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Case 201

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10 year-old female patient attends to the pediatric consultation complaining about pain in the anterior region of the right thigh to move it. She reports sudden onset of the symptom combined with claudication 5 months ago. Physical examination: weight: 61kg (z-score: > +3); height: 1,58m (z-score: > +3); severe loss of internal rotation of the flexed hip. It was requested a frog-leg radiography of the pelvis.

According to the clinical data and exam, which is the most likely diagnosis?

a) Legg-Calvé-Perthes disease

25%

b) Developmental dysplasia of the hip

25%

c) Transient synovitis of the hip

25%

d) Proximal femoral epiphysiolysis

25%
   

Image analysis

Image 1: Simple pelvic radiography (AP) in frog-leg position, revealing parcial inferior slip of the right femoral head in the growth plate level (red dotted line). There are also bone resorption (yellow arrow) and thinning (green arrow) in the metaphysis.

 

Figure 1: Clinical finding of EFP. In supine, the hip is flexed, showing loss of internal rotation. The thigh then slips into external rotation and abduction (Netter Orthopedics).

 

Figure 2: Schematic of the normal joint (Trethowan Sign) and the joint with epiphysiolysis (http://www.hanciau.net).

 

 

Image 2: AP pelvis radiography showing bilateral fixation in situ with cannulated screw in the event of light slip. Taken from: SPINELLI, Leandro de Freitas et al. Treatment of severe proximal femoral osteotomy subtrochanteric epiphysiolysis with the Ilizarov method. 

Figure 3: Schematic of the osteotomy for the treatment of EFP with moderate or severe slip (http://cirurgiadoquadril.org).

Highlights 

- The proximal femoral epiphysiolysis is the most common hip disease in adolescence and is characterized by sliding of the femoral head over the neck.
- Its etiology is elusive, but associated with obesity, hormonal disorders and orientation of the growth plate.
- There is bilateralism in approximately 20% of the cases.
- The main symptom is pain in the proximal thigh enhanced by exercise.
- The diagnosis is based on clinical examination (loss of internal rotation of the flexed hip) associated with hip radiography in AP and frog-leg position.
- In the radiography, it is observed epiphysiolistesis, absence of Trethowan Sign, rarefactions and metastatic resorption.
- The treatment is surgical and the main one is the fixation in situ with a cannulated screw.

References

- Greene WB, editor. Netter Ortopedia. 1 ed. Rio de Janeiro: Elsevier; 2006.

- Barros Filho TEP, Camargo OP, Camanho GL, editores. Clínica Ortopédica. Barueri: Manole; 2012.

- Spinelli LF, Faccioni S, Kim JH, Calieron LG, Rojas JCM. Tratamento da epifisiólise proximal femoral grave com osteotomia subtrocantérica pelo método de Ilizarov. Rev. bras. ortop.  [Internet]. 2010  [Access on July 2015] ; 45(1): 33-39.

- Mello GC, Grossi G, Coelho SP. Proximal femoral epiphysiolysis and subclinical hypothyroidism: case report. Rev. bras. ortop.  [Internet]. 2012  Out [Access on July 2015] ;  47(5): 662-664.

Author

Luísa Bernardino Valério, 4th year medical student at UFMG.

E-mail: luisabernardino[at]gmail.com

Supervisor

Auro Perdigão Sérgio de Brito, resident physician in Orthopedics at the Hospital das Clínicas da UFMG.
E-mail: aurosergio[at]hotmail.com

Reviewers

Fabio M. Satake, Júlia Petrocchi, Raíra Cezar, Professor Viviane Parisotto e Professor José Nelson Vieira.

Translated by

Luísa Bernardino Valério, 4th year medical student at UFMG.

E-mail: luisabernardino[at]gmail.com

 

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