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Question: Musculoskeletal

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An 11yo girl presents with 2 weeks of right knee pain and limp after falling off a bicycle. She has had no fever, rash, other trauma. Vital signs are: temperature 37.5, HR 80, RR 16, BP 110/60. Her exam is normal except for: a 1/6 musical systolic ejection murmur at the LLSB, acanthosis nigricans, and gait with a noticeable limp. Her right knee has no effusion, deformity, erythema, or warmth appreciable.

The appropriate initial diagnostic work-up for this patient is:

pemsou5_wp • August 25, 2020

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  1. Kelly August 25, 2020 - 10:24 pm Reply

    C) Right knee 3-view radiograph and AP/frog-leg lateral pelvis radiograph
    Hip pathology may present as knee pain in pediatric patients, due to referred pain or alterations in the patient’s gait placing strain on the knee. Acanthosis nigricans is commonly found in obesity, which is a clue that this patient is at risk of slipped capital femoral epiphysis (SCFE). Even in a non-obese pediatric patient, if there is not a clear cause for knee pain, the hips should be evaluated. Extremity radiographs should always be at least 2-view, so an AP and frog-leg lateral are indicated. Klein’s line aids in diagnosing SCFE, whereby a line drawn along the superior femoral neck does not intersect the femoral head. SCFE usually presents in girls aged 10-14 years and boys aged 12-16 years, is more common in obese patients, and is bilateral in up to 40%. Once diagnosed, patients should be non-weight bearing and an orthopedist should be urgently consulted for operative pinning. SCFE places the patient at risk for avascular necrosis.

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