Slipped capital femoral epiphysis or SCFE, a pediatric orthopedic disorder

1. SLIPPED CAPITAL
FEMORAL
EPIPHYSIS
Presented by DR Maulik patel
(RESIDENT -ORTHO)

2. Slipped capital femoral
epiphysis
 Slip capital femoral epiphysis is a disorder in
which capital femoral epiphysis is displaced
from the metaphysis through the physeal
plate
 SCFE is actually a misnomer in that the head
is held in the acetabulum by the ligamentum
teres,& thus it is actually the neck that comes
upward & outwards while the head remains
posterior & downward in the acetabulum.
 A varus relation exists between the head &
neck, but occasionally the slip is into valgus,
with head displaced superiorly & posteriorly
in relation to the neck

3.  Incidence => 2/100,000 (.002%)
 Boys(10 – 16 yrs) > girls(10 – 14 yrs) (2.5:1)
 Blacks > white
 5% of parents have had SCFE
 Left hip is twice as often affected as right hip
 Bilateral
 17-37% in adolescents
 50% are simultaneous, 50% sequential
 Younger child (physically or chronologically) the greater risk of
subsequent bilateral involvement
 a contra-lateral slip will usually present within 2 years
 20% are bilateral at time of presentation

4. Etiology
 The causes for the displacement are multifactorial
 Four important causes are indentified:-
1. Increased height of capital femoral physis.
2. Changes in the geometry of the capital physis and
adjacent bone
3. Abnormal loading of growth plate
4. Insufficiency of the tensile (collagen) and
(proteoglycans) hydrostatic component of the
growth plate.
It is not essential that all the factors exists for the
slip to occur

5.  Usually every capital epiphysis does not slip.
 Growth plate anatomic stability is responsible for
holding the physis against the shearing stress these
are:-
1. Perichondrium and the perichondrial ring
2. Transphysieal collagen fibres
3. The mamillary processes
4. The central and peripherral countour of the
physis
5. Inclination angle of the physis
6. Height of the growth plate.

6. Where does it slip?
 Slip occurs in the zone of hypertrophied
cartilage cell layer.
Bone marrow epiphysis
Bone of epiphysis
Zone of resting cartilage
Zone of proliferating cartilage
Zone of maturing cartilage
Zone of calcifying cartilage
Developing trabeculae of metaphysis

7.  Hormonal theory:- slipping of epiphysis occurs
only when the growth plate remains open.
 Growth and maturation of epiphyseal cartilage
plate depends on hormonal factors like growth
hormone, thyroid hormone and sex hormone.
 In connection with this Harris observed that the
epiphysis tends to slip at time of fast growth.

8.  Traumatic theory:- The epiphyseal line is the
weakest part of the normal adolescent bone.
 Key pointed out that the slipping of epiphysis is
neither in the bone nor in the cartilage, but in the
periosteum of the femoral neck.
 In the childhood the periosteum is thick and is
thrown into folds or ridges known as retinacula of
Weitbrecht, actually it is the chief factor holding the
head in place.
 In adults the periosteum becomes atrophy to
produce a point of weakness in the epiphyseal line.
 He also pointed out that most of the cases of coxa
vara gives a history of very rapid growth and during
this the the periosteum crossing the epiphyseal line
is stretched and thinned and consequently weaken
causing coxa vara.

9. Classification
 Traditional Classification : ( Fahey and O’brain )
 Acute < 3 weeks of symptoms
 Chronic > 3 weeks of symptoms
 Acute on Chronic> 3 weeks of symptoms +
sudden exacerbation
 Newer Classification ( LODER )
-Unstable – ambulation is impossible, w/ or without
crutches
-Stable – ambulation is possible w/ or without crutches

10.  Kallios , ultra sound :-
 Unstable - effusion is present, physeal
instability allows reduction , no metaphyseal
resorption or early remodelling
 Stable - effusion is absent, physeal stability
present ,does not allows reduction ,
metaphyseal resorption or early remodelling
present.

11. CATEGORIES AS PER SEVERITY OF
SLIP
 Wilson’s Classification:-
Pre-slip or grade I:
Widening & rarefaction of the physis, but no actual displacement.
Minimal slip or grade II:
Femoral head displaces up to one third of the superior metaphyseal
width of the neck
Moderate slip or grade III:
Femoral head displaces greater than one third & less than half of the
superior metaphyseal width of the neck.
Severe slip or grade IV:
Femoral head displaces more than 50% of the superior metaphyseal
width of the neck.

12. GROUP I
1%-32%
GROUP II
33-50%
GROUP III
>50%

13. PATHOLOGY
 The pathologic changes depend on the stage &
degree of displacement.
Pre-slipping stage:
 Physis is widened in zone of hypertrophy.
 Cartilage cells are in disarrayed clusters instead
of orderly columns in this layer.
 Island of unorganized cartilage dispersed
irregularly in the proximal metaphysis.
 Femoral head & acetabulum are normal.
 Synovial membrane is engorged, edematous &
swollen.

14. Slipping stage:
 The slip takes place in layer of hypertrophic
cartilage cells adjacent to the zone of provisional
calcification.
 The plane of separation is weaving & irregular due
to the irregularity of the contour of the physis.
 The slipping is usually gradual.
 Perichondrium remains attached to the femoral
neck, stretching & elongating as the physis
migrates.
 In an acute slip the perichondrium is stripped off the
neck anteriorly & inferiorly.
 Capital epiphysis with the acetabulum almost
always displace posteriorly & inferiorly.
 The displaces anteriorly & proximally as a hump.
 Except in acute traumatic slip there is no
hemarthosis.

15. Chronic stage:-
 With healing the inferior angle & anterior portion of
the neck adjacent to the physis is filled with callus.
 When remodeling takes place, the callus becomes
incorporated with the neck.
 The protruding hump becomes round & smooth.
 These hump impinges against the anterior &
superior margins of acetabulum & cause limitation
of abduction, medial rotation & full flexion.
 Swelling & edema of the synovial membrane
subsides.
 Physis ossifies & there is bony union between the
head & the neck.
 Degenerative osteoarthritis sets in the acetabulum.

16.  Clinical features:-
 Symptoms:-
 The onset is gradual and in many cases the earliest
symptom is that the patient gets tired after walking
or standing.
 Pain is the main complain, usually confined to hip
but may radiates to lower thigh and to knee.
 Pain is accompanied by limp, the limp may be
present even in the absence of pain.
 The affected leg becomes shorter and smaller and
tends to turn laterally, and its movement is
restricted.
 The limb is held in flexion, adduction and external
rotation.

17.  Signs:-
 Waddling gait is present
 The patient stands with the leg rotated laterally and
slightly adducted, while inspection shows the pelvis
to be tilted on the affected side.
 Scoliosis on the affected side is present
 Buttock is atrophied and the gluteal fold is lower
than on the normal side.
 On palpation hard mass is felt on which head moves
with femur.
 Trochanter is higher than the sound hip
 Adduction and lateral rotation are free but
abduction and medial rotation and extension are
greatly restricted.

18. MEASUREMENT OF AMOUNT OF SLIPPING
 Head shaft angle by Southwick:
In lateral view of normal hip the capital femoral
physis & femoral neck lie at right angles to each
other.The physeal neck angle decreases when
slipping takes place.
 In recent acute slip the distance between the
superior edge of the epiphysis & the upper margin
of the metaphysis indicated the amount of
displacement; which shows the greatest amount of
displacement.
 In chronic slip remodeling of the femoral neck
makes it difficult to measure the amount of
displacement of the capital femoral epiphysis.
Here Southwick’s method is useful,

19.  Lateral view of hip is taken,
First line is drawn between
the superior & inferior
margins of the metaphyseal
surface of the capital femoral
physis.
Second line is drawn
perpendicular to the first line.
Third line drawn along the
femoral shaft.
The head shaft angle
formed by the second & third
line is measured.
The head shaft angle of
abnormal side is substracted
from the normal side.It is
classified as
 Mild 1-29 degrees
 Moderate 30-60 degrees
 Severe > 60 degrees

20. Radiological appearance
 Pre-slipping stage:-
 In early cases x-ray shows,
 Minimal slipping indicated by the
absence of the normal shoulder on
the upper aspect of the neck and
head ( i.eTrethowan’s sign) in which
a line drawn along the superior
surface of the neck will pass above
the femoral head rather than
through it.
 The head is more or less sickle
shaped instead of hemispherical and
its height is diminished.
 The epiphyseal plate is widened and
rarefaction or even streaks of
sclerosis may be seen.
 The lateral view shows the slightest
backward displacement better than
in AP view.

21.  Early stage :-
 The head of the femur is rotated
so that it lower and posterior
border are displaced downward
and laterally.
 The femoral neck appears in
normal relation to the shaft, but
is upper border is lengthened
and roughly convex upwards,
while its lower border is
shortened and also appears to
be more sharply curved upward
than normally.
 Advanced stage:-
 The femoral head is atrophied
 The neck is short and thick and
its lower border bowed upward
 The joint space is clear and there
is no evidence of arthritis

22. OTHER INVESTIGATIONS
 Bone scan
 Ultrasound
 C-T scan
 MRI

23.  Differential diagnosis:-
 Tuberculosis of hip
 Perthes hip
 Congenital dislocation of hip

24. Surgical Treatment
 Goals:
– Prevent further slipping
 close the growth plate
– Safely restore normal anatomy
 reduction or osteotomy

25. Treatment Options
 Pin in situ
 Reduction and pinning
 Bone peg epiphyseodesis
 Osteotomy
 Reconstruction by arthroplasty, arthrodesis
- Each technique has proponents &
opponents, & the choice of t/t must be
individualized for each child, depending on
age, type of slip & severity of displacement

26. Pinning In Situ
 Internal Fixation [single cannulated
screws or pins ( Moore or Knowles) ]
 Screws are extremely effective for stable
SCFEs
 Decreased complications compared to
multiple pins, (pin protrusion &
chondrolysis)
 Controversial in the unstable SCFEs
 Some advocate 2 screws
 Others have excellent results with 1 screw
 No biomechanical benefit found with 2 screws
 The fixation device must enter the
epiphysis perpendicular to physeal plate
of femoral head & must cross it, but well
short of subchondral cortex

27. Reduction
 Very controversial, becoming timely
 Reduction gives poor results esp. in a
chronic SCFE
 Necessity
 Mild  no
 Moderate  probably no
 Unstable, severe slips
 Can make pinning technically easier

28. Bone peg epiphysiodesis
 ADVANTAGES:-
 Popularity increased after
complication followed after pin or
screw penetration into joint.
 Rapid physeal closure & low incidence
of complication.
 Useful in moderate or severe slips.
 DISADVANTAGES:-
 Need longer operating time,
increased blood loss, longer
hospitilization & rehabilitation.
 Bad results in mild acute & chronic
slips.

29. Osteotomy
 Indication
 Moderately or severely displaced chronic slips
 Mal union of a chronic slip in poor position

30. Subcapital
osteotomy
Through
femoral neck
Trochanteric
region

31. Femoral neck osteotomies
 Cuneiform osteotomy of femoral neck (FISH)

32. Femoral neck osteotomy
 Cuneiform osteotomy of femoral neck( DUNN)

33. Femoral neck osteotomy
 Compensatory basilar osteotomy of femoral neck
( KRAMER )

34. Femoral neck osteotomy
 Extra capsular base of neck osteotomy (ABRAHAM )

35. Intertrochanteric Osteotomy
 SCFE, when chronically slipped & united in poor
position, a trochanteric osteotomy to produce a
opposite deformity may be indicated
 Biplane wedge osteotomy (Southwick)

36. Two boys with SCFE
-Taller one post-operative
- Shorter one
-Shorter one pre-operative

37. Complications
 AVN – Etiology
 Single most repeatable finding is reduction
 Stable SCFE
 - iatrogenic with reduction
 Unstable SCFE
 More likely result of slip, not reduction
 Immediate reduction and fixation vs. traction prior
to fixation to reduceAVN
 One screw vs. 2
 Role of pre-treatment bone scan

38. Complications
 Chondrolysis – associations:
 5-7% of SCFEs
 Increased incidence in more severe slips
 Increased with spica casts
 Pin penetration

39. Complications
 Chondrolysis - Diagnosis
 Clinical
 Pain out of proportion to SCFE severity
 Radiographic
 Increased joint space narrowing 50%
 Persistent juxtaarticular osteoporosis
 Subchondral errosion of femoral head/acetabulum
 Bone Scan
 Marked periarticular uptake

40. Complications
 Chondrolysis - Treatment
 Remove protruding pins
 Rest & NWB
 NSAIDs

41. THANKYOU