Case 10: Eleven year old with limp
Wednesday, March 2nd, 2011An 11 year old girl attends the paediatric ED having fallen during a PE lesson at school. She is limping slightly on her left side but is still managing to play happily in your waiting room. Her mother tells you that she has in fact has noticed a slight limp over the last four months. She hasn’t sought medical review however, as it doesn’t appear to prevent her doing anything. She has no medical history of note.
1. What is the diagnosis?
Click to see the answerThis patient has bilateral Slipped Upper Femoral Epiphyses (SUFE). These patients present during puberty with atraumatic or very minimal trauma hip pain. The left hip is most commonly affected however bilateral involvement is seen in up to 40% of cases so close inspection must be given to the ‘normal hip’. Interestingly, the epiphysis actually remains in the correct position in the acetabulum anchored by the ligamentum teres and it is in fact the metaphysis that moves.
There are broadly four groups of patients: Pre slip, acute slip, acute on chronic and chronic. This girl has acute on chronic SUFE.
2. Name two causative factors
Click to see the answerThe commonly associated factors are:
• Habitus – Obesity (at least 50% of patients are >95th centile) is often quoted however the second most common factor is associated with tall thin boys!
• Endocrinpoathies – acromegaly and hypothyroidism
• Renal failure
• Radiotherapy
3. What is this X ray view called?
Click to see the answerThis is a frog’s leg view that accentuates the clarity of the slip. A routine AP pelvis may not show an early stage SUFE as clearly, and may delay diagnosis. Always order a FL view if you suspect SUFE.
4. Name three other paediatric hip problems that should be considered in any limping child?
Click to see the answerLimping child is a common ED and Exam presentation. The specific problems that must always be considered are septic arthritis, transient synovitis, Perthes, traumatic injury and SUFE.
Certain conditions are more common by age but all diagnoses must be considered and excluded.
5. What is the management of this girl acutely?
Click to see the answerGood analgesia is always paramount however the pain may not be unbearable and strong opiates may not always be needed first line. Take a good history and utilise paediatric pain scoring (Visual analogue scores etc) to ascertain if pain is mild moderate or severe and treat appropriately.
The treatment of SUFE is essentially surgical. Principles of treatment are stabilization of the slip to prevent progression, and promotion of closure of the upper femoral physis. The current treatment methods include Hip-spica cast immobilization and stabilization with single or multiple screws.