Working Diagnosis:
Slipped capital femoral epiphysis of the right hip, aka SCFE.

Treatment:
Once the diagnosis was confirmed, the patient was placed on crutches to remain non-weight bearing, and pediatric orthopedic surgery was consulted. The patient was admitted to the hospital and underwent percutaneous in situ fixation of the femoral head of the right hip without complication. While still debated, there is evidence to do prophylactic fixation of the contralateral side in high risk patients. This risk varies by age, skeletal maturity, and if there are underlying disorders. Given this patient's age and low Modified Oxford Score, prophylactic fixation of her contralateral hip was offered and the associated risks and benefits were discussed in detail with the family. The patient's family elected not to proceed with contralateral pinning and instead will closely monitor and return to care immediately if similar pain occurs on either leg.

Outcome:
Percutaneous in situ fixation of the patient's right hip was done without complication. Follow up radiographs at two and six weeks post op Case Photo #5 showed appropriate postoperative healing with no abnormalities compared to intra-operative imaging Case Photo #4 . All imaging demonstrated preservation of good alignment, an improved Klein line on the AP view, and minimal posterior slippage on the lateral view. The patient was slowly advanced back to weight bearing activities starting at 2 weeks post-op, and at 6 weeks post-op was cleared for a gradual return to all activity as tolerated. She is now back to both basketball and fast pitch softball without pain and without recurrence or contralateral slip Case Photo #6 .

Author's Comments:
This case is unique in several ways. First and likely the most notable is that this patient does not fit the typical population presenting with SCFE. Most commonly, SCFE's are seen in non-Caucasian (African American, Pacific Islander, and Latino) adolescent, obese males. Additionally, while the reason is unknown, in most studies unilateral SCFE's tend to occur more often on the left. This data contrasts completely with our patient who is a thin, young, Caucasian female with right sided pathology. An important takeaway from this case study is to take a careful history trust the exam; one should not limit the differential diagnosis when a patient does fit the "norm" for a specific condition.

Editor's Comments:
Slipped capital femoral epiphysis is the most common hip pathology in adolescents. Prevalence ranges from 0.71 to 10.8 per 100,000 children. Bilateral SCFE is found in 20-80% of cases, and most commonly the contralateral slip occurs within 1 year of the initial SCFE presentation. Age of onset ranges from 12.7 to 13.5 years in boys and 11.2 to 12 years in girls. Common presentation includes hip pain, particularly with weightbearing and exertion, limp, external rotation of the hip, and shortening of the affected leg. Some patients may present with knee pain rather than hip pain. Notably, the incidence of SCFE has been increasing in recent decades. Hence, it is critical to keep SCFE high on the differential diagnosis list when considering a patient with hip or knee pain.

References:
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