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SLIPPED CAPITAL FEMORAL EPIPHYSIS

(S.C.F.E.)EPIPHYSIOLYSIS

BYPROF. HUSSEIN ABDEL FATTAH

Definition

S.C.F.E. is a disorder of the adolescent hip involving progressive displacement of the femoral head in relation to the femoral neck, through the open growth plate, posteriorly and inferiorly.

However, the epiphysis actually remain seated in the acetabulum, it is the neck which displaces usually anteriorly and superiorly.

ETIOLOGY Exact cause is disputed. Multiple interdependent factors

involved.

• Overweight.• Abnormally tall child.• Black races.• Endocrinopathies

Risk Factors

1 – Biomechanical Factors Change of physeal angle. Increase of physeal activity with

growth spurt. Obesity and lengthening of the neck. Abnormal retroversion of the neck. Weakness of the fibrocartilagenous

perichondrial ring of la Croix.

2 – Endocrine Disorders Harris, (1950)

• Growth Hormone Widening of physeal plate and reduction of

shearing strength,PITUITARY TUMOURS• Sex Hormones

Reduction of physeal plate and increase of shearing strength

Adiposogenital, PITUITARY DIFFICENCY

3 – Metabolic Factors Decreased Vitamin D activity Rickets Renal Osteodystrophy

4 – InflammationMorrissy et al, (1983)

Immune complexes in the synovial fluid.This decreases and disappears when the head is fixed.

Blood supply of the proximal end of the femur

microstructure of the growth plate

Pathology of S.C.F.E. The growth plate is widened and irregular Loose irregular proliferative zone Disarranged and thickened hypertrophic

zone

• Chondrocytes are clustered, not columnar• Disturbed endochondral ossification• Perichondral fibrous ring of LA CROIX is attenuated

Weakening occurs in the hypertrophic zone of the growth plateSlipping occur in this zone

BABY two years traumatic fracture sparation of capital epiphysis

United two months later

RT.

Traumatic fracture separation capital epiphysis five years old boy L. side

Recent

united

A.H.

Remodelling after slip varies with age, younger is more completeFemale age 11 ysRemod.in six m.

10/934/93

Missed fourth degree slip age 13 years

D.M.T. F. Age (13 yrs.) 3/90

Three & half years later natural healing poor remodeling lack of congruity

D.M.T 10/93

Natural History Time of Presentation:

• 1 – Acute Slip: Less than 2 weeks Pain in knee, hip and thigh Mild trauma

2 – Chronic slip:More than 3 weeksVague thigh and knee painMild hip symptoms

3 – Acute on Chronic SlipLong duration of symptomsAcute episode of pain and limping

Diagnosis 1 – Pain

• The commonest presenting symptom: Vague in the knee and thigh Exaggerated with activity Severe in acute episodes

2 – Limping• Antalgic gait in acute conditions• Lurching in long standing conditions• Leg is externally rotated

3- Deromity External rotation of the whole limb• Extension and adduction deformity (on

examination)• Mild shortening

4 – Hip Movements• Limited internal rotation, abduction and flexion

• Flexion of the hip is accompanied by external rotation and abduction

DIAGNOSIS continued

16 YS. 95 K. ADIPOSGENITALIA, BILAT. SLIP RT AFTER S.O.LEFT FULLY EXTERNAL ROTATED & SHORTER .

Plain Radiogram (In early slip)

• Blurring, widening of physeal plate• Decreased height of the epiphysis• A line drown along the lat. Neck not

crossing the epiphysis

Rt .hip is apparently normal

In the A.P. VIEW

First degree slip in lithotomyLateral view

X

LINES IN NORMAL HIP

90 70

Head neck angle

Head shaft angle

Degree of Slipping 1. Mild:

• Slipping of less than 1/3 of epiphysis 2. Moderate:

• Slipping of 1/3 to ½ of epiphysis 3. Severe:

• Slipping of more than ½ of epiphysis

C.T. Scan Demonstrates early slipping Accurate measurement of angle and

degree of slip.the degree of External femoral rotation at the knee

Treatment Aim

• To stop slipping• To enhance healing• To correct deformities• To avoid complications

Treatment Non Surgical Treatment

• Prolonged traction in internal rotation• Immobilization in plaster• Manipulative reduction (condemned)

Adjuvant Hormonal Therapy11 CasesChorionic Gonadotrophic Hormones.

(1500–5000 units/week)

Surgical Treatment Epiphyseal Fixation (Pinning) BOYD

• For mild slips and most moderate slips• Only one or maximum two pins• In mild slips, inserted from lateral

approach• In moderate slips, it is inserted from

anterior

Pinning Pin position in the lower and

posterior half Upper and anterior position is

dangerous > Penetration and avascular necrosis

A.A.Afify M. Lt. Early slip. Rt. N.BILAT .FIX. BY CANULTED

SCREWS

Pinning The Other Hip If painful with no slip Especially in over weight child Only 10% of painless other side may

slip

Preoperative Traction and Pinning In acute and acute on top of chronic

cases• skin Traction in Abduction and internal

rotation by a plaster boot and derotation bar for few days.

• When reduction is achieved pin fixation is done.

SHERBENY pain rt. Hip 30/1o/ 91,acute slip 8/12/91,reduced by traction 3 D.

Sherbiny pins after gradual traction with good reduction

R.R.S. (F.) B.D. 4/2/1986 age 9 ys. X 6/1995 LEFT MISSED SLIP. RIGHT

NORMAL

Acute slip before reduction. R.R.S. 11 (YS) 20/2/1997

R.R.S. AFTER REDUCTION BY GRADUAL TRACTION & FIXATION PINS IN GOOD POSITION

R.R.S. Rt. Hip two pins, Lt. hip remodelled

H.SHARAWY 12 YRS ACUTE SLIP 5/2/86 1O/2/86 5 DAYS

TRACTION

Two pins 10/2/86

H.S. Preslip left side 11/86

H.Sharawy.pins left side 5/87

10. 8810.88

Surgical Treatment Open Reduction

• Dunn (1964) and Dunn & Angle (1978)• High incidence of ischaemic necrosis

and chondrolysis• For severe slipping

Lateral diagram of femoral head showing vascular supply

Blood supply of the S.C.F.E. from medial circumflex artery posteriorly

M.S.O. 16YRS.SUDANESE GIANT DURATION TW0 WEAKS

SLIP 1O.2.1988

4 M .P.O. 6/88

OPEN REDUCTION & INTERNAL. FIXATION

VIABLE HEAD

Implants removed 20/1/1989

1.1989

O.R. for acute slip 6/90

Osteotomy for chondrolysis7/91 Mobile hip mild limp, shortening 10/93

Trochanteric-Osteotomy Triplane osteotomy (Southwick J.B.J.S

1967 A.V.)

• Remove Anterior wedge to correct extension. Remove lateral wedge to correct coxa vara

• Internal rotation to correct ext. rotation

Subtrochanteric triplane osteotomy Correction of the head shaft angle

Fixation by double angle conylar plate

A.E.H. 20/12.1983. AGE 16 YS. RT.Gr.4 LT.Gr.1. PIN 11/11/1999

Left hip

A.EMAD.H. B.D. 20/12/1983 AGE 16 YS. LEFT. HIP PIN 11/1999

EXTRACTED 2/4/2000.RT. HIP VALGUS DEROTATION OSTEOTOMY

2/4/2000

Complications Ischaemic Necrosis

A complication of treatment• Forcible Manipulation• Forcible Traction• Cervical Osteotomy

Chondrolysis acute cartilage necrosis Secondary O.A. Within 20 years More with severe deformities In mild early pinned cases, much less

Secondary O.A. Within 20 years More with severe deformities In mild early pinned cases, much less

Presentation of 42 cases 33 M. mean age 14.2 YS. 9 F. mean age 11.2 YS. never

after menarche

Degree of SlipMild 14 33.3%Moderate 16 38.1%Severe 12 28.6%

• Chronic 47.6%• Acute 33.3%• Acute on Chronic 19%

Mode of Presentation

Side Affected Left side twice the right side in boys,

equal in girls Bilateral in 20 – 80%

• (Weinstein, 1984)

51%HypogonadismOver Weight

18% Abnormally tall31% Normal

Body features

Treatment Non Surgical: 6 Pinning in-situ: 15 Traction-Pinning: 7 S.T.F.O.: 12 Open Reduction: 2

Conclusion S.C.F.E. is an ailment of teenagers Knee pain and limp are early complaints Early diagnosis by hip examination

clinically is important Plain X-Ray of both hips in A.P. and A.P.

Lithotomy position is mandatory C.T. is helpful for further management Early pinning is the best solution Prophylactic pinning may be done Complications chondrolysis early and late

osteoarthritis Treatment of the predisposing factor is

important

Thank YouTHANK

YOU

The Journal of Bone and Joint Surgery

American VolumeVolume 64-A, No 5 July 1967Osteotomy through Lesser Trochanter

for Slipped Captial Femoral Epiphysis*

By Wyane O. Southwick M.D.Y., New Haven Connecticut

From the Department of Surgery, Section of Orthopaedic Surgery, Yale University School of

Medicine, New Haven

Remodeling After Pinning for Slipped Capital Femoral Epiphysis

Nathan R. Jones, Dennis C.Paterson, Terence M. Hiller, Bruce K. Foster.

• From Adelaide Children Hospital, South Australia