Question of the week # 298

298) A 6 year old boy presents to your office with a limp on the right side. He denies any falls or trauma. Mother reports that the limp has been present for several weeks. She reports that the patient was seen in the Emergency Room when the limp was first observed. X-rays obtained at that time were normal and so, he was discharged. There is no history of fever. He denies any pain. Family history is unremarkable. On examination, he is afebrile . His right lower extremity appears one inch shorter than the left. Upon standing and walking, his pelvis appears to be tilted towards the left. Which of the following is most likely to be abnormal in this condition?

A) External rotation of hip

B) Tibial tuberosity

C) X-ray of the Knee

D) Erythrocyte Sedimentation Rate

E) Internal rotation and abduction of hip

11 Responses

  1. D

  2. By the age, gender and physical exam, I will said pacient has….slipped capital femoral epiphysis…..

    Typically, a child with a stable slipped capital femoral epiphysis has a history of intermittent limp and pain of several weeks’ or months’ duration that is often poorly localized to the thigh, the groin or the knee. Hip pain is reported less frequently. Often, a vague history of antecedent trauma calls attention to the limp and pain. As the epiphysis continues to slip, the child loses hip motion, including internal rotation, flexion and abduction. Because of this loss of motion, the child and the parents often describe a progressive external rotation and shortening of the lower extremity. This description is often accompanied by complaints of increasing difficulty in sports or in the performance of certain daily tasks, such as tying shoes.

    Children with a minimal slipped capital femoral epiphysis experience only slight loss of internal rotation of the hip and have pain only at the extremes of motion. The gait is often antalgic; limb length discrepancy is not apparent, and muscle atrophy is minimal. As the slipped capital femoral epiphysis becomes more severe, the child’s gait becomes more antalgic, with obvious external rotation. Discrepancy in limb length and thigh atrophy become readily apparent. Over time, internal rotation decreases, and abduction and flexion of the hip increases, along with automatic external rotation of the lower extremity with flexion of the hip.

    Children with unstable slipped capital femoral epiphysis present with extreme pain, often after sports-related trauma or a fall with a twisting injury, such as from a curb. Most children have no prior history of symptoms.

    During the office examination, the child typically reclines on the examination table, unable to move, and refuses any passive motion of the limb by the physician. In fact, if a slipped capital femoral epiphysis is suspected, no passive motion should be attempted for fear of further displacing the epiphysis. The hip is typically held in a position of flexion, external rotation and abduction, similar to that seen in an elderly patient with a displaced hip fracture. Distal neurovascular examination is normal.

    Often, early in the course of a slipped capital femoral epiphysis, the anteroposterior radiograph is normal since the initial early slippage is posterior. Consequently, a lateral radiograph must always be obtained. The early sign seen on the lateral radiograph is a minimal posterior step-off at the anterior epiphyseal-metaphyseal junction, or physeal plate (Figure 1). On anteroposterior radiographs, subtle early signs include Klein’s line and the blanch sign of Steel.5 Klein’s line is a line drawn along the superior surface of the femoral neck. The epiphysis should normally project superiorly to it (Figure 2, left), whereas in early slipped capital femoral epiphysis, the epiphysis is flush with it (Figure 2, right). The blanch sign of Steel on the anteroposterior radiograph represents superimposition of the posteriorly displaced epiphysis on the femoral neck

  3. The answer is A

  4. E…antalgic gait suggests some progression of slipped capital femoral epiphysis. The signs are similar to fracture of femoral neck in that the child will have external rotation of the hip, whereas internal rotation and abduction will be limited/abnormal.

  5. aaa

  6. i think its Legg calve perthes disease ,because here the pt is a prepubertal boy………slipped capi.femo.epiphysis is common in adolescents …..and there will be a h/o reffered knee pain

  7. ans is E……..Dr Red pls help…we are stuck

    • Answer. E. In evaluation of child presenting with a limp, it is important to consider the duration, age at presentation, presence of pain, gait and physical examination findings. This child most likely has Legg –Calve perthes disease which charecterestically presents between ages 3 and 10 years. Most cases present between 5 and 7 years of age. It is idiopathic avascular necrosis of femur head that presents with limp on the affected side and may not always be associated with pain (painless limp). In the early stages, plain x-rays can be normal. On physical examination, Trendelenberg gait is observed and there is asymmetry in the length of the extremities. Internal rotation and abduction of the hip are limited and helps in diagnosis. Management includes non-weight bearing on the affected side and referral to orthopedic surgery.
      Differential diagnosis includes Slipped Capital Femoral epiphysis (SCFE), Transient synovitis, Developmental dysplasia of Hip (DDH). DDH can be excluded here because the typical age of presentation in DDH is at 2 years of age when the child first begins to walk.
      A is incorrect. External rotation is preserved. Internal rotation is limited in legg Calve Perthes Disease (LCP).
      D is incorrect. ESR can be increased in transient synovitis of the Hip. Transient synovitis is an important differential diagnosis. It usually presents between 3 and 8 years of age, peak incidence is at age 6. However, it is associated with pain and fever and the presentation is acute rather than chronic. The child in the question has had painless limp for several weeks and this excludes Acute Transient Synovitis.
      B. Tibial tuberosity is tender and appears prominent in Osgood Schattler disease which is a overuse syndrome that can present with knee pain and limp. There is no hip pain or trendelenberg gait in OSD.
      C. is incorrect. LCP involves neck of the femur. Plain x-rays of the hip may reveal widening of joint space and radiolucent zone in the subchondral area of anterolateral epiphysis ( Crescent Sign). X-rays of the knee are normal.

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