WIDI - P12) Worsening hip pain in a 12-year-old

P12) Worsening hip pain in a 12-year-old

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a pediatric patient with difficulty ambulating.
Review the DDx considerations in a pediatric patient with difficulty ambulating.
Identify the spectrum of imaging findings in appropriate modalities for evaluating a pediatric patient with difficulty ambulating.

History

A 12-year-old male presents with one-week history of aching, non-radiating, dull right hip pain that has progressively worsened over the last two months. He has difficulty bearing weight on his right lower extremity. He has a history of hypothyroidism and severe obesity. The patient denies any history of trauma or recent infection.

Physical Exam

BP: 120/60, HR 95, RR 19, Temp 37C, O2 saturation 99%. General: Average stature. MSK: Antalgic gait. Tenderness to palpation on right hip. Range of motion limited secondary to pain.

Labs

CBC and TSH wnl.

Provisional Diagnosis

Select the Dx you believe is most appropriate

Slipped Capital Femoral Epiphysis (SCFE)

Legg-Calves-Perthes (LCP) disease

Septic Arthritis

Transient Synovitis

Developmental Dysplasia of the hip (DDH)

This 12-year-old patient with a history of obesity and hypothyroidism with pain and difficulty bearing weight on the right hip is most likely presenting with SCFE. While LCP is also high in the differential, it is more common children aged 4-10. DDH is commonly diagnosed in infants. Septic arthritis would likely present with fever. Transient synovitis is less likely considering there was no preceding viral infection.

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

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While the patient’s condition is not immediately life threatening, they require further workup.

First Imaging Study

What is the first imaging study you will order?

AP Pelvis XR

Frog Leg XR

CT Abdomen & Pelvis w/o IV Con

Both A and B

AP and lateral frog leg X-ray provide views of the hip joint and the femoral head, neck, and epiphysis which are sufficient for diagnosis of SCFE. A frog leg lateral X-ray is most sensitive to the diagnosis.

View ACR Appropriateness Criteria

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Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

AP and frog-leg Pelvis XR

What best describes the findings on the AP and frog-leg Pelvis XRs? (check all that apply)

Widening of the physeal line

Irregularity of physeal line

Posterior displacement of capital epiphysis

All of the above

Compared to the left hip, there is widening and blurring of the right physeal line. The capital epiphysis is also posteriorly displaced.

View Report

Watch our video

View the full study if you'd like to take a look yourself.

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Second Imaging Study

What is the next imaging study you will order?

CT Abdomen/Pelvis

Bone Biopsy

CT Angiography

None

No further imaging is needed as the diagnosis is confirmed with X-rays.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

LCP disease

Septic Arthritis

Transient Synovitis

SCFE

DDH

This patient’s clinical presentation and imaging findings are consistent with SCFE.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Though the patient’s condition is not immediately life-threatening, they require expedited care.

Assessment and Plan

Please provide your assessment and plan for this patient

This patient is a 12-year-old male presenting with SCFE. Orthopedic surgery will be consulted for evaluation of internal fixation with pinning of the femoral head. He will need to avoid weight bearing before stabilization. Other possible underling endocrine abnormalities should be evaluated and addressed.

Lessons Learned:
- SCFE is more likely to occur in males than females
- SCFE is more likely to occur in obese children with endocrine abnormalities such as hypothyroidism, pituitary tumors, and low testosterone.
- The diagnosis should be suspected in children 10-16.
- The first best diagnostic modality is an AP Pelvic XR and Frog Leg Lateral XR. The epiphysis will look like a scoop of ice cream that has fallen off its cone.

Socioeconomic Factors: Time to diagnosis and slip angles are positively correlated, and patients without insurance have a higher mean slip angles than patients with insurance.

That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.

Contributors:
Jacob Surges, MS3 - Content Contributor
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator