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
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
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
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