidal anti-inflammatory drugs
  3. Anteroposterior and frog-leg lateral radiographs of both hipsCevap
  4. D
    Diagnostic aspiration of the right hip joint
  5. E
    Empiric administration of intravenous cefazolin

Cevap

Anteroposterior and frog-leg lateral radiographs of both hips are the most appropriate next step.
The correct step is obtaining bilateral anteroposterior and frog-leg lateral radiographs of the hips. This patient exhibits the hallmark signs of Slipped Capital Femoral Epiphysis (SCFE): an obese adolescent presenting with a limp, referred knee pain, limited internal hip rotation, and obligate external rotation when the hip is passively flexed. Radiographs are required to confirm the posterior and inferior slippage of the epiphysis before surgical pinning can be planned.

Adım Adım Çözüm

1
Analyze the patient's demographic and historical data.
The patient is an obese 13-year-old with subacute, atraumatic right knee pain and a limp.
Identifying the classic demographic (obese adolescent) narrows the differential diagnosis to specific pediatric orthopedic conditions like SCFE.
2
Interpret the physical examination findings.
The knee exam is entirely normal, but hip flexion causes obligate external rotation, and internal rotation is restricted.
Normal knee findings indicate that the knee pain is referred (often via the obturator nerve). The specific hip range-of-motion abnormalities localize the true pathology to the hip.
3
Determine the optimal diagnostic modality for the suspected condition.
The suspected condition is Slipped Capital Femoral Epiphysis (SCFE), which is best diagnosed initially with AP and frog-leg lateral radiographs of both hips.
Radiographs can definitively demonstrate the 'ice cream slipping off a cone' appearance typical of SCFE. Bilateral imaging is preferred because SCFE often presents bilaterally.

Anahtar Kavram

Slipped Capital Femoral Epiphysis (SCFE) frequently presents with referred knee pain in obese adolescents. It is characterized by obligate external rotation upon passive hip flexion and is diagnosed via bilateral hip radiographs.
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