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Updated: 2/26/2022

Slipped Capital Femoral Epiphysis (SCFE)

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  • summary
    • Slipped Capital Femoral Epiphysis, is a common condition of the proximal femoral physis that leads to slippage of the metaphysis relative to the epiphysis, and is most commonly seen in adolescent obese males.
    • Diagnosis can be confirmed with radiographs of the hip. 
    • Treatment is usually percutaneous pin fixation. Contralateral pinning is indicated for patients at high risk such as those with an initial slip at age < 10, obese males, and those with endocrine disorders.
  • Epidemiology
    • Incidence
      • most common disorder affecting adolescent hips
      • found in 10 per 100,000
    • Demographics
      • more common in
        • obese children
        • males 
          • male to female ratio is 2:1.4
        • specific ethnicities including African Americans, Pacific islanders, Latinos
        • periods of rapid growth 
          • 10-16 years of age
      • average age range is
        • 12-13.4 for boys
        • 11.2-12.2 for girls
        • occurs when going through puberty
    • Anatomic location
      • left hip is a more common location
      • can be bilateral in 17% to 50% (average of 25%)
    • Risk factors
      • obesity
        • single greatest risk factor
        • recent data shows a trend towards younger age and increased frequency of bilaterality at presentation
          • may be related to increased rates of childhood obesity
      • acetabular retroversion and femoral retroversion
        • secondary to increased mechanical shearing forces at the physis
      • history of previous radiation therapy to the femoral head region
  • Etiology
    • Pathophysiology
      • mechanism
      • occurs due to axial and rotational mechanical forces which act on a susceptible physis
        • direction of slip/angulation
          • metaphysis translates anterior and externally rotates
          • epiphysis remains in the acetabulum and lies posterior/inferior to the translated metaphysis
      • pathoanatomy
        • slippage occurs though the hypertrophic zone of the physis
          • histology sections reveal granulation tissue between the columns in the hypertrophic zone
          • cartilage in the hypertrophic zone acts as a weak spot
        • increased risk in adolescence because:
          • the perichondrial ring thins and weakens
          • undulating mammillary processes in physis unlocks, further destabilizing the physis
          • physis is still vertical in this age group (160° at birth to 125° at skeletal maturity), which results in increased shearing forces
          • the epiphyseal tubercle can provide a rotational pivot point
            • this represents an anatomic structure in the posterior superior epiphysis that shrinks with skeletal maturity
        • similar to Salter-Harris type I fracture, but may differ based on
          • antecedent epiphysiolysis
          • slower displacement
          • periosteum remains intact (chronic SCFE)
            • in acute SCFE, periosteum can be partially torn anteriorly over the prominent metaphysis
    • Associated conditions
      • endocrine disorders
        • associated conditions
          • hypothyroidism
            • most common etiology of nonidiopathic SCFE
            • labs: elevated TSH
          • renal osteodystrophy
            • labs: elevated BUN and creatinine
          • growth hormone deficiency
          • panhypopituitarism
        • endocrine workup indicated if
          • child is < 10 years old
          • weight is < 50th percentile
      • Down syndrome
  • ANATOMY
    • Osteology
      • normal proximal femur neck shaft-angle is 130 +/- 7°
      • normal proximal femur anteversion is 10 +/- 7°
      • proximal femur consists of tensile and compressive trabecular groups
      • proximal femoral physis is where pathology occurs with slip of epiphysis and metaphysis
    • Muscles
      • hip abductors
        • if injured during surgical hip dislocation or if greater trochanteric osteotomy doesn't heal, this can lead to abductor lurch and Trendelenburg gait
    • Ligaments
      • iliofemoral, ischiofemoral and pubofemoral ligaments attach to outer hip capsule and help to prevent excessive hip motion
    • Blood supply
      • a confluence of arteries which forms an extracapsular arterial ring that divides into the ascending cervical arteries which supply the femoral neck and head via perforators
        • main blood supply in adolescents and adults is the medial femoral circumflex artery which is derived from the lateral epiphyseal artery
        • lateral femoral circumflex contributes to anterior arterial ring
        • superior and inferior gluteal arteries also give small contributions to arterial ring
        • artery of ligamentum teres comes from obturator or medial femoral circumflex
          • plays a relatively insignificant role in blood supply
      • initial slip as well as iatrogenic causes are thought to increase the risk of damage to blood supply
        • unstable SCFE at greater risk for blood supply injury
    • Biomechanics
      • in double-leg stance, the force vector through hip is vertical and in single-leg stance it is parallel to the neck and head
        • axial/rotational forces through physis place stress on weak hypertrophic zone in population at risk
  • Classification
    • Loder classification
      • Loder Classification
      • Based on ability to bear weight
      • Stable
      • Able to bear weight with or without crutches
      • Minimal risk of osteonecrosis (<10%)
      • Unstable
      • Unable to ambulate (not even with crutches)
      • High risk of osteonecrosis (originally ~47%, recent data ~24%)
    • Temporal classification
      • Temporal Classification
      •  Based on duration of symptoms; rarely used; no prognostic information
      • Acute
      • Symptoms that persist for less than 3 weeks
      • Chronic
      • Symptoms that persist for more than 3 weeks
      • Acute on Chronic
      • Acute exacerbation of long-standing symptoms
    • Southwick Slip Angle Classification
      • epiphyseal-diaphyseal angle can be measured on both AP and frog lateral pelvis radiographs
      • slip angle classification is based on the degree of difference between the affected and unaffected hip
      • if bilateral hips are involved, use 145° as "unaffected" hip reference for AP and 10° as "unaffected" hip reference for lateral
      • Southwick Slip Angle Classification
      • Based on femoral epiphyseal-diaphyseal angle difference
      • Mild
      • < 30°
      • Moderate
      • 30-50°
      • Severe
      • > 50°
    • Grading system
      • Grading System 
      • Based on percentage of slippage
      • Grade I
      • 0-33% of slippage
      • Grade II
      • 34-50% of slippage
      • Grade III
      • >50% of slippage
  • Presentation
    • History
      • most commonly atraumatic, although some present after an injury
      • pain has often been present for several months
    • Symptoms
      • pain in hip (52%), groin (14%) and thigh (35%) 
        • pain is most common presenting symptom
      • knee pain
        • 15-50% present with knee pain
          • due to pain activation of the medial obturator nerve
          • can lead to missed diagnosis
      • patients prefer to sit in a chair with affected leg crossed over the other
      • duration
        • symptoms are usually present for weeks to several months before diagnosis is made
          • 88% of patients that presented with an unstable SCFE had unappreciated antecedent symptoms for ~42 days prior to diagnosis
    • Physical exam
      • inspection
        • abnormal gait / limp
          • antalgic, waddling, externally rotated gait or Trendelenburg gait
        • abnormal leg alignment
        • externally rotated foot progression angle
        • motion
          • obligatory external rotation during passive flexion of hip (Drehmann sign)
            • due to a combination of synovitis and impingement of the displaced anterior-lateral femoral metaphysis on the acetabular rim
          • loss of hip internal rotation, abduction, and flexion
      • neurovascular
        • weakness and thigh atrophy
        • no true neurovascular compromise usually seen
  • Imaging
    • Radiographs
      • recommended views
        • AP & frog-leg lateral of both hips
          • lateral radiograph is best way to identify a subtle slip
            • if slip is unstable, cross-table lateral should be performed instead of frog-leg
      • findings  
        • Klein's line
          • line drawn along superior border femoral neck on AP pelvis
            • will intersect less of the femoral head or not at all in a child with SCFE
              • intersects lateral femoral head in a normal hip due to natural lateral overhang of the epiphysis
          • evaluate for asymmetry between sides
        • "S" sign
          • line drawn along inferior cortical outline of femur in frog-leg lateral view 
          • normally extends from proximal femur head/neck junction to the proximal femoral physis but in SCFE there will be a sharp turn or break in continuity of this line
        • epiphysiolysis (growth plate widening or lucency)
          • an early radiographic finding
        • blurring of proximal femoral metaphysis 
          • known as the metaphyseal blanch sign of Steel
          • seen on AP due to overlapping of the metaphysis and posteriorly displaced epiphysis
    • MRI
      • indications
        • may help diagnose a preslip condition when radiographs are negative
      • findings
        • growth plate widening
        • edema in metaphysis
          • decreased signal on T1, increased signal on T2
  • STUDIES
    • Labs 
      • if patient is <10 years old, pre-pubertal or has short stature or weight below 50th percentile for age.
      • consist of:
        • TSH
        • free T4
        • BUN
        • serum creatinine
  • DIFFERENTIAL
    • Septic arthritis/transient synovitis
    • Osteomyelitis
    • Legg-Calve-Perthes disease
    • Developmental dysplasia of hip (DDH)
    • Traumatic injuries
      • adductor strain, AIIS avulsion, pelvic/femur fractures
  • Treatment
    • Operative
      • percutaneous in situ fixation
        • technique
          • one vs. two cannulated screws is controversial
            • 2 screw constructs have greater biomechanically stable than the single screw constructs
            • benefit of 2 screws needs to be considered in the face of greater screw related complications including articular surface penetration
          • capsulotomy is also controversial
            • goal is to decrease intra-capsular pressure
            • primarily indicated in the setting of unstable SCFE
              • intracapsular pressure in unstable SCFE is double that of control hips, while pressure in stable SCFE is roughly equal to control hips
            • may mitigate intracapsular tamponade, though there is no clear evidence that this reduces AVN rates
        • outcomes
          • good or excellent outcomes in >90% of cases
          • important to understand that fixation does not treat deformity at head/neck junction
            • has lead to popularization of other techniques that correct deformity to mitigate long-term risk of chondral damage
      • contralateral hip prophylactic fixation
          • controversial
          • current indications are patients at high risk of contralateral slip
            • initial slip at young age (< 10 years-old)
            • those with open triradiate cartilage
            • obese males
            • endocrine disorders (e.g. hypothyroidism)
      • open epiphyseal reduction and fixation
        • indications (controversial)
          • unstable and severe slips
        • technique
          • capital realignment via the Modified Dunn procedure
            • thought to allow acute deformity correction while maintaining blood supply
        • outcomes
          • there is a steep learning curve 
          • AVN rates of ~26% (compared to 24% for unstable SCFE treated by in situ screw fixation)
          • overall complication rate is 37%
    • Operative management of symptoms after initial in situ fixation
      • osteochondroplasty
        • indications
          • symptomatic femoroacetabular impingement (FAI) of cam lesion from metaphyseal bump
          • mild to moderate SCFE deformity (slip angle < 30°)
        • techniques
          • arthroscopy
          • limited anterior arthrotomy
          • surgical hip dislocation
        • outcomes
          • no long term data, but appears to show improvements in pain/function
          • low rates of osteonecrosis
          • poor outcomes in cases with pre-existing cartilage damage
      • proximal femoral osteotomy
        • indications
          • painful or function-limiting proximal femoral deformity
          • severe SCFE deformity (slip angle >30- 45°)
          • absence of severe hip osteoarthritis and osteonecrosis
        • technique
          • femoral neck cuneiform osteotomy
            • can provide greatest correction of deformity
            • use is controversial due to high rates of AVN (37%) and osteoarthritis (37%)
          • intertrochanteric (Imhauser) osteotomy
            • most commonly used
          • subtrochanteric (Southwick) osteotomy
        • outcomes
          • good to excellent functional results
          • 2-7% risk of AVN
          • Useful in preventing hip arthrosis long-term
  • Techniques
    • Percutaneous in situ fixation
      • goal
        • to stabilize the epiphysis from further slippage
      • approach
        • percutaneous wire insertion to anterior/lateral thigh using radiographic localization
      • technique
        • reduction
          • a forceful reduction is not indicated and increases risk of osteonecrosis
          • "serendipitous reduction" may be obtained with positioning on OR table
        • number of screws
          • a single cannulated screw typically sufficient and decreases risk of osteonecrosis (compared to multiple screws)
          • some surgeons may add second screw for unstable SCFE
        • screw insertion
          • perpendicular to physis
            • screw starts on the anterior surface of the proximal femur in order to cross perpendicular to the physis and enter into the central portion of the femoral head on both the AP and lateral views
            • starting point should not be medial to intertrochanteric line - will result in impingement between the head of the screw and acetabulum with hip flexion
          • oblique to physis
            • in severe slips, a relatively oblique insertion starting at the intertrochanteric region may be required, rather than perpendicular, to avoid impingement from head of the screw
        • screw position
          • advance until 5 threads cross physis
            • < 5 threads engaged in epiphysis increases risk of progression of slip >10° 
              • in one study, those with <5 threads across the epiphysis progressed 41% of the time compared to 0% of those with >= 5 threads into the epiphysis
          • screws should be ~ 5mm from subchondral bone in all views
        • imaging
          • confirm that pin is not penetrating the hip joint
            • there is a higher risk with screw placement in anterior/superior quadrant of femoral head 
          • approach-withdraw technique
            • rotate hip from maximal internal rotation or maximal external rotation under live fluoroscopy
            • the screw tip should appear to approach the subchondral bone, then withdraw from it
            • the moment of change from approach to withdraw is the true position of the screw and can be used to insert the screw to appropriate position
              • appropriate position confirmed when screw does not violate articular surface in all views
        • postoperatively
          • stable slips are able to bear weight after fixation
          • unstable slips are typically kept touch-down weight bearing
      • complications
        • osteonecrosis of femoral head
        • residual deformity & limb length discrepancy
        • chondrolysis 
          • higher risk if pin placed into anterosuperior femoral head as screw can penetrate the joint here
    • Surgical hip dislocation, open capital realignment and fixation (Modified Dunn procedure)
      • goal
        • to correct the acute proximal femoral deformity and stabilize the epiphysis while protecting the femoral head blood supply 
      • technique
        • surgical hip dislocation using the Ganz technique
          • lateral decubitus position
          • straight lateral skin incision centered over greater trochanter
          • interval: gluteus maximus (inferior gluteal n.) / gluteus medius (superior gluteal n.)
          • trochanteric flip osteotomy
          • Z-shaped anterior capsulotomy
            • visualize slip with prominent metaphysis
          • temporarily pin epiphysis with K-wires prior to dislocation
          • bone hook placed around femoral neck for traction
          • ligamentum teres cut
          • hip is dislocated
        • develop retinacular soft tissue flaps
          • incise periosteum along femoral neck
          • extend incision distally to level of lesser trochanter, to reduce tension on retinacular vessels
          • bluntly develop periosteal flaps anteriorly and posteriorly using periosteal elevator
        • mobilize epiphysis
          • starting anterior, use chisel to free epiphysis entirely from metaphysis
          • epiphysis will remain attached to posterior retinacular flap (blood supply)
        • debride metaphysis
          • there will be prominent reactive callus along the posterior metaphysis, which needs to be removed to permit proper epiphyseal reduction and avoid kinking of retinacular vessels
        • reduce epiphysis to metaphysis
        • fixation
          • 2-3 3.0mm K-wires 
            • one antegrade starting from fovea across epiphysis
            • one to two retrograde across epiphysis
          • 1 or 2 screws may also be used (6.5mm - 7.3mm)
          • greater trochanter osteotomy must be re-fixed
        • postoperatively
          • touch-down weight bearing for 6 weeks
      • complications
        • osteonecrosis of femoral head 
          • theoretically higher risk of disrupting blood supply with this approach
    • Osteochondroplasty
      • goal
        • to address pain and loss of motion related to hip impingement from prominent metaphyseal bump in mild to moderate chronic SCFE deformity
      • technique
        • arthroscopy
          • reserved for mild SCFE deformity
          • remove metaphyseal bump with arthroscopic burr
            • difficult to fully resect superior and lateral portions of the bump
        • limited anterior arthrotomy
          • useful when metaphyseal bump cannot be fully removed arthroscopically
          • performed using modified Smith-Peterson approach
        • surgical hip dislocation
          • moderate SCFE deformity
          • trochanteric flip osteotomy performed
          • hip is dislocated anteriorly
          • curved osteotome used to remove bump
          • burr is used to recreate normal contour of head-neck junction
    • Flexion intertrochanteric (Imhauser) femoral osteotomy
      • goal
        • to correct symptomatic proximal femoral deformity in moderate to severe chronic SCFE deformity
      • technique
        • lateral approach
          • supine position
          • straight lateral skin incision from greater trochanter distal down the femoral shaft
          • reflect vastus lateralis to expose lateral femur
        • transverse osteotomy just proximal to lesser trochanter
        • correction
          • flexion through the osteotomy
          • internal rotation of distal shaft
          • mild valgus correction
        • postoperative
          • touch-down weight bearing for 3 months
      • complications
        • osteonecrosis
        • arthritis
  • Complications
    • Osteonecrosis of femoral head
      • incidence
        • low in stable slips, 24-47% in unstable slips
          • unstable slip is greatest predictor 
      • risk factors
        • initial trauma
        • operative complication (4-6%)
          • hardware placement in posterosuperior femoral neck has the greatest risk of disrupting the vascular supply
      • treatment
        • symptomatic management, core decompression, arthroplasty
    • Contralateral hip SCFE
      • incidence
        • 20-80% after unilateral hip fixation
        • most common complication after unilateral surgical fixation
      • risk factors 
        • male, obesity, young age of initial slip (< 10 years old, open triradiate cartilage), endocrine disorders
      • treatment/prevention
        • surgical fixation of contralateral hip as needed
        • weight loss programs
          • decreased BMI reduces rates of subsequent contralateral SCFE
    • Chondrolysis 
      • incidence
        • 0-2%
        • seen with narrowed joint space, pain, and decreased motion
      • risk factors
        • unrecognized implant penetration of the articular surface occurring in 0-2% of cases
          • pin placement into the anterosuperior quadrant of the femoral head has the highest rate of joint penetration
          • intra-articular hardware penetration best assessed by CT scan
            • decreased prevalence with the use of modern fluoroscopy
        • spica cast immobilization
    • Residual proximal femoral deformity & limb length discrepancy
      • risk factors
        • increased α-angle associated with symptomatic impingement
          • caused by failure of proximal femur to remodel
            • can lead to a pistol-grip deformity
      • treatment
        • intertrochanteric osteotomy (Imhauser)
          • produces flexion, internal rotation and valgus
        • subtrochanteric osteotomy (Southwick)
        • femoral neck cuneiform osteotomy (controversial due to high rate of osteonecrosis and arthritis)
    • Slip progression
      • incidence
        •  1-2% of cases following single screw fixation
    • Delayed diagnosis
    • Infection 
      • incidence
        • 0-2%
    • Chronic pain
      • incidence
        • 5-10%
    • Degenerative arthritis
    • Labral tearing and degeneration
      • risk factors
        • seen with high anterior and medial 2nd screw in-situ fixation
          • if screw lies medial to intertrochanteric line on AP radiograph, has increased risk of impingement on acetabulum and labrum with hip flexion

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(OBQ15.70) A 13-year-old overweight patient presents to the emergency department with left knee pain and is lying in bed with his hip slightly flexed. 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?

QID: 5755
1

Internal rotation

9%

(200/2225)

2

External rotation

84%

(1863/2225)

3

Extension

1%

(14/2225)

4

Abduction

3%

(68/2225)

5

Adduction

2%

(55/2225)

L 2 B

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(OBQ13.215) A 12-year-old male previously presented with 4 days of left groin pain and inability to bear weight. Radiographs taken preoperatively, 1 week and 8 months postoperatively are seen in Figures A through C. What complication has occurred?

QID: 4850
FIGURES:
1

Hardware migration

1%

(38/3335)

2

Secondary loss of fixation

3%

(93/3335)

3

Slip progression

5%

(152/3335)

4

Avascular necrosis

84%

(2806/3335)

5

Chondrolysis

6%

(195/3335)

L 1 B

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(OBQ12.240) A 12-year-old mildly overweight female presents with complaints of left hip pain. She is not dependent on crutches for ambulation. Physical examination reveals external rotation of the extremity with hip flexion. Her parents indicate that outside radiographs were interpreted to be normal. They present an MRI of the pelvis, as shown in Figures A and B. What is next best step in management?

QID: 4600
FIGURES:
1

Observation

1%

(50/3479)

2

Arthroscopic labral repair

0%

(12/3479)

3

In situ screw fixation

90%

(3137/3479)

4

Closed reduction and percutaneous pinning

7%

(245/3479)

5

Debridement of CAM impingement femoral lesion

0%

(15/3479)

L 1 B

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(OBQ12.259) A 13-year-old male presents with left hip pain and an inability to ambulate. He does not have a history of kidney disease. The initial radiograph is shown in Figure A. Which of the following zones of the growth plate (Figures B-F, all the same magnification) is most commonly involved in this condition?

QID: 4619
FIGURES:
1

Figure B

2%

(97/4552)

2

Figure C

16%

(713/4552)

3

Figure D

66%

(3005/4552)

4

Figure E

13%

(579/4552)

5

Figure F

2%

(104/4552)

L 1 B

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(OBQ11.127) A 12-year-old girl presents with groin pain six months after treatment of a slipped capital femoral epiphysis. Preoperative radiographs are seen in Figure A, radiographs six months after in situ fixation are seen in Figure B. Which of the following is associated with the radiographic abnormality seen in Figure B?

QID: 3550
FIGURES:
1

Lack of reduction prior to fixation

10%

(241/2487)

2

Single screw fixation

9%

(214/2487)

3

Female sex

2%

(57/2487)

4

Inability to bear weight preoperatively

72%

(1796/2487)

5

Obesity

7%

(167/2487)

L 2 C

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(OBQ11.81) An 11-year-old obese male presents with a slipped capital femoral epiphysis. Which of the following figures accurately represents the method used to determine the radiographic severity of the epiphyseal slip and help guide treatment?

QID: 3504
FIGURES:
1

Figure A

82%

(3511/4269)

2

Figure B

14%

(619/4269)

3

Figure C

1%

(53/4269)

4

Figure D

1%

(27/4269)

5

Figure E

1%

(34/4269)

L 1 C

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(OBQ10.66) A 13-year-old boy complains of a 3-month history of left knee, thigh and groin pain. His pain has significantly worsened over the past week. He denies pain in the right leg. Radiographs are taken and shown in Figures A and B. The history and physical do not reveal any findings concerning for an endocrine disorder. What is the preferred method of treatment?

QID: 3153
FIGURES:
1

Subtrochanteric valgus, extension, and external rotational osteotomy

1%

(23/3023)

2

Non weight bearing on the left side for 6 weeks.

1%

(43/3023)

3

Bilateral in situ single screw insertion across the proximal femoral physis

9%

(258/3023)

4

In situ single screw insertion across the left proximal femoral physis only

88%

(2656/3023)

5

Varus derotational osteotomy of the proximal femur

1%

(29/3023)

L 1 A

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(OBQ07.75) A 10-year-old female with right hip pain presents with the radiographs in Figure A. She has a past medical history of hypothyroidism. She undergoes in-situ screw fixation of her right hip with no intra-operative complications. Which of the following problems is most likely to occur in this scenario?

QID: 736
FIGURES:
1

Chondrolysis

2%

(49/2936)

2

Ostenecrosis

6%

(184/2936)

3

Septic hip

0%

(5/2936)

4

Ipsilateral knee pain

2%

(50/2936)

5

SCFE on contralateral hip

90%

(2636/2936)

L 1 A

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(SAE07PE.86) Figures 39a and 39b show the current radiographs of an 8-year-old girl who has had pain in the left thigh for the past 3 months. She was recently diagnosed with hypothyroidism and started treatment 1 week ago. Examination reveals a mild abductor deficiency limp on the left side. She lacks 30 degrees internal rotation on the left hip compared with the right hip. Management should consist of

QID: 6146
FIGURES:
1

abductor muscle strengthening.

1%

(4/493)

2

a left 1-½ hip spica cast.

1%

(4/493)

3

closed reduction and pinning of the left hip.

16%

(81/493)

4

symptomatic treatment with crutch walking and nonsteroidal anti-inflammatory drugs.

1%

(6/493)

5

in situ pinning of both hips.

81%

(397/493)

L 3 D

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(SAE07PE.45) A 12-year-old boy reports limping and chronic knee pain that is now inhibiting his ability to participate in sports. Clinical examination and radiographs of the knee are normal. Additional evaluation should include

QID: 6105
1

mechanical alignment radiographs.

2%

(8/441)

2

stress radiographs of the knee.

2%

(9/441)

3

comparison radiographs of both knees.

2%

(8/441)

4

an erythrocyte sedimentation rate and a C-reactive protein.

2%

(9/441)

5

examination of the hip.

91%

(403/441)

L 1 D

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(SAE07PE.27) Of the following clinical situations, which is most likely to lead to osteonecrosis associated with a slipped capital femoral epiphysis (SCFE)?

QID: 6087
1

A girl younger than age 15 years

0%

(0/408)

2

A boy younger than age 15 years

0%

(2/408)

3

An unstable SCFE

95%

(387/408)

4

A stable SCFE

0%

(1/408)

5

A stable SCFE associated with morbid obesity

4%

(16/408)

L 1 D

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(OBQ07.187) Which of the following treatment techniques decreases the risk of osteonecrosis in patients with unstable slipped femoral capital epiphysis (SCFE)?

QID: 848
1

Open reduction and pinning with multiple cannulated screws in an inverted triangle configuration

5%

(61/1170)

2

Closed reduction and pinning with multiple cannulated screws in an inverted triangle configuration

4%

(51/1170)

3

Closed reduction and pinning with a single cannulated screw

8%

(94/1170)

4

In situ percutaneous pinning with multiple cannulated screws in an inverted triangle configuration

9%

(106/1170)

5

In situ percutaneous pinning with a single cannulated screw

73%

(849/1170)

L 2 B

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(OBQ07.2) Southwick angle (epiphyseal-shaft angle) serves what purpose in the evaluation of a slipped capital femoral epiphysis (SCFE)?

QID: 663
1

Determine prognosis for AVN

5%

(108/2119)

2

Determine the severity of the slip

87%

(1838/2119)

3

Determine the presence or absence of a slip

7%

(146/2119)

4

Determine the etiology of a slip

0%

(8/2119)

5

Determine the chronicity of the slip

0%

(8/2119)

L 1 D

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(OBQ06.183) Hypothyroidism is most commonly associated with which of the following pediatric conditions?

QID: 369
1

Legg Calve Perthes

3%

(55/1789)

2

Slipped capital femoral epiphysis

88%

(1572/1789)

3

Toxic synovitis

1%

(10/1789)

4

Achondroplasia

3%

(59/1789)

5

Rickets

4%

(79/1789)

L 2 B

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(OBQ05.60) An 11-year-old girl with hypothyroidism and obesity presents with groin pain and the inability to ambulate. Her radiograph is shown in Figure A. What is the most appropriate treatment?

QID: 946
FIGURES:
1

Toe-touch weightbearing for 3 weeks

0%

(4/1762)

2

Hip spica cast and non-weight bearing for 4 weeks

1%

(11/1762)

3

In situ pinning of the right hip

15%

(273/1762)

4

Open reduction and pinning of the right hip

3%

(51/1762)

5

In situ pinning of both hips

80%

(1410/1762)

L 1 A

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(OBQ05.125) A 13-year-old Polynesian boy presents with left groin pain and inability to place weight on the left leg. His radiographs are shown in Figures A and B. All of the following are true regarding this condition EXCEPT:

QID: 1011
FIGURES:
1

The left hip is more commonly involved

21%

(301/1459)

2

Forceful manipulation is not indicated because it is associated with an increased risk of complications

3%

(50/1459)

3

Associated with decreased femoral anteversion and decreased femoral neck-shaft angle

23%

(334/1459)

4

Pain is localized to the knee more often than the hip on initial presentation

48%

(703/1459)

5

Males are more commonly affected than females

4%

(65/1459)

L 2 B

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(OBQ05.162) A 14-year-old boy presents with left groin and knee pain for 3 weeks. He is now unable to place weight on the left lower extremity, even with the assistance of crutches. AP pelvis radiograph is shown in Figure A. He is treated with surgical intervention and post-operative radiographs are shown in Figures B and C. What is the most common limb length and rotational profile found as a sequelae of this condition?

QID: 1048
FIGURES:
1

Limb shortening, decreased hip flexion and decreased hip internal rotation

80%

(1187/1475)

2

Limb lengthening, increased hip flexion, and increased hip internal rotation

1%

(15/1475)

3

Limb lengthening, decreased hip flexion, and decreased hip external rotation

2%

(35/1475)

4

Limb shortening, decreased hip flexion, and increased hip internal rotation

7%

(108/1475)

5

Limb shortening, increased hip flexion, and decreased hip internal rotation

8%

(123/1475)

L 2 C

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(SBQ04PE.46) Figure A is the radiograph of a 10-year-old girl who sustained a left hip injury while playing soccer. She reports the inability to bear weight on the left lower extremity. Figures B and C are the 1-week and 8-week postoperative radiographs, respectively. Which of the following is considered a risk factor for developing the complication seen in Figure C?

QID: 2231
FIGURES:
1

Hardware placement in the posterosuperior femoral neck

49%

(832/1693)

2

Use of cannulated screws

14%

(237/1693)

3

Having <5 screw threads engaged in the epiphysis

28%

(479/1693)

4

Not attempting a forceful reduction maneuver

2%

(30/1693)

5

Performing a capsulotomy

6%

(103/1693)

L 4 D

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(OBQ04.67) A 14-year-old female presents with a history of an undiagnosed left slipped capital femoral epiphysis 3 years ago. She has 2 years of activity-related left hip pain and pain with prolonged sitting. On physical examination she has restricted hip flexion motion, an external rotation deformity, and obligatory external rotation upon hip flexion manuevering. Radiographs are shown in Figures A and B. Which of the following osteotomies is MOST appropriate?

QID: 1172
FIGURES:
1

Medial displacement Chiari salvage osteotomy

1%

(10/1206)

2

Proximal femoral varus osteotomy

4%

(54/1206)

3

Flexion, internal rotation, and valgus-producing proximal femoral osteotomy (Imhauser osteotomy)

70%

(848/1206)

4

Bernese periacetabular osteotomy with extension, external rotation, and valgus-producing femoral osteotomy

7%

(81/1206)

5

Valgus-producing intertrochanteric proximal femoral osteotomy (Pauwel osteotomy)

17%

(204/1206)

L 2 D

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(OBQ04.83) A right hip of an 8-year-old patient is modeled in Figure A. Which of the following vessels gives the greatest blood supply to the femoral head?

QID: 1188
FIGURES:
1

1

1%

(20/1420)

2

2

1%

(8/1420)

3

3

83%

(1179/1420)

4

4

11%

(159/1420)

5

5

3%

(44/1420)

L 1 C

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(OBQ04.165) A 14-year-old overweight boy complains of vague left knee pain which worsens with activity. He has an antalgic gait and increased external rotation of his foot progression angle compared to the contralateral side. Knee radiographs, including stress views, are negative. What is the next step in management?

QID: 1270
1

Knee MRI

2%

(26/1341)

2

Knee CT

0%

(6/1341)

3

AP pelvis and frog-lateral views

95%

(1279/1341)

4

Diagnostic knee arthroscopy

0%

(5/1341)

5

Hip MRI

1%

(10/1341)

L 1 B

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VIDEOS & PODCASTS (15)
CASES (3)
EXPERT COMMENTS (107)
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