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Slipped capital epiphysis
- 1. SLIPPED CAPITAL FEMORAL EPIPHYSIS Presenter- Dr. Prashant Bhavani AIIMS New Delhi
- 2. Misnomer Epiphysis “STAYS” Neck and Shaft “DISPLACES” SLIPPEDCAPITAL FEMORAL EPIPHYSIS 2
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- 4. Incidence 0.33/100,000 to24.58/100,000 4
- 5. Race/Ethnicity RRF, Caucasians at1.0 5.6 – Polynesians 3.9 – Blacks 2.5 – Hispanics RRF 9.6 - India* 5 *Y. J. Lim, F. Kagda, K. S. Lam et al., “Demographics and clinical presentation of slipped capital femoral epiphysis in Singapore: comparing the East with the West,” Journal of Pediatric Orthopaedics B, vol. 17, no. 6, pp. 289–292, 2008.
- 6. Gender & Age Male predominence, 90% → 60% ↓ Indo-Mediterranean's – 90% male* Polynesians – M:F equal* Age- Prepubescence & Early Adolescence 13.5 yrs → 12.0 yrs in boys 12 yrs → 11.2 yrs in Girls ?????? Early maturation Obese children present early 6 * R. T. Loder, “The demographics of slipped capital femoral epiphysis: an international multicenter study,” Clinical Orthopaedics and Related Research, no. 322, pp. 8–27, 1996.
- 7. Symptom Duration StableSCFE (Avg) – 4 to 5 mths 4.5 mths – Boys 3.6 mths – Girls 7 * R. T. Loder, T. Starnes, G. Dikos, and D. D. Aronsson, “Demographic predictors of severity of stable slipped capital femoral epiphyses,” Journal of Bone and Joint Surgery, American, vol. 88, no. 1, pp. 97–105, 2006. Symptom duration as a function of slip severity
- 8. Body weight, Obesity,BMI Majority are Obese ◦ > 50% are > 95th percentile weight for age Age at Diagnosis - ↓ with ↑ obesity ◦ 12.4 yrs – Obesity (95th percentile) ◦ 14.3 yrs – Others (< 10th percentile) BMI (Avg) ◦ 25 to 30 kg/m2 or ◦ > 85thpercentile B/L SCFE (31.1) v/s U/L SCFE (26.8) 8 * R. T. Loder, “The demographics of slipped capital femoral epiphysis: an international multicenter study,” Clinical Orthopaedics and Related Research, no. 322, pp. 8–27, 1996.
- 9. Seasonal Variation Latitudenorth of 40 ̊- Late Summer & Autumn months 9 N. Maffulli and A. S. Douglas, “Seasonal variation of slipped capital femoral epiphysis,” Journal of Pediatric Orthopaedics B, vol. 11, no. 1, pp. 29–33, 2002.
- 10. Bilaterality Overall –18 to 50% M/C Africans (34%) v/s Asians (18%), Hispanics (17%), White (7%) Rx affect risk of B/L involvement † 36% - In-situ pinning 7% - spica cast Close attention “MANDATORY” B/L SCFE * 50% to 60% - Simultaneous SCFE 80% to 90% - Sequential SCFE within 18 mths 10 *R. T. Loder, D. D. Aronson, and M. L. Greenfield, “The epidemiology of bilateral slipped capital femoral epiphysis: a study of children in Michigan,” Journal of Bone and Joint Surgery, American, vol. 75, no. 8, pp. 1141–1147, 1993. † J. M. Hurley, R. R. Betz, R. T. Loder, R. S. Davidson, P. D.nAlburger, and H. H. Steel, “Slipped capital femoral epiphysis: the prevalence of late contralateral slip,” Journal of Bone and Joint Surgery, American, vol. 78, no. 2, pp. 226–230, 1996.
- 11. Predictors of riskof B/L involvement Young age Modified Oxford Hip bone age < 16 Endocrine cause Obesity Tri-radaite cartilage fusion – Risk 4% ↑ Post slope angle epiphysis (>12) - ↑ Risk 11 T. A. Bidwell and N. S. Stott, “Sequential slipped capital femoral epiphyses: who is at risk for a second slip?” Aus NZ Journal of Surgery, vol. 76, no. 11, pp. 973–976, 2006.
- 12. Classification Traditional classification ◦Based on History, Duration of symptoms, Examination, Radiography Pre-slip Acute slip - < 3wks symptom Chronic slip - > 3 wks symptom Acute on chronic - > 3wks symptom + Acute slip 12
- 13. Classification Kullio etal given a classification ◦ Based on USG findings Acute Effusion without Metaphyseal remodeling Chronic No Effusion with Metaphyseal remodeling 13
- 14. Classification Loder`s Classification ◦Based on ability to bear weight Stable slip ◦ able to bear weight with or without crutches ◦ No AVN Unstable slip ◦ unable to bear weight, with or without crutches ◦ 47% incidence of AVN 14
- 15. Etiopathogenesis Etiology (unknown) Biomechanical factors ↑Shear stress across physis Biochemical factors ↓ Resistance to shear Weaken physis FAILURE 15
- 16. Biomechanical factors Obesity Femoral retroversion Increased physeal obliquity Thinning of Perichondrial fibrocartilaginous complex 16
- 17. Biochemical factors Hypogonadism(M/C) Growth hormone supplementation Hypothyroidism Hyperparathyroidism ( Sec to CRF ) 17
- 18. Pathology Slipping in hypertrophic Zoneof physis Zone of hypertrophy is widened and composed of chondrocytes in disarrayed clusters instead of orderly columns Chondrocytes of the hypertrophied zone at the cleft (C) region are in disordered clusters and irregular columns 18
- 19. Watch it inPre-slip Weakness in lower extremity Limping Exertional pain ◦ Felt as referred pain at groin, thigh or knee O/E – ◦ ↓ IR (most consistent finding) 19
- 20. Acute slip 15%of SCFE patients Trivial trauma Prodromal symp < 3 wks Abrupt displacement Unable to bear weight O/E ◦ External rotational deformity ◦ Shortening ◦ Marked limitation of ROM # NOF/typ1physeal Separation Yes Yes Yes 20
- 21. Acute slip 15%of SCFE patients Trivial trauma Prodromal symp < 3 wks Abrupt displacement Unable to bear weight O/E External rotational deformity Shortening Marked limitation of ROM # NOF/typ1physeal Separation Yes Yes Yes 21
- 22. Chronic Slip M/Ctype – 85% Pain in groin, thigh or knee - > 3 wks Walks with limp Knee pain delays diagnosis – 46% O/E – Antalgic gait Loss of IR, Abd & flexion LLD – severe cases With flexion – spontaneous Abd + ER 22
- 23. Acute on chronicslip Prodromal symptom > 3 wks Sudden exacerbation of pain Precludes weight bearing Imp ???? S/d be differentiated from Acute slip Attempted reduction - ↑ AVN 23
- 24. Radiographic findings Mild slip Klein'sline Trethowan's sign 24
- 25. Radiographic findings Mild slip Metaphysealblanch sign of Steel 25
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- 29. Severity of SCFE Frog-leglateral pelvis radiograph of a patient with a 44° slipped capital femoral epiphysis (moderate), with an epiphyseal-shaft angle of 56° on the right and of 12° on the left (56° – 12° = 44°). 29
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- 31. Role of otherinvestigation Bone scan Increased Uptake – Chondrolysis Decreased Uptake – AVN USG Early slips – Effusion + Step b/n neck & epiphysis Severity of slippage MRI - early AVN 31
- 32. Natural History ofSCFE All slips STOPS Gradual displacement Physis closure Degree of slip Timing of cessation SHORTTERMCOURSELONGTERMCOURSE Premature 2 ͦ Osteoarthritis α to Severity Resultant deformity 32
- 33. What should beour GOALS? Detect early → Deformity (↓) → 2 ͦ OA (↓) Prevent further slippage → Severity (↓) → 2 ͦ OA (↓) Avoid complications → 2 ͦ OA (↓) 33
- 34. How can wedetect early ? Meticulous History taking Proper Examination Proper Investigations and their analysis 34
- 35. Differential Diagnosis Fractures •Significant trauma •↑Soft tissue shadow •Displacement any direction •Trivial trauma • No Soft tissue shadow •Displacement post-inf direction Perthes disease •Sclerosis, cyst, collapse of head •MRI - ↑&↓ signal intensity T2 & T1 •Displaced epiphysis •Remodeling changes Osteomyelitis •↑ WBCs, ESR, CRP Fever •MRI - ↑ signal intensity T2 / Intra- osseous/subperiostea l abscess •Normal •No fever •No abscess SlippedCapitalFemoral Epiphysis 35
- 36. Cont….. Septic arthritis •X-ray -↑ joint space •USG - Effusion •Normal/ ↑ joint space •USG – Effusion + step deformity b/n Epiphysis & neck Groin pull/ Adductor muscle strain •Rare •Pain on adduction •Tenderness – groin & adductor tendon •No Ext rotation deformity • No Tenderness – groin & adductor tendon • Ext rotation deformity Stress # MRI - Edema/stress reaction femoral neck Absent SlippedCapitalFemoralEpiphysis 36
- 37. How can weprevent further slippage? Stable SCFE (Chronic) Unstable SCFE (Acute) 1.In-situ pinning 2.Epiphysiodesis 3.Femoral Osteotomies without surgical dislocation 4.Surgical dislocation of the hip with modified Dunn osteotomy, reduction, and fixation (5. Urgent reduction, fixation and arthrotomy) 37
- 38. In Situ pinor screw fixation • Percutaneous - Acute and chronic slips ◦ Mild ◦ Moderate ◦ Some severe Open ◦ More severe Acute & ◦ Acute on chronic slip 38
- 39. In Situ pinor screw fixation Technical Aspect Supine position ◦ Fracture table ◦ Radiolucent table top Entry point ◦ Mark trajectory lines AP & Lateral views 39
- 40. In Situ pinor screw fixation Technical Aspect Intersection of line Pass guide wire Pass drill bit over wire Insert cannulated screw Insertion of Guide wire Measurement & Drilling Insertion of Screw40
- 41. Ideal Placement ofscrew Entry point ◦ Anterior femoral neck Extent ◦ 8mm ◦ ⅓ Femoral head radius No.of screws ◦ 1- Chronic ◦ 2- Acute Placement ◦ perpendicular to physis ◦ centre of epiphysis Pin penetration ◦ Rotating fluoroscopic beam Ideal position 41
- 42. Osteotomy Closing wedge osteotomy(femoral neck) Cuneiform osteotomy Subcapital realignment of epiphysis Base of neck osteotomy Compensatory osteotomy (Trochanter) Imhauser/ Southwick osteotomy 42
- 43. Rate ofcomplications α Proximity of the osteotomy ◦ Highest -osteotomies at the apex (intracapsular in the superior neck) ◦ Lowest -osteotomies performed extracapsularly in the intertrochanteric area Severity of 2 ͦ compensating deformity α Distal the corrective osteotomy 43
- 44. Cuneiform osteotomy ofthe femoral neck (FISH) 44 Exposure & capsule incision Osteotomy Removal of wedge of bone More bone removed Realignment Fixation
- 45. Cuneiform osteotomy ofthe femoral neck (DUNN) 45 Osteotomy of GT Elevation of synovium Removal of callus Osteotomy Line Realignment Fixation
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- 51. Spica Cast Usedas an Adjunct Also definitive management of slipped epiphysis Complications Pressure sores Chondrolysis 51
- 52. Spica Cast Littleindication - modern management Reserved for the occasional desperate situation Very young patients Chronic renal failure 52
- 53. Conclusions: A systematicreview of the literature recommends on the basis of level of evidence that the best treatment for a stable SCFE is single screw in situ fixation and for unstable SCFEs urgent gentle reduction, decompression, and internal fixation. 53
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- 55. Most common complaintsare Excessive external rotation, Limitation of flexion, Trendelenburg lurch, Combination of these Residual Deformity after Closure of the Physis (Femeroacetabular Impingement) 55
- 56. TREATMENT Osteoplasty of thefemoral neck May be done in conjunction with fixation of the epiphysis (usually epiphysiodesis) or independently, after closure of the physis 56
- 57. TREATMENT Intertrochanteric repositioning osteotomyperformed for complaints of restricted flexion and internal rotation after in situ fusion. A, Before intertrochanteric osteotomy. B, After intertrochanteric osteotomy. The patient was pleased with the more functional position of the hip arc of motion, with increased flexion and internal rotation. Intertrochanteric repositioning osteotomy 57
- 58. Complications of SCFE Chondrolysis AVN 58
- 59. Chondrolysis Epidemiology Incidence - 1.5%after In-situ pinning - 50% with spica cast Rx Girls > Boys Black patients Spontaneously/After treatment 59
- 60. Etiology Unknown, buttheories says……. Loss of synovial fluid - ↓ Nutrition Autoimmunity - ↑ IgM & C₃ Metallic Implant penetration Impingement of labrum & acetabulum (“Pistol grip deformity”) 60
- 61. Clinical features Persistentpain – groin/upper thigh Flexion, Abduction & ER ROM- painful/decreased in all planes Walking/activities-adversely affected Radiography Loss of joint space > 50% Joint space of 3mm/less Bone scan Increased uptake-seldom necessary 61
- 62. Natural History Pain+ Restriction ROM + ↓ joint space 6 wks to 4 mths – after treatment 6 to 12 mths – max ↓ joint space Reconstitute (variable extent) – 3 yrs 62
- 63. Treatment Non-specific &supportive Rule out Infection – Hip aspiration Implant penetration – CT scan Supportive care Modification of activities Use of crutches Gentle ROM Ex Anti-inflammatory medications 63
- 64. AVN Severe complication Occur with/without Rx M/C occur Closed/open reduction of unstable slips Osteotomy of the femoral neck Less Open epiphysiodesis In situ pinning of stable slips 64
- 65. How it occurs? Unstable slips- tearing of the periosteum →lateral epiphyseal arterial system damage Forcible reduction → tear the posterior periosteum During surgery→ direct injury to the periosteum Intra-articular tamponade by traumatic effusion 65
- 66. How they present? Can occur – few wks/ 1yr/ 18mths Increasing pain + deformity + loss of motion Develop progressive deformity and restriction of motion Radiography- Two patterns of distribution Total head necrosis Partial (or segmental) necrosis 66
- 67. TREATMENT Prevention -↓ surgeon's control How? ◦ Open reduction ◦ Femoral neck osteotomies ◦ Manipulation of stable slips ◦ Forcible manipulation of unstable slips 67
- 68. TREATMENT Educate thepatient - potential outcome Ascertain metallic implants 2 ͦ encroachment Remove the implant Physis not fused – Manipulate/Reinsert Intertrochanteric osteotomy - little pain + deformity + poor functional position Arthroplasty or Hip fusion - Debilitating pain with progressive radiographic changes 68
- 69. Contralateral Slips B/LSlips ◦ Simultaneous – 50% to 60% ◦ Subsequent – 80% to 90% Castro et al – 2335 times risk Rx controversial Indication ◦ Age ◦ Endocrine cause ◦ Follow up not feasible ◦ Posterior slope angle >12 deg ◦ Young obese children
- 70. Conclusion SCFE isnot an uncommon disease Most commonly occurs in Adolescent obese male, involving left hip Take meticulous history, do proper examination, get proper investigations Detect early, intervene early and avoid complications In-situ fixation gold standard surgical option stable SCFE Surgical dislocation with modified Dunn osteotomy provides promising result by reducing the Incidence of AVN 70
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Editor's Notes
- #25 Anteroposterior radiographic appearance of a normal hip and a hip with mild chronic slipped capital femoral epiphysis. A, Normal hip. A line drawn parallel to the superior femoral neck (Klein's line) will intersect the lateralmost portion of the capital femoral epiphysis. B, Hip with mild chronic slip. Klein's line does not intersect the capital epiphysis (Trethowan's sign). Lateral radiographs will confirm the diagnosis.
- #26 Metaphyseal blanch sign of Steel in slipped capital femoral epiphysis. A crescent-shaped area of increased density lies over the metaphysis of the femoral neck adjacent to the physis. This density is produced by overlapping of the femoral neck and the posteriorly displaced capital epiphysis on the anteroposterior view of the hip.
- #27 Scham's sign of slipped capital femoral epiphysis. A, In the normal hip, the inferomedial femoral neck overlaps the posterior wall of the acetabulum, producing a triangular radiographic density on the anteroposterior view. B, With displacement of the capital epiphysis, this dense triangle is lost because this portion of the femoral neck is located lateral to the acetabulum.
- #28 Radiographic appearance of slipped capital femoral epiphysis (SCFE) on presentation. A, Appearance of acute SCFE on a frog-leg lateral view. The displacement of the epiphysis is suggestive of a Salter-Harris type I fracture of the upper femoral physis. There are no secondary adaptive changes noted in the femoral neck. B, Frog-leg lateral radiographs in a patient with many months of thigh discomfort and a chronic slipped epiphysis. Adaptive changes in the femoral neck predominate, and the epiphysis is centered on the adapted femoral neck. C, Frog-leg lateral radiographs of a patient with acute-on-chronic SCFE. The patient had several months of vague thigh pain, with sudden, severe exacerbation of that pain. The acute displacement of the epiphysis is evident. Unlike in acute SCFE (see A), secondary adaptive remodeling changes are also present in the femoral neck, beyond which the epiphysis has acutely displaced.