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

1
Avascular Necrosis in an Adolescent Female With a
History of an Eating Disorder

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

2
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

3
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

4
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

5
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

6
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

7
Labs

• CBC, CMP, Protein C and S, PT/PTT
• TSH
• RF, ANA
• ESR and CRP
• All labs normal

8
Radiology
9
Radiology
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(No Transcript)
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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 200544,352-359
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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

13
Johnson E, et. al Vascular anatomy and
microcirculation of skeletal zones vulnerable
toosteonecrosis vascularization of the femoral
head. Orthop Clin N Am 2004
14
Discussion Children

• Legg-Calve-Perthes
• Idiopathic
• self limiting
• First decade between 4-8
• 41 Male to female

15
Discussion

• Slipped Capital Femoral Epiphysis (SCFE)
• slippage of proximal femoral epiphysis
• Peak incidence around 11 years age
• Increased BMI
• Slight Male predominance

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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

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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
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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

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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

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References

• Brunet M Female Athlete Triad. Clin Sports Med
  2005, 24623-636.
• DeFranco M, et. al, Stress Fractures of the
  Femur in Athletes. Clin Sports Med 2006,
  2589-103.
• Robb A Master of Disguise Eating Disorder in
  the Emergency Department, Clin Ped Emer Med 2004,
  5181-186.
• 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 94568.
• Agarwala S, et. al Efficacy of alendronate, a
  bisphosphonate, in the treatment of AVN of the
  hip. Rheumatology Mar 200544,352-359.
• Johnson E, et. al Vascular anatomy and
  microcirculation of skeletal zones vulnerable
  toosteonecrosis vascularization of the femoral
  head. Orthop Clin N Am 2004 35285-291.

21

• Mont MA, Hungerfor DS. Non-traumatic avascular
  necrosis of the femoral head. J Bone Joint Surg
  Am 1995 77459.
• Marx Rosens Emergency Medicine Concepts and
  Clinical Practice, 6th ed., 2006 Mosby Inc.
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• Kocher M, Tucker R Pediatric Athlete Hip
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• Joy E, Campbell D Stress Fractures in the Female
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