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Slipped capital
femoral epiphysis
       (SCFE)
   Introduction and definition
   Epidemiology and risk factors
   classification
   Pathogenesis
   Signs and symptoms
   Diagnosis
   Investigations
   Management modalities
   Complications
INTRODUCTION

 The capital femoral epiphysis is
somewhat unique. It is one of the
few epiphyses in the body that is
inside the joint capsule. (The joint
capsule is the tissue that
surrounds the joint.)
DEFINITION
Slipped upper femoral epiphysis" term refer
to slippage of the overlying epiphysis of
proximal femur posteriorly and inferiorly
due to weakness of the growth plate in
relation to metaphysis.

 Most often, it develops during periods of
accelerated growth, shortly after the onset
of puberty.

The femoral epiphyses maintains its relation
with acetabulum ,it’s the femoral neck and
shaft upward and anterior movement on
epiphyses thus epiphyses displaces
relatively posterior
Femoral Neck Deflection
EPIDEMIOLOGY AND RISK FACTORS
 Incidence is 2-3 per 100000 population
 Most common in adolescent period with rapid growth plate
  (boys aged 10-16 y, girls aged 12-14 y).

 Very early onset[<10yrs] and late onset[>16] should be
  evaluated for endocrine disorders

 Males have 2.4 times the risk as females.

 Obesity is a risk factor because it places more shear forces
  around the proximal growth plate in the hip at risk.

 Bilateral slippage is common of which 2nd slip is about 12-
  18mths later to 1st (left hip is more common than right).
ETIOLOGY-multifactorial
1. Local trauma , obesity

2. Endocrine disorders (e.g primary or secondary hypothyroidism,
    adiposogenital dystrophy(hypogonadal male),

3. Deficiency or increase of androgens.

4. Acute trauma

5. Growth hormone deficiency

6. ATYPICAL SCFE associated with renal failure,radiation therapy

 Slipping of the upper femoral epiphysis occurs predominantly in
  obese children with underdeveloped sexual characteristics and
  less commonly, in tall, thin children.
MECHANICAL FACTORS
Important features of the predisposed hip that may be the primary
cause of slipped epiphysis are:

1.Thinning of the perichondrial ring complex with maturation

2.Relative or absolute retroversion of the femoral neck-making it
more suceptable to AP shear forces

3.A change in the inclination of the adolescent proximal femoral
physis relative to the femoral neck shaft .

•Associated conditions with mechanical etiology-

1.Infantile and adolescent blount diasease

2.Patients with peroneal spastic flatfoot and Legg-Calve-Prthes
disease
   Based on onset of symptoms-acute
                              -chronic
                              -acute on chronic

   FUNCTIONAL CLASSIFICATION-stable
                             -Unstable

   MORPHOLOGICAL CLASSIFICATION-mild
                                -moderate
                                -severe
SYMPTOMS            <2WKS              >2WKS grdual
  X-RAY       displaced epiphyses   remodelling and
               no remodelling       healing noted
ACUTE ON CHRONIC SLIPS-Symptoms lasting longer than
 1mth and recent sudden exacerbation pain after trivial
 trauma
FUNCTIONAL CLASSIFICATION-
It is important to determine ability of the patient to bear weight.

According to LODER-

 1. "Stable" SCFEs allow the
 patient to (walk) with or
 without crutches (walking
 aids).

 2. "Unstable" SCFEs do not
 allow the patient to
 ambulate at all regardles
 of duration of symptoms;
 these cases carry a higher
 rate of complication,
 particularly of AVN.
FROG LEG LATERAL POSITION-
AP VIEW-145*        -Best shows posterior slippage and
LATERAL VIEW-170*   subtle slipping also
                    -Normally 10*posteriorly
                    -Increases in slippage
MORPHOLOGICAL CLASSIFICATION-Grading
Severity of SCFE according to AP and Lateral X-
ray views
PRESLIP-irregularity,widening,and indistinctness
of physes




   Grade-1       Grade-II      Grade-III
 the displacement is either superior and posterior
  (so-called valgus slip)or, even more rarely, anterior.
 In valgus slips there is a restriction of adduction as
  well as of flexion.
 In anterior slips there is a limitation of extension
  and external rotation—exactly the opposite of what
  is found in typical slips.
 X-RAY of valgus slip show
  -superior or lateral displacement of the capital
  epiphysis on the femoral neck on the AP projection
  -posterior displacement on the lateral projection.
 Anterior slips may appear little different from
  typical slips on the AP projection, but the anterior
  displacement of the capital epiphysis is identified
  on the lateral projection.
Pathology
Grossly , with gradual slipping of the capital epiphysis in the typical
posterior position

Periostium is stripped from the anterior and inferior surface of the
femoral neck

So the area between the original femoral neck and the posterior
periostium fills with callus which ossifies and become progresively
more dense

The anterior and superior portion of the neck forms a hump or ridge
that can impinge on the rim of acetabulum

Normally ,this ridge will remodel with anterior portion of the neck
contouring into smoother surface

In case of acute slipping the periostium is torn anteriorly and
               haemarthrosis will be present.
 Microscopically
Characteristc changes
 in PROLIFERATIVE
and HYPERTROPHIC
ZONES of epiphyses
 chondrocytes
-number decrease and
-irregularly arranged
 collagen fibres and
Matrix are increased
SYMPTOMS
1. Pain : in the groin and around the knee.

2. Antalgic Limp (intermittent).

3. Shortening of the affected limb (1-2 cm).

4. The limb is in external rotation.[frog leg position]

5. Flexion, abduction, medial rotation are limited

6. External rotation, adduction are increased.

7.The presence of hip flexion contracture points towards the
    possibility of chondrolysis.

8.Axis deviation – pathognomonic – when hip is flexed, the
     limb goes into external rotation
Slipped capital femoral epiphysis vamshi kiran feb 6/2013
DIAGNOSIS
The diagnosis is a combination of clinical suspicion plus
radiological investigation.

20-50% of SCFE are missed or misdiagnosed on their first
presentation to a medical facility.

This is because the common symptom is knee pain. This is
referred pain from the hip. The knee is investigated and found to
be normal

In acute cases it is essential to differentiate between SCFE and type
1 epiphseal#as most of time both come with history injury/trauma

SCFE pt has prodromal pain in groin,thigh or knee.insidious onset
whereas in type 1 epiphyseal # pt is normal acute pain associated
with high energy trauma
SCFE                                 PERTHE’S DISEASE

Usually occurs in 10-14yrs age       Usually in 4-7yrs age
        late onset in 14-16yrs       late onset in 7-10yrs age

Thin and tall adolescents or short   Occurs in normal child
and obese individuals

Presents as pain with slippage       Initially the child limps and then at
 and limping noted at later stage    later stages complaints of pain

Limb never has fixed flexion         Fixed flexion deformity is usually
deformity                            noted
It may be in hyperextension state
   X-RAYS-AP VIEW-thretowan’s sign[kleins line]
                  -steel metaphysel blanch sign
                  -sham’s sign
                  -capner’s sign
                  -widening of growth plate
                  -decrease of epiphyseal height
    X-RAY -frog-leg [lowenstein]lateral view
   CT-SCAN
   MRI SCAN
LATERAL VIIEW-to
A.P. VIEW-
                       measure lateral
Posterior ,inferior,
                       epiphyseal shaft
And medial
                       angle
translation of
epiphyses
   In normal hip a line drawn tangential to superior
    femoral neck[klein’s line] intersects small
    portion of lateral capital epiphyseal.
   In posterior displacement of epiphyses the line
    doesn’t intersect.
 In AP VIEW-crescent-shaped area of increased
  density overlying the
  metaphysis adjacent to
  the physis
 This increased density is
   due to the overlapping of
   the femoral neck and the
   posteriorly displaced
   capital epiphysis
   In the normal hip the inferiomedial femoral neck overlaps
    the posterior wall of the acetabulum producing triangular
    radiographic density
   With displacement of capital epiphysis this dense triangle
    is lost because this portion of the femoral neck is located
    lateral to the acetabulum.
CAPENERS SIGN-

In pelvic AP view in the normal hip, the posterior acetabular margin
cuts across the medial corner of the upper femoral metaphysis
With slipping, the entire metaphysis is lateral to the posterior
acetabular margin
   Very early slips may appear to be normal in AP
    VIEW but may be clearly noted in lateral view

   CHRONIC CASE OF SCFE X-RAY-
   Reactive bone formation along superolateral
    aspect of neck
   Bone remodelling and broadening of neck
    resulting in PISTOL GRIP like
    appearance[hordons hump]
Slipped capital femoral epiphysis vamshi kiran feb 6/2013
USG-It has been useful in the detection of early slips
  -joint effusion and a ―step‖ between the femoral
  neck and the epiphysis created by slipping.
 Absolute displacement of 6 mm, >2 mm is
  diagnostic of a slipped epiphysis.
 CT-useful in documenting presence of decreased
  upper femoral neck anteversion or true retroversion.
 it’s more accurate measure head–neck angle.
 CT is useful in the management of slips.
 First, CT of the hip can be very helpful in
  demonstrating whether penetration of the hip joint
  by fixation devices has occurred (Fig. 18-9).
 CT is also used to confirm closure of the proximal
  femoral physis and also when reconstructive
  osteotomy is being considered.
 MRI-useful to assess AVN
COMPLICATIONS
1. Avascular necrosis.

2. Chondrolysis.

3. Osteoarthritis.

4. Coxa vara (is a deformity of the
    hip, whereby the angle
    between the ball and the shaft
    of the femur is reduced to
    less than 120 degrees).

5. Slipping of the opposite hip ≈
     20% to 805 of cases
NATURAL HISTORY
•30-40% second slip asymptomatic (slow)


•Premature OA (pistol grip deformity 40% primary
OA)


•Onset of OA directly related to severity of slip
IDEAL TREATMENT
•Prevent further slippage
•Stimulate early physeal closure
•Reduction of epiphyseal displacement
•Avoid complications like osteonecrosis , chondrolysis
and osteoarthritis

•Any child with SCFE and open epiphyses needs
treatment ,without stabilisation it progresses.
•In a patient with closed physes, the only
surgical treatment in the absence of severe
degenerative changes is proximal femoral
osteotomy. Indications are functional
limitations, unacceptable gait, or cosmetic
deformity
   Conservative management-rest and traction
   Closed manipulative reduction
   Operative management
     -In situ pinning
     -ORIF
    -BONE PEG Epiphysiodesis
    -Osteotomy
    -reconstruction by-Arthroplasty
                      -Arthrodesis
                      -Cheilectomy
   Rest for atleast 12wks and traction can be
    an alternative to surgical treatment
   Indicated in – temporary measure before
                         operative ℞
                - slip due to hypothyroidism
   Rest in spica cast - ⇧ incidence of
    complications like chondrolysis
Operative treatment
1.Percutaneous     and open in situ pinning
• Percutaneous pinning is done for mild, moderate and some
  severe acute or chronic SCFE

• Open pinning is used for more severe acute or acute on
  chronic slipping and when closed reduction pinning fail

• Generally 2 cannulated screws for acute (unstable) slips
               1 screw for chronic stable slips.

•Entry point is anterior rather than lateral aspect of femoral neck.

• With increasing severity of the slip, the entry point will be found
progressively more superior on the femoral neck.

•After in situ pinning –early wt bearing in stable slips
•                       -after 6-8wks in unstable slips
•Sports activities only after physeal closure.
HERE


NOT
 -Screw should enter head perpendicular to its physeal surface and in its
HERE
 centre.
 -If two screws are to be inserted, first screw should lie in central axis of head
 and second screw below it avoiding superolateral quadrant.
-pin tip be advanced to 8 mm or one third of the femoral head
radius from subchondral bone, whichever projection is the
closest. This places the actual tip 7 to 18 mm from the
subchondral bone, leaving a safe margin.
Serious disadvantage is    Persistent pin penitration

Adverse affects attributed to unrecognized pin penitration :

•Joint sepsis

•Localised acetabular erosions

•Synovitis

•Post operative hip pain

•Chondrolysis

•Late degenerative osteoarthritis
Prophylactic pinning of the contralateral
hip


•Follow Up till skeletal maturity

•Pin if symptoms are present

•Pin if there is known metabolic/endocrine disorders

•Pin if Follow up is unreliable
   Only for acute and acute on chronic severe
    slips
   Within 24 hours of slip
   High risk of ischemic necrosis of head.
   So, manipulate only acute severe slips that
    may be technically difficult or impossible
    to pin in situ.
   Alternatively gradual reduction by skin
    traction and internal rotation over 3 – 4
    days.
OPEN REDUCTION
•Biomechanical disturbances caused by the tilt of the epiphysis
may cause early degenerative joint changes,

•So open reduction, limited osteotomy, and internal fixation, if
necessary, have been recommended if a severe acute or chronic
slip which cannot be reduced by closed methods


•Dunn emphasized the need to shorten the femoral neck to
prevent tension on the posterior vessels when the epiphysis is
reduced, making the procedure a closing wedge osteotomy,
rather than a simple open reduction.

• The Heyman-Herndon procedure gave consistently good
results for moderate slips,
• Dunn's procedure gave better results for severe slips
Bone peg epiphysiodesis            is not done now a days because
of associated postoperative complications:

•Osteonecrosis

•Chondrolysis

•Infection

•Thigh hypesthesias

•Heterotopic ossification


•After bone peg epiphysiodesis of acute slips, spica cast
immobilization may be necessary for 6 weeks or more to prevent
further slipping
OSTEOTOMY:
 Because moderately or severely displaced chronic slips produce
 permanent irregularities in the femoral head and acetabulum, some
 form of realignment procedure often is indicated to restore the
 normal relationship of the femoral head and neck and possibly
 delay the onset of degenerative joint disease
Two basic types of osteotomies:

•Closing wedge osteotomy through the
femoral neck, usually near the physis to
correct the deformity.

•Compensatory osteotomy through the
trochanteric region to produce a deformity in
the opposite direction
Four femoral neck osteotomies are
described:

(1)the technique of Fish,

(2) the technique of Dunn just distal to
   the slip,

(3) the base of the neck technique of
   Kramer et al., and

(4) the technique of Abraham et al.

(5)Compensatory osteotomies in the
   trochanteric region and partial
   cheilectomy to reduce deformity also
   are described
(6)1 and 2 in open epiphyses
Fish technique: just distal to the the physis
Dunn technique: just distal to the slip
Kramer technique: base of the neck
Abraham technique: at the trochanteric region
•   The advantage of osteotomy through the
    femoral neck [DUNN and FISH type]is that the
    deformity itself is corrected, but incidences
    of osteonecrosis ranging from 2% to 100%
    and of chondrolysis from 3% to 37% have
    been associated
•   ABRAHAM and KRAMMER are osteotomies
    done adjusting according to deformity
•Make the wedge anterior and superior to correct epiphyseal position-
subcapitally
•The more severe the slip the more is wedge superiorly
•Reduce the epiphysis by flexion, abduction, and internal rotation of the limb
•After wedging, diameter of femoral head is greater than femoral neck.

•Indication-severe chronic or acute on chronic slips
  intent of this procedure is to reduce
 the capital femoral epiphysis on the
femoral neck by resecting a portion of
 superior femoral neck,carefully
preserving the posterior periosteum of
femoral neck and preventing tension on
 it during reduction.
 The a lateral approach allows stripping of
 the periosteum and its contained vessels
 under direct vision to avoid damaging
the blood supply to the femoral head.
 In the lateral view, the head
should appear to sit squarely on
 neck,
 In the anteroposterior view,
   the head should be tilted into
   about 20 degrees of valgus
 2WKS later walking with crutches
3-4mths later partial wt bearing
   Its basal femoral neck osteotomy that corrects the
    varus and retroversion components of moderate or
    severe chronic SCFE.
   It is safer than an osteotomy made near or at the
    physis because the line of the osteotomy is distal to
    the major blood supply in the posterior retinaculum




Widest part of wedge (at base of neck) is in line with widest part of slip,
correcting varus and retroversion components
The osteotomy site is closed by medial rotation and abduction of the distal
segment
 Osteotomy done from
lesser to greater
trochanter with
posterior cortex intact
Then fixed with
cancellous screws
   Risk of AVN is low.
   Correction of varus & retroversion is less.
   Does not affect Limb Length Discrepency.
   Improves hip range of motion.
   Usually for malunited slip.
   If physis is still open, in situ pinning with osteotomy.

   Closing wedge Trochanteric Osteotomy
          - to correct varus deformity with some ER.

   Triple deformity – coxa vara + ER + hyperextension
        - Southwick biplane wedge oseotomy
        - Clark’s modification of Southwick osteotomy
        - Ball & Socket Osteotomy
   For residual deformity correction after physeal closure
   When a capital femoral epiphysis has chronically slipped and
    has united in a poor position, a trochanteric osteotomy to
    produce an opposite deformity is done.
   distal femoral fragment osteotomy done and flexed and
    medially rotated making femoral shaft parallel to epiphysis.
   it restores articulotrochanteric distance (ATD), trochanter–
    center of head distance (TCH), and epiphyseal-shaft angle
   AP & lateral views taken
   Head shaft angle
    measured
   Difference of head shaft
    angle between slipped
    side and normal side is
    taken as angle of wedge
    to be taken
   Anterior and lateral based
    wedge OSTEOTOMY done
   Transverse line is drawn on
    ant & lat surface of femur
    at level of lesser
    trochanter.
   Point X is measured 15 mm
    proximal from tranverse
    line along longitudinal
    orientation mark.
   Triangle X‖XT -> Ant
    wedge
   Point X’ is measured 13mm
    post to longitudinal mark
    at level of transverse mark.
   Triangle X’XT -> lat wedge
CHEILECTOMY
When a prominence on the anterosuperior aspect of the femoral
neck blocks internal rotation or abduction by impinging against
the acetabulum


Simple resection of the prominence removes the obstruction
and improves motion

 Care to preserve the integrity of the neck of the femur and the
 physis because fractures of the neck of the femur and further
 acute slipping of the epiphysis may occur when too much is
 excised.

 Intraarticular epiphysiodesis using bone from the crest of the
 ilium was recommended by Herndon.
MANAGEMENT
COMPLICATIONS

SCFE Osteonecrosis
-Rare in untreated SCFE

-Results from interruption of the retrograde
blood supply by:

•Original injury tamponade of the blood supply to
the proximal femoral epiphysis as a result of
acute hemorrhage within the capsule

•Increase with severity of slip

•increase in acute, unstable slips

•increases with forcefull repititive manipulation,

•pin placement in superior quadrant

•                  Osteotomy of femoral neck
DIAGNOSIS: Early postoperative bone scan has excellent sensitivity and
predictive value for detection of osteonecrosis after surgical treatment
of SCFE


TREATMENT
• Remove metal work

• Maintain ROM

• Realignment

• Shelf acetabuloplasty

• Arthrodesis/THR
SCFE Chondrolysis

Dissolution of articular cartilage with joint
stiffness and pain

Causes:

• Persistent pin penitration

• After trochantric osteotomy, open

  reduction,femoral neck osteotomy

   •Synovial malnutrition, ischaemia,
   excessive pressure
   •Autoimmune

   •Females>males
Slipped capital femoral epiphysis vamshi kiran feb 6/2013
Diagnosis: Joint pace of less than 3mm wide ( normal 4 to 6 mm)

               Decrease range of motion at hip joint

TREATMENT

•Bed rest

•Traction

•Salicylates

•Nsaids drugs

•Intraarticular cortisone injections

•Sugical manipulation in form of : Subtotal circumferential capsulectomy

•                Continuous passive motion and physical therapy
Slipped capital femoral epiphysis vamshi kiran feb 6/2013

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Slipped capital femoral epiphysis vamshi kiran feb 6/2013

  • 2. Introduction and definition  Epidemiology and risk factors  classification  Pathogenesis  Signs and symptoms  Diagnosis  Investigations  Management modalities  Complications
  • 3. INTRODUCTION The capital femoral epiphysis is somewhat unique. It is one of the few epiphyses in the body that is inside the joint capsule. (The joint capsule is the tissue that surrounds the joint.)
  • 4. DEFINITION Slipped upper femoral epiphysis" term refer to slippage of the overlying epiphysis of proximal femur posteriorly and inferiorly due to weakness of the growth plate in relation to metaphysis. Most often, it develops during periods of accelerated growth, shortly after the onset of puberty. The femoral epiphyses maintains its relation with acetabulum ,it’s the femoral neck and shaft upward and anterior movement on epiphyses thus epiphyses displaces relatively posterior
  • 6. EPIDEMIOLOGY AND RISK FACTORS  Incidence is 2-3 per 100000 population  Most common in adolescent period with rapid growth plate (boys aged 10-16 y, girls aged 12-14 y).  Very early onset[<10yrs] and late onset[>16] should be evaluated for endocrine disorders  Males have 2.4 times the risk as females.  Obesity is a risk factor because it places more shear forces around the proximal growth plate in the hip at risk.  Bilateral slippage is common of which 2nd slip is about 12- 18mths later to 1st (left hip is more common than right).
  • 7. ETIOLOGY-multifactorial 1. Local trauma , obesity 2. Endocrine disorders (e.g primary or secondary hypothyroidism, adiposogenital dystrophy(hypogonadal male), 3. Deficiency or increase of androgens. 4. Acute trauma 5. Growth hormone deficiency 6. ATYPICAL SCFE associated with renal failure,radiation therapy  Slipping of the upper femoral epiphysis occurs predominantly in obese children with underdeveloped sexual characteristics and less commonly, in tall, thin children.
  • 8. MECHANICAL FACTORS Important features of the predisposed hip that may be the primary cause of slipped epiphysis are: 1.Thinning of the perichondrial ring complex with maturation 2.Relative or absolute retroversion of the femoral neck-making it more suceptable to AP shear forces 3.A change in the inclination of the adolescent proximal femoral physis relative to the femoral neck shaft . •Associated conditions with mechanical etiology- 1.Infantile and adolescent blount diasease 2.Patients with peroneal spastic flatfoot and Legg-Calve-Prthes disease
  • 9. Based on onset of symptoms-acute -chronic -acute on chronic  FUNCTIONAL CLASSIFICATION-stable -Unstable  MORPHOLOGICAL CLASSIFICATION-mild -moderate -severe
  • 10. SYMPTOMS <2WKS >2WKS grdual X-RAY displaced epiphyses remodelling and no remodelling healing noted ACUTE ON CHRONIC SLIPS-Symptoms lasting longer than 1mth and recent sudden exacerbation pain after trivial trauma
  • 11. FUNCTIONAL CLASSIFICATION- It is important to determine ability of the patient to bear weight. According to LODER- 1. "Stable" SCFEs allow the patient to (walk) with or without crutches (walking aids). 2. "Unstable" SCFEs do not allow the patient to ambulate at all regardles of duration of symptoms; these cases carry a higher rate of complication, particularly of AVN.
  • 12. FROG LEG LATERAL POSITION- AP VIEW-145* -Best shows posterior slippage and LATERAL VIEW-170* subtle slipping also -Normally 10*posteriorly -Increases in slippage
  • 13. MORPHOLOGICAL CLASSIFICATION-Grading Severity of SCFE according to AP and Lateral X- ray views PRESLIP-irregularity,widening,and indistinctness of physes Grade-1 Grade-II Grade-III
  • 14.  the displacement is either superior and posterior (so-called valgus slip)or, even more rarely, anterior.  In valgus slips there is a restriction of adduction as well as of flexion.  In anterior slips there is a limitation of extension and external rotation—exactly the opposite of what is found in typical slips.  X-RAY of valgus slip show -superior or lateral displacement of the capital epiphysis on the femoral neck on the AP projection -posterior displacement on the lateral projection.  Anterior slips may appear little different from typical slips on the AP projection, but the anterior displacement of the capital epiphysis is identified on the lateral projection.
  • 15. Pathology Grossly , with gradual slipping of the capital epiphysis in the typical posterior position Periostium is stripped from the anterior and inferior surface of the femoral neck So the area between the original femoral neck and the posterior periostium fills with callus which ossifies and become progresively more dense The anterior and superior portion of the neck forms a hump or ridge that can impinge on the rim of acetabulum Normally ,this ridge will remodel with anterior portion of the neck contouring into smoother surface In case of acute slipping the periostium is torn anteriorly and haemarthrosis will be present.
  • 16.  Microscopically Characteristc changes in PROLIFERATIVE and HYPERTROPHIC ZONES of epiphyses  chondrocytes -number decrease and -irregularly arranged  collagen fibres and Matrix are increased
  • 17. SYMPTOMS 1. Pain : in the groin and around the knee. 2. Antalgic Limp (intermittent). 3. Shortening of the affected limb (1-2 cm). 4. The limb is in external rotation.[frog leg position] 5. Flexion, abduction, medial rotation are limited 6. External rotation, adduction are increased. 7.The presence of hip flexion contracture points towards the possibility of chondrolysis. 8.Axis deviation – pathognomonic – when hip is flexed, the limb goes into external rotation
  • 19. DIAGNOSIS The diagnosis is a combination of clinical suspicion plus radiological investigation. 20-50% of SCFE are missed or misdiagnosed on their first presentation to a medical facility. This is because the common symptom is knee pain. This is referred pain from the hip. The knee is investigated and found to be normal In acute cases it is essential to differentiate between SCFE and type 1 epiphseal#as most of time both come with history injury/trauma SCFE pt has prodromal pain in groin,thigh or knee.insidious onset whereas in type 1 epiphyseal # pt is normal acute pain associated with high energy trauma
  • 20. SCFE PERTHE’S DISEASE Usually occurs in 10-14yrs age Usually in 4-7yrs age late onset in 14-16yrs late onset in 7-10yrs age Thin and tall adolescents or short Occurs in normal child and obese individuals Presents as pain with slippage Initially the child limps and then at and limping noted at later stage later stages complaints of pain Limb never has fixed flexion Fixed flexion deformity is usually deformity noted It may be in hyperextension state
  • 21. X-RAYS-AP VIEW-thretowan’s sign[kleins line]  -steel metaphysel blanch sign  -sham’s sign  -capner’s sign  -widening of growth plate  -decrease of epiphyseal height  X-RAY -frog-leg [lowenstein]lateral view  CT-SCAN  MRI SCAN
  • 22. LATERAL VIIEW-to A.P. VIEW- measure lateral Posterior ,inferior, epiphyseal shaft And medial angle translation of epiphyses
  • 23. In normal hip a line drawn tangential to superior femoral neck[klein’s line] intersects small portion of lateral capital epiphyseal.  In posterior displacement of epiphyses the line doesn’t intersect.
  • 24.  In AP VIEW-crescent-shaped area of increased density overlying the metaphysis adjacent to the physis  This increased density is due to the overlapping of the femoral neck and the posteriorly displaced capital epiphysis
  • 25. In the normal hip the inferiomedial femoral neck overlaps the posterior wall of the acetabulum producing triangular radiographic density  With displacement of capital epiphysis this dense triangle is lost because this portion of the femoral neck is located lateral to the acetabulum.
  • 26. CAPENERS SIGN- In pelvic AP view in the normal hip, the posterior acetabular margin cuts across the medial corner of the upper femoral metaphysis With slipping, the entire metaphysis is lateral to the posterior acetabular margin
  • 27. Very early slips may appear to be normal in AP VIEW but may be clearly noted in lateral view  CHRONIC CASE OF SCFE X-RAY-  Reactive bone formation along superolateral aspect of neck  Bone remodelling and broadening of neck resulting in PISTOL GRIP like appearance[hordons hump]
  • 29. USG-It has been useful in the detection of early slips -joint effusion and a ―step‖ between the femoral neck and the epiphysis created by slipping.  Absolute displacement of 6 mm, >2 mm is diagnostic of a slipped epiphysis.  CT-useful in documenting presence of decreased upper femoral neck anteversion or true retroversion.  it’s more accurate measure head–neck angle.  CT is useful in the management of slips.  First, CT of the hip can be very helpful in demonstrating whether penetration of the hip joint by fixation devices has occurred (Fig. 18-9).  CT is also used to confirm closure of the proximal femoral physis and also when reconstructive osteotomy is being considered.  MRI-useful to assess AVN
  • 30. COMPLICATIONS 1. Avascular necrosis. 2. Chondrolysis. 3. Osteoarthritis. 4. Coxa vara (is a deformity of the hip, whereby the angle between the ball and the shaft of the femur is reduced to less than 120 degrees). 5. Slipping of the opposite hip ≈ 20% to 805 of cases
  • 31. NATURAL HISTORY •30-40% second slip asymptomatic (slow) •Premature OA (pistol grip deformity 40% primary OA) •Onset of OA directly related to severity of slip
  • 32. IDEAL TREATMENT •Prevent further slippage •Stimulate early physeal closure •Reduction of epiphyseal displacement •Avoid complications like osteonecrosis , chondrolysis and osteoarthritis •Any child with SCFE and open epiphyses needs treatment ,without stabilisation it progresses. •In a patient with closed physes, the only surgical treatment in the absence of severe degenerative changes is proximal femoral osteotomy. Indications are functional limitations, unacceptable gait, or cosmetic deformity
  • 33. Conservative management-rest and traction  Closed manipulative reduction  Operative management -In situ pinning -ORIF -BONE PEG Epiphysiodesis -Osteotomy -reconstruction by-Arthroplasty -Arthrodesis -Cheilectomy
  • 34. Rest for atleast 12wks and traction can be an alternative to surgical treatment  Indicated in – temporary measure before operative ℞ - slip due to hypothyroidism  Rest in spica cast - ⇧ incidence of complications like chondrolysis
  • 35. Operative treatment 1.Percutaneous and open in situ pinning • Percutaneous pinning is done for mild, moderate and some severe acute or chronic SCFE • Open pinning is used for more severe acute or acute on chronic slipping and when closed reduction pinning fail • Generally 2 cannulated screws for acute (unstable) slips 1 screw for chronic stable slips. •Entry point is anterior rather than lateral aspect of femoral neck. • With increasing severity of the slip, the entry point will be found progressively more superior on the femoral neck. •After in situ pinning –early wt bearing in stable slips • -after 6-8wks in unstable slips •Sports activities only after physeal closure.
  • 36. HERE NOT -Screw should enter head perpendicular to its physeal surface and in its HERE centre. -If two screws are to be inserted, first screw should lie in central axis of head and second screw below it avoiding superolateral quadrant.
  • 37. -pin tip be advanced to 8 mm or one third of the femoral head radius from subchondral bone, whichever projection is the closest. This places the actual tip 7 to 18 mm from the subchondral bone, leaving a safe margin.
  • 38. Serious disadvantage is Persistent pin penitration Adverse affects attributed to unrecognized pin penitration : •Joint sepsis •Localised acetabular erosions •Synovitis •Post operative hip pain •Chondrolysis •Late degenerative osteoarthritis
  • 39. Prophylactic pinning of the contralateral hip •Follow Up till skeletal maturity •Pin if symptoms are present •Pin if there is known metabolic/endocrine disorders •Pin if Follow up is unreliable
  • 40. Only for acute and acute on chronic severe slips  Within 24 hours of slip  High risk of ischemic necrosis of head.  So, manipulate only acute severe slips that may be technically difficult or impossible to pin in situ.  Alternatively gradual reduction by skin traction and internal rotation over 3 – 4 days.
  • 41. OPEN REDUCTION •Biomechanical disturbances caused by the tilt of the epiphysis may cause early degenerative joint changes, •So open reduction, limited osteotomy, and internal fixation, if necessary, have been recommended if a severe acute or chronic slip which cannot be reduced by closed methods •Dunn emphasized the need to shorten the femoral neck to prevent tension on the posterior vessels when the epiphysis is reduced, making the procedure a closing wedge osteotomy, rather than a simple open reduction. • The Heyman-Herndon procedure gave consistently good results for moderate slips, • Dunn's procedure gave better results for severe slips
  • 42. Bone peg epiphysiodesis is not done now a days because of associated postoperative complications: •Osteonecrosis •Chondrolysis •Infection •Thigh hypesthesias •Heterotopic ossification •After bone peg epiphysiodesis of acute slips, spica cast immobilization may be necessary for 6 weeks or more to prevent further slipping
  • 43. OSTEOTOMY: Because moderately or severely displaced chronic slips produce permanent irregularities in the femoral head and acetabulum, some form of realignment procedure often is indicated to restore the normal relationship of the femoral head and neck and possibly delay the onset of degenerative joint disease Two basic types of osteotomies: •Closing wedge osteotomy through the femoral neck, usually near the physis to correct the deformity. •Compensatory osteotomy through the trochanteric region to produce a deformity in the opposite direction
  • 44. Four femoral neck osteotomies are described: (1)the technique of Fish, (2) the technique of Dunn just distal to the slip, (3) the base of the neck technique of Kramer et al., and (4) the technique of Abraham et al. (5)Compensatory osteotomies in the trochanteric region and partial cheilectomy to reduce deformity also are described (6)1 and 2 in open epiphyses
  • 45. Fish technique: just distal to the the physis Dunn technique: just distal to the slip Kramer technique: base of the neck Abraham technique: at the trochanteric region
  • 46. The advantage of osteotomy through the femoral neck [DUNN and FISH type]is that the deformity itself is corrected, but incidences of osteonecrosis ranging from 2% to 100% and of chondrolysis from 3% to 37% have been associated • ABRAHAM and KRAMMER are osteotomies done adjusting according to deformity
  • 47. •Make the wedge anterior and superior to correct epiphyseal position- subcapitally •The more severe the slip the more is wedge superiorly •Reduce the epiphysis by flexion, abduction, and internal rotation of the limb •After wedging, diameter of femoral head is greater than femoral neck. •Indication-severe chronic or acute on chronic slips
  • 48.  intent of this procedure is to reduce the capital femoral epiphysis on the femoral neck by resecting a portion of superior femoral neck,carefully preserving the posterior periosteum of femoral neck and preventing tension on it during reduction.  The a lateral approach allows stripping of the periosteum and its contained vessels under direct vision to avoid damaging the blood supply to the femoral head.  In the lateral view, the head should appear to sit squarely on neck,  In the anteroposterior view, the head should be tilted into about 20 degrees of valgus  2WKS later walking with crutches 3-4mths later partial wt bearing
  • 49. Its basal femoral neck osteotomy that corrects the varus and retroversion components of moderate or severe chronic SCFE.  It is safer than an osteotomy made near or at the physis because the line of the osteotomy is distal to the major blood supply in the posterior retinaculum Widest part of wedge (at base of neck) is in line with widest part of slip, correcting varus and retroversion components The osteotomy site is closed by medial rotation and abduction of the distal segment
  • 50.  Osteotomy done from lesser to greater trochanter with posterior cortex intact Then fixed with cancellous screws  Risk of AVN is low.  Correction of varus & retroversion is less.  Does not affect Limb Length Discrepency.  Improves hip range of motion.
  • 51. Usually for malunited slip.  If physis is still open, in situ pinning with osteotomy.  Closing wedge Trochanteric Osteotomy - to correct varus deformity with some ER.  Triple deformity – coxa vara + ER + hyperextension - Southwick biplane wedge oseotomy - Clark’s modification of Southwick osteotomy - Ball & Socket Osteotomy
  • 52. For residual deformity correction after physeal closure  When a capital femoral epiphysis has chronically slipped and has united in a poor position, a trochanteric osteotomy to produce an opposite deformity is done.  distal femoral fragment osteotomy done and flexed and medially rotated making femoral shaft parallel to epiphysis.  it restores articulotrochanteric distance (ATD), trochanter– center of head distance (TCH), and epiphyseal-shaft angle
  • 53. AP & lateral views taken  Head shaft angle measured  Difference of head shaft angle between slipped side and normal side is taken as angle of wedge to be taken  Anterior and lateral based wedge OSTEOTOMY done
  • 54. Transverse line is drawn on ant & lat surface of femur at level of lesser trochanter.  Point X is measured 15 mm proximal from tranverse line along longitudinal orientation mark.  Triangle X‖XT -> Ant wedge  Point X’ is measured 13mm post to longitudinal mark at level of transverse mark.  Triangle X’XT -> lat wedge
  • 55. CHEILECTOMY When a prominence on the anterosuperior aspect of the femoral neck blocks internal rotation or abduction by impinging against the acetabulum Simple resection of the prominence removes the obstruction and improves motion Care to preserve the integrity of the neck of the femur and the physis because fractures of the neck of the femur and further acute slipping of the epiphysis may occur when too much is excised. Intraarticular epiphysiodesis using bone from the crest of the ilium was recommended by Herndon.
  • 57. COMPLICATIONS SCFE Osteonecrosis -Rare in untreated SCFE -Results from interruption of the retrograde blood supply by: •Original injury tamponade of the blood supply to the proximal femoral epiphysis as a result of acute hemorrhage within the capsule •Increase with severity of slip •increase in acute, unstable slips •increases with forcefull repititive manipulation, •pin placement in superior quadrant • Osteotomy of femoral neck
  • 58. DIAGNOSIS: Early postoperative bone scan has excellent sensitivity and predictive value for detection of osteonecrosis after surgical treatment of SCFE TREATMENT • Remove metal work • Maintain ROM • Realignment • Shelf acetabuloplasty • Arthrodesis/THR
  • 59. SCFE Chondrolysis Dissolution of articular cartilage with joint stiffness and pain Causes: • Persistent pin penitration • After trochantric osteotomy, open reduction,femoral neck osteotomy •Synovial malnutrition, ischaemia, excessive pressure •Autoimmune •Females>males
  • 61. Diagnosis: Joint pace of less than 3mm wide ( normal 4 to 6 mm) Decrease range of motion at hip joint TREATMENT •Bed rest •Traction •Salicylates •Nsaids drugs •Intraarticular cortisone injections •Sugical manipulation in form of : Subtotal circumferential capsulectomy • Continuous passive motion and physical therapy