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Pediatric Orthopedics RoundsNov 2002

Abdulaziz Al-Ahaideb

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12 year-old girl with sore left hip

Questions

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History V.C. 12y.0. girl c/o painful Lt hip last two weeks . fell 4

days ago. Pain increased but still able to wt bear. It was activity related but never went away with rest

on admission day oct7.2002 she was about to get on the bus and her leg gave out from under her. She had acute pain in the Lt hip and couldn’t bear weight. Otherwise healthy

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No constitutional symptoms No problems in the other joints Healthy otherwise

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Physical Examination

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Couldn’t put weight on the Lt hip Pain with range of motion Limitation of internal rotation Examination of the knee was unremarkable N/V intact

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What is the DDx ?

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Investigations

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What would you tell the parents ?

What exactly would you do in the OR ?

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Intraop. fluoroscopy

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Postoperative radiographs

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Is it urgent to take the patient to OR ?

What are the complications of SCFE ? And How to avoid them?

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What is your postoperative management ?

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Slipped Capital Femoral Epiphysis The term is a misnomer because the epiphysis

stays in the acetabulum (held by ligamentum teres) and it is the metaphysis that slips

SCFE results from a Salter-Harris–type physeal fracture. In adolescents with SCFE, the epiphyseal growth plate is unusually widened, primarily due to expansion of the zone of hypertrophy

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Etiology Vast majority of cases are idiopathic Associated conditions :

Endocrine disorders (e.g. hypothyroidism) Renal osteodystrophy Radiation therapy

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Etiology Mechanical factors:

Obesity Increased femoral retroversion Deep acetabulum

Hormonal Testosterone reduces physeal strength

SCFE is not a heritable disorder, however, there is a family predisposition

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Epidemiology 60 % are males Mean age is 13.5 yrs for boys and 12 yrs for

girls May be bilateral in up to 50 % (esp. in those

with endocrine disorders) Lt hip is more common

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History Hip Pain

Duration, location Ability to bear weight

Limping Some patients present with Knee pain History of injury Ask about medical problems and their

symptoms

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Physical Examination Obese children are at higher risk for this problem. Determine the patient's gait pattern (eg, antalgic,

Trendelenburg) and ability to bear weight. Active and passive range of motion of both hips and

knees (usually limited internal rotation) The lower extremity may rotate externally on gentle

passive flexion of the hip when a SCFE is present. Note any lower extremity deformity, such as external

rotation or shortening.

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DDx Perthe’s disease Femoral Head Avascular Necrosis Femoral Neck Fracture Femoral Neck Stress Fracture Femur Injuries and Fractures Osteitis Pubis

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Classification Acute (if less than 3 wks) versus chronic versus

acute on chronic (don’t forget pre-slip) Stable or unstable - Stable patients are able to bear

weight on the affected limb with or without crutches or assistive devices. Unstable patients are unable to bear weight due to pain.

Radiographic - Determined by percentage of displacement of the hip in relation to the neck, as follows: grade I (<33%), grade II (33-50%), and grade III (>50%)

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Radiography Klein's Line:

line drawn along superior border of femoral neck should cross at least a portion of the femoral epiphysis

slip must be suspected if a straight line drawn up lateral surface of femoral neck does not touch the femoral head

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Management Goal of treatment is to relieve pain, stop slip

progression while avoiding complication, acceleration of epiphysiodesis

The recommended treatment for all types is pinning in situ

Forceful reduction before treatment is not indicated

Pin placement can be done percutaneously with one pin

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Management In-situ pinning:

Technique: pt supine, percutaneous screw under fluoro , cross physis perpendicularly in both planes and to the centre of epiphysis

Don’t put the screw in superior posterior quadrant

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Management Hip spica is a historical treatment. Open epiphysiodesis with bone grafting Open reduction and a corrective osteotomy Compensating base-of-neck osteotomy Intertrochanteric osteotomy with internal

fixation

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Prophylactic pinning Prophylactic Pinning of the Contralateral Hip in

Patients with SCFE Proponents- Emphasize rate of B/L disease and

higher risk of osteoarthritis with the increase in slip severity

Opponents- Stress that in situ pinning can be associated with severe complications and that many hips would be treated unnecessarily

Trend- Observation of the unaffected hip

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SCFE Loder examined two groups early and late in

situ pinning and found no difference in rate of AVN

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Complications Avascular necrosis

Risk factors: acute unstable SCFE, forceful reduction, placement of screw in the superiorposterior quadrant and femoral neck osteotomy

It is rare in pts with stable slip Chondrolysis

Risk factors are pin penetration Incidence 5-8 %

Degenerative arthritis

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