1. By Bashar AlSaify

2. I.
Slipped capital femoral
epiphysis (SCFE)
II.
Traumatic hip
dislocation
III. Osteoarthritis

3. aka " Slip p e d up p e r fe m o ra l
e p ip hy s is " is a medical term referring
to slippage of the overlying
epiphysis of proximal femur
posteriorly and inferiorly d ue
weakness of the growth
plate. M s t o fte n, it d e ve lo p s d uring
o
to
p e rio d s o f a c c e le ra te d g ro wth, s ho rtly

4. A Klein line is a line drawn along
the superior border of the femoral
neck that would normally pass
through a portion of the femoral
head. If not, slipped capital
femoral epiphysis is diagnosed.
The patient's left hip (arrow)
shows that a slight shift of the
head of the femur occurred
through the growth plate.

5. 1. Risk Factors
 most
common in the adolescent period
(bo y s a g e d 10-16 y , g irls a g e d 12-14 y ).
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 (but the left
hip is a ffe c te d m o re c o m m o nly tha n the
 Males

6. 2. Etiology
1. Overweight
2. Endocrine disorders (e . g a d ip o s o g e nita l
d y s tro p hy , p rim a ry o r s e c o nd a ry hy p o thy ro id is m ).
3. Deficiency or increase of androgens.
4. Acute trauma.
 Slip p ing o f the up p e r fe m o ra l e p ip hy s is o c c urs
p re d o m ina ntly in obese c hild re n with
underdeveloped sexual c ha ra c te ris tic s a nd le s s
c o m m o nly , in ta ll, thin c hild re n.

7. 3. Pathology
 The slip occurs in the hypertrophic zone of the growth
plate.
 70% slow and progressive (This is g ra d ua l, with s lo wly
inc re a s ing s y m p to m s o ve r a p e rio d o f weeks or even
m
onths. I c hro nic s lip p ing , the re m a y be no history of
n
traum a nd the sym
a
ptom are often quite m
s
ild).
 30% acute due to trauma (Le a s t c o m m o n, this us ua lly
fo llo ws
severe traum s uc h a s a fa ll fro m a he ig ht ).
a
 If the slip is sever anterior retinacular vessels are torn
→
avascular necrosis.
 Physeal slip → premature fusion of the epiphysis within
2
years.

8. 4. Clinical Features
1.
2.
3.
4.
5.
Pain : in the g ro in a nd a ro und the kne e .
Limp (inte rm itte nt).
Shortening of the affected limb (1 -2 c m ).
The limb is in external rotation.
Flexion, abduction, medial rotation are
limited.
6. External rotation, adduction are increased.

9. 5. Diagnosis

Ultra sound :

AP X-ray : (melting ice cream cone)

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
Lateral X-ray :
1. W
idening of the growth plate.
2. Trethowan’s sign : Line up superior margin of neck should
intersect
epiphysis (us ua lly 2 0 % o f the fe m o ra l he a d la te ra l
to this line )
3. 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
Slip
Posterior horn of the neck is lower than anterior horn.

12. Grading
Severity of
SCFE according
to AP and
Lateral X-ray
views

13.  It is important to determine if the lesion is stable or
unstable :
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; these
cases carry a higher
rate of complication,
particularly of AVN.

14. 6. Complications
1.
2.
3.
4.
Avascular necrosis.
Chondrolysis.
Osteoarthritis.
Coxa vara (is a d e fo rm ity o f
the hip , whe re by the a ng le
be twe e n the ba ll a nd the s ha ft o f
the fe m ur is re d uc e d to le s s tha n
1 2 0 d e g re e s ).
5. Slipping of the opposite
hip ≈ 20% of cases

15. NOTE:
Coxa Vara
a deformity of the hip,
whereby the angle between
the ball and the shaft of the
femur is reduced to less than
120 degrees. This results in
the leg being shortened, and
therefore a limp occurs. It is
commonly caused by injury,
such as a fracture. It can also
occur when the bone tissue in
the neck of the femur is softer
than normal, meaning it
bends under the weight of the
body.

16. 7. Treatment
1. Mild Cases :
Epiphysis fixation by
kirschner wires or
screws
2. Severe Cases :
In-situ pinning correction of
the deformity by
subtrochantric osteotomy

17. X-ray of a hip following operative percutaneous fixation of
a slipped capital femoral epiphysis

18. Occurs when the head of femur slips out of its socket in
the hip bone (pelvis).
In approximately 90% of patients femur is pushed out of its
socket posteriorly  This leaves the hip in a fixed position,
bent and twisted in toward the middle of the body.
Femur can also slip out of its socket anteriorly  the hip will
be bent only slightly, and the leg will twist out and away from the
middle.
Ahip d is lo c a tio n is very painful. Pa tie nts a re unable to m
ove the leg a nd , if
the re is ne rv e d a m a g e , m a y no t ha ve a ny fe e ling in the fo o t o r a nkle a re a .

19. NOTE: Hip
dislocations are relatively uncommon during athletic
events. Injuries to small joints (e g , fing e r, wris t, a nkle , kne e ) are
much more common. However, serious morbidity can be
associated with hip dislocations.
 Direct
force trauma (m ino r o r m a jo r fo rc e ) to the
 Large
force traumas (e . g m o to r ve hic le
thigh is the most common cause of hip
dislocation.
a c c id e nts , p e d e s tria ns be ing s truc k by
a uto m o bile s ). This type of injury also is
associated with high-energy impact athletic
events (e . g A e ric a n fo o tba ll, rug by , wa te r s kiing )
m
 Children may have a hip dislocation due to
relatively minor trauma.

20. 1. Posterior Hip Dislocation (9 0 % ) :
• Posterior dislocations occur when the knee and hip are flexed and a
posterior force is applied at the knee while the leg is in adducted
position. hip dislocations occur
• Posterior
typically during RTAs, when the knees
of the front-seat occupant strike the
dashboard.

21. Signs & Symptoms of Posterior Hip
Dislocation :
1. pain in the hip and buttock area.
2. The affected limb is shortened, adducted, and internally
rotated, with the hip and knee held in slight
flexion.
3. Patient may be unable to walk or adduct the leg.
4. Signs of vascular or sciatic nerve injury may be
present :
- Pain in hip, buttock, and posterior leg
- Loss of sensation in posterior leg and foot
- Loss of dorsiflexion (p e ro ne a l bra nc h) or plantar flexion
(tibia l bra nc h)
- Loss of DTRs at the ankle.
- Local hematoma in vascular injury.

22. Management of Posterior Hip
Dislocation :
the Bigelow
maneuver 
may be performed with minimal
assistance with the patient in the
supine position . Place the patient
supine on a stretcher that is
elevated to the height of the waist
of the practitioner performing the
reduction.
The injured hip is initially held in a position of adduction and internal
rotation, with one practitioner applying longitudinal distraction and an
assistant applying pressure on the patient's anterior superior iliac
spines so as to stabilize the patient's pelvis.

23. Management of Posterior Hip
Dislocation :
Allis maneuver
Under GA, place the patient in supine
position.
While a n a s s is ta nt s ta biliz e s the p e lvis with
d ire c t p re s s ure , Flex the hip and knee to 90°
and pulls the thigh vertically upward.
Complications of Posterior Hip
Dislocation : nerve injury.
1. Sciatic
2. Vascular injury
(he m a to m a ).
3. Avascular necrosis.

24. 2. Anterior Hip Dislocation :
Anterior dislocation of the hip
occurs from a direct blow to
the posterior aspect of the
hip or, more commonly, from
a force applied to an
abducted leg that displace
the hip anteriorly out of the
acetabulum.

25. Signs & Symptoms of Anterior Hip
Dislocation :
1. Pain in the hip area and inability to walk or adduct the leg
2. The leg is externally rotated, abducted, and extended at the
hip.
3. The femoral head may be palpated anterior to the pelvis.
 Signs of injury to the femoral nerve or artery may be
present:
femoral nerve :
Paresis of lower extremity
Weak or absent DTR at knee
Paresthesias of lower extremity
femoral artery:

26. Management of Anterior Hip Dislocation :
•R
eduction : almost identical to post. dislocation, except
while the thigh is pulled upward it should be adducted then
an assistant helps by applying lateral traction to the thigh.
Complications of Anterior Hip
Dislocation :
Avascular necrosis.
femoral nerve injury.
femoral artery injury.

27. 3. Central Hip Dislocation :
The third type of hip
dislocation is a central
dislocation in which a
direct impact to the
lateral aspect of the hip
forces the hip centrally
through the acetabulum
into the pelvis. This is a
fracture -dislocation.

28. Indications for Open Reduction :
1. Irreducible dislocation
2. Persistent instability of the joint following
reduction (e . g fra c ture -d is lo c a tio n o f the p o s te rio r
a c e ta bulum )
3. Fracture of the femoral head or shaft
4. Neurovascular deficits that occur after
closed reduction

29. Chronic degenerative disorder in which
there is progressive articular hyaline
cartilage destruction and new bone
formation, with remodeling of joint
contour.
Accompanied by new cartilage and bone
proliferation at the joint margins.

30. Most common nontraumatic disorder of the hip in
middle and late age. Healthy fit
and over 50 years of age.
 In younger patients it may
appear as a sequel to
acetabular dysplasia, coxa
vara ,slipped epiphysis.
 Secondary osteoarthritis
arthritis is seen in older patients
after secondary R avascular
A,
necrosis, or paget’s disease.

31. Pathology :
 Area of maximal loading (top of the joint) shows
marked changes:
1. Articular cartilage becomes soft and fibrillated.
2. underlying bone shows cyst formation and
sclerosis.
 At the margins of the joint there are the
characteristic osteophytes.
 Synovial hypertrophy and capsular fibrosis.

32. Clinical features :
1. Pain : fe lt in the g ro in a nd ra d ia te s to
the kne e ty p ic a lly a fte r p e rio d s o f a c tivity ,
la te r it be c o m e s c o ns ta nt a nd d is turbs
s le e p .
2. Stiffness.
3. Limping.
4. Muscle wasting.
5. Deep tenderness.

33. X – Ray :
 Earliest sign is a decreased joint space.
 Later signs are subarticular sclerosis, cyst
formation and osteophytes at the edges of the
joint.

34. 
Osteoarthritis of the
hip showing joint
space narrowing
at the weight
bearing surface and
osteophyte
formation.

35.  Osteophytosis
(a rro w) is
noted at
the articular
margin of the
femoral head.

36. Treatment :
M
ainly sym
ptom .
atic
1. Analgesics.
2. Use of a walking stick.
3. Preserve movement and stability by performing exercises
within the range of comfort.
4. Joint manipulation sometimes relieves pain for long
periods.
5. changing life style to reduce impact loading on the
affected hip e . g Clim bing up a nd d o wn the s ta irs , c a rry ing he a vy
we ig hts

37. Operative Treatment :
Indicated in :
• Severe pain
• Progressive decrease in joint movement
• Increase difficulty with activities of daily living
• X-ray signs showing progressive joint
deterioration.
 The procedure of choice is total hip
replacement.

38. Hip Replacement :
Hip replacement is a surgical procedure in
which the hip joint is replaced by a prosthetic
implant. Hip replacement surgery can be
performed as a total replacement or a hemi
(half) replacement. Such joint replacement
orthopaedic surgery generally is conducted to
relieve arthritis pain or fix severe physical joint
damage as part of hip fracture treatment. A
total hip replacement (total hip arthroplasty)
consists of replacing both the acetabulum and
the femoral head while hemiarthroplasty
generally only replaces the femoral head. Hip
replacement is currently the most successful
and reliable orthopaedic operation with 97%

39. www.sawa2006.com
Bashar