INFORMATION FOR CANDIDATE Your next patient in general practice is a 12 year old girl, Samantha, who is brought in by her

father, John, because Samantha has complained about right knee pains over the last 3 months, although over the last few days, the pain worsened and she walks with a marked limp and also complains about pains in her right hip. She is a keen sports person, plays netball and cricket and is usually very active, although a bit overweight. There is no history of trauma. YOUR TASK IS TO: Take a further history Examine the patient Organise appropriate investigations Discuss the diagnosis and management with the father

HOPC: Samantha first complained about a painful knee about 3 months ago after a net ball competition in which she played a lot of games. She saw another GP who examined the knee but did not find much wrong and recommended resting it for a week and start graduated exercises as tolerated and Samantha improved a lot although she still complained occasionally about knee and right thigh pains which usually settled with a few days rest. Over the last few days she felt increasing pains also in her right hip and she started to walk with a limp and could not go for training. She never had a trauma. PHx,: Normal pregnancy and delivery, development and growth normal, although she has always been a bit overweight. FHx.: unremarkable SHx: one of three children, lives at home, doing well at school, no problems, immunisation up to date. EXAMINATION: GA-well looking, no rashes, mildly overweight (weight 90th percentile), normal vital signs. Samantha is able to walk with a limp on her right side. The right hip appears externally rotated and slightly shortened. There is generally decreased range of motion, particularly diminished internal rotation and abduction. All other joints and rest of physical examination normal. INVESTIGATIONS: X-ray hip: 1. Pelvis: Klein's lines are drawn on the superior border of the femoral neck in this patient with slipped capital femoral epiphysis of the right hip. Note that the femoral head is below Kline's line on the affected right side, whereas a significant portion of the femoral head is above the line on the unaffected left side.

2. Frog leg lateral of the affected hip

She was very happy with that. Asked how soon do I need to visit the orthopaedic? ASAP , because of avascular necrosis of the neck, explained it Reassured mum everything will be alright with good orthopaedics we have . Bell rang. DIAGNOSIS: SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE) SCFE is movement of the femoral neck upward and forward on the femoral epiphysis. It usually occurs in early adolescence and preferentially affects boys. Obesity is a significant risk factor. Genetic factors also contribute. SCFE is bilateral in 15 of patients, and unilateral SCFE becomes bilateral in up to 23 of patients. 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. Because treatment of advanced slippage is difficult, early diagnosis is vital. Anteroposterior and frog-leg lateral x-ray studies of both hips are taken. X-ray studies 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-ray studies are normal. SCFE represents a Salter-Harris type I through the proximal femoral physis. Stress around the hip causes a shear force to be applied at the growth plate. Certainly, trauma has a role in the manifestation of the fracture, but an intrinsic weakness in the physeal cartilage also is present. The almost exclusive incidence of SCFE during the adolescent growth spurt indicates a hormonal role. Complications: Osteonecrosis, chondrolysis from pin fixation, varus deformity, osteoarthritis. MANAGEMENT: 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. Urgent

orthopaedic referral and surgical treatment (reduction and screw fixation through the physis) prevent further slipping and chance of complications.