Dolor de cadera en adolescentes: estudio y tratamiento / Hip pain in adolescent: assessment and treatment

En adolescentes que consultan por dolor de cadera o pelvis, es crucial una adecuada historia clínica para orientarnos sobre la etiología del dolor y comprender los mecanismos que lo generan. Es importante conocer y realizar un exhaustivo examen físico, con especial énfasis en la cadera, incluyendo pruebas específicas para diferentes patologías, además de comprender las indicaciones de los diferentes estudios de imágenes, para así lograr un correcto diagnóstico.Entre las causas más frecuentes de coxalgia en adolescentes debemos considerar la epifisiolisis, el pinzamiento femoroacetabular con o sin roturas del labrum, las lesiones avulsivas de la pelvis, la coxa saltans, entre otras. Aunque son poco frecuentes, patologías sistémicas como reumatológicas y oncológicas también deben ser descartadas en adolescentes. Un diagnóstico de certeza nos permitirá realizar una adecuada estrategia de tratamiento, a fin de lograr una rehabilitación precoz y evitar futuras complicaciones.

In adolescents presenting with hip or pelvis pain, an adequate medical history is crucial to guide the etiology and understand the mechanisms that generate it. It is important to know and carry out an exhaustive physical examination, with special attention to the hip, including specific tests for different pathologies, in addition to understand the indications of the different imaging studies, in order to achieve a correct diagnosis. Among the most frequent causes of hip pain in adolescents, we must rule out slipped capital femoral epiphysis, femoroacetabular impingement with or without labral tears, avulsion lesions of the pelvis, snapping hip, among others. Although rare, systemic pathologies such as rheumatologic and oncologic diseases must also be ruled out in adolescents. An accurate diagnosis will allow us to carry out an adequate treatment strategy, in order to achieve early rehabilitation and avoid future complications.

Acute hindlimb lameness in a 6-month-old cat.

CLINICAL PRESENTATION: A 6-month-old female spayed domestic shorthair cat was presented for investigation of acute right hindlimb lameness and paresis. WHAT IS YOUR DIAGNOSIS?: Readers are encouraged to review the case history and consider what their diagnostic suspicion is. Also what is the preferred treatment for this injury? And what is the primary cause of this injury?

Slipped Capital Femoral Epiphysis: Diagnosis and Management.

Slipped capital femoral epiphysis (SCFE) is the most common hip disorder in adolescents, occurring in 10.8 per 100,000 children. SCFE usually occurs in those eight to 15 years of age and is one of the most commonly missed diagnoses in children. SCFE is classified as stable or unstable based on the stability of the physis. It is associated with obesity, growth spurts, and (occasionally) endocrine abnormalities such as hypothyroidism, growth hormone supplementation, hypogonadism, and panhypopituitarism. Patients with SCFE usually present with limping and poorly localized pain in the hip, groin, thigh, or knee. Diagnosis is confirmed by bilateral hip radiography, which should include anteroposterior and frog-leg views in patients with stable SCFE, and anteroposterior and cross-table lateral views in unstable SCFE. The goals of treatment are to prevent slip progression and avoid complications such as avascular necrosis, chondrolysis, and femoroacetabular impingement. Stable SCFE is usually treated using in situ screw fixation. Treatment of unstable SCFE also usually involves in situ fixation, but there is controversy about timing of surgery and the value of reduction. Postoperative rehabilitation of patients with SCFE may follow a five-phase protocol.

[Slipped capital femoral epiphysis]. / Épiphysiolyse fémorale supérieure.

Slipped capital femoral epiphysis (SFCE) is a disorder of the hip, characterized by a displacement of the capital femoral epiphysis from the metaphysic through the femoral growth plate. The epiphysis slips posteriorly and inferiorly. SCFE occurs during puberty and metabolic and epidemiologic risk factors, such as obesity are frequently found. Most chronic slips are diagnosed late. Sagittal hip X-rays show epiphysis slip. In case of untreated SCFE, a slip progression arises with an acute slip risk. Treatment is indicated to prevent slip worsening. The clinical and radiological classification is useful to guide treatment and it is predictive of the prognosis. In situ fixation of stable and moderately displaced SCFE with cannulated screws gives excellent results. Major complications are chondrolysis and osteonecrosis and the major sequelae are femoroacetabular impingement and early arthritis.

Trends in the Presentation, Management, and Outcomes of Little League Shoulder.

BACKGROUND: With rising participation in youth sports such as baseball, proximal humeral epiphysiolysis, or Little League shoulder (LLS), is being seen with increasing frequency. However, there remains a paucity of literature regarding the causes, natural history, or treatment outcomes of LLS. PURPOSE: To analyze the demographic, clinical, and diagnostic features of a population of LLS patients, with an emphasis on identifying underlying risk factors for the development and recurrence of LLS after nonoperative treatment. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A departmental database at a high-volume regional children's hospital was queried to identify cases of LLS between 1999 and 2013. Medical records were reviewed to allow for analysis of age, sex, athletic information, physical examination and radiologic findings, treatment details, clinical course, and rates of recurrence. RESULTS: Ninety-five patients (93 males, 2 females; mean age, 13.1 years; range, 8-16 years) were diagnosed with LLS. The number of diagnosed cases increased annually over the study period. All patients had shoulder pain with overhead athletics; secondary symptoms included elbow pain in 13%, shoulder fatigue or weakness in 10%, and mechanical symptoms in 8%. While the majority of patients (97%) were baseball players (86% pitchers, 8% catchers, 7% other positions), a small subset (3%) were tennis players. On physical examination, 30% were reported to have glenohumeral internal rotation deficit (GIRD), defined as a decreased arc of rotational range of motion of the shoulder. Treatment recommendations included rest in 99% of cases, physical therapy in 79% (including 100% of patients with GIRD), and position change upon return to play in 26%. Average time to full resolution of symptoms was 2.6 months, while average time to return to competition was 4.2 months. Recurrent symptoms were reported in 7% of the overall cohort at a mean of 7.6 months after initial diagnosis. The odds of recurrence in the group with diagnosed GIRD (14%) were 3.6 times greater than those without GIRD (5%; 95% CI: 0.7-17.1), but this difference was not statistically significant (P = .11). CONCLUSION: Little League shoulder is being diagnosed with increasing frequency. While most common in male baseball pitchers, the condition can occur in females, youth catchers, other baseball positions players, and tennis players. Concomitant elbow pain may be seen in up to 13%. After rest and physical therapy, recurrent symptoms may occur in a small subset of patients (7%), generally 3 to 6 months after return to sports. Almost one-third of LLS patients had GIRD, and this group had approximately three times higher probability of recurrence compared with those without GIRD.

Overuse throwing injuries in skeletally immature athletes--diagnosis, treatment, and prevention.

The number of skeletally immature athletes participating in organized sport is near an all-time high. For nearly half a century, the medical community has investigated the link between shoulder and elbow injuries with repetitive throwing. Despite substantial literature and research, several controversies still exist, including when to begin throwing breaking pitches. Furthermore, despite introduction of pitch recommendations for youth baseball, misconceptions, poor understanding of, and adherence to these guidelines persist. High-velocity and high-volume throwing and throwing while fatigued are significant risk factors for injury. Improved awareness and adherence to throwing guidelines should limit the number of injuries. Proper identification and treatment of injuries when they do occur can allow our skeletally immature athletes to safely return to overhead sports activities.

Digital Chondrolysis and Epiphysiolysis Associated With Snakebite: A Report of 2 Cases.

BACKGROUND: Here, we present 2 cases of the unusual sequelae of a venomous bite to the finger in children resulting in chondrolysis and physeal loss. There have been few isolated case reports documenting this phenomenon. Currently, there is no preventative treatment, and patients should be warned of this possible complication of envenomation. METHODS: Two patients with chondrolysis and physeal loss have been seen in our practice. RESULTS: Chondrolysis and epiphysiolysis occurred in 2 patients. One patient was treated with proximal interphalangeal joint fusion and one is being managed conservatively. CONCLUSION: The toxic action of snake venom may cause loss of the growth plate and chondrolysis in the pediatric hand. LEVEL OF EVIDENCE: Level IV.

Neuropatía cubital secundaria a artropatía neuropática del codo por siringomielia cervicotorácica / Ulnar neuropathy due to neuropathic arthropathy of the elbow caused by cervicothoracic syringomyelia

La artropatía neuropática o articulación de Charcot es una artritis degenerativa progresiva asociada a un déficit neurosensorial con múltiples etiologías, siendo la siringomielia la segunda causa más frecuente después de la diabetes mellitus. El hombro es la articulación que con más frecuencia se afecta en miembros superiores, siendo la artropatía neuropática del codo una entidad muy poco prevalente. La neuropatía cubital es una complicación rara, que puede aparecer en los pacientes con artropatía neuropática del codo debido al atrapamiento nervioso que ocasiona la desestructuración articular. Existen muy pocos casos descritos en la literatura de neuropatía cubital secundaria a una artropatía neuropática del codo por siringomielia. El objetivo de este trabajo es presentar el caso de una paciente de 61 años con neuropatía cubital secundaria a artropatía neuropática del codo por siringomielia cervicotorácica (AU)

Neuropathic arthropathy, or Charcot joint, is a progressive degenerative arthritis with multiple causes, syringomyelia being the second most common cause after diabetes mellitus. The shoulder is the most frequently affected joint in the upper limbs, and neuropathic arthropathy of the elbow is very infrequent. Ulnar neuropathy is a complication that can occur in patients with neuropathic arthropathy of elbow due to nerve entrapment causing by joint disintegration. There are very few previous case reports of ulnar neuropathy secondary to neuropathic arthropathy of the elbow due to syringomyelia. This report describes the case of a 61-year-old woman with ulnar neuropathy due to neuropathic arthropathy of the elbow caused by cervicothoracic syringomyelia (AU)

Acetabulotrochanteric distance in slipped capital femoral epiphysis.

BACKGROUND: A pathognomonic finding of slipped capital femoral epiphysis (SCFE) is a combination of the decrease in the height of the slipped epiphysis and the position of external rotation and flexion of hip. We believe that decrease in the acetabulotrochanteric distance (ATD) on an anteroposterior (AP) radiograph represents this finding. MATERIAL AND METHODS: In a retrospective study of 25 consecutive cases of unilateral SCFE, we defined ATD as the distance between a line connecting the superolateral margins of the acetabulae with a second line, parallel to the first line, which goes through the tip of the greater trochanter on each hip and acetabulotrochanteric angle (ATA) as the angle between a line connecting the superolateral margins of the acetabulae with a second line connecting the tip of greater trochanter on each side. The difference in ATD and ATA between both hips in each case was evaluated and their correlation was determined using the Pearson correlation coefficient. RESULTS: Nineteen cases (76%) showed difference in ATD of > 2 mm and positive ATA divergence of >1 degree. The average difference in ATD was 6.6 mm (range, 0 to 25 mm); the average ATA divergence was 2.4 degree (range, 0 to 5.3 degree). CONCLUSIONS: Our findings show that the difference in acetabulotrochanteric distance (ATD) between hips is an easy, reliable, and sensitive finding present on an AP radiograph of patients with unilateral SCFE. ATD should be taken into consideration while evaluating AP radiographs of a patient suspected to have SCFE, and further evaluation with lateral hip radiographs should be carried out to confirm the diagnosis. LEVEL OF EVIDENCE: Level IV.

Deformidad en varo del tobillo del niño: corrección mediante fijación externa / Varus deformity of the ankle in a child: correction using external fixation

Introducción y objetivo. La deformidad en varo del tobillo durante la infancia es una secuela no infrecuente tras una epifisiolisis de tibia distal o una infección de esta zona durante la infancia. Los autores revisan los casos tratados mediante fijación externa. Material y métodos. Se revisaron de forma retrospectiva 14 casos de tobillo varo estudiados clínica y radiológicamente mediante telerradiografía anteroposterior de EEII en bipedestación y tratados mediante fijación externa monolateral. Se analizó la causa de la deformidad, su magnitud, procedimiento empleado, complicaciones y cierre precoz de fisis tras el tratamiento. Resultados. Se revisaron retrospectivamente todos los casos de tobillo varo, siendo las causas más frecuentes de deformidad en varo del tobillo durante la infancia: las epifisiolisis de la porción medial de la tibia distal (lesiones SH II, III o IV), infección de tibia distal y sepsis. Hubo dos casos de epifisiolisis tipo II, tres de tipo III y tres de tipo IV. Los métodos de corrección empleados fueron en cuatro casos la distracción fisaria cuando había fisis abierta o la osteotomía metafisaria distal y callotasis posterior en ocho casos. En dos se realizó la corrección de forma aguda asociando otro método de tratamiento para corregir una discrepancia concomitante. En todas las callotasis se realizó osteotomía del peroné, fijándolo con aguja de Kirschner excepto en tres casos. Las complicaciones más frecuentes fueron infecciones alrededor de los tornillos y desplazamiento ad-latum. Discusión y conclusiones. En esta serie se han obtenido buenos resultados en el tratamiento de la deformidad en varo del tobillo del niño mediante la condrodiastasis, la osteotomía y la callotasis. La distracción fisaria antes de alcanzar la madurez esquelética puede ser el método de elección. Si se realiza precozmente es presumible el cierre precoz del resto de fisis fértil. Si el tratamiento es hemicallotasis es recomendable además de la osteotomía del peroné su fijación intramedular con aguja de Kirschner (AU)

Introduction and objective. Varus deformity of the ankle during infancy is a not uncommon after effect after epiphysiolysis of the distal tibial or an infection in this area during childhood. The authors review the cases treated using external fixation. Material and methods. A retrospective review was made of 14 cases of varus ankle clinically and radiologically studied using lower limb antero-posterior teleradiography in the standing position and treated using monolateral external fixation. The cause of the deformity, its magnitude, procedure employed, complications, and premature physeal closure after treatment. Results. All cases of varus ankle were retrospectively reviewed, with the most frequent cause of the deformity in ankle varus during infancy being epiphysiolysis of the middle portion of the distal tibia (SH II, III or IV lesions), distal tibia infection or sepsis. There were two cases of epiphysiolysis type II, three of type III, and three of type IV. The methods of correction employed were, physeal distraction when the physis was open in four cases, and distal metaphyseal osteotomy and subsequent callus distraction in eight cases. In two cases correction was performed acutely combining another treatment method to correct a concomitant discrepancy. The callotasis was performed on all of them using fibular osteotomy, fixing it with a Kirschner wire, except in three cases. The most frequent complications were infections around the screws and ad-latum displacement. Discussion and conclusions. Good results have been obtained in this series of varus deformity of the ankle in the child by means of physeal distraction, osteotomy and callotasis. Physeal distraction before reaching skeletal maturity may be the method of choice. If it is performed earlier the premature closure of the rest of the fertile physis is likely. If the treatment is hemicallotasis, besides the fibular osteotomy, intramedullary fixation with a Kirschner wire is also recommended (AU)

Experiencias del manejo de epifisiolistesis capital femoral / Epifisiolistesis experience of femoral capital

Analizar los resultados clínicos y radiológicos postquirúrgicosen pacientes con epifisiolistesis femoral proximal. Estudio prospectivo con seguimiento de 4 años, se valoró la clínica, estabilidad, el ángulo de Southwick, y cadera afectada. Se reportaron a 14 pacientes,15 caderas (1 caso bilateral), edad promedio de 11,28 años, el ángulo de Southwick promedio fue de 30,6°. Todos los casos fueron tratados con fijación in situ con un tornillo canulado bajo técnica de FrancisYoung-In Lee, y 3 ameritaron osteotomía triplanar con sistema de fijación externa multiplanar tipo Ilizarov. No se reportaron casos de deslizamiento contralateral. Como complicaciones dismetría asociada a coxa brevay marcha extrarrotada. Los resultados clínicos fueronuniformemente buenos en este grupo de pacientes que típicamente se han considerado de difícil de tratamiento,radiológicamente se observó una anatomía relativamentenormal y sólo se presentó un caso bilateral asociado a trastornos endocrinos.

Analyze the postoperative clinical and radiographic resultsin patients with slipped proximal femoral epiphysis.Retrospective follow up of 4 years, we have evaluatedclinics, stability, the Southwick’s angle, and most affected hip. We reported 14 patients, 15 hips (1 bilateralcase), average age of 11.28 years; the Southwick’s angle averaged 30.6°. All cases were treated with in situ fixation with a cannulated screw, Francis Young-In Lee’s technique, and 3 merited triplane osteotomy with multiplanar external fixation system of Ilizarov type.There were no cases of contralateral slip. The most common complications were associated with coxa brevadysmetria and extrarotated walk. The clinical results were uniformly good in this group of patients who have typically been considered difficult to treat; radiographicallythere was a relatively normal anatomy and only one case the presentation was bilateral associated with endocrine disorders.

In situ fixation of slipped capital femoral epiphysis with Steinmann pins.

BACKGROUND AND PURPOSE: Slipped capital femoral epiphysis (SCFE) is often treated by surgical fixation; however, no agreement exists regarding technique. We analyzed the outcome of in situ fixation with Steinmann pins. PATIENTS AND METHODS: All 67 subjects operated for slipped capital femoral epiphysis at Haukeland University Hospital during the period 1990-2007 were included. All were treated by in situ fixation with 2 or 3 parallel Steinmann pins (8 mm threads at the medial end). The follow-up evaluation consisted of clinical examination and hip radiographs. Radiographic outcome was based on measurements of slip progression, growth of the femoral neck, leg length discrepancy, and signs of avascular necrosis and chondrolysis. RESULTS: 67 subjects (41 males) were operated due to unilateral slips (n = 47) or bilateral slips (n = 20). Mean age at time of diagnosis was 13 (7.2-16) years. Mean age at follow-up was 19 (14-30) years, with a mean postoperative interval of 6.0 (2-16) years. The operated femoral neck was 9% longer at skeletal maturity than at surgery, indicating continued growth of the femoral neck. At skeletal maturity, 12 subjects had radiographic features suggestive of a previous asymptomatic slip of the contralateral hip. The total number of bilateral cases of SCFE was 32, i.e half of the children had bilateral SCFE. 3 subjects required additional surgery and mild avascular necrosis of the femoral head was seen in 1 patient. None had slip progression or chondrolysis. INTERPRETATION: In situ pinning of SCFE with partly threaded Steinmann pins appears to be a feasible and safe method, with few complications. The technique allows further growth of the femoral neck.

Avaliação da apresentação de sinais e sintomas de impacto femoroacetabular após epifisiólise do fêmur proximal / Evaluation of presentation of signs and symptoms of femoroacetabular impingement after epiphysiolysis of the proximal femur

OBJETIVO: Neste trabalho, procuramos avaliar se existe relação entre o grau de deslizamento da epifisiólise femoral proximal (EFP) e a presença de impacto femoroacetabular (IFA). Ainda, analisou-se o arco de movimento do quadril (ADM) em relação ao IFA, além de revisar a literatura sobre o assunto. MÉTODO: Foram analisados 19 casos de EFP em 15 pacientes tratados cirurgicamente com epifisiodese in situ com um parafuso canulado, com seguimento médio de 27 meses. Realizou-se a análise do grau de deslizamento da EFP pelos ângulos epimetafisário (âEM) e coloepifisário (âCE) da radiografia em perfil, dos sinais de impacto radiográficos na incidência anteroposterior, dos sintomas clínicos e do ADM do quadril. RESULTADOS: Evidenciou-se que o grau de deslizamento da EFP (através do âEM) apresenta relação inversa estatisticamente significante com a presença de IFA no período médio de seguimento deste estudo. Ou seja, os pacientes que demonstraram um quadro sintomático de IFA apresentaram graus menores de deslizamento. Isso pode ser explicado pelo fato que o tipo de impacto que ocorre na EFP (came de inclusão ou de impacção) depende do grau de deslizamento, e estes se apresentam de forma e cronologia diferentes. O ADM do quadril não apresentou relação com o IFA. CONCLUSÃO: Há relação entre o grau de deslizamento e a presença de IFA clínicoradiológica após EFP.

OBJECTIVES: In this study, we sought to evaluate whether there is any relationship between the degree of epiphysiolysis of the proximal femur (EPF) and the presence of femoroacetabular impingement (FAI). Hip range of motion (ROM) was also analyzed in relation to FAI, and the literature on this topic was reviewed. METHODS: Nineteen cases of EPF in fifteen patients who had been treated surgically by means of in situ epiphysiodesis with a cannulated screw were evaluated. The mean follow-up was 27 months. The degree of EPF was analyzed using the epimetaphyseal and neck-epiphyseal angles on lateral-view radiographs, the radiographic signs of FAI on anteroposterior-view radiographs, clinic symptoms and hip ROM. RESULTS: It was found that the degree of EPF (through the epimetaphyseal angle) presented a statistically significant inverse relationship with the presence of FAI over the mean follow-up period of this study. In other words, the patients with symptoms of FAI presented lesser degrees of slippage. This can be explained by the fact that the types of impingement that occurs in cases of EPF (i.e. cam impaction or inclusion) depends on the degree of slippage, and these present different clinical forms and chronology. The ROM did not present any relationship with FAI. CONCLUSION: There is a relationship between the degree of slippage and the presence of clinical-radiological FAI after EPF.

Osteotomía cervical cuneiforme femoral para el tratamiento de la secuela de epifisiolisis / Cuneiform osteotomy of femoral neck as treatment for slipped capital femoral epiphysis sequelae

Introducción. La alteración anatómica de la epifisiolisis no tratada, prototipo de la deformidad del pinzamiento femoro-acetabular tipo cam, causa degeneración articular precoz de la cadera. Objetivo. Describir una técnica original de osteotomía cervical cuneiforme (OCC) para reposicionar anatómicamente la epífisis femoral, en la secuela de epifisiolisis. Material y método. Se operaron 7 caderas en 6 pacientes masculinos, con secuela de epifisiolisis severa; edad promedio de 15 años (13-16), cuyo motivo de consulta fue coxalgia y claudicación severa de 9,2 meses promedio. Todos con cierre del cartílago fisiario femoral al momento de la consulta. Técnica quirúrgica y resultados . En todos los casos se efectuó una OCC y reposición de la epífisis femoral. Se realizó disección y elevación del periostio cervical para proteger los vasos epifisiarios de la cabeza femoral; a continuación se ejecutó la OCC, se reposicionó la epífisis femoral en la ubicación anatómica y se realizó una osteosíntesis. Se logró una corrección del ángulo eje epifisiario desde 66° preoperatorio a 11° postoperatorio. El seguimiento promedio fue 37 meses (4-59). Conclusión. La OCC femoral, propuesta en pacientes con secuela de epifisiólisis, es una alternativa de tratamiento, que logra buenos resultados anatómicos y radiológicos en pacientes jóvenes (AU)

Introduction: Abnormal hip anatomy of untreated Slipped Capital Femoral Epiphysis (SCFE), a prototype of cam impingement deformity, is a cause of early hip degeneration. Objective: To describe an original technique of cuneiform osteotomy of the femoral neck to relocate femoral epiphysis in patients with sequelae of SCFE. Methods: Seven hips in 6 male patients with sequelae of severe SCFE, with a mean age of 15 years (13-16), and with a mean of 9.2 months of hip pain and severe limp, were treated. All of the cases had closed growth cartilage at the time of consultation. Surgical technique and results: In all cases we performed a cuneiform osteotomy of the femoral neck with relocation of epiphysis. A dissection and elevation of cervical periosteum to protect the epiphyseal vessels of the femoral head was performed. Then, the cuneiform osteotomy of the femoral neck was performed with relocation of the femoral epiphysis to the anatomical position and osteosynthesis. We achieved an epiphyseal-shaft angle correction from 66◦ preoperative to 11◦ postoperative. The mean follow up was 37 months (4-59). Conclusion: Cuneiform osteotomy of the femoral neck proposed in patients with sequelae of SCFE is an alternative treatment that achieves good anatomical and imaging results in young patients (AU)

Single screw fixation in stable and unstable slipped upper femoral epiphysis.

The aim of this single centre retrospective study was to assess the outcome of patients after the fixation of slipped upper femoral epiphysis (SUFE) using a single cannulated screw. Thirty-eight slips, 28 stable and 10 unstable were treated with single in-situ screw fixation. The minimum follow-up was 1 year. The overall adverse outcome in terms of avascular necrosis (AVN), chondrolysis and revision surgery for slip progression was 18%, which was considered satisfactory. Slip progression of more than 10° was higher in the unstable when compared with the stable group but not statistically significant. Two out of the nine satisfactorily fixed unstable slips required revision surgery as opposed to none in the stable group. The incidence of AVN in the unstable group was 20%. There were no cases of AVN in the stable group. The adverse outcome in terms of AVN, chondrolysis and revision surgery for slip progression was significantly higher in the unstable group. In our study, results of single screw fixation for SUFE were found to be satisfactory as shown by earlier studies with the unstable SUFEs as expected having a poorer outcome when compared with the stable SUFEs.