Increasing incidence of slipped capital femoral epiphysis in Trinidad and Tobago: A 50-year review.

Slipped Capital Femoral Epiphysis (SCFE) is a physeal disorder of the proximal femur. Misdiagnosis and late treatment are associated with poorer outcomes. The epidemiology and delays in treatment of the disease between 1968 and 2018 were investigated in North Trinidad. The number of cases presenting annually has increased over the decades and the incidence between 2008-2018 was 2.2 cases per 100 000 per year. Almost 70% of cases were above the 95th percentile for body weight. Delay in treatment from onset of symptoms was 278 ± 258 days. Awareness of the risk factors and clinical presentation of SCFE may facilitate early diagnosis and treatment, and prevent severe hip disability in adulthood.

Slipped Capital Femoral Epiphysis in Children without Obesity.

OBJECTIVE: To evaluate rates and characteristics of slipped capital femoral epiphysis (SCFE) in children who are not obese to prevent missed diagnoses and subsequent complications. STUDY DESIGN: A multicenter, retrospective review identified all patients with SCFE from January 1, 2003 to December 31, 2012. Patients were excluded if they received previous surgery at an outside institution, had no recorded height and weight, or had medical co-morbidity associated with increased risk of SCFE. Body mass index (BMI) percentile for age was calculated and categorized for each patient (patients without obesity vs with obesity). RESULTS: In total, 275 patients met inclusion criteria. Average BMI was 91.2 percentile (range: 8.4-99.7). Thirteen percent (34 patients) were considered "normal weight" (BMI 5%-85%), 17% (48 patients) were considered "overweight" (BMI 85%- 95%), and 70% (193 patients) were considered "obese" (BMI >95%). Average BMI percentile was higher in male than female patients (93.2 ± 12.7 vs 88.5 ± 21.4, P = .034). Patients without obesity were older compared with patients with obesity (12.2 ± 1.7 vs 11.7 ± 1.6 years, P = .015). Fewer patients without obesity were seen at the hospital in the southwest. The southwest had fewer patients without obesity than the northeast (18.3% vs 36.1%, P = .002). Patients without obesity were more likely to present with a severe slip as graded by Wilson percent displacement (27.2% vs 11.4%, P = .007) and an unstable slip (32.9% vs 14.7%, P = .001). CONCLUSION: Rates of nonobese SCFE in this study are higher than reported in the previous literature. Normal weight patients with SCFE are more likely to be older, female, and present with a severe and unstable SCFE.

Patterns of Pain in Adolescents with Slipped Capital Femoral Epiphysis.

OBJECTIVE: To prospectively characterize pain locations in slipped capital femoral epiphysis (SCFE) and evaluate pain locations as predictors of a delay in diagnosis. STUDY DESIGN: This was an institutional review board approved prospective study of 110 children who underwent surgery for SCFE at a tertiary children's hospital between 2009 and 2015. Standardized pain diagrams were completed by 107 children. Pain zones were designated via a composite diagram. Hips without hip pain were categorized as atypical; hips with hip pain were typical. RESULTS: In total, 122 hips were eligible for pain zone analysis. Seventy hips (57.4%) had hip pain. Atypical pain was present in 52 hips (42.6%), which included groin pain in 17 hips (13.9%), thigh/leg pain in 43 (35.2%), knee pain in 32 (26.2%), and posterolateral pain of the hip and leg in 13 (10.7%). A combination of pain zones was present in 48 hips (39.3%). Forty-nine percent of patients had more than 1 visit until diagnosis. The three most common pain locations for typical hips were hip, hip/thigh, and hip/knee pain (77.2% of typical hips). The 3 most common pain locations for atypical hips were isolated thigh, knee, and groin (65.4% of atypical hips). The least common pain presentations had a longer duration of symptoms (P = .04) and more healthcare visits before diagnosis (P = .04). CONCLUSIONS: A combination of pain locations is common in SCFE. Less frequent pain presentations may delay diagnosis. Delays in diagnosis continue despite education efforts.

Continuing Delay in the Diagnosis of Slipped Capital Femoral Epiphysis.

OBJECTIVE: To evaluate whether the time from symptom onset to diagnosis of slipped capital femoral epiphysis (SCFE) has improved over a recent decade compared with reports of previous decades. STUDY DESIGN: Retrospective review of 481 patients admitted with a diagnosis of SCFE at three large pediatric hospitals between January 2003 and December 2012. RESULTS: The average time from symptom onset to diagnosis of SCFE was 17 weeks (range, 0-to 169). There were no significant differences in time from symptom onset to diagnosis across 2-year intervals of the 10-year study period (P = .94). The time from evaluation by first provider to diagnosis was significantly shorter for patients evaluated at an orthopedic clinic (mean, 0 weeks; range, 0-0 weeks) compared with patients evaluated by a primary care provider (mean, 4 weeks; range, 0-52 weeks; r = 0.24; P = .003) or at an emergency department (mean, 6 weeks, range, 0-104 weeks; r = 0.36; P = .008). Fifty-two patients (10.8%) developed a second SCFE after treatment of the first affected side. The time from the onset of symptoms to diagnosis for the second episode of SCFE was significantly shorter (r = 0.19; P < .001), with mean interval of 11 weeks (range, 0-104 weeks) from symptom onset to diagnosis. There were significantly more cases of mildly severe SCFE, as defined by the Wilson classification scheme, in second episodes of SCFE compared with first episodes of SCFE (OR, 4.44; P = .001). CONCLUSION: Despite reports documenting a lag in time to the diagnosis of SCFE more than a decade ago, there has been no improvement in the speed of diagnosis. Decreases in both the time to diagnosis and the severity of findings for the second episode of SCFE suggest that the education of at-risk children and their families (or providers) may be of benefit in decreasing this delay.

Knee Pain in Children, Part II: Limb- and Life-threatening Conditions, Hip Pathology, and Effusion.

On the basis of primarily consensus due to lack of relevant clinical studies, the most important evaluative step for knee pain is to identify any emergent conditions, including limb- and life-threatening disorders (septic arthritis, osteomyelitis, and malignancy), hip pathology, or conditions associated with effusions. (2)(3)(6)(8)(11)(13)(14)

Klein line on the anteroposterior radiograph is not a sensitive diagnostic radiologic test for slipped capital femoral epiphysis.

OBJECTIVE: To correlate the amount of slipped capital femoral epiphysis (SCFE) that results in an abnormality of the Klein line. In mild slips, the Klein line on the anteroposterior (AP) radiograph may remain normal, potentially leading to a delay in diagnosis and emphasizing the importance of obtaining a frog lateral radiograph in patients with a suspected SCFE. STUDY DESIGN: A retrospective review of 55 patients with SCFE was performed from January 2004-March 2009. Of the 55 patients, 32 were missing radiographs and were excluded, leaving 23. The 23 sets of radiographs were reviewed. RESULTS: Of the 23 hips studied with SCFE, only 9 (39%) were able to be diagnosed on the AP radiograph using the classic definition of the Klein line. Twenty cases (87%) of SCFE were identified on the AP radiograph using the modified Klein line. All 23 cases (100%) of SCFE were identified on frog lateral radiographs. CONCLUSIONS: Relying on the Klein line will fail to identify many mild or moderate slips. An AP and a frog lateral pelvic radiograph should be obtained in any child when an SCFE is suspected to accurately identify the disorder and to prevent delays in diagnosis.