Description of the presentation, incidence and management of slipped upper femoral epiphysis in children .

1. SLIPPED CAPITAL FEMORAL EPIPHYSIS

2. INTRODUCTION
 It is the disruption along the growth plate.
 It results into displacement of capital femoral epiphysis from the neck through the physeal
plate.
 SCFE is one of the most important pediatric and adolescent hip disorders.
 SCFE represents a unique type of instability of the proximal femoral growth plate.
 Common condition of the proximal femoral physis

3. ANATOMY
 The hip is a ball & socket joint supported by the acetabulum and strong ligaments.
 The femur is made up of epiphysis, metaphysis & diaphysis
 The physis contains five zones
 The main blood supply to the femoral head and neck is medial femoral circumflex artery
derived from lateral epiphyseal artery

5. EPIDEMIOLOGY
 Most common disorder affecting adolescent hips
 Average age range is 10-14 years in girls
12-16 years in boys
 The left hip is the most common location
 Can be bilateral in 17-50 %

6. RISK FACTORS
 Obesity – most present with bilateral SUFE
 History of previous radiation
 Elevated leptin levels
 Endocrine disorders: hypothyroidism, growth hormone deficiency, panhypopituitarism
 Down’s syndrome
 Family history of SCFE
 Renal failure

7.  SCFE results from a Salter-Harris type physeal fracture.
 the epiphyseal growth plate is widened due to expansion of the zone of hypertrophy
 Shearing forces applied to the femoral head exceed the strength of the capital femoral
epiphysis.
 Slippage occurs through this weakened area.
 The position of the proximal physis normally changes from horizontal to oblique during
preadolescence and adolescence, redirecting hip forces from compression forces to shear
forces
 Inflammatory synovitis in the hip is present.
 Some cases occurs after some falls, however , the condition occurs gradually with no
previous injury

8. CLASSIFICATION
STABLE SCFE UNSTABLE SCFE
Weight bearing possible Weight bearing not possible even with crutches
Less severe slips More severe slips
Effusion absent Effusion mostly present
Less chances of AVN More chances of AVN
Good prognosis Bad/poor prognosis

10.  Acute slip: sudden onset of severe symptoms present for less than 2 weeks . X-ray shows
displacement without any bone healing
 Chronic slips: gradual onset of symptoms >2 weeks . Some bony healing & remodeling
 Pre-slip : an x-ray finding characterized by irregularity and indistinctness of epiphyseal plate.

11. HYPOTHYROIDISM
 Thyroid hormone activates synthesis of bone matrix by increasing the secretion of growth
hormone and insulin like growth factor
 Hypothyroidism leads to delay in ossification & inactivation of growth factor and IGF
 Hypothyroidism causes decreased gene expression of proteoglycans & type X collagen.
 This causes weakening of the epiphysis & delayed closure.
 Can cause SCFE in adults

12. CLINICAL FEATURES
 Insidious onset
 Slow progressive course
 Pain around the groin and hip
 Knee pain – referral obturator nerve
 Antalgic gait
 Limited range of motion(flexion, abduction, internal rotation)
 Axis deviation. On flexion of hip, the limb goes into external rotation

13. PHYSICAL EXAMINATION
 Length
 Gait
 Muscle bulk (thigh)
 Sitting position
 Alignment
 Range of motion and muscle guarding
 Drehmann sign

15. INVESTIGATIONS
 Appropriate lab tests should be completed for endocrinopathies and medical disorders .
 Patients with atypical presentations should be considered.
 Atypical presentation for children with SCFE includes : <10yrs/ >16 yrs.
short stature
not obese but within 10-16 yrs.

16. X-RAY FINDINGS
 Cross table lateral view or AP
 Frog lateral view
 Metaphyseal blanch sign of steel – overlap of metaphysis and posteriorly displaced epiphysis
 Epiphylolysis– early sign
 Klein’s line – doesn’t intersect with the femoral head

19. MANAGEMENT
 Operative management. Aim to prevent further slip
Reduce displacement
Effect early epiphyseal closure
 Percutaneous In situ fixation
 Open reduction
 Contralateral hip prophylactic fixation
 Osteochondroplasty

20. IN SITU FIXATION
 Use of cannulated screws .
 Most common

21. RECOVERY
 Non-weight bearing for several weeks
 Analgesics
 Physiotherapy
 Restricted vigorous and sport activities
 Follow up till 24 months post-op

22. COMPLICATIONS
 Avascular necrosis – occurs when there is disruption of blood supply to the capital femoral
epiphysis.
Happens at time of injury but may occur during forced manipulation of unstable
slip
Avascular necrosis may occur in up to 50% of unstable SCFEs and may lead to
OA.
 Chondrolysis - Chondrolysis is destruction of the articular cartilage.
It is associated with more severe slips and with intraarticular penetration of operative
hardware leads to severe OA and disability.
 Contralateral hip SCFE
 Chondrolysis
 Osteoarthritis

23. PERTHES VS SCFE
Perthes disease SCFE
Age 4-8 yrs. Ages 10- 15 yrs.
Children shorter in stature Children tend to be overweight
Deformity of femoral head Displacement of femoral neck
Treatment primarily conservative Treatment primarily operative
Surgery may involve femoral osteotomy Surgery usually involves in situ fixation

24. REFERENCES
 Nelson’s textbook of pediatrics
 Medscape

25. CASE STUDY
 A 14-year-old adolescent male presented with right hip pain and stiffness which was affecting his gait with
gradual onset over the past 4 months. Clinical examination revealed severe short stature with obesity. He
had painful and restricted range of movements of the right hip. Internal rotation was limited. He had facial
puffiness, dry skin, sonorous voice, sinus bradycardia and delayed tendon reflexes.