Consequences of diagnostic delays in slipped capital femoral epiphysis

Abstract

Delay in diagnosis of slipped capital femoral epiphysis has important implications with regard to slip severity and long-term hip outcomes. The aims of this review were to identify the incidence of delayed diagnosis of slipped capital femoral epiphysis in the hospital to which the authors are affiliated, and the causes for such delays. A retrospective review was conducted of all patients admitted to the Women's and Children's Hospital in Adelaide between January 1997 and October 2004 with a diagnosis of slipped capital femoral epiphysis. The inpatient and outpatient medical records for each patient were analysed to clarify the history of presentation and identify those patients with a delayed diagnosis. All radiographs were reviewed and the severity of the slip graded according to Southwick's classification. One hundred and two patients were included in this review, of which 20 had a delayed diagnosis and 25 a late presentation. Of the 20 (19.6%) patients who had a delayed diagnosis in this series, a minimum of 2 weeks elapsed between presentation to a health professional and diagnosis of slipped capital femoral epiphysis. Eight patients had seen their local doctor but the diagnosis was not made. The remaining 12 patients with delayed diagnosis had not seen a medical practitioner and had self-referred to a chiropractor or a physiotherapist. All of these patients underwent hip manipulation prior to diagnosis. There was a significant relationship between delay in diagnosis and an increased slip severity, when compared with both the remainder of this series and the late presentation group. Knee or distal thigh pain in slipped capital femoral epiphysis remains the commonest pitfall in diagnosis for local doctors, as well as mild slips being missed on radiograms by inexperienced surgeons or radiologists. An increasing presentation of adolescents with this disorder to allied health professionals for initial management warrants a broader education strategy than has been previously advocated. Slipped capital femoral epiphysis remains an enigmatic disorder; consequently delayed diagnosis of this condition is not likely to disappear. Despite this, the medical community must strive toward early diagnosis through continued education and vigilance.

What Is the Best Evidence for the Treatment of Slipped Capital Femoral Epiphysis?

“…14 Once the diagnosis is made, treatment is indicated to prevent slip progression. [15][16][17] The goals of treatment for any SCFE or to stop progression of the SCFE, avoid complications (chondrolysis, AVN, SCFE progression, fixation problems), and realignment if/when to improve hip motion and potentially postpone the development of degenerative hip arthrosis. There are multiple treatment options, each having specific advantages and disadvantages.…”

Point-of-care ultrasound diagnosis of SCFE

“…Emergency physicians must promptly identify patients with a SCFE, as delays in this diagnosis are associated with increased slip severity and morbidity [1]. Unfortunately, plain radiography including an antero-posterior pelvis view and a frog-leg lateral hip view has a poor overall sensitivity, ranging from 40 to 79% [2].…”

The Need for Musculoskeletal Education in Primary Care Residencies

“…In contrast, EM physicians were less likely than orthopedic surgeons to request an ED consultation for a hip dislocation; this could result in avascular necrosis, which can have long-term negative effects for a patient. [2][3][4][5] The authors also noted a significant difference between years in training regarding recognizing the need for an urgent orthopedic consult. The results showed that pediatricians' and EM physicians' ability to assess the proper level of urgency for an orthopedic consultation increased as they accumulated years of residency.…”

“…1 Neglecting to call for an urgent consultation for particular orthopedic diagnoses can lead to incomplete reduction, missed fractures, malunion, nonunion, avascular necrosis, increased infection rate, or growth disturbances. [2][3][4][5] Understanding the key role of primary care and EM physicians, the authors investigated the decision-making process of orthopedic surgeons, pediatricians, and EM physicians to determine whether these 3 specialties reached different conclusions on the urgency of ED orthopedic consults. The authors also studied whether these decisions varied by year in training, to ascertain if variable or no musculoskeletal education during medical school was made up for during the residency training years.…”