Slipped capital femoral epiphysis

Slipped captial femoral epiphysis and gait.

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Yesterday in the clinic a young teenager was brought into the office with a gait problem. Or so it seemed. The patient was walking with a "peg legged" locked knee gait on the right side. It was as if she was wearing a straight leg knee immobilizer. There was no knee bend during gait, she was not in much pain. A month prior, when the problem started, she recalls "straining" the right thigh during tennis. There was a sudden sharp jabbing pain in the mid thigh, and over the next 2 days , much thigh and lateral hip pain. Radiographs of the femur were unremarkable by another doctor. Physical therapy exercises by another facility have been fruitless.
On the exam table there was a terrible pelvis distortion pattern and the affected leg looked, no kidding, 1 inch longer on the table. The knee and quad during exam were splinted, she did not want the knee bent. or so I thought.
As the exam went on, it became clear that it was not the knee that did not want bent, it was hip flexion that she did not want, she was just unaware it was the hip, because the pain would only come on into the thigh during the exam.
I proceeded to gently press over the anterior femoral head, and she screamed.

This is a SCFE until proven otherwise. This was a 13 year old, with sudden onset of thigh pain after an abrupt load. I have seen this a few times in practice, and they have often presented in just this manner. Growth plates have to be high on the list in teenagers, especially when pain remains ongoing, and there are extraordinary joint splinting and compensations such as in her gait. She was clearly splinting through the quads, in an attempt to completely unload the gluteal generated hip joint compression. She could not activate or contract her quadriceps, at all ! She wanted no part of compression or load across this hip joint. The locked knee gait was her attempt to depend on more quad generated hip/limb stability during loading.

If you are training or treating teens, the growth plate always has to be on the differential diagnosis list.
* this is not her radiograph above, i am still waiting to hear from someone.

Gait Posture. 2017 Oct;58:358-362. doi: 10.1016/j.gaitpost.2017.08.026. Epub 2017 Aug 26.
Gait deviations in transverse plane after SCFE in dependence on the femoral offset. Hummel S1, Rosenthal D2, Zilkens C2, Hefter H2, Krauspe R2, Westhoff B2.