slipped femoral epiphysis, SCFE, screw fixation, CT scan in SCFE, Fixation in situ

1. Slipped Capital Femoral Epiphysis
Vinod Naneria
Girish Yeotikar
Arjun Wadhwani
Choithram Hospital & Research Centre, India

2. Incidence
• SCFE occurs between the ages of 10 & 16 yrs.
• 20% bilateral involvement at the time of
presentation.
• 20-40% will subsequently progress to bilateral
slips.
• When the presentation is sequential, the
second hip usually presents within 18 months
of the first SCFE.

3. Risk factors
• Pre puberty / puberty / growth spurt
• obesity,
• Hypothyroidism,
• low growth hormone level,
• Pituitary tumors,
• Craniopharyngioma,
• Down syndrome,
• Renal osteodystrophy,
• Adiposogenital syndrome.

4. Theory
• Biomechanical events versus biochemical
events having impact at the time of puberty.
• The zone of slipping always occurs primarily
through the zone of hypertrophy in a
corrugated undulating fashion.
• The growth plate at the time of puberty is
weakened in SCFE, leads to a mechanical
failure of the growth plate.

5. Theory
• The prepubertal obesity + an increasingly
oblique physis + degree of retroversion
creates a mechanical environment that,
coupled with alterations in the hormonal
balance of thyroid hormone, growth
hormone, testosterone, and estrogen, render
the plate intrinsically suspectible to slip by
innocuous forces occurring in a shear plane.

6. SCFE results from a Salter-
Harris type 1 epiphyseal
fracture.
The growth plate is
unusually widened, primarily
due to expansion of the
zone of hypertrophy.
The hypertrophic zone,
which constitutes 15-30% of
the normal epiphysis, can
account for up to 80% of the
width of the epiphyseal
plate in affected patients.

7. Pathophysiology
• The position of the proximal physis normally
changes from horizontal to oblique during
preadolescence and adolescence, redirecting
hip forces from compression forces to shear
forces. There is an association between
femoral neck retroversion and a reduced neck-shaft
angle with SCFE. These changes can
increase the shear forces across the hip,
leading to SCFE

8. Investigations
• Clinical history – pain hip / thigh / knee
• Hip movements – flexion / abd / int rotation
• X-rays – both hips, frog leg lateral
• CT scan – 3D for quantification – screw
placement
• MRI – non specific marrow edema
• Ultrasonography
• Bone scan – for AVN in severe slip

9. Investigations
• Endocrine profile
• Routine hormonal screening of children with
slipped capital femoral epiphysis (SCFE) is not
indicated.
• Age below 10 and above 16 years needs
endocrine profile

10. classification
• "Stable" SCFEs allow the patient to ambulate
with or without crutches.
• "Unstable" SCFEs do not allow the patient to
ambulate at all; these cases carry a higher rate
of complication, particularly of AVN.
Acute: < 3wks, Chronic: > 3wks,
Mild – Moderate – Severe

11. Radiological classification
• Type I slippage is less than 33% displacement.
• Type II slippage is between 33% and 50%
displacement.
• Type III slippage is greater than 50%
displacement.
The blurring of physis (Blanch sign)

12. Plain Radiology
• In the pre-slip phase, there widening of the growth
plate with irregularity and blurring of the physeal
edges.
• The slip that occurs is posterior and to a lesser extent,
medial and therefore is more easily seen on the frog-leg
lateral view rather than the AP hip view.
• A line drawn up the lateral edge of the femoral neck
(line of Klein) fails to intersect the epiphysis during the
acute phase
• Additionally, because the epiphysis moves posteriorly,
it appears smaller because of projectional factors.

13. Southwick angle

14. Southwick angle
• Radiographic angle used to measure the severity
of a slipped capital femoral epiphysis (SCFE) on a
radiograph.
• The angle is measured on a frog lateral view of
the bilateral hips. It is measured by drawing a line
perpendicular to a line connecting two points at
the posterior and anterior tips of the epiphysis at
the physis. A third line is drawn down the axis
of femur. The angle between the perpendicular
line and the femoral shaft line is the angle.

15. Southwick angle
• The angle is measured bilaterally. The slipped
side is then subtracted from the normal side.
The number calculated determines the
severity. Mild is classified by < 30°. Moderate
is 30°-50°. Severe is >50°. 12° is the normal
control value and can be used in the case of
bilateral involvement.

16. http://radiopaedia.org/articles/slipped-upper-femoral-epiphysis

17. 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

18. Frog leg radiograph
• Frog leg radiograph: A straight line through
the center of the femoral neck proximally
should be at the center of the epiphysis. If
not, and the line is anterior in the epiphysis, it
is likely an SCFE.

19. http://radiopaedia.org/articles/slipped-upper-femoral-epiphysis

20. CT Scan
• Is a sensitive and an accurate method of
measuring the degree of upper femoral
epiphyseal tilt and detecting the disease in its
early stage.
• 3 D images - the relationship of femoral head to
the metaphysis in three planes.
• A metaphyseal blanch sign is an increase in
density in the proximal metaphysis. It represents
an attempt of healing process that occurs before
the visible displacement of the epiphysis.

27. Treatment
• Surgical emergency
• Fixation in situ
• Avoid joint penetration
• Corrective osteotomy
• Safe surgical dislocation
• Sub-trochanteric osteotomy

30. 20/10/2014

32. Case two
Open Epiphyseal plate Closed Epiphyseal plate

33. Lateral view in frog leg position

34. 13/3/04

35. 7/11/2004

36. 7/11/2004

37. 21/4/2005
Epiphyseal closure complete

39. Case three

42. 28/4/2004

43. 28/4/2004

44. 2/6/2004

45. 2/6/2004

46. Old SCFE

47. Severe slipped capital femoral epiphysis: The
Dunn's operation
• After extra-digital trochanterotomy, subperiosteal detachment was
achieved by disinserting first the vastus lateralis muscle, then the
entire trochanteric region; after anterosuperior capsulotomy,
detachment continued right around the neck of the femur. The
epiphysis was then detached from the neck by a spatula gently
introduced into the physis, so as to remain in contact with the
vessel-bearing periosteal lamina. The metaphyseal region, and the
postero-inferior beak in particular, was then regularized. This
completely separated the epiphysis and metaphysis. The reduction
was maintained by backward and forward pinning previously
implemented in the neck of the femur, with a compression screw
when the diameter was sufficient. Postoperative traction was
systematically maintained for between 15 and 21 days.
http://www.boneandjoint.org.uk/highwire/filestream/5328/field_highwire_articl
e_pdf/0/833.full-text.pdf

48. Potential complications include
• AVN of the femoral head: 10-15%.
• Chondrolysis (7-10%): acute cartilage necrosis
deformity
• Degenerative osteoarthritis: 90%
• Acetabular impingement.
• limb length discrepancy

49. Follow up
• Both osteonecrosis and chondrolysis usually
appear, clinically or radiographically, during
the first year after the operation.
• Osteonecrosis and chondrolysis develop
between three and eight months after surgical
treatment.
• Follow-up interval of at least one year should
have been sufficient to identify most such
complications.

50. DISCLAIMER
Information contained and transmitted by this presentation is
based on personal experience and collection of cases at
Choithram Hospital & Research centre, Indore, India. It is
intended for use only by the students of orthopaedic surgery.
Views and opinion expressed in this presentation are
personal. Depending upon the x-rays and clinical
presentations viewers can make their own opinion. For any
confusion please contact the sole author for clarification.
Every body is allowed to copy or download and use the
material best suited to him. I am not responsible for any
controversies arise out of this presentation. For any
correction or suggestion please contact naneria@yahoo.com