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X-Ray Rounds
Cass Djurfors
Feb 20, 2003
10 y.o. boy with leg pain
• Obese 10-year old male presents with a
two week history of right thigh and knee
pain.
• He states that the pain is mainly in his
thigh (points to his upper thigh) but
radiates down to his knee.
10 y.o. boy with leg pain
• He was playing basketball when he
collided with another player and fell. He
noted severe pain in his thigh and had
to limp home, mostly on his left leg.
• The pain is worse with weight-bearing
and much better when lying in bed.
• No history of fever, rash, chest
discomfort, or pains in other joints.
On Exam…
• Vitals:
–
–
–
–
–
–
T37.0 (oral)
P66
R20
BP 112/65
weight 69.3 kg (>>95th percentile)
height 152 cm (>95th percentile)
• Alert, cooperative, in no distress
• Head and neck, CVS, Respiratory and
Abdominal exam all normal
On Exam…
• Right lower extremity:
– Moderate tenderness in the upper anterior thigh
– Severely tender in the hip, ROM not done
– Pubic symphysis, mid thigh, knee, tibia/fibula all
non tender
– No joint swelling
– ROM knee normal
• Left lower extremity:
– Non-tender, normal exam
And the answer is…SCFE!
• Hip radiographs show a slipped capital
femoral epiphysis on the right
• Left hip appears normal (but difficult to
rule out an early slip)
SCFE
• The radiographic diagnosis of slipped capital
femoral epiphysis (SCFE) can be subtle
• In this case, the physis appears to be wider
and more lucent in the patient's right hip
compared to his left
• The position of the femoral head epiphysis
should resemble a cap over the physis
• Subtle cases may just show a slight
malpositioning of the epiphysis
•Klein line: a line drawn along the superior border of the proximal femoral
metaphysis should intersect part of the proximal femoral epiphysis
•In this patient, right hip shows the line just touching the lateral margin of
the epiphysis… this is abnormal and indicates that the femoral capital
epiphysis has slipped inferiorly and medially
•The patient's normal left hip shows the line intersecting the lateral part
of the femoral epiphysis
Management
• Patient is hospitalized and put on
bedrest
• He is taken to the operating room for
internal fixation of his right capital
femoral epiphysis.
Much more obvious:
• Severe left slipped capital femoral
epiphysis
• The slipped capital femoral epiphysis on
the right is not as obvious
• This patient has bilateral SCFE, severe
on the left, and moderate on the right
SCFE
• Presents with acute, subacute, or
chronic pain in the hip, thigh, or knee
• Ambulatory ability may range from nonweight bearing to a normal gait
• Most comfortable with hip externally
rotated
• Unable to fully internally rotate affected
hip
SCFE
•
•
•
•
Occurs during adolescent growth spurt
Most frequent in obese children
40-80% are bilateral
Classification emphasizes epiphyseal stability
– Stable=ambulation possible
– Unstable=ambulation impossible…do not attempt
passive ROM on exam for fear of further slip
– Mild/Mod/Severe: 1/3, ½, >1/2
• 90% are stable: good prognosis if diagnosed
early
• Unstable SCFE has a much poorer prognosis
due to high risk of avascular necrosis
Diagnosis
• SCFE can be detected radiographically in
most instances
• AP views show only inferior and medial slips
• Early slips tend to be posterior…best seen on
lateral x-ray
• CT scanning can be helpful, but is not usually
needed in the emergency department
• Obvious cases are hard to miss
Diagnosis
• Subtle cases:
– Widened or irregular epiphyseal plate (compare to
opposite side)
– The physis may alternatively appear thinner than
the normal side (esp with posterior slips)
– A line drawn along the superior border of the
metaphysis (the Klein line) will intersect less of the
epiphysis compared to the normal side
– The “blanch sign of Steel” (AP view): crescentshaped area of increased density represents
superimposition of the posteriorly displaced
epiphysis on the femoral neck
Treatment
• Ensure child is non weight-bearing
• Orthopedic referral
• Most are fixed with a single central
screw
Lateral view showing an early slipped capital
femoral epiphysis. Note the subtle posterior step-off
of the epiphysis on the metaphysis at the physeal
level (arrow).
Klein's line, the line along the superior aspect of the femoral
neck. (Left) In the normal hip, the superior border of the
epiphysis projects superiorly to Klein's line. (Right) In a hip
with an early slipped capital femoral epiphysis, the superior
border of the epiphysis lies on Klein's line. In more
advanced cases, the epiphysis projects inferiorly to it. Note
the metaphyseal blanch sign of Steel (arrow).