Avascular Necrosis in an Adolescent Female With a History of an Eating Disorder

Erik Richardson, Capt, USAF, MC Eglin AFB Family Medicine Residency

Introduction

Musculoskeletal complaints one of most common for adolescents

Family Physicians are the front line in encountering patients with eating disorders Females with a history of an eating disorder and menstrual changes are at risk for stress fractures Menstrual history must be taken in our adolescent females with musculoskeletal complaints

Presented

17 y/o female evaluated in orthopedics department for left sided hip pain Referred from ED after plain films and MRI showed evidence of avascular necrosis of her left hip

History

Gradual onset of left hip pain starting at age 14 with no prior history of trauma
Involved in daily volley ball practice as well as a 4 mile round trip run/walk to school Initial medical evaluation for hip pain at age 16 growing pains

Past medical history - unremarkable

History

Poor self-image and symptoms consistent with eating disorder began one year prior to hip pain
Menarche at age 12 with continued irregular cycles Tobacco use 2-3 cigarettes per day, no alcohol, no history of steroid use

Physical Exam

Well developed adolescent female with normal habitus and secondary development
Marked guarding with antalgic gait External and Internal rotation 30 and 15 with significant pain, Flexion over 90 Pain with log roll Normal neurological exam, no neural tension

Labs

CBC, CMP, Protein C and S, PT/PTT

TSH

RF, ANA
ESR and CRP All labs normal

Radiology

Radiology

Outcome

Meds: alendronate, ibuprofen and oxycodone/acetamenophen for pain

University orthopedic referral Referrals for nutrition, counseling and family therapy

Total hip replacement will be required

Agarwala S, et. al: Efficacy of alendronate, a bisphosphonate, in the treatment of AVN of the hip. Rheumatology; Mar 2005;44,352-359

Discussion

Avascular necrosis: uncommon disorder with significant morbidity

Vascular compromise and ischemia of femoral head Atraumatic: chronic steroid use, excessive alcohol intake, sickle cell, lupus and decompression disease Traumatic: Femoral neck fractures disrupt vascular supply leading to avascular necrosis

Johnson E, et. al: Vascular anatomy and microcirculation of skeletal zones vulnerable toosteonecrosis: vascularization of the femoral head. Orthop Clin N Am 2004

Discussion: Children

Legg-Calve-Perthes:
Idiopathic self limiting First decade between 4-8 4:1 Male to female

Discussion

Slipped Capital Femoral Epiphysis (SCFE)

slippage of proximal femoral epiphysis Peak incidence around 11 years age Increased BMI Slight Male predominance

Discussion

Risk factors for this patient:

No steroid or EtOH use Caucasion with normal hematologic studies Rheumatoid labs normal No history of trauma Age 14 at onset of symptoms Normal BMI with no evidence of SCFE on radiographs

Female Athletic Triad

Amenorrhea/Oligomenorrhea, disordered eating and osteoporosis/osteopenia Decreased caloric intake with excessive expenditure may cause hypothalamic dysfunction leading to decreased estrogen Disrupts hypothalamic-pituitary-ovarian axis causing abnormal menses Estrogen deficiency leads to decreased bone mass
Brunet M: Female Athletic Triad. Clin Sports Med 2005

Female Athletic Triad

Patient not screened for Triad despite three years of symptoms Due to delay in diagnosis, exact etiology unknown in this patient Components of Triad increased patients risk to stress fractures Stress fractures of femoral neck are known to lead to avascular necrosis Current treatment options for patient are limited

Conclusion

Female athletic triad is a well documented triad of risk factors for stress fractures
Review of common risk factors shows female athletic triad most likely contributing factor Menstrual history must be taken for musculoskeletal complaints in adolescent females Failure to intervene can have devastating consequences

References

Brunet M: Female Athlete Triad. Clin Sports Med 2005, 24:623-636. DeFranco M, et. al,: Stress Fractures of the Femur in Athletes. Clin Sports Med 2006, 25:89-103. Robb A: Master of Disguise: Eating Disorder in the Emergency Department, Clin Ped Emer Med 2004, 5:181-186. Spahn G, Schiele R, Langoltz A, Jung, R. Hip pain in adolescents: Results of a cross-sectional study in German pupils and a review of the literature. Acta Paediatr 2005; 94:568. Agarwala S, et. al: Efficacy of alendronate, a bisphosphonate, in the treatment of AVN of the hip. Rheumatology; Mar 2005;44,352-359. Johnson E, et. al: Vascular anatomy and microcirculation of skeletal zones vulnerable toosteonecrosis: vascularization of the femoral head. Orthop Clin N Am 2004; 35:285-291.

Mont MA, Hungerfor DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am 1995; 77:459. Marx: Rosens Emergency Medicine: Concepts and Clinical Practice, 6th ed., 2006 Mosby Inc. p739-741. Kocher M, Tucker R: Pediatric Athlete Hip Disorders. Clin Sports Med 2006, 25:241-253. Kazis K, Iglesias E: The Female Athlete Triad. Adolescent Medicine 2003, 14(1):87-95. Joy E, Campbell D: Stress Fractures in the Female Athlete. Current Sports Medicine Reports 2005; 4(6)-323-328.