Age / Sex : 10 / F

Chief complaint: Left hip pain for several days after exercise

What is your impression?

Two weeks later, you can see the final diagnosis with a brief discussion of this case.

(답안은 한 개만 보내주시기 바랍니다)

Courtesy: 하동호 (Dong Ho Ha), 동아대학교 의료원(DongA university Hospital)

slipped femoral capital epiphysis

Discussion

Findings:

Anterior-posterior pelvis radiography

Lack of intersection of a line (Klein’s line) drawn along the superior border of the left femoral neck with the epiphysis

MR

Bone marrow edema along the physis

Sclerotic change of growth plate

Mild slippage on axial images

Diagnosis: 

At 5 days follow up AP pelvis view, marked slippage of epiphysis is noted.

Slipped capital femoral epiphysis (SCFE)

Discussion:

 1) Slipped capital femoral epiphysis (SCFE)

SCFE is a childhood disorder of the hip characterized by posterior inferior displacement of proximal femoral epiphysis

An accurate diagnosis combined with immediate treatment is critical. Delayed treatment increased the complication such as avascular necrosis, chondrolysis, leg length discrepancy, and osteoarthritis.

Initial evaluation should include anteroposterior (AP) and lateral frog-leg view. These are the easiest images to obtain and provide an excellent screening examination.

Subtle changes early in the course are more difficult to detect using anteroposterior (AP) pelvis view. Since the major direction of the slip is usually posterior, it is often most easily noted on a lateral view. Lateral view remains the gold standard

Magnetic resonance imaging (MRI) can demonstrate early marrow edema, widened growth plate and slippage.

2) Klein line (a line along the superior edge of the neck of femur)

 The line should normally intersect the lateral part of the superior femoral epiphysis. If the line of klein fails to intersect the epiphysis, it is called Trethowan's sign.

If a difference of the width of epiphysis lateral to Klein’s line 2mm between both hips indicates a slip of epiphysis.

References:

Stoller DW, Sampson T, Bredella M. The hip. In stoller DW ed. Magnetic resonance imagings in orthopedics and sports medicine, 3rd ed. Philadelphia: Lippincott Williams and Wilkins, 2007:143-145

Green DW1, Mogekwu N, Scher DM, Handler S, Chalmers P, Widmann RF. A modification of Klein's Line to improve sensitivity of the anterior-posterior radiograph in slipped capital femoral epiphysis. J Pediatr Orthop. 2009 Jul-Aug;29(5):449-453.