The document discusses slipped capital femoral epiphysis (SCFE), a condition where the femoral head slides out of position in the hip. It begins by defining SCFE and describing the typical displacements seen, which are usually upward and anterior. It then covers the pathoanatomy of SCFE, focusing on the growth plate and zones of the physis. Finally, it discusses the incidence, risk factors, clinical presentation, investigations, and treatment options for SCFE.
Deformity: It’s the position of a limb/Joint, from which it cannot be brought back to its normal anatomical position.
Described as abnormalities of :
Length
Angulation
Rotation
Translation
Combination
Deformity: It’s the position of a limb/Joint, from which it cannot be brought back to its normal anatomical position.
Described as abnormalities of :
Length
Angulation
Rotation
Translation
Combination
A fractured neck of femur (NOF) is a serious injury, especially in older people. It is likely to be life changing and for some people life threatening.
Neck of femur fractures (NOF) are common injuries sustained by older patients who are both more likely to have unsteadiness of gait and reduced bone mineral density, predisposing to fracture. Elderly osteoporotic women are at greatest risk.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
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2. SCFE –
Femoral neck and shaft displace relative to the
femoral epiphysis and the acetabulum
Misnomer as neck displaces relative to the epiphysis
Usually, upward & anterior
Head remains posterior and downward in the
acetabulum.
INTRODUCTION
7. 1 Reserve Zone-
Composed of chondrocytes
Type II collagen is present in its highest amount
Oxygen tension is low
2 Proliferative Zone.
Chondrocytes form matrix
Oxygen tension is high
Rich vascular supply.
The majority of the longitudinal growth of the growth plate
occurs in this zone.
Growth plate
8. The zone is avascular,
low oxygen tension (similar to the reserve zone).
Chondrocytes prepare matrix for mineralization and
calcification.
Slip occurs through the weakest structural area of
the plate, the hypertrophic zone.
3 Hypertrophic Zone
9. Varies according to race, sex, geography
Estimated 2 per 100,000
Males > females (male to female ratio is 2:1)
left > right
During adolescence, max skeletal growth
boys 13-15 years, avg 14
girls 11-13 years, avg 12
associated with puberty
Bilateral - 20-25 %
When bilateral slips occur, the second slip usually occurs
within 12 to 18 months of the initial slip.
Incidence/Epidemiology
10. Often unknown
Majority are normal by current endocrine work-up
Etiologic –
Altering the strength of the zone of hypertrophy
Affecting the shear stress to the plate
1)Endocrine
2)Mechanical
ETIOLOGY
11. Predisposing features:
-thinning of perichondral ring complex
-retroversion of femoral neck
-change in inclination of prox femoral physis relative to
femoral neck/shaft
Mechanical Factors
12. Fibrous band that encircles physis at cartilage-bone
interface
Acts as limiting membrane,
mechanical support to physis
Thins rapidly with maturation strength
1) Perichondral Ring Thinning
13. 2) Retroversion of Femoral Neck
Relative or femoral retroversion
Physis more susceptible to AP shearing forces
3)Inclination
Increased slope of proximal femoral physis on both affected
and non-affected sides
Increased obliquity
Patients with a slipped epiphysis have a slope 11 degrees more
on the affected side and 5 degrees more on the unaffected side
14. 1) Obesity,
2) Hypogonadal males (adiposogenital syndrome)
3) Growth spurt
4) Hypothyroidism (treated or not)
5) GH administration
6) CRF
Growth hormone - stimulate growth of the physis converting cartilage
to bone. too much un-ossified cartilage unable to resist stress
imposed by increased body weight
No screening unless clinical suspicion
Endocrine Factors
15. Periosteum stripped from ant/inf surface of femoral
neck
Area btw neck & post periosteum fills with callus &
ossifies
Anterosuperior neck forms “hump”(remodel)
Acute slips will have hemarthrosis
PATHOLOGY-GROSS
16. -Edematous synovial membrane,periosteum,capsule
Light microscopic - physis is widened and irregular
Resting zone -60 to 70% of the width of the physis,
Hypertrophic zone -15 to 30%.
SCFE, the hypertrophic zone may constitute up to
80% of the physis width.
Microscopic
17. A,Slipping hypertrophied zone of the physis
B The zone of hypertrophy is widened
C The chondrocytes of the hypertrophied zone at
the cleft
18. Temporally, according to onset
acute
acute-on-chronic
chronic
Functionally, according to ability to WB(weight bear)
stable
unstable
Morphologically, according to extent of displacement
CLASSIFICATION
21. STABLE UNSTABLE
Weight bearing Possible Not possible
Severity of slip Less severe More severe
Effusion Absent Present
Good prognosis 96% 47%
AVN 0% 50%
22. Preslip phase-
i)Weakness in the leg
ii) limping on exertion;
iii)On physical examination,
Lack of medial rotation of hip , hip in extension.
Affected leg is fixed, the thigh goes into abduction
and external rotation
CLINICAL FEATURES
23. i)The clinical criterion- acute onset of symptoms < 2 weeks
ii)Prodromal symptoms - weakness, limp, and intermittent groin,
medial thigh, or knee pain
Uable to weight bear.
iii) Antalgic gait
iv) An external rotation deformity
v) Shortening
vi) limitation of motion.
The greater the amount of slip, the greater is the restriction of
motion.
Unstable Acute or Acute-on-Chronic Slipped
Capital Femoral Epiphysis
24. i)Groin or medial thigh/knee pain for months to years.
ii)Exacerbations and remissions of the pain or limp
iii)Limitation of motion(particularly medial rotation) the
leg fixed external rotation
iv) Increased- hip extension
external rotation
adduction
Decreased
flexion , internal rotation ,abduction
CHRONIC SLIP/ STABLE SLIP
25. v) Antalgic limp
vi)Local tenderness over the hip joint
vii)Shortening
viii)Thigh or calf atrophy.
ix) Hip flexion contracture -Chondrolysis.
Stable, Chronic Slipped Capital Femoral Epiphysis
26. DISORDER AGE SEX BILATERAL
DDH 0-2yrs FEMALES
1:4
20%
PERTHES
DISEASE
4-6yrs MALES
5:1
10%
SCFE 10-15yrs MALES
2:1
25-40%
Causes of Limp & Hip, Thigh or Knee Pain in
Children
27. 1)X-RAY-
Frog-leg lateral accentuate the deformity
Lateral view the best to detect the slip - head is
posterior in relation to the neck
DIAGNOSIS
30. A crescent-shaped area of increased density over the
metaphysis of the femoral neck
This density is produced by
overlapping of femoral neck
and the posteriorly displaced
capital epiphysis
Metaphyseal blanch sign-Steel sign
31. SCHAM SIGN-
A) Normal hip, the inferomedial femoral neck
overlaps the posterior wall of the acetabulum-
triangular radiographic density
B) Displacement of the capital epiphysis - dense
triangle is lost
32.
33. Capeners sign
AP view in the normal hip the posterior
acetabular margin cuts across the medial
corner of the upper femoral metaphysis.
With slipping the entire metaphysis is
lateral to the posterior acetabular margin
34. Acute- little or no of the femoral neck
Chronic-remodeling of the femoral neck
Remodeling
39. More accurate in the measurement of the head–neck
angle
Demonstrating penetration of the hip joint by
fixation devices
Confirm closure of the proximal femoral physis
Assess the severity of residual deformity of the
upper femur
II) CT SCAN
40. Measurement of the head–neck angle on computed
tomography (CT) scan
41. 3)Technetium-99 Bone Scan
Increased uptake -involved hip,
Decreased uptake -AVN,
Increased uptake in the joint space - chondrolysis.
4) Ultrasonography
5) Magnetic Resonance Imaging
42. Goals in treatment
1)To prevent further displacement of the epiphysis
2)To promote closure of the physeal plate.
Long-term goals of treatment include
1)Restoration of a functional range of motion
2)Freedom from pain
3) Avoidance of aseptic necrosis and chondrolysis
TREATMENT
43. 1. Absolute Bed Rest
2. Traction
3. Hip Spica Cast
1)NON OPERATIVE TREATMENT
44. • Bilateral BK cast
• Holding the hips in Abd & IR
• Weight bearing not allowed usually for 3 - 4 months
Spica Cast immobilization
45. i)Percutaneous and open in situ pinning
ii)Open reduction and internal fixation
iii) Epiphysiodesis
iv)Osteotomy
v)Reconstruction by arthroplasty, arthrodesis, or
cheilectomy
2)OPERATIVE TREATMENT
46. Single
Central pin- the screw in the center of the femoral
head
DISADVANTAGE
Persistent pin penetration
.
In Situ Pin or Screw Fixation
47. AFTER TREATMENT
Range-of-motion exercises - begun the day.
Unstable slips- partial weight bearing 6 to 8 weeks.
sports and other activities forbidden until physes
have closed.
The screws removed after physeal closure
48. A, Anterior approach to hip and H-shaped capsular
incision.
B, Use of hollow mill to create tunnel across physis
C, Sandwiched iliac bone grafts are driven across
physis.
Bone Peg Epiphysiodesis
49. A portion of the residual physis is removed and a
dowel or “peg” of autologous bone graft (ipsilateral
iliac crest) is inserted into the epiphysis.
In unstable slips, supplementary internal fixation,
postoperative traction, or spica cast immobilization
for 3 to 8 weeks until early stabilization has occurred
50. Disadvantages
1)Graft insufficiency
2)Increase in severity of slip
3)Failure of physeal fusion
4)longer operating time, increased blood loss, longer
hospitalization, and longer rehabilitation.
51. AFTER TREATMENT
In acute slips - spica cast for 6 weeks
In chronic slips weight bearing started at
approximately 10 weeks.
53. There are two basic types of osteotomy:
1)Closing wedge osteotomy through the femoral
neck - correct the deformity.
2)Compensatory osteotomy through the trochanteric
region - produce a deformity in the opposite
direction
55. To restore the normal relationship of the femoral
head and neck
Delay the onset of degenerative joint disease.
Prevent further slippage
Correct preexisting deformity .
INDICATIONS
56. 1)Curetting the physis and securing the capital
epiphysis to the neck
2) Fixing the capital epiphysis with a bone graft
epiphysiodesis or metallic implant
2) Inducing fusion by reorienting the plane of the
capital physis into a more horizontal position
The goal of preventing further slippage is
achieved
57. Trapezoidal osteotomy of the femoral neck
Referred as “an open replacement of the displaced
femoral head”
should not be done if the physis is closed.
Reduce the capital femoral epiphysis on the femoral
neck by resecting a portion of the superior femoral
neck.
Advantage - the deformity itself is corrected
Results.
High risk of complications, AVN and chondrolysis.
1) Dunn Procedure
58.
59. Indicated to correct residual deformity after closure
of the physis.
corrects the varus and retroversion components of
moderate or severe chronic SCFE.
Pose less risk to interruption of the blood supply to
the femoral head than the Dunn procedure
Osteotomy held with threaded Steinmann pins,
which extended into the capital epiphysis if the
physis is still open
2)Base-of-Neck Osteotomy (Kramer and
Barmada Procedures).
60. Barmada's group –
Extracapsular base-of-neck osteotomy performed
slightly more distally
Recommended for moderate to severe chronic SCFE
with a greater than 30-degree head–shaft angle on
lateral radiographs.
61.
62. Preferable method to correct deformity associated with SCFE
Southwick osteotomy –
chronic or healed slips with head–shaft deformities between 30 and
70 degrees
Biplane osteotomy
Performed at the level of the lesser trochanter.
Imhauser's procedure - Intertrochanteric
COMPLICATIONS
I)Chondrolysis
2)Post operative narrowing of joint space
4)Intertrochanteric Osteotomy
(Imhauser/Southwick Procedure).
63.
64. Not performed routinely.
Symptomatic slipping of the contralateral slip after
unilateral treatment - 12.5%
Asymptomatic slipping of the contralateral hip has -
40%.
Prophylactic Pinning of Contralateral Slips
66. 1)CHONDROLYSIS
Occasionally referred to as “acute cartilage necrosis”
NATURAL HISTORY
Symptoms develop between 6 weeks and 4 months
after treatment,
Progressive joint space narrowing occurs, maximum
reduction - 6 to 12 months of onset of symptoms.
COMPLICATIONS
67.
68. EPIDEMIOLOGY
Spontaneously
Depends on mode of treatment
1.5% percutaneous in situ pinning
50% - spica cast.
Pin penetration of the joint
Intertrochanteric osteotomy.
Girls are more likely to be affected than boys.
69. CLINICAL FEATURES
Stiffness
Pain in the groin or upper thigh.
Walking affected.
The hip held in flexion, abduction, and external rotation.
There is substantial reduction in the arc of motion of the
hip in all planes, and motion is usually painful.
70. Radiographically,
Loss of joint space.
The radiographic criterion - loss of more than 50% of
the joint space
or an absolute measurement of 3 mm or less.(normal-
4-6mm)
A technetium bone scan shows increased uptake in
an affected joint space.
71. ETIOLOGY
Etiology is not known various theories-
1) Lack of synovial fluid production- failure of nutrition
of articular cartilage
2) Autoimmune - Produce an antigen
3) Metallic implant penetration
4) Impingement - labrum and acetabulum by
anterior “pistol grip” deformity of the femoral neck
72. 1)CT of the hip to confirm that no implant
encroachment is present.
2) Aspiration of the hip to rule out a low-grade
infection.
3)If pin penetration has occurred, the implant must
be removed or replaced if the physis is not fused.
4)Supportive care
5) Muscle releases or capsulotomy,
6) Arthrodesis or total joint arthroplasty.
TREATMENT
74. Axhausen in 1924 used the term aseptic necrosis
Without treatment
Acute displacement (unstable slip).
Closed or open reduction of unstable slips
Osteotomy of the femoral neck.
Intertrochanteric osteotomy.
lowest open epiphysiodesis or in situ pinning of
stable slips
AVASCULAR NECROSIS
75. The blood supply to the femoral head is interrupted,
The lateral epiphyseal arterial system may be
damaged
EPIDEMIOLOGY
76. RADIOGRAPHIC FINDINGS AND CLINICAL
FEATURES
Two patterns of distribution are typically seen:
Total head necrosis
Partial (or segmental) necrosis
Affected epiphysis first fails to become osteopenic
Resorption of the necrotic bone
collapse of the affected portion of the epiphysis.
77. TREATMENT
1)prevention.
2)Implant removal
3) Joint arthroplasty (total or partial) or hip fusion
4)Hip arthrodesis
78.
79. 10% to 15% of patients with SCFE
Osteonecrosis is rare in untreated patients
Results from interruption of the retrograde blood
supply by the original injury (superior retinacular
artery of the medial circumfl ex femoral)
1) unstable (acute) slips,
2) forceful repetitive manipulations
3) open reduction, or
4) osteotomy of the femoral neck.
5) Superolateral placement of pins
3) OSTEONECROSIS
80. Anterior physeal separation.
a sign indicating a high rise for avascular
necrosis
separation of the anterior lip of the
epiphysis from the metaphysis
81. ETIOLOGY
i) Fixation of SCFE with multiple pins
ii) Unused drill holes
iii) After nail removal
iv) Thermal injury caused by reaming of the femoral
neck
.
Femoral Neck Fracture
83. The complication can be decreased by
avoiding drilling unnecessary holes in the bone
avoiding overzealous reaming of the femoral neck
Untreated Slipped Capital Femoral Epiphysis
i)Severe degree and that degenerative arthritis
ii)AVN
iii)Chondrolysis
84. The displacement is either superior and posterior
Increased femoral anteversion.
Clinical picture
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
Treatment
1)in situ pinning.
2)limited open approach for in situ pinning-valgus slip
2)Open bone graft epiphysiodesis -if percutaneous pinning is inadvisable or
unsuccessful
ANTERIOR AND VALGUS SLIPS