SCFE (Iliotibial band syndrome, Legg-Calvé-Perthes, AVN)

• Slipped capital femoral epiphysis (SCFE) results from failure of the upper femoral epiphysis, which allows displacement of the femoral head on the femoral neck.

• The majority of patients who have SCFE are 7 to 15 years of age and are above the 95th percentile for weight. The increased weight adds to the stress on the hip and the mechanical failure of the growth plate.

• Inflammation of the hip and posterior-inferior slipping of the femoral head lead to loss of medial hip rotation. 

Presentation

• Onset may be sudden, but more often it is gradual.
• Pain frequently is referred to the knee, but it also can occur in the hip.
• Limp and out-toeing, as reported for the boy in the vignette, are common.
• "painful limp" (vs painless limp in Legg-Calves-Perthe)

Exam

• limp
• femur/hip
  • limitation of medial rotation
  • pain on passive motion
  • obligate external rotation of hip
  • flexion at hip

X-rays

• An anterior-posterior or frog-leg lateral radiograph of the hip generally reveals the abnormality (get BOTH views); frog-leg lateral x-ray is most sensitive for picking up early slip; AP view may show irregularity and widening of growth plate
• “ice cream cone” sign best seen on frog leg view
• may be associated with endocrine (e.g., hypothyroidism) or systemic disorders (e.g., rickets)

Treatment

• Emergency!!! To Ortho in wheelchair!!
• includes pinning of epiphysis to prevent further slip; possible osteotomies in future.

DDx

Osteomyelitis often presents with fever and localized pain and should be considered in any child who has a limp. It usually is associated with an elevated erythrocyte sedimentation rate.

A cruciate ligament tear generally results from significant trauma and is characterized by severe pain and an obvious knee effusion.

Avascular necrosis (AVN) of the femoral head

Iliotibial band syndrome

• is a common injury among runners because of the repetitive nature of their running activity.
• It involves inflammation of the iliotibial band from rubbing over the lateral femoral condyle, sometimes causing a snapping sensation during flexion or extension.
• The iliotibial band itself is a thickened strip of fascia that extends from the tubercle of the iliac crest and provides the insertion for the tensor fascia lata and gluteus maximus muscles. The iliotibial band continues down the lateral side of the leg, and in conjunction with the patellar retinaculum ultimately attaches onto the lateral tubercle of the tibia ( Gerdy's tubercle ) and lateral proximal fibular head. A bursa located at this attachment facilitates movement of the iliotibial band over the lateral epicondyle. The iliotibial band's primary function is to provide static stability to the lateral aspect of the knee. When the knee is flexed to an angle greater than 30 degrees, the iliotibial band shifts posteriorly behind the lateral femoral epicondyle. During knee extension, the band shifts anteriorly in front of the lateral femoral epicondyle. It is this motion that commonly leads to irritation and inflammation within the iliotibial band, bursa, and the periosteum of the lateral femoral epicondyle
• It is not uncommon then to have an absence of pain with stiff-legged walking by the athlete suffering from ITBFS. Logically this type of gait would remove the problematic friction that the sliding ITB causes.
• As described by Southmayd and Hoffman (15) ITBFS usually starts with minor discomfort, and becomes progressively worse. Sometimes it begins after a single run. "I felt particularly good, so I ran an extra three miles, and the pain developed after the run" is a common scenario. The pain is located almost always on the outer aspect of the knee
• Most sufferers of ITBFS cannot put their finger on one particular tender spot. They will usually use the flat of their hand to describe the location of the pain
• Structural anatomical abnormalities also put the athlete at risk. By carefully inspecting the areas around the affected site we should be able to identify an ITB problem.
  • Some structural abnormalities identified during inspection can be leg length discrepancy. The effects are a lateral pelvic tilt which results in a tightening of the ITB on the lower leg and thus causing a higher chance for irritation.
  • Another inspectable abnormality might be excessive pronation or Cavus feet. An inspection of the patients footwear might clue us on to this. Pronation of the foot causes the tibia to rotate internally and in consequence, tightens the ITB.
  • Thirdly, we should notice a genu varum condition, an increase in the angle of the femur and the tibia (valgus 170 to 175 degrees). This also results in a tightened ITB across the knee joint.
• A condition known as osteonecrosis, having a prominent lateral femoral condyle has been associated with ITBFS. Once structural abnormalities have been introduced we must remember to also make an observation regarding swelling and/or discoloration.
• Careful palpation of the affected area is the next step in the evaluation process. A patient with ITBFS will exhibit extreme point tenderness about two cm. over the joint line when the knee is flexed at thirty degrees and palpated over the lateral femoral epicondyle. Active flexion and extension of the knee may produce what can be said to be a "creaking" sound. During palpation, care must be taken to rule out other knee pathologies. One of the key points about ITBFS is that it is a problem not inside the knee joint, but around it. In this way, it can be easily distinguished from internal knee-joint problems such as a torn cartilage or ligament or loose body ( a joint mouse )
• The first phase of care is the Immediate Phase. This is the phase in which pain and inflammation are to be controlled, requiring a reduction of activity and the appropriate administration of oral anti-inflammatories. Numerous modalities may be implemented at this point if deemed advantageous by the trainer. Such appropriate treatments may include; ice, heat, ultrasound, and/or electrical stimulation. It must also be noted that stretching exercises are also used here to combat any excessive ITB tightness.
• Phase two, or the Short Term Phase, becomes a consideration if painful symptoms do not resolve within  approximately 10 days of the documented onset. Previous treatment should be continued at this point with the possible addition of physician administered steroid injections (given in 2-week intervals) and further restriction of activity may be a necessity.
• If deconditioning of the athlete becomes a concern during this phase of rehabilitation, he/she may participate in other activities such as swimming or cycling so long as the activity remains pain-free.
• The third, and optimistically final, stage of the treatment is known as the Long Term Phase, begins only after pain and inflammation are resolved and typically in close association with the athlete's return to sport. During this stage, it is of utmost importance to prevent any reoccurrence of the resolved symptoms. A gradual return to play with extensive structurally specific stretching exercises both before and after workout is essential to ensure rehabilitation success.
• If training errors have not been corrected or inflammation significantly reduced, return to activity will not be satisfactory.
• http://www.csuchico.edu/phed/atc/Projects/ITband/ITBFS.html
   

References:
Baskin MN. Injury—knee. In: Fleisher GR, Ludwig S, eds. Textbook of
Pediatric Emergency Medicine. 4th ed. Philadelphia, Pa: Lippincott
Williams & Wilkins; 2000:339-347
Richards BS. Slipped capital femoral epiphysis. Pediatr Rev. 1996;17: 69-70
Staheli LT. Hip. In: Fundamentals of Pediatric Orthopedics. 2nd ed.
Philadelphia, Pa: Lippincott-Raven; 1998:68-71