slipped capital femoral epiphysis...

Slipped Capital Femoral Epiphysis SCFE

Slipped Capital Femoral Epiphysis SCFE

George SM Dyer, Harvard Medical School Year-IIIGillian Lieberman, MD

George SM Dyer, Harvard Medical School Year-IIIGillian Lieberman, MD

George DyerGillian Lieberman, MD

January 2001

22

What is it?What is it?

•

In a person with an open femoral physis, mild trauma shifts the femoral head in relation to the femoral neck

•

Femoral head

slips posteriorly

and medially

•

In a person with an open femoral physis, mild trauma shifts the femoral head in relation to the femoral neck

•

Femoral head

slips posteriorly

and medially

http://www.packardchildrenshospital.org/health/orthopaedics/scfe.htm


33

Simplified Concept of SCFESimplified Concept of SCFE


44

Simplified Concept of SCFESimplified Concept of SCFE

Open physisOpen Open physisphysis Slipped physisSlipped Slipped physisphysis


55

EpidemiologyEpidemiology

•

Incidence 30/100,000•

Age: 10 -

15 yrs

•

Boys > girls•

Blacks > whites

•

More common in overweight children

•

Incidence 30/100,000•

Age: 10 -

15 yrs

•

Boys > girls•

Blacks > whites

•

More common in overweight children


66

History and Differential DiagnosisHistory and Differential Diagnosis

•

Ernst Mueller, 1889•

Described it pathologically using dissected specimens

•

“There occurs in young individuals aged 14-18, without trauma to the hip, a limp, a weariness, and gradual shortening of the affected limb”

•

Ernst Mueller, 1889•

Described it pathologically using dissected specimens

•

“There occurs in young individuals aged 14-18, without trauma to the hip, a limp, a weariness, and gradual shortening of the affected limb”

•

Distinguished by Mueller from other hip disorders of the young

•

Congenital Hip Dysplasia

•

Legg-Calve-Perthes

disease•

Can be related to renal osteodystrophy, especially if bilateral

•

Distinguished by Mueller from other hip disorders of the young•

Congenital Hip Dysplasia

•

Legg-Calve-Perthes

disease•

Can be related to renal osteodystrophy, especially if bilateral


77

Radiologic StudiesRadiologic Studies

•

Plain Film Projections•

Posterior-Anterior•

Frog-leg Lateral

•

CT•

May resolve finer anatomy (Guzzanti

V, Falciglia

F, 1991)

•

MR•

Most sensitive for small changes in soft tissues (Umans

H, et al. 1998)

•

But diagnosis is still most often made on plain film

•

Essential

to recognize

•

Plain Film Projections•

Posterior-Anterior•

Frog-leg Lateral

•

CT•

May resolve finer anatomy (Guzzanti

V, Falciglia

F, 1991)

•

MR•

Most sensitive for small changes in soft tissues (Umans

H, et al. 1998)

•

But diagnosis is still most often made on plain film

•

Essential

to recognize


88

Radiographic FindingsRadiographic Findings

•

It’s easy when the findings are clear…

•

It’s easy when the findings are clear…

http://www.aafp.org/afp/980501ap/loder.html


99

Radiographic Findings in SCFERadiographic Findings in SCFE

•

Klein’s Criteria (1951)•

Earliest: Widened and irregular growth plate, compared to contralateral

hip Increased lucency

medially

•

Angulated contour of femoral head, then becomes rounded with adaptation•

Periosteal

proliferation at inferior, posterior margins and further slippage create “crow’s beak”

•

Klein's Line•

Line drawn along superior border of femoral neck should cross at

least a portion of the femoral epiphysis (Klein, 1951)

•

Most sensitive indicator of a mild slip on plain filmClassification

Grade I: displacement of epiphysis less than 30% of width of femoral neckGrade II: slip between 30%-60%Grade III: includes slips of greater than 60% the width of neck

•

Klein’s Criteria (1951)•

Earliest: Widened and irregular growth plate, compared to contralateral

hip Increased lucency

medially•

Angulated contour of femoral head, then becomes rounded with adaptation•

Periosteal

proliferation at inferior, posterior margins and further slippage create “crow’s beak”

•

Klein's Line•

Line drawn along superior border of femoral neck should cross at

least a portion of the femoral epiphysis (Klein, 1951)

•

Most sensitive indicator of a mild slip on plain filmClassification

Grade I: displacement of epiphysis less than 30% of width of femoral neckGrade II: slip between 30%-60%Grade III: includes slips of greater than 60% the width of neck


1010

Klein’s LineKlein’s Line

Courtesy of Dr. Carlo Buonomo, Children’s Hospital, Boston

Klein’s line demonstrates

slipped femoral head on right, normal on left


slipped femoral head on right, normal on left


1111

Importance of the Frog Leg: Patient DG: Is There a Slip?

Importance of the Frog Leg: Patient DG: Is There a Slip?



1212

Patient DG: Frog LegPatient DG: Frog Leg



slipped femoral head bilaterally




1313

Comparison PatientsComparison Patients

•

Now it’s time to practice finding SCFE in other patients•

For each, identify whether there is a slip on the right side, the left side, or both sides

•

Now it’s time to practice finding SCFE in other patients•

For each, identify whether there is a slip on the right side, the left side, or both sides


1414

Patient JB: 15 year old boy Is the Slip on the Right, the Left,

Or Bilateral?

Patient JB: 15 year old boy Is the Slip on the Right, the Left,

Or Bilateral?



1515Courtesy of Dr. Carlo Buonomo, Children’s Hospital, Boston





Patient JB: Frog leg view Is the Slip on the Right, the Left,

Or Bilateral?

Patient JB: Frog leg view Is the Slip on the Right, the Left,

Or Bilateral?




slipped femoral head on right


slipped femoral head on right

Patient MC Is the Slip on the Right, the Left,

Or Bilateral?

Patient MC Is the Slip on the Right, the Left,

Or Bilateral?


1717

Patient KG: 11 year old girl Is There a Slip?

Sometimes Klein’s Line is Equivocal

Patient KG: 11 year old girl Is There a Slip?

Sometimes Klein’s Line is Equivocal




Patient KG: Frog leg view Is the Slip on the Right, the Left,

Or Bilateral?

Patient KG: Frog leg view Is the Slip on the Right, the Left,

Or Bilateral?


1919

When Klein’s Line Fails, Try Capener’s

Sign

When Klein’s Line Fails, Try Capener’s

Sign

•

On PA, ischium

and femoral head overlap to yield crescent of double density

•

SCFE reduces overlap area•

Sometimes more sensitive than Klein’s line alone

•

On PA, ischium

and femoral head overlap to yield crescent of double density

•

SCFE reduces overlap area•

Sometimes more sensitive than Klein’s line alone




Capener’s

sign suggests slipped left

and normal right

Capener’s

sign suggests slipped left

and normal right

Patient KG: Capener’s

Sign Is the Slip on the Right, the Left,

Or Bilateral?

Patient KG: Capener’s

Sign Is the Slip on the Right, the Left,

Or Bilateral?



Capener’s

sign suggests slipped right

and normal left

Capener’s

sign suggests slipped right

and normal left

Patient MG: Is the Slip on the Right, the Left, Or Bilateral?

Patient MG: Is the Slip on the Right, the Left, Or Bilateral?




slipped left

and normal right


slipped left

and normal right

Patient MO: Is the Slip on the Right, the Left, Or Bilateral?

Patient MO: Is the Slip on the Right, the Left, Or Bilateral?




slipped left

and normal right


slipped left

and normal right

Patient MT: Is the Slip on the Right, the Left, Or Bilateral?

Patient MT: Is the Slip on the Right, the Left, Or Bilateral?




slipped left

and normal right

Klein’s line Klein’s line demonstrates demonstrates

slipped leftslipped left

and and normal rightnormal right

Patient RW: Is the Slip on the Right, the Left, Or Bilateral?

Patient RW: Is the Slip on the Right, the Left, Or Bilateral?




slipped right

and normal left


slipped right

and normal left

Patient SP: Is the Slip on the Right, the Left, Or Bilateral?

Patient SP: Is the Slip on the Right, the Left, Or Bilateral?


2626

ComplicationsComplications

Deformityas bones grow

Deformityas bones grow

Acute cartilage necrosis (chondrolysis)

Acute cartilage necrosis (chondrolysis)

Avascular

Necrosis (AVN)

Avascular

Necrosis (AVN)

Time

•

If undetected, SCFE has disabling sequelae•

If undetected, SCFE has disabling sequelae


2727

Tenuous Blood Supply of Femoral HeadTenuous Blood Supply of Femoral Head

•

Arterial supply to the head of the femur is from the medial and lateral circumflex arteries, distally, and from the foveal

artery in the ligamentum

teres, proximally •

All three are threatened by SCFE•

Shift of the femoral head in relation to the femoral neck can shear the circumflex arteries

•

The displacement of the femoral head within the acetabulum

often shears or damages the ligamentum

teres

•

The result is avascular

necrosis of the femoral head

•

Arterial supply to the head of the femur is from the medial and lateral circumflex arteries, distally, and from the foveal

artery in the ligamentum

teres, proximally•

All three are threatened by SCFE•

Shift of the femoral head in relation to the femoral neck can shear the circumflex arteries

•

The displacement of the femoral head within the acetabulum

often shears or damages the ligamentum

teres

•

The result is avascular

necrosis of the femoral head


2828

Progression of AVN in a Sickle-Cell Patient

Progression of AVN in a Sickle-Cell Patient

http://gait.aidi.udel.edu/res695/homepage/pd_ortho/educate/clincase/clcsimge/sickle1.jpg

Age Age Age Age Age Age

Progressive Progressive

•

This patient does not have SCFE, but the pathologic changes of AVN would look similar to those pictured here

•

This patient does not have SCFE, but the pathologic changes of AVN would look similar to those pictured here


2929

Treatment by Femoral Head FixationTreatment by Femoral Head Fixation

Femoral head pinned for

reduction and stability

Femoral head pinned for

reduction and stability

http://www.aafp.org/afp/980501ap/loder.html

•

If detected early, standard-of-care treatment for SCFE is fixation of the femoral head

•

If detected early, standard-of-care treatment for SCFE is fixation of the femoral head


3030

Early Detection Leads to Better OutcomesEarly Detection Leads to Better Outcomes

Excellent % Good % Fair % Poor %Early Treatment 72 14 4 10Delayed < 3 mo 67 20 7 6Delayed 3-6 mo 64 12 12 12Delayed >6 mo 36 9 49 9Delayed >9 mo 28 18 18 36

(Cowell, 1966)(Cowell, 1966)

•

It is crucial to detect even subtle indication of SCFE because early detection leads to much better long-term outcome

•

It is crucial to detect even subtle indication of SCFE because early detection leads to much better long-term outcome


3131

SummarySummary

•

Devastating if missed, essential

to recognize

•

Diagnosis is still most often made on plain film

•

When SCFE is in question, get a frog leg

•

Look for Klein’s line and Capener’s

sign

•

Devastating if missed, essential

to recognize

•

Diagnosis is still most often made on plain film

•

When SCFE is in question, get a frog leg

•

Look for Klein’s line and Capener’s

sign


3232

ReferencesReferences

•

Mueller E. Ueber

die Verbiegung

des Schenkelhalses

im

Wachstumsalter, Eine

neus

Krankheitsbild. Beitraege

zur

Klinische

Chirurgie

1889; 4: 137. Transby

Bick EM, Clin

Orthopedics 1966; 48: 7-10

•

Klein A, Joplin RJ, Reidy

JA, Havelin

J. Roentgenographic

features of slipped capital femoral epiphysis. Am J Roentgenography

1951; 66: 361-364

•

Umans

H, Liebling

MS, Moy L, Haramati

N, Macy NJ, Pritzker

HA. Slipped capital femoral epiphysis: a physeal

lesion diagnosed by MRI, with radiographic and CT correlation. Skeletal Radiol

1998 Mar;27(3):139-44

•

Guzzanti

V, Falciglia

F. Slipped capital femoral epiphysis: comparison of a roentgenographic

method andcomputed

tomography in determining slip severity. J Pediatr

Orthop

1991 Jan-Feb;11(1):6-12

•

Stanitski

CL, Litts

CS, Stanitski

DF J Pediatr

Orthop

Tibial

torsion in chronic, stable slipped capital femoral epiphyses: evaluation by CT scan. 1997 Sep-Oct;17(5):657-8

•

Cowell

H. Significance of early diagnosis and treatment of slipped capital femoral epiphysis. Clin


•

Slipped capital femoral epiphysis. Wheeless

on-line textbook of orthopedics. http://www.medmedia.com/05/314.htm

•

Mueller E. Ueber

die Verbiegung

des Schenkelhalses

im

Wachstumsalter, Eine

neus

Krankheitsbild. Beitraege

zur

Klinische

Chirurgie

1889; 4: 137. Transby

Bick EM, Clin


•

Klein A, Joplin RJ, Reidy

JA, Havelin

J. Roentgenographic

features of slipped capital femoral epiphysis. Am J Roentgenography

1951; 66: 361-364•

Umans

H, Liebling

MS, Moy L, Haramati

N, Macy NJ, Pritzker

HA. Slipped capital femoral epiphysis: a physeal

lesion diagnosed by MRI, with radiographic and CT correlation. Skeletal Radiol

1998 Mar;27(3):139-44•

Guzzanti

V, Falciglia

F. Slipped capital femoral epiphysis: comparison of a roentgenographic

method andcomputed

tomography in determining slip severity. J Pediatr

Orthop

1991 Jan-Feb;11(1):6-12•

Stanitski

CL, Litts

CS, Stanitski

DF J Pediatr

Orthop

Tibial

torsion in chronic, stable slipped capital femoral epiphyses: evaluation by CT scan. 1997 Sep-Oct;17(5):657-8

•

Cowell

H. Significance of early diagnosis and treatment of slipped capital femoral epiphysis. Clin

Orthopedics 1966; 48: 89-94•

Slipped capital femoral epiphysis. Wheeless

on-line textbook of orthopedics. http://www.medmedia.com/05/314.htm


3333

AcknowledgementsAcknowledgements

•

Thanks to Ms. Beverlee

Turner for her invaluable technical assistance in preparing this presentation for publication on the internet

•

Special thanks to Dr. Carlo Buonomo, Children’s Hospital Boston, for his expert instruction on reading pelvic plain film, and for generously allowing access to his teaching collection

•

Larry Barbaras and Ben Crandall our webmasters

•

Thanks to Ms. Beverlee

Turner for her invaluable technical assistance in preparing this presentation for publication on the internet

•

Special thanks to Dr. Carlo Buonomo, Children’s Hospital Boston, for his expert instruction on reading pelvic plain film, and for generously allowing access to his teaching collection

•

Larry Barbaras and Ben Crandall our webmasters


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