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The Peritubercle Lucency Sign is a Common and Early Radiographic Finding in Slipped Capital Femoral Epiphysis

Maranho, Daniel A. MD, PhD*,†; Miller, Patricia E. MS*; Novais, Eduardo N. MD*

Journal of Pediatric Orthopaedics: August 2018 - Volume 38 - Issue 7 - p e371–e376
doi: 10.1097/BPO.0000000000001198

Background: A rotational mechanism of slipped capital femoral epiphysis (SCFE) in which the epiphyseal tubercle acts as a fulcrum has been recently described. However, there is limited radiographic evidence supporting this theory. We aimed to investigate whether a radiographic lucency around the epiphyseal tubercle (peritubercle lucency sign) could be observed before or at the diagnosis of a subsequent slip in patients initially presenting with unilateral SCFE.

Methods: We evaluated 70 patients with unilateral SCFE who were followed until a contralateral slip was diagnosed, and 180 patients with unilateral SCFE who had no contralateral slip until skeletal maturity between 2000 and 2017. We revised anteroposterior and lateral radiographs from the initial presentation, surveillance, and diagnosis of a contralateral SCFE. The presence or absence of the peritubercle lucency sign in the contralateral initially uninvolved hip was recorded for every radiograph. The presence of hip pain, and the presence of classic radiographic parameters for SCFE diagnosis (epiphyseal tilt and Klein’s line) were recorded when the peritubercle lucency sign became noticeable.

Results: The peritubercle lucency sign was observed in 84% [59/70; 95% confidence interval (CI), 73%-92%] of the patients who developed contralateral slip. Most patients (46/59=78%; 95% CI, 65%-87%; P<0.001) had the peritubercle lucency sign visible within 9 months after the initial diagnosis of unilateral SCFE. The sign preceded the definitive diagnosis of the contralateral slip at a median of 9 weeks (interquartile range, 0 to 10 wk). At the time of first observation of the peritubercle lucency sign, 36% (25/70; 95% CI, 25%-48%) of the patients were asymptomatic and 49% (34/70; 95% CI, 36%-61%) of the hips showed no abnormalities in the tilt angle or the Klein line. Among patients who did not experience a contralateral slip (n=180), the sign was observed in 2 patients (1.1%; 95% CI, 0.2%-4.4%). The sensitivity was 84% and specificity was 99%.

Conclusions: A peritubercle lucency is an early imaging sign, present in >80% of contralateral slips following an initial presentation of unilateral SCFE. The presence of the peritubercle lucency sign may be helpful for contralateral hip surveillance. Future studies are necessary to establish the clinical validity of the peritubercle lucency sign and whether it may serve as a predictor of contralateral involvement.

Level of Evidence: Diagnostic level III.

*Department of Orthopedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA

Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, SP, Brazil

D.A.M.: study design, data collection, imaging evaluation, analysis, manuscript writing, figures selection, and critical revision. P.E.M.: data curation, statistical analysis, manuscript revision. E.N.N.: study design, supervision, imaging evaluation, manuscript editing, and critical revision.

This study was performed at Boston Children’s Hospital.

D.A.M. received a postdoctorate scholarship (grant 2016/04376–3) from São Paulo Research Foundation (FAPESP).

The authors declare no conflicts of interest.

Reprints: Eduardo N. Novais, MD, 300 Longwood Avenue, Hunnewell 231, Boston, MA 02115. E-mail:

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