Working Diagnosis:
Slipped Capital Femoral Epiphysis (SCFE)

Treatment:
The knee pain was initially thought to be a patellar tendon strain, which was treated with a knee immobilizer, crutches and physical therapy. Upon re-evaluation, there was concern for a Salter-Harris 1 fracture of the proximal tibia, which was treated with a knee immobilizer, weight bearing as tolerated, Tylenol and physical therapy. The patient then presented with difficulty walking and sitting with pain in the left hip, prompting imaging of the hip that showed the slipped capital femoral epiphysis. She underwent an emergent in situ fixation of the left hip and prophylactic fixation of the right hip.

Outcome:
She was initially ambulatory with crutches with progressive weight bearing. She continued physical therapy for months and was ultimately cleared for return to sport.

Author's Comments:
Fractures can be missed when they present atypically. In this case, the patient was found to have both a Salter-Harris type 1 injury of the proximal tibia and a slipped capital femoral epiphysis (SCFE). Salter-Harris fractures involve the growth plate, which can limit vertical growth or cause limb length discrepancy in the future (4). In the proximal tibia, injury to the popliteal artery can cause vascular compromise or compartment syndrome (2). There are different categories of Salter-Harris injuries. Salter-Harris 1 injuries occur across a growth plate and are diagnosed clinically though radiographs which can show a widened growth plate(1). Further imaging including magnetic resonance imaging (MRI) or computed tomography (CT) can also help confirm the diagnosis. Salter-Harris 1 injuries are treated non-surgically with closed reduction, immobilization and load management (3).
She was then diagnosed with SCFE where the proximal femoral epiphysis is displaced posteriorly to the metaphysis. She would be described as having an unstable SCFE because she could not ambulate with or without assistance (5). Unstable SCFE injuries require surgical intervention. As her pain did not present in the hip and the hip was not initially imaged, the condition almost went undiagnosed. SCFE can present with Drehmann's sign, which is when the patient tries to abduct or externally rotate the hip when it is flexed (6).

In conclusion, it is important to perform bilateral radiographs and look above and below the area of interest in children who undergo trauma to the extremities due to the high possibility of severe sequelae of a fractured growth plate to reduce the incidence of anchoring bias or patient related limitations in missed diagnoses (7). Another takeaway is the importance of reading radiographic imaging for oneself and not relying on a formal read for diagnostic purposes to avoid radiographic error as a cause of any missed diagnoses as delayed diagnosis and care can lead to complications and worse outcomes (4).

Editor's Comments:
This case describes a pediatric patient presenting with knee pain of several weeks duration that worsens after a fall. As the author states, it is always important to investigate the joints above and below the presenting joint. This is particularly true in pediatric patients presenting with knee pain as hip injuries (including SCFE) can present as knee pain. Prompt diagnosis of SCFE is important to prevent complications including an unstable injury that will require surgical fixation.

References:
Cepela, D. J., Tartaglione, J. P., Dooley, T. P., Patel, P. N. (2016). Classifications In Brief: Salter-Harris Classification of Pediatric Physeal Fractures. Clinical orthopaedics and related research, 474(11), 2531–2537. https://doi.org/10.1007/s11999-016-4891-3

David, V. K., Prakash, A., Mittal, S. (2021). Salter-Harris Type 2 Injury of the Proximal Tibial Epiphysis in a 15-year-old Athlete: A Rare Case Report. Journal of orthopaedic case reports, 11(11), 95–98. https://doi.org/10.13107/jocr.2021.v11.i11.2532

Duffy, S., Gelfer, Y., Trompeter, A., Clarke, A., Monsell, F. (2021). The clinical features, management options and complications of paediatric femoral fractures. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie, 31(5), 883–892. https://doi.org/10.1007/s00590-021-02933-1

Levine, R. H., Thomas, A., Nezwek, T. A., Waseem, M. (2023). Salter-Harris Fracture. In StatPearls. StatPearls Publishing.

Obana, K. K., Siddiqui, A. A., Broom, A. M., Barrett, K., Andras, L. M., Millis, M. B., Goldstein, R. Y. (2020). Slipped Capital Femoral Epiphysis in Children without Obesity. The Journal of pediatrics, 218, 192–197.e1. https://doi.org/10.1016/j.jpeds.2019.11.037

Otani, T., Kawaguchi, Y., Marumo, K. (2018). Diagnosis and treatment of slipped capital femoral epiphysis: Recent trends to note. Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association, 23(2), 220–228. https://doi.org/10.1016/j.jos.2017.12.009

Singh, A., Mahajan, P., Ruffin, J., Galwankar, S., Kirkland, C. (2021). Approach to Suspected Physeal Fractures in the Emergency Department. Journal of emergencies, trauma, and shock, 14(4), 222–226. https://doi.org/10.4103/JETS.JETS_40_21

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