Slipped capital femoral epiphysis, trauma, SCFE, SUFE, FEMORAL epiphysis slip, valgus slip, dunn osteotomy, Southwick osteotomy

1. SCFE ( slipped capital femoral epiphysis)
Presented by : Dr Surya Vijay Singh (PG3 CIO, VMMC and SJH)
Moderator : Dr Tankeshwar Baruah (faculty spine care unit,
CIO, VMMC and SJH)

2. SCFE
• Introduction and definition
• Epidemiology and risk factors
• classification
• Pathogenesis
•
Signs and symptoms
• Diagnosis
• Investigations
• Management modalities
• Complications

3. • INTRODUCTION
• The capital femoral epiphysis is somewhat
unique. It is one of the few epiphyses in
the body that is inside the joint capsule.
(The joint capsule is the tissue that
Surround the joints).
surrounds the joint.)

4. Definition of SCFE (slipped capital femoral
epiphysis)
• Slipped upper femoral epiphysis" term refer to
slippage of the overlying epiphysis of proximal
femur posteriorly and inferiorly due to weakness of
the growth plate in relation to metaphysis.
• Most often, it develops during periods of
accelerated growth, shortly after the onset Of
puberty.
• The femoral epiphyses maintains its relation with
acetabulum ,it’s the femoral neck and shaft
upward and anterior movement on epiphyses thus
epiphyses displaces relatively posterior

5. • 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 1218mths later to 1st (left
hip is more common than right).

6. • ETIOLOGY-multifactorial
• Local trauma , obesity
• Endocrine disorders (e.g primary or secondary hypothyroidism,
adiposogenital dystrophy(hypogonadal male),
• Deficiency or increase of androgens.
• Acute trauma
• Growth hormone deficiency
• 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.

7. MECHANICAL FACTORS
Important features of the predisposed hip that may be the primary
cause of slipped epiphysis are:
1.Thinning of the perichondrial ring complex with maturation
2.Relative or absolute retroversion of the femoral neck-making it
more suceptable to AP shear forces
3.A change in the inclination of the adolescent proximal femoral
physis relative to the femoral neck shaft .
•Associated conditions with mechanical etiology-
1.Infantile and adolescent blount diasease
2.Patients with peroneal spastic flatfoot and Legg-Calve-Prthes
disease

8. Classification of SCFE
} Based on onset of symptoms [temporal classification]
-acute ( <3 weeks)
-Chronic (> 3 weeks)
-acute on chronic (acute exacerbation of long standing symptoms)
FUNCTIONAL CLASSIFICATION [ Loder classification]
-stable (able to bear wt with or without crutches, min risk of osteonecrosis <10%)
-Unstable (unable to ambulate – not even with crutches, high risk of osteonecrosis
~47%)
MORPHOLOGICAL CLASSIFICATION [Southwick angle classification]
-mild (<30°)
-moderate (30-50°)
-severe (>50°)

9. SYMPTOMS : <2WKS >2WKS grdual
X-RAY : displaced epiphyses remodelling
no remodelling healing noted
ACUTE ON CHRONIC SLIPS-Symptoms lasting longer than 1mth and
recent sudden exacerbation pain after trivial trauma

10. • FUNCTIONAL CLASSIFICATION
• It is important to determine ability of the
patient to bear weight.
• Stable" SCFEs allow the patient to (walk) with or
without crutches (walking aids).
• "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.

11. • AP VIEW-145* -Best
shows posterior slippage
and LATERAL VIEW-170*
subtle slipping also
FROG LEG LATERAL POSITION-
-Normally 10*posteriorly
-Increases in slippage

12. • MORPHOLOGICAL
CLASSIFICATION-
• Grading Severity of SCFE
according to AP and Lateral Xray
• PRE SLIP-irregularity,widening,and
indistinctness
of physes
Grade-1 Grade-II Grade-III

13. • 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.

14. Pathology
• Grossly , with gradual slipping of the capital epiphysis in the typical posterior
position
• Periostium is stripped from the anterior and inferior surface of the femoral neck
• So the area between the original femoral neck and the posterior periostium fills
with callus which ossifies and become progresively more dense
• The anterior and superior portion of the neck forms a hump or ridge that can
impinge on the rim of acetabulum
• Normally ,this ridge will remodel with anterior portion of the neck contouring
into smoother surface
• In case of acute slipping the periostium is torn anteriorly and haemarthrosis will
be present.

15. Microscopically change in SCFE
Microscopically :
• Characteristc changes in PROLIFERATIVE
and HYPERTROPHIC ZONES of epiphyses,
• chondrocytes -number decrease and -
irregularly arranged,
• collagen fibres and Matrix are increased.

16. SYMPTOMS
• Pain : in the groin and around the knee.
• Antalgic Limp (intermittent).
• Shortening of the affected limb (1-2 cm).
• The limb is in external rotation.[frog leg position]
• Flexion, abduction, medial rotation are limited
• External rotation, adduction are increased.
• The presence of hip flexion contracture points towards the possibility of
chondrolysis.
• Axis deviation – pathognomonic – when hip is flexed, the limb goes into external
rotation

17. DIAGNOSIS
• The diagnosis is a combination of clinical suspicion plus radiological
investigation.
• 20-50% of SCFE are missed or misdiagnosed on their first presentation to a
medical facility.
• This is because the common symptom is knee pain. This is referred pain from the
hip. The knee is investigated and found to be normal
• In acute cases it is essential to differentiate between SCFE and type
• 1 epiphseal#as most of time both come with history injury/trauma
• SCFE pt has prodromal pain in groin,thigh or knee.insidious onset whereas in
type 1 epiphyseal # pt is normal acute pain associated with high energy
trauma

18. SCFE PERTHE’S DISEASE
Usually occurs in 10-14yrs age late onset in 14-16yrs Usually in 4-7yrs age late onset in 7-10yrs
age
Thin and tall adolescents or short and obese
individuals
Occurs in normal child
Presents as pain with slippage and limping noted
at later stage
Initially the child limps and then at later stages
complaints of pain
Limb never has fixed flexion deformity
It may be in hyperextension state
Fixed flexion deformity is usually noted

19. • X-RAYS-AP VIEW
• -thretowan’s sign[kleins line]
• -steel metaphysel blanch sign
• -sham’s sign
• -capner’s sign
•
-widening of growth plate
• -decrease of epiphyseal height
• X-RAY -frog-leg [lowenstein]lateral view
• CT-SCAN
• MRI SCAN

20. A.P. VIEW-
Posterior ,inferior, And medial
translation of epiphyses
FROG lateral view :
To measure lateral
epiphyseal shaft angle

21. •
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.

22. • In AP VIEW-crescent-shaped area
of increased density overlying
thethe metaphysis adjacent to
the physis
• This increased density is due to
the overlapping of the femoral
neck and the posteriorly
displaced capital epiphysis

23. •  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.

24. CAPENERS SIGN-
• In pelvic 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.

25. • 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]

26. • 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.

27. COMPLICATIONS
• Avascular necrosis
• Chondrolysis
• Osteoarthritis.
• 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).
• Slipping of the opposite hip ≈ 20% to
80% of cases

28. NATURAL HISTORY
•30-40% second slip asymptomatic (slow).
•Premature OA (pistol grip deformity 40% primary OA)
•Onset of OA directly related to severity of slip.

29. • IDEAL TREATMENT
• •Prevent further slippage
• •Stimulate early physeal closure
• •Reduction of epiphyseal displacement
• •Avoid complications like osteonecrosis , chondrolysis and osteoarthritis
• •Any child with SCFE and open epiphyses needs treatment ,without stabilisation it
progresses.
• •In a patient with closed physes, the only surgical treatment in the absence of
severe degenerative

30. Management of SCFE
• Conservative management-rest and traction
• Closed manipulative reduction
• Operative management
-In situ pinning
-ORIF
-BONE PEG Epiphysiodesis
-Osteotomy
- reconstruction by-Arthroplasty
-Arthrodesis
-Cheilectomy

31. Conservative treatment of SCFE
• 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

32. Percutaneous in situ fixation
• Cannulated Screw placed percutaneously into
center of epiphyses and perpendicular to
physis.
• Min 5 screw thread should be contained within
the physis in order to provide adequate stability
and prevent slip.
• Screw s/b at least 5 mm from subchondral bone
in all views.
• The use of 1 vs 2 screw is contraversial.
• Screw must be start on anterior surface of the
neck in order to cross perpendicular to physis
on both AP and Lateral view.

33. Prophylactic fixation of asymptomatic hip
Indications
• Children with HIGH RISK of contralateral slip,
• Young at primary diagnosis ( <10years),
• Have Endocrine disorder, or
• Obese with delayed presentation.
After in situ pinning:
–early wt bearing in stable slips,
-after 6-8wks in unstable slips

35. Open reduction for SCFE
indications
- Highly displaced,
- Unstable scfe,
- Not reduce in Closed maneuver
- Sever slip
Types
1) Modified Dunn procedure
2) Bone PEG Epiphysiodesis
3) Proximal femoral osteotomy

36. Modified Dunn procedure for SCFE
-Used to reduce the epiphyses, performed anteriorly via Surgical
Dislocation of Hip.
-Opportunity to assess and confirm blood flow to femoral head thereby
reducing risk of both AVN and Femoral acetabular impingement.

37. Bone PEG Epiphysiodesis for SCFE
• Anterior approach to hip and H-shaped
capsular incision,
• Use of hollow mill to create tunnel across
physis,
• Sandwiched iliac bone grafts are driven across
physis.
-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.

38. Bone PEG Epiphysiodesis for SCFE
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.

39. Osteotomy in SCFE
• 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

40. Osteotomy in SCFE

41. Osteotomy in SCFE
Four femoral neck osteotomies are described:
• (1)the technique of Fish - just distal to the the physis,
• (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.- at the trochanteric region.

42. 1)Cuneiform osteotomy of femoral neck ( FISH)
•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

43. 2)Dunn osteotomy
• 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.

44. 3)Base-of-Neck Osteotomy (Kramer and
Barmada Procedures)
• Indicated to correct residual deformity
after closure of the physis.
• corrects the varus and retroversion
components of moderate or severe chronic
SCFE.
• 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.

45. 4)Intertrochanteric Osteotomy (Imhauser/
Southwick Procedure)
• 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

46. Imhauser/Southwick
Procedure

47. Complication
1) Chondrolysis
Dissolution of articular cartilage with joint
stiffness and pain
Causes:
• Persistent pin penitration
• After trochantric osteotomy, open
reduction,femoral neck osteotomy
•Synovial malnutrition, ischaemia, excessive
pressure
•Autoimmune
•Females>males

48. Chondrolysis...
-Diagnosis:
Joint pace of less than 3mm wide ( normal 4 to 6 mm),
Decrease range of motion at hip joint.
-TREATMENT :
•Bed rest
•Traction
•Salicylates
•Nsaids drugs
•Intraarticular cortisone injections
•Sugical manipulation in form of : Subtotal circumferential capsulectomy
•Continuous passive motion and physical therapy

49. Complications...
2) Osteonecrosis of femoral head ( 4-6%)
-Rare in untreated SCFE
-Results from interruption of the retrograde blood supply by:
•Original injury tamponade of the blood supply to the proximal femoral
epiphysis as a result of acute 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

50. DIAGNOSIS:
Early postoperative bone scan has excellent sensitivity and predictive
value for detection of osteonecrosis after surgical treatment of SCFE
TREATMENT
• Remove metal work
• Maintain ROM
• Realignment
• Shelf acetabuloplasty
• Arthrodesis/THR

51. Complications...
3) Contralateral hip SCFE
Most common complication after UNILATERAL surgical fixation of slip
(20-80%).
Risk factors for contralateral slip :
• Male,
• Obesity,
• Young age of initial slip,
• Endocrine disorders.

52. Complications..
4) chronic pain
5) Infection
6) Degenerative arthritis
7) Residual proximal femoral deformity and LLD
8) Slip progression
9) Labral tear and degeneration.