A child with LCPD presents often with a limp that may or may not be painful. Physical activity often can produce pain. If pain is present, it can be localized to the hip, groin, thigh, or knee. There often is no history of trauma.

Physical exam may be normal outside of the limp but often there is a reduction in hip abduction and internal rotation. Difficulty walking may be present. If the process has been present for a longer time, limited range of motion is more likely and there may be evidence of muscle atrophy. Trendelenburg test may be positive.

Plain film radiographs, an anteroposterior (AP) and frog leg lateral, are often the only diagnostic imaging needed to diagnose LCPD. Findings can include widening of the joint space of the affected hip, lucencies in the femoral epiphysis, and various stages of deformity of the femoral head (Fig. 7.2). These deformities can include flattening, fragmentation, and sclerosis. Further advanced imaging can be conducted with an MRI if LCPD is suspected, as early in this condition, plain radiographs may be normal.

Various classification systems exist for LCPD. The Catterall system is one of the more commonly used systems. Catterall groups are I, II, III, and IV and represent the relationship of the involvement of the femoral head to outcome. Femoral head involvement is divided from 25 % through 100 % (total) head involvement. As expected, more head involvement is associated with poorer outcomes although the Catterall system was criticized for poor interobserver reliability [8]. The lateral pillar classification system is a 4 group system (A, B, B/C, or C). The system rates the height of the lateral pillar, which is the height of the lateral aspect of the epiphysis. Group A is no loss, Group B is <50 % loss, and group C is >50 % loss [8].

Treatment goals for LCPD include preventing secondary osteoarthritis of the hip through early diagnosis and keeping deformation of the femoral head to a minimum [5]. Patients presenting prior to age 8 were found to have a better outcome than those presenting after age 8 [9].

Controversy exists as to the most effective management for LCPD. In younger children, nonsurgical management is usually appropriate. Containment of the femoral head with the acetabulum is an important goal of treatment and may be accomplished through abduction casts or braces, which typically is more effective in children younger than age 5. Various surgical treatments exist to accomplish surgical containment of the femoral head although the majority of patients will not need surgical management. A varus osteotomy is one of the more common surgical procedures utilized if surgical management is considered [5].

A typical history for the child or adolescent presenting with an SCFE is that of a limp with groin, hip, thigh, or medial knee pain. One study reported 15 % of patients with SCFE had knee pain alone as the presenting complaint [15]. Pain may be vague or significant but often worsens with physical activity in a stable SCFE. Pain may be severe and have marked limp or inability to bear weight with or without history of trauma in unstable SCFE.

Physical examination is often notable for the hip to be externally rotated and flexed. Pain is often increased with passive internal rotation of the hip. Unstable SCFE may present with the patient in a FABER (flexed, abducted, and externally rotated) position of the hip with guarding present with any passive hip maneuvers.

Standard radiographs of an AP pelvis and frog leg lateral are obtained for evaluation for SCFE (Fig. 7.3). Klein’s line, extending a line along the superior femoral neck that intersects with the femoral epiphysis, has often been used to diagnose the condition although its sensitivity has been questioned [16, 17]. Steel proposed the metaphyseal blanch sign which is an extra dense area around the physis due to the slip [18]. Other notable findings can include widening or irregularity of the physis and periosteal elevation. Contralateral hip radiographs should be obtained given the possibility of a contralateral SCFE. Advanced imaging such as a bone scan or MRI may help identify the condition in questionable cases although this is often identified with plain radiographs alone.

In cases where presentation occurs before the age of 10, after the age of 16 and age or height is below the 50th percentile, associated endocrine conditions should be considered [19].

Originally, SCFE was classified as acute (onset of symptoms 3 weeks or less), chronic (symptoms greater than 3 weeks), or acute-on-chronic (acute worsening of symptoms lasting longer than 3 weeks) [20]. Acute slips accounted for 15 % of the cases. In 1993, a new classification system was proposed dividing the condition into cases of stable or unstable SCFE [14]. A stable SCFE is considered if the patient is able to walk with or without crutches. Unstable SCFE is a patient who is unable to walk with or without crutches and is associated with increased incidence of AVN. Rates of AVN in stable SCFE are nearly zero, whereas unstable SCFE progress to AVN about 25 % of the time [21].

The goals of treatment of SCFE are to stabilize the slip, prevent the slip from progressing, and avoiding complications such as AVN. Various methods of treating the slip are utilized and considerable controversy and debate still occurs regarding the ideal method. Methods include single in situ screw fixation, multiple pin fixation, osteotomy, spica cast, or epiphysiodesis. A systematic review of SCFE treatment methods found single screw in situ fixation to be the most effective for stable slips [22].

Controversy exists regarding prophylactic fixation of the contralateral hip. In children with endocrine abnormalities, where the incidence of bilateral SCFE is much higher, prophylactic pinning may be a more reasonable consideration. Unnecessary surgery would often be the case for the majority of patients given the typical 20 % estimate of bilateral SCFE in the general population [23].

Patients typically present with acute onset of anterior hip or groin pain and limited weight bearing ability. Often the hip is held in a flexed, abducted, and external rotated (FABER) position, which maximizes comfort for the patient. The child is generally well appearing, in contrast to the patient with septic arthritis who often is ill appearing. Patients are often afebrile in this condition.

Transient synovitis is often felt to be a diagnosis of exclusion given the broad differential that exists with this presentation. Differential diagnosis includes osteomyelitis, LCPD, SCFE, Lyme arthritis, rheumatoid arthritis, malignancy, septic arthritis, and pelvic abscess.

Plain film radiographs of the hip often are normal but may show slight medial widening of the joint spaces suggesting a joint effusion. Ultrasound is helpful in determining the presence of an effusion but unfortunately does not distinguish between septic arthritis and transient synovitis or other sources of effusion. MRI has been demonstrated to be helpful in distinguishing between transient synovitis and septic arthritis [28].

Kocher et al. proposed an evidence-based algorithm to help predict the likelihood of transient synovitis versus septic arthritis [29, 30]. A history of fever, complete blood cell count (CBC) greater than 12,000/mm³, inability to bear weight and erythrocyte sedimentation rate greater than 40 mm/h are the factors used. A patient with all four criteria had a probability of septic arthritis greater than 99 % [29]. Luhmann et al. attempted to validate the Kocher clinical prediction rule and found only a predicted probability of 59 % in their study, calling into question the validity and reproducibility of the Kocher algorithm [31]. Their study proposed a three-variable algorithm of history of fever, CBC greater than 12,000/mm³ and prior health-care visit with a predicted probability of septic arthritis at 71 %. A 2006 prospective study found fever (oral temperature greater than 38.5 °C) as the best predictor of septic arthritis. A CRP greater than 2.0 mg/dl was also found to be a strong independent risk factor for assessing for suspected septic arthritis [32].

Once the diagnosis of transient synovitis has been established, no treatment is required since it is a self-limited condition. Ibuprofen has been found to shorten the course of the condition [33]. Most cases typically resolve within 3–10 days [34]. Recurrence rates have been reported at about 4 % [24]. In prolonged courses of this condition, other inflammatory conditions of the hip should be considered. Interestingly, the incidence of LCPD has been demonstrated to be higher than the general population incidence following transient synovitis [24, 35].

Patients often will present with a history of painful or painless popping localized deep to the anterior hip and groin or to the lateral hip. When localized to the lateral hip, patients often will describe that the hip pops out of socket. If one asks a patient to recreate this, if they can voluntarily produce the problem, the patient often will rotate the pelvis and a visible and/or audible snapping is seen across the greater trochanter. Dancers often describe their snapping most commonly when in the “second position.”

On physical exam , a snapping may be felt with the iliopsoas condition with simple flexion and extension of the hip. More commonly it is reproduced by starting with the problematic hip in a flexed, externally rotated and abducted position and then internally rotating the hip back into full extension.