A 2-year-old Hispanic male with a 3-day history of nasal congestion presents with a barking cough and hoarseness. He is afebrile. The examination reveals tachypnea, inspiratory and expiratory stridor, noticeable intercostal retractions, and good color.
Which one of the following is indicated?
Correct Answer C:
This child has a history and physical findings typical of viral laryngotracheobronchitis, or croup. In rare instances, this illness can be complicated by critical upper airway obstruction. The symptoms of cough, respiratory stridor, and distress result from edema of the subglottic portion of the upper airway. Humidification of inspired air is sometimes beneficial, but the child should not be sent home until improvement is demonstrated. Because this child has stridor and intercostal retractions, aerosolized epinephrine is indicated, along with intramuscular dexamethasone, and hospitalization may be required for observation and continued treatment. Antibiotics do not have a role in the treatment of viral croup, and attempted visualization of the epiglottis is not indicated since it will increase the child’s anxiety and worsen the symptoms.
A very obese 12-year-old boy is brought in because he has developed a limp when he walks.
He also complains of some hip pain.
What is the most likely diagnosis?
Slipped capital femoral epiphysis (SCFE) usually occurs in early adolescence and preferentially affects boys. Obesity is a significant risk factor. Genetic factors also contribute. Exact cause is unknown but probably relates to weakening of the physis (growth plate), which can result from trauma, hormonal changes, inflammation, or increased shearing forces due to obesity.
Onset is usually insidious, and symptoms are associated with stage of slippage. The 1st symptom may be hip stiffness that abates with rest; it is followed by a limp, then hip pain that radiates down the anteromedial thigh to the knee. Up to 15% of patients present with knee or thigh pain, and the true problem (hip) may be missed until slippage worsens. Early hip examination may detect neither pain nor limitation of movement. In more advanced stages, findings may include pain during movement of the affected hip, with limited flexion, abduction, and medial rotation; knee pain without specific knee abnormalities; and a limp. The affected leg is externally rotated. If blood supply to the area is compromised, avascular necrosis and collapse of the epiphysis may occur.
Because treatment of advanced slippage is difficult, early diagnosis is vital. Anteroposterior and frog-leg lateral x-rays of both hips are taken. X-rays show widening of the epiphyseal line or apparent posterior and inferior displacement of the femoral head.
SCFE usually progresses; it requires surgery as soon as it is diagnosed. Patients should not bear weight on the affected leg until SCFE has been ruled out or treated. Surgical treatment consists of screw fixation through the epiphysis.
A 13-year-old obese child presents with painful right knee and right hip pain with difficulty walking and reduced abduction and internal rotation.
What is your diagnosis?
Correct Answer E:
Slipped capital femoral epiphysis (SCFE) usually occurs in early adolescence and preferentially affects boys. Obesity is a significant risk factor. Exact cause is unknown but probably relates to weakening of the physis (growth plate), which can result from trauma, hormonal changes, inflammation, or increased shearing forces due to obesity.
Onset is usually insidious, and symptoms are associated with stage of slippage. The 1st symptom may be hip stiffness that abates with rest; it is followed by a limp, then hip pain that radiates down the anteromedial thigh to the knee. Early hip examination may detect neither pain nor limitation of movement. In more advanced stages, findings may include pain during movement of the affected hip, with limited flexion, abduction, and medial rotation; knee pain without specific knee abnormalities; and a limp. The affected leg is externally rotated.
Because treatment of advanced slippage is difficult, early diagnosis is vital. Anteroposterior and frog-leg lateral x-rays of both hips are taken. X-rays show widening of the epiphyseal line or apparent posterior and inferior displacement of the femoral head. Ultrasonography and MRI are also useful, especially if x-rays are normal.
An overweight 13-year-old male presents with a 3-week history of right lower thigh pain. He first noticed the pain when jumping while playing basketball, but now it is present even when he is just walking. On examination he can bear his full weight without an obvious limp. There is no localized tenderness, and the patella tracks normally without subluxation. Internal rotation of the hip is limited on the right side compared to the left. Based on the examination alone, which one of the following is the most likely diagnosis?
This is a classic presentation for slipped capital femoral epiphysis (SCFE) in an adolescent male who has probably had a recent growth spurt. Pain with activity is the most common presenting symptom, as opposed to the nighttime pain that is typical of malignancy. Obese males are affected more often. The pain is typically in the anterior thigh, but in a high percentage of patients the pain may be referred to the knee, lower leg, or foot. Limited internal rotation of the hip, especially with the hip in 90° flexion, is a reliable and specific finding for SCFE and should be looked for in all adolescents with hip, thigh, or knee pain.
Meralgia paresthetica is pain in the thigh related to entrapment of the lateral femoral cutaneous nerve, often attributed to excessively tight clothing. Legg-Calvé-Perthes disease (avascular or aseptic necrosis of the femoral head) is more likely to occur between the ages of 4 and 8 years. Juvenile rheumatoid arthritis typically is associated with other constitutional symptoms including stiffness, fever, and pain in at least one other joint, with the pain not necessarily associated with activity.
A 13-year-old male presents with a 3-week history of left lower thigh and knee pain. There is no history of a specific injury, and his past medical history is negative. He has had no fevers, night sweats, or weight loss, and the pain does not awaken him at night. He tried out for the basketball team but had to quit because of the pain, which was worse when he tried to run.
Which one of the following physical examination findings would be pathognomonic for slipped capital femoral epiphysis?
Slipped capital femoral epiphysis (SCFE) typically occurs in young adolescents during the growth spurt. Physical activity, obesity, and male gender are predisposing factors for the development of this condition, in which the femoral head is displaced posteriorly through the growth plate. There is pain with physical activity, most commonly in the upper thigh anteriorly, but one-third of patients present with referred lower thigh or knee pain, which can make accurate and timely diagnosis more difficult. The hallmark of SCFE on examination is limited internal rotation of the hip. Specific to SCFE is the even greater limitation of internal rotation when the hip is flexed to 90°. No other pediatric condition has this physical finding, which makes the maneuver very useful in children with lower extremity pain. Orthopedic consultation is advised if SCFE is suspected. Hip extension and abduction are also limited in SCFE, but these findings are non-specific. The knee findings in this patient are not associated with SCFE.
The Drehmann sign is an important orthopedic clinical finding observed during hip examination. It is considered positive when passive hip flexion causes unavoidable external rotation and often abduction of the hip, with limited or painful internal rotation.
This sign reflects mechanical deformity of the proximal femur or femoro-acetabular relationship and is most classically associated with slipped capital femoral epiphysis (SCFE).
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