Slipped capital femoral epiphysis vamshi kiran feb 6/2013
Slipped capitalfemoral epiphysis (SCFE)
Introduction and definition Epidemiology and risk factors classification Pathogenesis Signs and symptoms Diagnosis Investigations Management modalities Complications
INTRODUCTION The capital femoral epiphysis issomewhat unique. It is one of thefew epiphyses in the body that isinside the joint capsule. (The jointcapsule is the tissue thatsurrounds the joint.)
DEFINITIONSlipped upper femoral epiphysis" term referto slippage of the overlying epiphysis ofproximal femur posteriorly and inferiorlydue to weakness of the growth plate inrelation to metaphysis. Most often, it develops during periods ofaccelerated growth, shortly after the onsetof puberty.The femoral epiphyses maintains its relationwith acetabulum ,it’s the femoral neck andshaft upward and anterior movement onepiphyses thus epiphyses displacesrelatively posterior
EPIDEMIOLOGY AND RISK FACTORS Incidence is 2-3 per 100000 population Most common in adolescent period with rapid growth plate (boys aged 10-16 y, girls aged 12-14 y). Very early onset[<10yrs] and late onset[>16] should be evaluated for endocrine disorders Males have 2.4 times the risk as females. Obesity is a risk factor because it places more shear forces around the proximal growth plate in the hip at risk. Bilateral slippage is common of which 2nd slip is about 12- 18mths later to 1st (left hip is more common than right).
ETIOLOGY-multifactorial1. Local trauma , obesity2. Endocrine disorders (e.g primary or secondary hypothyroidism, adiposogenital dystrophy(hypogonadal male),3. Deficiency or increase of androgens.4. Acute trauma5. Growth hormone deficiency6. ATYPICAL SCFE associated with renal failure,radiation therapy Slipping of the upper femoral epiphysis occurs predominantly in obese children with underdeveloped sexual characteristics and less commonly, in tall, thin children.
MECHANICAL FACTORSImportant features of the predisposed hip that may be the primarycause of slipped epiphysis are:1.Thinning of the perichondrial ring complex with maturation2.Relative or absolute retroversion of the femoral neck-making itmore suceptable to AP shear forces3.A change in the inclination of the adolescent proximal femoralphysis relative to the femoral neck shaft .•Associated conditions with mechanical etiology-1.Infantile and adolescent blount diasease2.Patients with peroneal spastic flatfoot and Legg-Calve-Prthesdisease
Based on onset of symptoms-acute -chronic -acute on chronic FUNCTIONAL CLASSIFICATION-stable -Unstable MORPHOLOGICAL CLASSIFICATION-mild -moderate -severe
SYMPTOMS <2WKS >2WKS grdual X-RAY displaced epiphyses remodelling and no remodelling healing notedACUTE ON CHRONIC SLIPS-Symptoms lasting longer than 1mth and recent sudden exacerbation pain after trivial trauma
FUNCTIONAL CLASSIFICATION-It is important to determine ability of the patient to bear weight.According to LODER- 1. "Stable" SCFEs allow the patient to (walk) with or without crutches (walking aids). 2. "Unstable" SCFEs do not allow the patient to ambulate at all regardles of duration of symptoms; these cases carry a higher rate of complication, particularly of AVN.
FROG LEG LATERAL POSITION-AP VIEW-145* -Best shows posterior slippage andLATERAL VIEW-170* subtle slipping also -Normally 10*posteriorly -Increases in slippage
MORPHOLOGICAL CLASSIFICATION-GradingSeverity of SCFE according to AP and Lateral X-ray viewsPRESLIP-irregularity,widening,and indistinctnessof physes Grade-1 Grade-II Grade-III
the displacement is either superior and posterior (so-called valgus slip)or, even more rarely, anterior. In valgus slips there is a restriction of adduction as well as of flexion. In anterior slips there is a limitation of extension and external rotation—exactly the opposite of what is found in typical slips. X-RAY of valgus slip show -superior or lateral displacement of the capital epiphysis on the femoral neck on the AP projection -posterior displacement on the lateral projection. Anterior slips may appear little different from typical slips on the AP projection, but the anterior displacement of the capital epiphysis is identified on the lateral projection.
PathologyGrossly , with gradual slipping of the capital epiphysis in the typicalposterior positionPeriostium is stripped from the anterior and inferior surface of thefemoral neckSo the area between the original femoral neck and the posteriorperiostium fills with callus which ossifies and become progresivelymore denseThe anterior and superior portion of the neck forms a hump or ridgethat can impinge on the rim of acetabulumNormally ,this ridge will remodel with anterior portion of the neckcontouring into smoother surfaceIn case of acute slipping the periostium is torn anteriorly and haemarthrosis will be present.
MicroscopicallyCharacteristc changes in PROLIFERATIVEand HYPERTROPHICZONES of epiphyses chondrocytes-number decrease and-irregularly arranged collagen fibres andMatrix are increased
SYMPTOMS1. Pain : in the groin and around the knee.2. Antalgic Limp (intermittent).3. Shortening of the affected limb (1-2 cm).4. The limb is in external rotation.[frog leg position]5. Flexion, abduction, medial rotation are limited6. External rotation, adduction are increased.7.The presence of hip flexion contracture points towards the possibility of chondrolysis.8.Axis deviation – pathognomonic – when hip is flexed, the limb goes into external rotation
DIAGNOSISThe diagnosis is a combination of clinical suspicion plusradiological investigation.20-50% of SCFE are missed or misdiagnosed on their firstpresentation to a medical facility.This is because the common symptom is knee pain. This isreferred pain from the hip. The knee is investigated and found tobe normalIn acute cases it is essential to differentiate between SCFE and type1 epiphseal#as most of time both come with history injury/traumaSCFE pt has prodromal pain in groin,thigh or knee.insidious onsetwhereas in type 1 epiphyseal # pt is normal acute pain associatedwith high energy trauma
SCFE PERTHE’S DISEASEUsually occurs in 10-14yrs age Usually in 4-7yrs age late onset in 14-16yrs late onset in 7-10yrs ageThin and tall adolescents or short Occurs in normal childand obese individualsPresents as pain with slippage Initially the child limps and then at and limping noted at later stage later stages complaints of painLimb never has fixed flexion Fixed flexion deformity is usuallydeformity notedIt may be in hyperextension state
In normal hip a line drawn tangential to superior femoral neck[klein’s line] intersects small portion of lateral capital epiphyseal. In posterior displacement of epiphyses the line doesn’t intersect.
In AP VIEW-crescent-shaped area of increased density overlying the metaphysis adjacent to the physis This increased density is due to the overlapping of the femoral neck and the posteriorly displaced capital epiphysis
In the normal hip the inferiomedial femoral neck overlaps the posterior wall of the acetabulum producing triangular radiographic density With displacement of capital epiphysis this dense triangle is lost because this portion of the femoral neck is located lateral to the acetabulum.
CAPENERS SIGN-In pelvic AP view in the normal hip, the posterior acetabular margincuts across the medial corner of the upper femoral metaphysisWith slipping, the entire metaphysis is lateral to the posterioracetabular margin
Very early slips may appear to be normal in AP VIEW but may be clearly noted in lateral view CHRONIC CASE OF SCFE X-RAY- Reactive bone formation along superolateral aspect of neck Bone remodelling and broadening of neck resulting in PISTOL GRIP like appearance[hordons hump]
USG-It has been useful in the detection of early slips -joint effusion and a ―step‖ between the femoral neck and the epiphysis created by slipping. Absolute displacement of 6 mm, >2 mm is diagnostic of a slipped epiphysis. CT-useful in documenting presence of decreased upper femoral neck anteversion or true retroversion. it’s more accurate measure head–neck angle. CT is useful in the management of slips. First, CT of the hip can be very helpful in demonstrating whether penetration of the hip joint by fixation devices has occurred (Fig. 18-9). CT is also used to confirm closure of the proximal femoral physis and also when reconstructive osteotomy is being considered. MRI-useful to assess AVN
COMPLICATIONS1. Avascular necrosis.2. Chondrolysis.3. Osteoarthritis.4. Coxa vara (is a deformity of the hip, whereby the angle between the ball and the shaft of the femur is reduced to less than 120 degrees).5. Slipping of the opposite hip ≈ 20% to 805 of cases
NATURAL HISTORY•30-40% second slip asymptomatic (slow)•Premature OA (pistol grip deformity 40% primaryOA)•Onset of OA directly related to severity of slip
IDEAL TREATMENT•Prevent further slippage•Stimulate early physeal closure•Reduction of epiphyseal displacement•Avoid complications like osteonecrosis , chondrolysisand osteoarthritis•Any child with SCFE and open epiphyses needstreatment ,without stabilisation it progresses.•In a patient with closed physes, the onlysurgical treatment in the absence of severedegenerative changes is proximal femoralosteotomy. Indications are functionallimitations, unacceptable gait, or cosmeticdeformity
Rest for atleast 12wks and traction can be an alternative to surgical treatment Indicated in – temporary measure before operative ℞ - slip due to hypothyroidism Rest in spica cast - ⇧ incidence of complications like chondrolysis
Operative treatment1.Percutaneous and open in situ pinning• Percutaneous pinning is done for mild, moderate and some severe acute or chronic SCFE• Open pinning is used for more severe acute or acute on chronic slipping and when closed reduction pinning fail• Generally 2 cannulated screws for acute (unstable) slips 1 screw for chronic stable slips.•Entry point is anterior rather than lateral aspect of femoral neck.• With increasing severity of the slip, the entry point will be foundprogressively more superior on the femoral neck.•After in situ pinning –early wt bearing in stable slips• -after 6-8wks in unstable slips•Sports activities only after physeal closure.
HERENOT -Screw should enter head perpendicular to its physeal surface and in itsHERE centre. -If two screws are to be inserted, first screw should lie in central axis of head and second screw below it avoiding superolateral quadrant.
-pin tip be advanced to 8 mm or one third of the femoral headradius from subchondral bone, whichever projection is theclosest. This places the actual tip 7 to 18 mm from thesubchondral bone, leaving a safe margin.
Serious disadvantage is Persistent pin penitrationAdverse affects attributed to unrecognized pin penitration :•Joint sepsis•Localised acetabular erosions•Synovitis•Post operative hip pain•Chondrolysis•Late degenerative osteoarthritis
Prophylactic pinning of the contralateralhip•Follow Up till skeletal maturity•Pin if symptoms are present•Pin if there is known metabolic/endocrine disorders•Pin if Follow up is unreliable
Only for acute and acute on chronic severe slips Within 24 hours of slip High risk of ischemic necrosis of head. So, manipulate only acute severe slips that may be technically difficult or impossible to pin in situ. Alternatively gradual reduction by skin traction and internal rotation over 3 – 4 days.
OPEN REDUCTION•Biomechanical disturbances caused by the tilt of the epiphysismay cause early degenerative joint changes,•So open reduction, limited osteotomy, and internal fixation, ifnecessary, have been recommended if a severe acute or chronicslip which cannot be reduced by closed methods•Dunn emphasized the need to shorten the femoral neck toprevent tension on the posterior vessels when the epiphysis isreduced, making the procedure a closing wedge osteotomy,rather than a simple open reduction.• The Heyman-Herndon procedure gave consistently goodresults for moderate slips,• Dunns procedure gave better results for severe slips
Bone peg epiphysiodesis is not done now a days becauseof associated postoperative complications:•Osteonecrosis•Chondrolysis•Infection•Thigh hypesthesias•Heterotopic ossification•After bone peg epiphysiodesis of acute slips, spica castimmobilization may be necessary for 6 weeks or more to preventfurther slipping
OSTEOTOMY: Because moderately or severely displaced chronic slips produce permanent irregularities in the femoral head and acetabulum, some form of realignment procedure often is indicated to restore the normal relationship of the femoral head and neck and possibly delay the onset of degenerative joint diseaseTwo basic types of osteotomies:•Closing wedge osteotomy through thefemoral neck, usually near the physis tocorrect the deformity.•Compensatory osteotomy through thetrochanteric region to produce a deformity inthe opposite direction
Four femoral neck osteotomies aredescribed:(1)the technique of Fish,(2) the technique of Dunn just distal to the slip,(3) the base of the neck technique of Kramer et al., and(4) the technique of Abraham et al.(5)Compensatory osteotomies in the trochanteric region and partial cheilectomy to reduce deformity also are described(6)1 and 2 in open epiphyses
Fish technique: just distal to the the physisDunn technique: just distal to the slipKramer technique: base of the neckAbraham technique: at the trochanteric region
• The advantage of osteotomy through the femoral neck [DUNN and FISH type]is that the deformity itself is corrected, but incidences of osteonecrosis ranging from 2% to 100% and of chondrolysis from 3% to 37% have been associated• ABRAHAM and KRAMMER are osteotomies done adjusting according to deformity
•Make the wedge anterior and superior to correct epiphyseal position-subcapitally•The more severe the slip the more is wedge superiorly•Reduce the epiphysis by flexion, abduction, and internal rotation of the limb•After wedging, diameter of femoral head is greater than femoral neck.•Indication-severe chronic or acute on chronic slips
intent of this procedure is to reduce the capital femoral epiphysis on thefemoral neck by resecting a portion of superior femoral neck,carefullypreserving the posterior periosteum offemoral neck and preventing tension on it during reduction. The a lateral approach allows stripping of the periosteum and its contained vessels under direct vision to avoid damagingthe blood supply to the femoral head. In the lateral view, the headshould appear to sit squarely on neck, In the anteroposterior view, the head should be tilted into about 20 degrees of valgus 2WKS later walking with crutches3-4mths later partial wt bearing
Its basal femoral neck osteotomy that corrects the varus and retroversion components of moderate or severe chronic SCFE. It is safer than an osteotomy made near or at the physis because the line of the osteotomy is distal to the major blood supply in the posterior retinaculumWidest part of wedge (at base of neck) is in line with widest part of slip,correcting varus and retroversion componentsThe osteotomy site is closed by medial rotation and abduction of the distalsegment
Osteotomy done fromlesser to greatertrochanter withposterior cortex intactThen fixed withcancellous screws Risk of AVN is low. Correction of varus & retroversion is less. Does not affect Limb Length Discrepency. Improves hip range of motion.
Usually for malunited slip. If physis is still open, in situ pinning with osteotomy. Closing wedge Trochanteric Osteotomy - to correct varus deformity with some ER. Triple deformity – coxa vara + ER + hyperextension - Southwick biplane wedge oseotomy - Clark’s modification of Southwick osteotomy - Ball & Socket Osteotomy
For residual deformity correction after physeal closure When a capital femoral epiphysis has chronically slipped and has united in a poor position, a trochanteric osteotomy to produce an opposite deformity is done. distal femoral fragment osteotomy done and flexed and medially rotated making femoral shaft parallel to epiphysis. it restores articulotrochanteric distance (ATD), trochanter– center of head distance (TCH), and epiphyseal-shaft angle
AP & lateral views taken Head shaft angle measured Difference of head shaft angle between slipped side and normal side is taken as angle of wedge to be taken Anterior and lateral based wedge OSTEOTOMY done
Transverse line is drawn on ant & lat surface of femur at level of lesser trochanter. Point X is measured 15 mm proximal from tranverse line along longitudinal orientation mark. Triangle X‖XT -> Ant wedge Point X’ is measured 13mm post to longitudinal mark at level of transverse mark. Triangle X’XT -> lat wedge
CHEILECTOMYWhen a prominence on the anterosuperior aspect of the femoralneck blocks internal rotation or abduction by impinging againstthe acetabulumSimple resection of the prominence removes the obstructionand improves motion Care to preserve the integrity of the neck of the femur and the physis because fractures of the neck of the femur and further acute slipping of the epiphysis may occur when too much is excised. Intraarticular epiphysiodesis using bone from the crest of the ilium was recommended by Herndon.
COMPLICATIONSSCFE Osteonecrosis-Rare in untreated SCFE-Results from interruption of the retrogradeblood supply by:•Original injury tamponade of the blood supply tothe proximal femoral epiphysis as a result ofacute hemorrhage within the capsule•Increase with severity of slip•increase in acute, unstable slips•increases with forcefull repititive manipulation,•pin placement in superior quadrant• Osteotomy of femoral neck
DIAGNOSIS: Early postoperative bone scan has excellent sensitivity andpredictive value for detection of osteonecrosis after surgical treatmentof SCFETREATMENT• Remove metal work• Maintain ROM• Realignment• Shelf acetabuloplasty• Arthrodesis/THR
SCFE ChondrolysisDissolution of articular cartilage with jointstiffness and painCauses:• Persistent pin penitration• After trochantric osteotomy, open reduction,femoral neck osteotomy •Synovial malnutrition, ischaemia, excessive pressure •Autoimmune •Females>males
Diagnosis: Joint pace of less than 3mm wide ( normal 4 to 6 mm) Decrease range of motion at hip jointTREATMENT•Bed rest•Traction•Salicylates•Nsaids drugs•Intraarticular cortisone injections•Sugical manipulation in form of : Subtotal circumferential capsulectomy• Continuous passive motion and physical therapy