Adolescent Male With Left Leg Pain

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• Diagnosis
• References
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[Ann Emerg Med. 2008;52:e1.]

A 15-year-old boy was brought in by his mother for left leg pain. The child was running hard the day before and now refused to walk. Medical history was significant for autism and incontinence. Vital signs were normal. Physical examination showed a thin, nonverbal boy lying in the gurney, with his left hip flexed and externally rotated. The patient screamed when touched anywhere in the leg.

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Diagnosis 

Slipped capital femoral epiphysis. The classic “ice cream falling off the cone” sign is due to the epiphysis slipping off of the femoral neck. The diagnosis is clear on the frog-leg view but is not apparent on the anterior-posterior view (Figure 1, Figure 2).

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• Figure 1. 

  Anterior-posterior view of the left hip.

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• Figure 2. 

  Frog leg view of the left hip. Used with permission by University Physicians Hospital at Kino Hospital, Tucson, AZ.

Risk factors for slipped capital femoral epiphysis include obesity, male sex, renal failure, radiation therapy, endocrine abnormalities, and genetic disorders.¹, ² Up to 25% cases are missed, especially when the proper radiographs are not obtained or are misread. Up to 40% of slipped capital femoral epiphysis occurs bilaterally, either at presentation or within 18 months of initial diagnosis.² Early detection is crucial for avoiding the complications of osteonecrosis and chondrolysis. This case was complicated by the lack of medical history and the difficulty of examining a nonverbal child.

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References 

1. Kienstra AJ, Macias CG. Slipped capital femoral epiphysis. UpToDate. Version 16.1: January 31, 2008 http://uptodate.comAccessed September 26, 2008
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2. Loder RT. Slipped capital femoral epiphysis. Am Fam Physician. 1998;57:2135–2142
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