3/28/07njm

**Knee pain in an adolescent: Web M + M**

**Moderator:** Terry Cullen, M.D.

**Summary**

This is the second care in our morbidity and mortality series. **This
pediatric case is illustrative of many issues that confront our
providers on a regular basis.** The discussion of this case raises many
issues from the initially perplexing chief complaint, a complicated
clinical course, to 'systems issues' of referral, including Contract
Health, the problems with lack of continuity of care, and something as
simple as the need for a re-evaluation of a patient's course if the
current management is not met with sustained improvement.

This is a disturbing, but unfortunately not uncommon case history which
ultimately showed a slipped capital femoral epiphysis (SCFE). This is an
orthopedic urgency, if not emergency.

 

Clinically, perceived knee pain can originate in the knee but can also
be referred pain from the hip joint. Any pediatric patient presenting
with knee or thigh pain needs to have an examination of the hip joint.
If the hip joint is involved, there will be pain on flexion of the hip
\>90 degrees and there is often severe pain on internal rotation of the
hip joint.

These findings may indicate that the knee is not a source of the
discomfort; this should prompt radiographs of the hip joint and
consultation with an orthopedist (preferably a pediatric orthopedist) if
there are any concerns. The differential can include toxic synovitis,
avascular necrosis and SCFE.  Toxic synovitis will resolve within 3- 5
days. Avascular necrosis and SCFE will feel better if the joint is
rested but will not resolve. If hip radiographs are normal, the patient
needs to be seen back in a week to make sure the pain is gone and hip
mobility is completely normal. If not, the patient needs further work-up
including possible a CT or MRI of the hip which can defect changes in
avascular necrosis or SCFE before they may be visible on plain films.

 

SCFE is a common orthopedic malpractice claim of children for
pediatricians. This likely reflects the practitioner focusing on the
site of pain and failing to consider hip involvement. SCFE, if treated
early with pinning, can prevent further slippage and the long term
outcome can be excellent. If the diagnosis is delayed, the slip will
progress. The slipped proximal femoral head cannot be reduced to its
original position because of the tenuous blood supply via the femoral
artery; the slip can only be pinned and stabilized in the location it is
found. A slipped proximal femoral head will heal but will no longer be
anatomically correct in position in the acetabulum. These patients begin
to have chronic hip pain in their 20s and often need hip replacements by
the time they are 30.

**Systems issues include:**

-Risk/benefits of on-site radiology reading availability exacerbated by
lack of timely off-site reads

-Risk/ benefits of continuity of care

-Risk/ benefits more frequent follow up

-Appropriate referral patterns

-Consultant availability

**Provider issues include:**

-Consideration of additional diagnoses at the initial time of
presentation and at subsequent visits

-Consideration of additional diagnoses due to 'the patient already had
an Ortho consult'

-Multiple provider visits that include the need to 're-evaluate' the
patient at each visit

**Communication issues include:**

-Adequate communication with the patient

-Adequate communication with the family

-Appropriate and timely follow up with family

....

We hope that this clinical discussion results in improved care for our
patients, as well as improved health status for American Indian / Alaska
Native communities.