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

11. 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

12. 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 • 4:1 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

16. 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

17. 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

18. 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 patient’s risk to stress fractures • Stress fractures of femoral neck are known to lead to avascular necrosis • Current treatment options for patient are limited

19. 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

20. 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.

21. Mont MA, Hungerfor DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am 1995; 77:459. • Marx: Rosen’s 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.