Transcript SLIPPED CAPITAL FEMORAL EPIPHYSIS

SLIPPED CAPITAL
FEMORAL EPIPHYSIS
(S.C.F.E.)
EPIPHYSIOLYSIS
BY
PROF. HUSSEIN ABDEL FATTAH
Definition
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S.C.F.E. is a disorder of the adolescent
hip involving progressive displacement
of the femoral head in relation to the
femoral neck, through the open growth
plate, posteriorly and inferiorly.
However, the epiphysis actually remain
seated in the acetabulum, it is the neck
which displaces usually anteriorly and
superiorly.
ETIOLOGY
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Exact cause is disputed.
Multiple interdependent factors
involved.
Risk Factors
•
•
•
•
Overweight.
Abnormally tall child.
Black races.
Endocrinopathies
1 – Biomechanical Factors
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Change of physeal angle.
Increase of physeal activity with
growth spurt.
Obesity and lengthening of the neck.
Abnormal retroversion of the neck.
Weakness of the fibrocartilagenous
perichondrial ring of la Croix.
2 – Endocrine Disorders
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Harris, (1950)
• Growth Hormone
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Widening of physeal plate and reduction of
shearing strength,PITUITARY TUMOURS
• Sex Hormones
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Reduction of physeal plate and increase of
shearing strength
Adiposogenital, PITUITARY DIFFICENCY
3 – Metabolic Factors
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Decreased Vitamin D activity
Rickets
Renal Osteodystrophy
4 – Inflammation
Morrissy et al, (1983)
Immune complexes in the synovial fluid.
This decreases and disappears when the
head is fixed.
Blood supply of the proximal end of the femur
microstructure of the growth plate
Pathology of S.C.F.E.
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The growth plate is widened and irregular
Loose irregular proliferative zone
Disarranged and thickened hypertrophic
zone
• Chondrocytes are clustered, not columnar
• Disturbed endochondral ossification
• Perichondral fibrous ring of LA CROIX is
attenuated
Weakening occurs in the hypertrophic zone of the growth plate
Slipping occur in this zone
BABY two years traumatic fracture
sparation of capital epiphysis
RT.
United two months later
Traumatic fracture separation capital
epiphysis five years old boy L. side
Recent
united
.
4/93
10/93
Remodelling after
slip varies with
age, younger is
more complete
Female age 11 ys
Remod.in six m.
D.M.T. F. Age
(13 yrs.) 3/90
Missed fourth degree slip age 13 years
D.M.T
10/93
Three & half years later natural healing poor
remodeling lack of congruity
Natural History
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Time of Presentation:
• 1 – Acute Slip:
 Less than 2 weeks
 Pain in knee, hip and thigh
 Mild trauma
2 – Chronic slip:
More than 3 weeks
Vague thigh and knee pain
Mild hip symptoms
3 – Acute on Chronic Slip
Long duration of symptoms
Acute episode of pain and limping
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1 – Pain
Diagnosis
• The commonest presenting symptom:
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Vague in the knee and thigh
Exaggerated with activity
Severe in acute episodes
2 – Limping
• Antalgic gait in acute conditions
• Lurching in long standing conditions
• Leg is externally rotated
DIAGNOSIS
continued
3- Deromity External rotation of the
whole limb
• Extension and adduction deformity (on
examination)
• Mild shortening
4 – Hip Movements
• Limited internal rotation, abduction and
flexion
• Flexion of the hip is accompanied by
external rotation and abduction
16 YS. 95 K. ADIPOSGENITALIA, BILAT. SLIP RT AFTER S.O.
LEFT FULLY EXTERNAL ROTATED & SHORTER .
Plain Radiogram
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(In early slip)
• Blurring, widening of physeal plate
• Decreased height of the epiphysis
• A line drown along the lat. Neck not
crossing the epiphysis
Rt .hip is
apparently normal
First degree slip
in lithotomy
In the A.P. VIEW
Lateral view
LINES IN NORMAL HIP
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X
Head shaft angle
90
70
Head neck angle
Degree of Slipping
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1. Mild:
• Slipping of less than 1/3 of epiphysis
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2. Moderate:
• Slipping of 1/3 to ½ of epiphysis
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3. Severe:
• Slipping of more than ½ of epiphysis
C.T. Scan
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Demonstrates early slipping
Accurate measurement of angle and
degree of slip.the degree of
External femoral rotation at the knee
Treatment
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Aim
• To
• To
• To
• To
stop slipping
enhance healing
correct deformities
avoid complications
Treatment
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Non Surgical Treatment
• Prolonged traction in internal rotation
• Immobilization in plaster
• Manipulative reduction (condemned)
Adjuvant Hormonal Therapy
11 Cases
Chorionic Gonadotrophic Hormones.
(1500–5000 units/week)
Surgical Treatment
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Epiphyseal Fixation (Pinning) BOYD
• For mild slips and most moderate slips
• Only one or maximum two pins
• In mild slips, inserted from lateral
approach
• In moderate slips, it is inserted from
anterior
Pinning
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Pin position in the lower and
posterior half
Upper and anterior position is
dangerous > Penetration and
avascular necrosis
A.A.Afify M. Lt. Early slip. Rt. N.
BILAT .FIX. BY CANULTED
SCREWS
Pinning The Other Hip
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If painful with no slip
Especially in over weight child
Only 10% of painless other side may
slip
Preoperative Traction and Pinning
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In acute and acute on top of chronic
cases
• skin Traction in Abduction and internal
rotation by a plaster boot and
derotation bar for few days.
• When reduction is achieved pin fixation
is done.
SHERBENY pain rt. Hip 30/1o/ 91,acute slip
8/12/91,reduced by traction 3 D.
Sherbiny pins after gradual
traction with good reduction
R.R.S. (F.) B.D. 4/2/1986 age 9 ys. X
6/1995 LEFT MISSED SLIP. RIGHT
NORMAL
Acute slip before reduction.
R.R.S. 11 (YS) 20/2/1997
R.R.S. AFTER REDUCTION BY GRADUAL
TRACTION & FIXATION PINS IN GOOD POSITION
R.R.S. Rt. Hip two pins, Lt. hip remodelled
H.SHARAWY 12 YRS ACUTE
SLIP 5/2/86
Two pins 10/2/86
1O/2/86 5 DAYS
TRACTION
H.S. Preslip left side 11/86
H.Sharawy.pins left side
5/87
10.88
10. 88
Surgical Treatment
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Open Reduction
• Dunn (1964) and Dunn & Angle (1978)
• High incidence of ischaemic necrosis
and chondrolysis
• For severe slipping
Lateral diagram of femoral head
showing vascular supply
Blood supply of the S.C.F.E. from medial
circumflex artery posteriorly
OPEN REDUCTION & INTERNAL.
FIXATION
4 M .P.O.
6/88
M.S.O. 16YRS.SUDANESE GIANT
DURATION TW0 WEAKS
SLIP 1O.2.1988
VIABLE HEAD
Implants removed 20/1/1989
1.1989
O.R. for acute slip 6/90
Osteotomy for chondrolysis
7/91
Mobile hip mild limp, shortening 10/93
Trochanteric-Osteotomy
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Triplane osteotomy (Southwick
J.B.J.S 1967 A.V.)
•Remove Anterior wedge to
correct extension. Remove
lateral wedge to correct coxa
vara
• Internal rotation to correct ext.
rotation
Subtrochanteric triplane osteotomy
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Correction of the head shaft angle
 Fixation by double angle conylar
plate
A.E.H. 20/12.1983. AGE 16 YS.
RT.Gr.4 LT.Gr.1. PIN 11/11/1999
Left hip
A.EMAD.H. B.D. 20/12/1983 AGE 16 YS. LEFT. HIP
PIN 11/1999
EXTRACTED 2/4/2000.
RT. HIP
VALGUS DEROTATION OSTEOTOMY
2/4/2000
Complications
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Ischaemic Necrosis
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A complication of treatment
• Forcible Manipulation
• Forcible Traction
• Cervical Osteotomy
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Chondrolysis acute cartilage necrosis
Secondary O.A.
Within 20 years
More with severe deformities
In mild early pinned cases, much less
Secondary O.A.
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Within 20 years
More with severe deformities
In mild early pinned cases, much
less
Presentation of 42 cases
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33 M. mean age
14.2 YS.
9 F. mean age
11.2 YS.
never after menarche
Mode of Presentation
•Chronic
•Acute
•Acute on Chronic
Mild
Moderate
Severe
47.6%
33.3%
19%
Degree of Slip
14
16
12
33.3%
38.1%
28.6%
Side Affected
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Left side twice the right side in boys,
equal in girls
Bilateral in 20 – 80%
• (Weinstein, 1984)
Body features
51%
18%
31%
Hypogonadism
Over Weight
Abnormally tall
Normal
Treatment
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Non Surgical:
Pinning in-situ:
Traction-Pinning:
S.T.F.O.:
Open Reduction:
6
15
7
12
2
Conclusion
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S.C.F.E. is an ailment of teenagers
Knee pain and limp are early complaints
Early diagnosis by hip examination
clinically is important
Plain X-Ray of both hips in A.P. and A.P.
Lithotomy position is mandatory
C.T. is helpful for further management
Early pinning is the best solution
Prophylactic pinning may be done
Complications chondrolysis early and late
osteoarthritis
Treatment of the predisposing factor is
important
Thank
You
THANK
YOU
The Journal of
Bone and Joint Surgery
American Volume
Volume 64-A, No 5
July 1967
Osteotomy through Lesser Trochanter
for Slipped Captial Femoral
Epiphysis*
By Wyane O. Southwick M.D.Y., New Haven
Connecticut
From the Department of Surgery, Section of
Orthopaedic Surgery, Yale University School of
Medicine, New Haven
Remodeling After Pinning for
Slipped Capital Femoral Epiphysis

Nathan R. Jones, Dennis C.Paterson,
Terence M. Hiller, Bruce K. Foster.
• From Adelaide Children Hospital, South
Australia