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

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


Physical Exam


Provisional Diagnosis

Select the Dx you believe is most appropriate
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.
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Potential Acuity

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

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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 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.
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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.

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Second Imaging Study

What is the next imaging study you will order?

No further imaging is needed as the diagnosis is confirmed with X-rays.
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What is your Diagnosis now that you have seen the imaging results?

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?

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.

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