Average 4. Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine. Just skip this one for now. He is found on imaging to have a severe slipped capital femoral epiphysis. If his leg is not manipulated for imaging, in what abnormal position is his left hip most likely to appear on an anteroposterior pelvic radiograph?
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Slipped upper femoral epiphysis is more common in boys than girls and more common in Afro-Caribbeans than Caucasians. Obesity is a significant risk factor. During growth, there is a widening of the physeal plate which is particularly pronounced during a growth spurt. Also, the axis of the physis alters during growth and moves from being horizontal to being oblique.
As the physis becomes more oblique, shear forces across the growth plate increase and result in an increased risk of fracture and resultant slippage.
In all situations, especially when imaging children, the fewest number of radiographs, with the smallest exposed area is performed. Gonad protection is usually used in pelvic x-rays of children. In the pre-slip phase, there is a widening of the growth plate with irregularity and blurring of the physeal edges and demineralization of the metaphysis.
This is followed by the acute slip which is posteromedial. In a chronic slip, the physis becomes sclerotic and the metaphysis widens coxa magna. It is therefore is more easily seen on the frog-leg lateral view rather than the AP hip view. Because the epiphysis moves posteriorly, it appears smaller because of projectional factors.
On the AP, a line drawn up the lateral edge of the femoral neck line of Klein fails to intersect the epiphysis during the acute phase Trethowan sign. The metaphysis is displaced laterally and therefore may not overlap posterior lip of the acetabulum as it should normally loss of triangular sign of Capener 5.
The metaphyseal blanch sign , a sign seen on AP views, involves increases in the density of the proximal metaphysis. It represents the superposition of the femoral neck and the posteriorly displaced capital epiphysis. Alignment of the epiphysis with respect to the femoral metaphysis can be used to grade the degree of slippage: see SUFE grading.
Ultrasound may be performed in the assessment of hip pain. However, it should not be used as a replacement for a pelvic radiograph. Findings are nonspecific and may include hip joint effusion. In some cases, malalignment of the femoral epiphysis and metaphysis may be seen. Multi-plane reconstruction allows assessment of the relationship of the femoral head to the metaphysis in three planes. However, the dose required for the examination means that it should not be used unless absolutely necessary.
In the acute stage, marrow edema results in an increased signal on T2-weighted sequences, e. Marrow edema is non-specific, and while it may indicate early bone changes in SUFE, there are numerous other causes, e.
MRI can be used to examine the contralateral hip which is important because of the high incidence of bilateral slip. Treatment of unstable slipped upper femoral epiphysis has progressively shifted exclusively towards surgical pinning. Conservative management e. Treatment of the contralateral hip is more controversial. As such prophylactic pinning is recommended by some 3. If a significant deformity is present, then osteotomies and even joint replacement may be required.
When the slip is evident, and no secondary degenerative changes are present, then the diagnosis is usually readily made.
Ideally, however, the diagnosis is made early in which case the differential is that of a painful hip and includes:. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys.
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Slipped upper femoral epiphysis is more common in boys than girls and more common in Afro-Caribbeans than Caucasians. Obesity is a significant risk factor. During growth, there is a widening of the physeal plate which is particularly pronounced during a growth spurt. Also, the axis of the physis alters during growth and moves from being horizontal to being oblique. As the physis becomes more oblique, shear forces across the growth plate increase and result in an increased risk of fracture and resultant slippage. In all situations, especially when imaging children, the fewest number of radiographs, with the smallest exposed area is performed. Gonad protection is usually used in pelvic x-rays of children.
Slipped Capital Femoral Epiphysis (SCFE)
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