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      Causes of Delayed Diagnosis of Slipped Capital Femoral Epiphysis: The Importance of the Frog Lateral Pelvis Projection

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          Abstract

          Delayed diagnosis and treatment is a universally reported problem that impairs the prognosis of slipped capital femoral epiphysis (SCFE). Quite frequently, a delayed diagnosis of SCFE is observed in spite of serial admissions and examinations of the limping adolescent. Why do health professionals globally fail to make a definitive diagnosis of SCFE during the first examination of the patient? A retrospective study of 36 adolescents treated for stable SCFE and two adolescents treated for unstable SCFE has been performed. In more than half of the delayed diagnosed stable slips (13/25, 52%), the diagnosis was set after serial examinations of the patient. Health professionals commonly order only the anteroposterior (AP) X-ray view of the pelvis when examining a non-traumatic limping adolescent. The frog lateral (FL) projection is usually spared in an attempt to limit the radiation exposure of the patient, especially in ambulating adolescents with mild symptoms. It is proposed that in the non-traumatic limping adolescent, the FL projection instead of the AP pelvis view should be requested by the health professional in order to timely diagnose a surgical emergency of the adolescent hip such as SCFE.

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          Most cited references 30

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          Delay in diagnosis of slipped capital femoral epiphysis.

          Delay in diagnosis of slipped capital femoral epiphysis (SCFE) has important implications in terms of slip severity and long-term hip outcome. The purpose of this study was to identify predictors of delay in the diagnosis of SCFE. A review of 196 patients with SCFE was performed. The primary outcome measure was delay from onset of symptoms to diagnosis. Covariates included age, gender, side, weight, pain location, insurance status, family income, slip severity, and slip stability. Delay in diagnosis was not normal in distribution; therefore, nonparametric univariate and multivariate analyses were performed. The median delay in diagnosis was 8.0 weeks. There was a significant relationship between delay in diagnosis and slip severity ( 50 degrees : 20.6 weeks). There were no significant associations between delay in diagnosis and covariates of age, gender, side, and weight. There were significant associations between longer delay in diagnosis and covariates of knee/distal-thigh pain versus hip/proximal-thigh pain (6.0 vs 15.0 weeks), Medicaid coverage versus private insurance (12.0 vs 7.5 weeks), lower family income, and stable slips versus unstable slips (8.0 vs 6.5 weeks). Controlling for the other covariates, knee/distal-thigh pain, Medicaid insurance, and stable slips remained significant independent multivariate predictors of delay in diagnosis. Patients who present with primarily knee or distal-thigh pain, patients with Medicaid coverage, and patients with stable slips have longer delays in diagnosis of SCFE. Focused intervention programs to reduce the delay in diagnosis of SCFE should emphasize patients with knee/thigh pain and patients with Medicaid coverage.
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            THE TREATMENT OF ADOLESCENT SLIPPING OF THE UPPER FEMORAL EPIPHYSIS.

             Barnaby Dunn (1964)
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              Outcomes of slipped capital femoral epiphysis treated with in situ pinning.

              Previous long-term studies have shown good outcomes for most patients after in situ pinning of slipped capital femoral epiphyses (SCFE). However, concern is growing about the effects of leaving the epiphysis in a nonanatomic position. We undertook a retrospective study to carefully document patient-reported outcomes and need for additional surgery after in situ pinning of SCFE. Further, we sought to determine the risk factors for persistent pain and dysfunction after in situ pinning. Between 1965 and 2005, 146 patients (176 hips) with SCFE underwent in situ pinning at a tertiary referral center. Medical records and radiographs were reviewed for slip characteristics and need for subsequent surgery. Patient-reported outcome measures were collected by mailed survey. Mean follow-up was 16 years (range, 2 to 43 y). Twenty-one hips (12%) underwent reconstructive surgery for persistent symptoms, including femoral osteotomy (11), surgical hip dislocation (2), and total hip arthroplasty (8). Mild slips, as well as moderate and severe slips, were treated with reconstructive surgery, including total hip arthroplasty. Of the remaining hips, 33% were painful with a mean overall visual analog score of 2.4 (range, 0 to 10). Mean outcome scores were as follows: Harris Hip Score 90 (max. 100); Hip Dysfunction Osteoarthritis Outcome score 411 (max. 500); UCLA Activity Score 8 (max. 10); and Marx Activity Score 5 (max. 16). Reconstructive surgery was performed in 12% of hips. Patients with mild, moderate, and severe slips underwent arthroplasty for degenerative changes. Persistent mild pain was common in one third of patients treated with in situ pinning. Level IV, therapeutic study, case series.
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                Author and article information

                Journal
                Cureus
                Cureus
                2168-8184
                Cureus
                Cureus (Palo Alto (CA) )
                2168-8184
                18 April 2020
                April 2020
                : 12
                : 4
                Affiliations
                [1 ] First Orthopaedic Department, Children’s General Hospital Panagiotis & Aglaia Kyriakou, Athens, GRC
                [2 ] Orthopaedics, Orthopaedic Research and Education Center, Attikon University Hospital, Athens, GRC
                [3 ] Orthopaedics, Children’s General Hospital Panagiotis & Aglaia Kyriakou, Athens, GRC
                [4 ] Paediatric Orthopaedics, Orthopedic Clinic, Chania, GRC
                [5 ] Sports Medicine, Children's General Hospital Panagiotis & Aglaia Kyriakou, Athens, GRC
                [6 ] Orthopaedics, Katholisches Krankenhaus Dortmund-West - St. Lukas Klinikum, Düsseldorf, DEU
                Author notes
                Panagiotis V. Samelis samelis_takis@ 123456yahoo.com
                Article
                10.7759/cureus.7718
                7234041
                Copyright © 2020, Samelis et al.

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Categories
                Orthopedics

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