health&medicine

1. Radiological imaging of Slipped Capital Femoral Epiphysis.
Dr/ ABD ALLAH NAZEER. MD.

2. Slipped capital femoral epiphysis (SCFE), is a relatively common condition
affecting the physis of the proximal femur in adolescents. It is one of commonest
hip abnormalities in adolescence and is bilateral in ~20% of cases.
Epidemiology
SUFE is more common in boys than girls and more common in Afro-Caribbeans
than Caucasians. The age of presentation is somewhat dependent on gender with
boys presenting later (10-17 years) than girls (8-15 years). Obesity is a significant
risk factor.
Clinical presentation
Patients present with hip pain progressing to a limp and even leg length
discrepancy.
If SUFE is confirmed on an X-ray, the child should be rested, admitted and not
allowed to weight-bear.
Pathology
SUFE is essentially a type I Salter-Harris growth plate injury due to repeated
trauma on a background of mechanical and probably hormonal predisposing
factors.
Conditions that may predispose to SUFE include:
hypothyroidism
hypopituitarism
hyperparathyroidism

3. Plain radiograph
AP and frog-leg: the commonest situation allows assessment of two
views In the pre-slip phase, there is a widening of the growth plate
with irregularity and blurring of the physeal edges and
demineralization of the metaphysis. This is followed by the acute
slip which is posteromedial. In a chronic slip, the physis becomes
sclerotic and the metaphysis widens (coxa magna).
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. Because the epiphysis moves posteriorly, it
appears smaller because of projectional factors.
On the AP, a line drawn up the lateral edge of the femoral neck (line
of Klein) fails to intersect the epiphysis during the acute phase
(Trethowan's Sign).
The metaphysis is displaced laterally, and therefore may not
overlap posterior lip of the acetabulum as it should normally (loss of
triangular sign of Capener).

4. Ultrasound: Ultrasound may be performed in the assessment of hip pain.
However, it should not be used as a replacement for a pelvic radiograph. Findings
are nonspecific and may include hip joint effusion. In some cases, malalignment of
the femoral epiphysis and metaphysis may be seen.
CT: CT is a sensitive and an accurate method of measuring the degree of upper
femoral epiphyseal tilt and detecting the disease in its early stage. Multiplane
reconstruction allows assessment of the relationship of the femoral head to the
metaphysis in three planes. However, the dose required for the examination means
that it should not be used unless absolutely necessary.
The metaphyseal blanch sign described increases in the density of the proximal
metaphysis. It represents an attempt of the healing process that occurs before the
visible displacement of the epiphysis.
MRI: In the acute stage, marrow edema results in increased signal on T2-weighted
sequences, e.g. STIR. Marrow edema is non-specific, and while it may indicate early
bone changes in SUFE, there are numerous other causes, e.g. infection or tumour.
MRI can be used to examine the contralateral hip which is important because of the
high incidence of bilateral slip.
STIR: high signal in epiphysis and metaphysis
joint effusion
T1: low signal in edematous regions
metaphyseal displacement

8. Radiographic 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 film
Classification
Grade I: displacement of epiphysis less than 30% of width
of femoral neck
Grade II: slip between 30%-60%
Grade III: includes slips of greater than 60% the width of neck

13. Radiographs showed subtle widening of the physis on the right side on anteroposterior view, (a) posterior and medial
displacement of the epiphysis of the right femur with respect to femoral neck on lateral (b) and frog's lateral view (c)

14. Bilateral slipped capital femoral epiphysis. One side shows evidence of remodeling
of the neck and an anterior bone bump that restricts flexion. The other side
demonstrates an acute slip as seen by the absence of any evidence of remodeling.

16. SLIPPED CAPITAL FEMORAL EPIPHYSIS.

19. Coronal TI-WI (a) and T2-WI (b) magnetic resonance imaging images reveals
physeal widening with indistinct margins and adjoining bone marrow edema

20. Axial TI-WI (a), T2-WI (b), Sagittal TI-WI (c) and T2-WI (d) magnetic resonance imaging images
reveal posterior and medial displacement of femoral capital epiphysis with respect to
metaphysis with physeal widening with indistinct margins and adjoining bone marrow edema.

21. Slipped capital femoral epiphysis.

22. Slipped
Capital
Femoral
Epiphysis.

23. Slipped capital
femoral
epiphysis
Coronal T1
(1a), coronal
fat-suppressed
T2 (1b),
sagittal fat-
suppressed
proton density
(1c) and axial
fat-suppressed
T2 (1d)
weighted
images.

25. Thank You.