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

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

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

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

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