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Three Part Question

In [children with Slipped Capital Femoral Epiphysis] has [ultrasound or plain radiography] [greater sensitivity for the diagnosis]?

Clinical Scenario

A 12-year-old boy presents to the emergency department with a history of limp and decreased range of movement at his right hip. You suspect that he may have a slipped capital femoral epiphysis. You wonder whether plain film radiograpy or ultrasound sonography would be a more sensitive diagnostic modality for slipped capital femoral epiphysis.

Search Strategy

Medline using the OVID interface 1946 to October Week 3 2013

slipped.af. AND capital.af AND (femur/ OR femur.af. OR femoral.af.) AND (epiphyses/ OR epiphyses.af. OR epiphysis.af.) AND (ultrasonography.hw. OR ultrasonography.af. OR ultrasound.af. OR Ultrasonography/ OR ultrasonics/ OR ultrasonics.af.) AND (radiography.hw. OR radiography.af. OR Radiography/) AND (diagnosis.hw. OR Diagnosis/ OR diagnosis.af.) Limit to English Language.


Embase using NICE Evidence 1980- date of searching 23.10.2013

slipped.af. AND capital.af AND (femur/ OR femur.af. OR femoral.af.) AND (epiphysis/ OR epiphyses.af. OR epiphysis.af.) AND (ultrasonography.af. OR ultrasound.af. OR Ultrasound/ OR ultrasonics.af.) AND (radiography.af. OR Radiography/) AND (Diagnosis/ OR diagnosis.af.) Limit to English Language


The Cochrane Library Issue 10 of 12, October 2013

(slipped:ti,ab,kw AND capital.ti.ab.kw.) OR (slipped:ti,ab,kw AND epiphyses.ti,ab,kw OR epiphysis,ti,ab,kw)

Search Outcome

Eleven papers were found in Medline, 12 in Embase and five in Cochrane. Three were relevant to the three-part question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Magnano et al 1998 Switzerland	Symptomatic overweight patients aged between 9 and 15 years	21 Symptomatic overweight patients (15 boys and 6 girls) aged 9–15 years with anteroposterior radiographs; frog leg images were not acquired in 3 cases only. Ultrasonography was performed in 19 cases and the images acquired with 5–7.5 MHz probes on the sagittal plane parallel to the femoral neck. MRI was performed in 9 cases, with coronal and sagittal T1 SE and T2* GE images	Sensitivity	66% for anteroposterior radiography with 6 false negatives	Small numbers
			Sensitivity	80% for combined anteroposterior and frog leg images (3 false negatives)
			Sensitivity	95% for US (1 false negative)
			Sensitivity	88% for MRI (1 false negative)
Terjesen T 1992 Norway	8 patients with non-acute slipped capital femoral epiphysis	Comparison of ultrasonography with radiography for diagnosis of slipped capital femoral epiphysis	Visualisation by ultrasound	Occurred in 7 out of 8 patients	Small numbers
Kallio et al 1991 Australia	Patients with recent Slipped Capital Femoral Epiphysis (SCFE) admitted to the Adelaide Children's Hospital	Prospective Study from December 1988 to May 1990 Comparing ultrasonography with radiography in the initial diagnosis and in the classification of SCFE. 21 consecutive patients with 26 episodes of SCFE admitted to Adelaide Children's Hospital were included in the study.	Diagnostic accuracy of sonography and radiography	In the 32 episodes of hip pain, 26 with SCFE and six irritable hips, sonographic diagnosis was correct in 31. The one patient with a false negative result had normal radiographs and sonographs, but was diagnosed as a preslip type of SCFE from the clinical signs and a positive bone scan. The frog lateral radiographs failed to demonstrate the SCFE in two cases	Small numbers

Comment(s)

Ultrasonography is accurate and harmless to the patient even if frequently repeated. The sonographic measurement of physeal displacement is free from projectional errors of radiological methods. These papers suggest that ultrasound is more sensitive in diagnosing minimal slips.

Editor Comment

GE, gradient echo; SCFE, slipped capital femoral epiphysis; SE, spin echo

Clinical Bottom Line

Ultrasonography is considered to be more sensitive than radiography for diagnosing slipped capital femoral epiphysis based on the results of small studies.

References

1. Magnano GM, Lucigrai G, De Filippi C et al. Diagnostic imaging of the early slipped capital femoral epiphysis. Radiol Med. 1998;95:16–20.
2. Terjesen T. Ultrasonography for diagnosis of slipped capital femoral epiphysis. Comparison with radiography in 9 cases. Acta Orthop Scand. 1992;63:653–7.
3. Kallio PE, Lequesne GW, Paterson DC, et al. Ultrasonography in slipped capital femoral epiphysis. Diagnosis and assessment of severity. J Bone Joint Surg Br. 1991;73:884–9.