Rosen & Barkin's 5-Minute Emergency Medicine Consult (655 page)

FOLLOW-UP

• Ventilatory failure, especially if intubation is necessary
  
• Hemodynamic instability
  

• Maintenance of O
  ₂
  saturation >85% for several hours using oxygenation or ventilation equipment available to the patient at home
  
• Very low likelihood of decompensation overnight
  
• Patients with sleep apnea who present after motor vehicle crashes:
  
  • Manage initially like other blunt trauma patients.
    
  • Later, consider the increased risk with sleep apnea and intervene to prevent future accidents.
    

• PCP referral for sleep apnea and associated comorbidities
  
• Encourage compliance, use of CPAP
  
• Referral of patients with suspected sleep apnea to a pulmonologist
  
• Encourage weight loss and diet control
  
• Cardiology referral is appropriate when sleep apnea is complicated by heart failure or dysrhythmias.
  

• Sleep apnea increases risk of cardiovascular disease, stroke, and diabetes mellitus.
  
• CPAP is the standard of treatment.
  
• Avoid the use of sedatives.
  
• Preparation is essential, as sleep apnea increases intubation complications.
  
• Primary care referral and CPAP compliance education improve therapy.
  

• Buchner NJ, Sanner BM, Borgel J, et al. Continuous positive airway pressure treatment of mild to moderate obstructive sleep apnea reduces cardiovascular risk.
  Am J Respir Crit Care Med
  . 2007;176(12):1274–1280.
  
• Caples SM, Gami AS, Somers VK. Obstructive sleep apnea.
  Ann Intern Med
  . 2005;142(3):187–197.
  
• Epstein LJ, Kristo D, Strollo PJ Jr, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults.
  J Clin Sleep Med
  . 2009;5(3):263–276.
  
• Mulgrew AT, Fox N, Ayas NT, et al. Diagnosis and initial management of obstructive sleep apnea without polysomnography: A randomized validation study.
  Ann Intern Med
  . 2007;146(3):157–166.
  
• Qaseem A, Holty JE, Owens DK, Dallas P, Starkey M, Shekelle P, for the Clinical Guidelines Committee of the American College of Physicians. Management of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians.
  Ann Intern Med.
  2013;159:471--483.
  
• Rosenberg R, Doghramji P. Optimal treatment of obstructive sleep apnea and excessive sleepiness.
  Adv Ther
  . 2009;26:295–312.
  
• Sharma SK, Agrawal S, Damodaran D, et al. CPAP for the metabolic syndrome in patients with obstructive sleep apnea.
  N Engl J Med
  . 2011;365:2277–2286.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Airway Management
  
• Dyspnea
  

The author gratefully acknowledges Mark Sagarin for his previous edition of this chapter.

CODES

• 327.21 Primary central sleep apnea
  
• 327.23 Obstructive sleep apnea (adult)(pediatric)
  
• 780.57 Unspecified sleep apnea
  

BASICS

• Femoral epiphysis translates (slips) posteriorly and inferiorly relative to the femoral head/neck
  
• Classification systems:
  
  • Degree of femoral head “slip” as a percentage of femoral neck diameter:
    
    • (Mild, grade 1) <33.3%
      
    • (Moderate, grade 2) 33.3–50%
      
    • (Severe, grade 3) >50%
      
  • Temporal:
    
    • Acute: <3 wk of symptoms
      
    • Chronic: >3 wk of symptoms
      
    • Acute on chronic: >3 wk of symptoms, now with acute pain
      
  • Stability:
    
    • Stable: Bears weight w/or w/o crutches
      
    • Unstable: Unable to bear weight
      
• Epidemiology:
  
  • Peak age: 12–14 yr (boys), 11–12 yr (girls)
    
  • Male > female (1.6:1)
    
  • Bilateral slips: 20% at presentation; additional 20–40% progress to bilateral
    
  • Atypical SCFE: Endocrinopathy associated:
    
    • Patient may be <10 yr age, >16 yr age, or weight <50th percentile
      
    • High risk of bilateral SCFE (up to 100%)
      

• Proximal physis position changes in adolescence from horizontal to oblique; hence hip forces shift from “compression” to “shear”
  
• Shear force > strength of femoral physis
  
• Weakest point of physis = zone of hypertrophy
  
• Risk factors:
  
  • Obesity: May contribute to shear forces
    
  • Down syndrome
    
  • Endocrinopathy such as hypothyroidism, growth hormone deficiency, renal osteodystrophy (2° hyperparathyroidism): May contribute to growth plate weakening
    

DIAGNOSIS

• Determine chronicity of symptoms and whether or not the patient can bear weight
  
• Pain in the knee, thigh, groin, or hip (referred pain from the obturator nerve):
  
  • Vague and dull for weeks in chronic SCFE
    
  • Severe and sudden onset in acute SCFE, often in the setting of trauma
    

• If stable, presents with limp or exertional limp
  
• If unstable (patient cannot ambulate), avoid further ambulation attempts
  
• Commonly presents with leg externally rotated
  
• Restricted internal rotation, abduction, and flexion (cannot touch thigh to abdomen)
  
• Anterior hip joint tenderness
  
• Test: Apply gentle passive hip flexion → if hip externally rotates + abducts → highly suggestive of SCFE
  
• Gait:
  
  • Antalgic (patient takes short steps on affected side to minimize weight-bearing during “stance” phase of gait)
    
  • Trendelenburg (shift of torso over affected hip; sign of moderate/severe slip)
    
  • Waddling (sign of bilateral SCFE)
    

• Plain radiographs:
  
  • Further imaging with aid from consultant
    
• Orthopedic consultation
  

• If no diagnostic radiographic abnormality, the practitioner may consider the following to help risk stratify possible alternative diagnoses:
  
  • CBC with differential, sedimentation rate, C-reactive protein
    
• If endocrinopathy suspected, consider thyroid function testing
  

• Both hips should be imaged for comparison
  
• Some clinicians prefer cross-table lateral view in acute SCFE instead of frog-leg view (theoretical risk of worsening displacement)
  
• Anteroposterior radiograph:
  
  • Widened or irregular physis
    
  • Bird’s beak appearance of the epiphysis “slipping” off of the femoral head
    
  • Klein line: Parallel line drawn from superior border of the femoral neck; line intersects the epiphysis in normal patient
    
• Lateral radiograph (frog-leg or cross-table)
  

If septic hip is suspected, aspiration and fluid analysis may be needed to exclude.

• Legg–Calvé–Perthes:
  
  • Typically seen in 4–9-yr-old age range
    
• Septic arthritis of hip
  
• Osteomyelitis
  
• Toxic synovitis
  
• Femur or pelvic fractures
  
• Inguinal or femoral hernia
  

TREATMENT