which is great to kind of see that. So case number three is a six-year-old Caucasian baseball player. He was limping while playing baseball, which is why his mom brought him in. He occasionally endorses some mild pain, especially after baseball, but doesn't really endorse any pain during baseball. He's able to play through the pain, which he's been doing, and it's been kind of going on for the last month or so. And then the pain has been progressive over the last month or two that he kind of endorses that he's had a little bit of pain. And he currently lives at home with his mom and two older brothers. There isn't a dad involved and he also has a younger sister. Mom does smoke, but she smokes outside the home. So he is obviously probably exposed to a little bit of secondhand smoke, which is important for this diagnosis. So this is what his x-rays looked like. And so this was it kind of initially, and then this is kind of the progression over several months. And so what you can see is this femoral head is very flattened and sort of looks like it's almost going away, particularly on that lateral column. We'll talk about why that's important. And then this is like several months later, about six months where he starts to continue to sort of have that lateral column collapse. And so what this is, is leg calf perthes. This is believed to sort of be an avascular necrosis and see that happens in childhood. We don't really know all the reasons of why it happens, but the peak incidence is really between four to eight. And males are much more affected than females at a ratio of five to one. Risk factors, which were kind of highlighted in the case that I gave you, are low socioeconomic status, Caucasian, and then passive smoke exposure. So this is one of the things that is much more common in kind of our Caucasian population. Typically, it's an insidious limp that they present with, and they're not really complaining of much pain. And on exam, they'll have some limited hip abduction and internal rotation. And that's really just because of that collapse of the lateral column. We don't really know, as I mentioned before, why it happens. We think it's from a disruption to the blood supply that just causes avascular necrosis. The stages of it are kind of defined, and they're important because we actually look at staging this as far as prognosis during the fragmentation stage. So this is sort of what it looks like in those stages. So the initial is kind of just the synovitis. So sometimes you'll have a little bit of widening in that hip space because of the effusion from the synovitis. And then you'll actually start to just kind of progress into getting a little bit of fragmentation, typically kind of around the nine month mark after diagnosis. And then re-ossification sort of starts around 32 months. And then by 10 years, it's healed. Obviously it doesn't look like a completely normal hip, but actually most of these kids, depending on sort of what stage they were in and what stage you define them as, which we'll talk about in a second, they actually do pretty well. And this is a fairly functional hip, which is great. And so this is kind of self-limiting. Occasionally there's some things going on or they're in a higher risk category where we'll intervene before that, or the orthopedic surgeon will. Most of the time they don't. So the two kind of classification systems are cateraul and then the lateral pillar classification. So cateraul is just the involvement of the femoral head. So classification, they're numbered one through four. So one, two, three, four. And it's basically just the amount of the femoral head that's involved. So if it's just the tip of the head here where it just collapses and it's flattened, that's cateraul one. And it's important to stage these during the fragmentation stage, because if you stage it before then, you oftentimes misclassify it. And that becomes problematic just when you're looking at outcome and how you counsel the family. And then basically it just progresses with increasing amounts of the femoral head that involves cateraul four, which is the entire femoral head collapses. And then the lateral pillar is also another classification system. This is where I was talking about. We look at that lateral pillar of how it collapses. And so there's just degrees of collapse with no collapse here to minimal, less than 50% of collapse, and then greater than 50% of collapse. And those are the three lateral pillar classifications. So the best prognosis is really a kid who gets diagnosed before age six. And that the extent of the involvement is lateral pillar A, which is basically where there is just femoral head. There's not really any lateral pillar collapse. And so that kind of is that cateraul stage one or two at best, where there's just that very tip and top of the femoral head that's involved. And then also looking at the duration of the disease process. And so the longer that those, the quicker those kids move through those stages, the better they usually, better outcome that they have. And then clinical range of motion. So the hallmark of this is really maintaining range of motion. And so our goals for treatment are to maintain the sphericity of the femoral head. And that we can do a lot by range of motion. So we really work with these kids in PT a lot. We try to keep them active. And so sometimes that just means modifying what we're doing activity wise. And then using NSAIDs to help with treatment. We do want to keep that hip contained within the acetabulum. Just like for the other diagnoses, once it comes out, we don't kind of form that acetabulum and have that nice matching acetabulum to the femoral head. So as you saw in that picture that I showed you at 10 years out, that kid had sort of formed his acetabulum to what his femoral head looked like. And that oftentimes will happen if we can keep the head contained. Most of these patients are managed conservatively, as I mentioned, and do fine. And then long-term prognosis just depends on what that deformity looks like in the end. And so the deformity often results if there's growth plate involvement. So if that femoral head collapses all the way down to the epiphysis, those kids tend to have sort of premature closure and they'll sort of form an abnormal head. Or the kids that really have lost that lateral column, it's hard for them when they're missing one side of that growth plate to kind of form it pretty evenly across to make that nice round femoral head. So the last group that I'm going to talk about today are the adolescents, which we see a lot of these. So obviously by far, most of the gait abnormalities you see in adolescents are antalgic from injury. But obviously the one I want to focus on today is really slipped capital femoral epiphysis because it does happen fairly commonly. And sometimes there is this injury that they elicit, but I think it's important to remember that it may not be injury-related. So my fourth case is a 13-year-old male. He comes in actually to clinic presenting with a three-month history of left knee pain. He is limping by the end of the day, but oftentimes starts the day without limping. He is active in football, flag football primarily. And then he doesn't miss any practices because he'll just plays through it and doesn't really endorse much pain while he's playing, but does have some afterwards. And then there's not really any history that he had of injury. He denies any night pain or fevers. And then on exam, he does limp, but he is able to run. He jumps, and then he doesn't have any tenderness about the knee. And so that's kind of the take-home point of this. We see many kids who come into clinic complaining of knee pain, and it's actually radiating from the hip. And so especially, there should always be, we talk about the joint above and below, but really, especially when you don't have any knee pain, you should really kind of focus on that hip exam and see if they have a normal hip exam. So this is the classic slipped capital femoral epiphysis kid, but they still play sports. We still see them, but cultural deconditioning is usually in their wheelhouse as well. And so it is the most common adolescent hip disorder. And classically, it's that overweight male. Many times when we don't have that classic presentation of the overweight male, we will do an endocrine workup in these kids to see if there's a reason why this happened, because we just don't typically expect it, but we do see it sometimes. And they'll complain of pain in the groin, hip, or the knee. The pain oftentimes doesn't start very bad. They're able to participate in activities through it. And then it progresses to the point where sometimes they get to the point where they can't walk, and that's not a good thing. And we'll talk about that. Many of these kids, just because of where the pain presents, oftentimes in the knee, or they have this injury that they did something funny and they think that's why it hurts. And everyone's like, oh, it's just gonna get better. And they don't X-ray it. We often have this missed or delay in diagnosis. The etiology of it still remains unknown. We think it's multifactorial from all these kind of areas. And then the age range for this is pretty narrow. For males, it's typically around 13 and a half years. It's right before that femoral head starts to close. And for females, it's a little bit early, at about 11 and a half years. And then we have started to see younger and younger kids. And we think that's also because kids are getting to skeletal maturity at younger ages. And this tends to happen right around that time of skeletal maturity. So here's an example of sort of what happens. This is what a normal hip looks like on the left-hand side of your screen. On the right-hand side, this one actually was missed initially by an outside radiologist. And then when they came in, we were like, oh no, that is already slipping. But many times these can be very subtle at the beginning. You'll just see some widening of that femoral growth plate. And what's great is you have two sides. And most of the time, SCIFI is not going to happen in both hips at the same time. Leg Calperthes does the same thing. It tends to be simultaneous instead of at the same time. And so this widening, you can always get the other hip and look at it and see, does it look more wide or does it look the same? And then it's also important just to be able to get a frog leg lateral as well as an AP, because sometimes you can't see this until you look at the frog leg lateral, but you miss it on the AP. Obviously, this is when it's starting to slip here and it has slipped. And then this has slipped as well here. And this was the same kid six weeks later. So this kid didn't initially have the diagnosis, was allowed to continue to participate in stuff. Six weeks later, he wasn't able to walk at all, was in severe pain and basically represented, or he'd been presented to our clinic. This is when we actually saw him. And of course, at that point, he had already slipped. The reason it's important to kind of catch these kids early, this is also where there's unstable. So that's already slipped. So unstable and stable SCIFI is an important differentiator. And unstable just means that they're not able to walk at that point. Stable means that they're able to still walk. We wanna catch these kids when they can still walk and it's stable. They have a much better prognosis long-term. So most of these kids basically get a big screw. We wanna catch them when they're still stable. They haven't slipped, they're walking. And we just basically pin them basically to not let it happen with a big screw. And so this is basically just what that sort of looks like over time. And so they'll continue to grow, develop, and do everything and it's fine. This is a 12-year-old female who presented with right knee pain to the outside. They referred her into ortho, but never x-rayed her hips. Three weeks later, she got into CS. And unfortunately, she had also gone from basically just having hip pain where there wasn't really much kind of going on to having some whitening and starting to slip there. And by the time she saw us in three weeks, she wasn't walking on this. So technically she was already unstable. And so this is basically what that looked like at that point when we did the frog leg lateral or this is actually her AP. So she had already slipped. And so three weeks before she hadn't slipped yet. She had some whitening. She had started to slip, but it was really subtle. And you can only see this on the frog leg lateral. So this is her AP. And so that's why it's important to get both of those views. And so we wanna identify these when they're stable to prevent that progression to slip. And then also just to minimize those risks of AVN and chondrolysis, which gives them the best long-term progression. There is a lot of debate on whether you should pin the contralateral hip. In our younger kids, which we consider kind of younger than 12, typically our orthopedic surgeons will pin the other side, particularly if they have that cultural deconditioning body habitus, we will pin the other side prophylactically. So just the key points with SCIFI, any child with knee pain, you wanna make sure that you examine the hip, particularly if you can't palpate any pain in the knee or re-elicit that pain in the knee. And then making sure you also check an AP and a frog leg lateral, and then looking for, particularly if they have a limited hip range of motion. You wanna make sure you read all of your X-rays. We have so many kids who come in where the radiologist on the outside read it as normal. The primary care physician or whoever saw them on the outside never looked at the X-rays themselves. And they come in to see us and we get their old imaging and you could see it on their old imaging. And it would have prevented them from being an unstable slip by the time they came into us. Also, any SCIFI is an urgent referral. This is where you need to call the orthopedic office. You need to send them to the ER. If you can't get ahold of somebody, these kids need to be made immediately non-weight bearing because if they are weight bearing at the time that you see them, we wanna keep them that way and not let that slip to the point that they're non-weight bearing or they're unable to weight bear and they become unstable.

2nd Edition, CASE 40

2nd Edition

Oncology

Legg-Calve-Perthes disease

avascular necrosis

pediatric orthopedics

hip treatment

physical therapy