Adolescent coxa vara
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Transcript of Adolescent coxa vara
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ADOLESCENT COXA VARA
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It is also known as Slipped Capital Femoral Epiphysis
Or Epiphysiolysis
It is displacement of the proximal femoral epiphysis
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WHO?
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•10 – 16 yrs•Boys•Obese or tall & thin•Blacks•Left > Right
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WHY?
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MOSTLY MULTIFACTORIAL
Local trauma
Obesity
Endocrine disease (hypothyroidism, hypopituitarism, chronic renal disease)
Genetic
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CLINICAL FEATURES
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H/O Injury
Pain in groin thigh or knee
Limp
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On Examination
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Leg is externally rotated
1-2cm short
Limitation of flexion, abduction and internal rotation
Classic Sign – there is increasing external rotation as the hip is flexed
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INVESTIGATIONS
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RADIOLOGICAL FEATURES
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XRAY
In AP view-Normal head-shaft angle is 1450
In Lateral view-Normal head-shaft angle is 1700
Lateral view – most reliable sign – femoral epiphysis is tilted backwards
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AP view – a line drawn on the superior surface of the neck remains superior to the
head instead of passing through it (TRETHOWAN’S SIGN)
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CT SCAN
It is helpful to confirm the diagnosis in early, mild slipping
X ray-
Trethowan’s Sign positive
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CLASSIFICATION
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DurationA. Acute slips – sudden onset of severe
symptoms, <2 weeks, Xray shows no evidence of bone healing
B. Chronic slips – gradual onset, >2 weeks, Xray shows some bony healing and remodelling along postr. and med. femoral neck
C. Preslip – Xray finding of irregularity, widening and indistinctness of physis
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D . Acute on Chronic – symptoms >1 month, recent exacerbation of pain following trivial trauma
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BASED ON XRAY
MILD (GRADE I) - Neck displaced <1/3rd of diameter of femoral head, angle deviation <300
MODERATE (GRADE II) – Displacement btw 1/3rd and 1/2, angle deviation btw 300 and 600
SEVERE (GRADE III) – Displacement >1/2, angle deviation more than 600.
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TWO PART CLASSIFICATION
UNSTABLE – Severe pain prevents walking even with crutches
STABLE – Walking is possible with orwithout crutches
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TREATMENT
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AIMS
Preserve epiphyseal blood supply
Stabilize the physis
To correct any residual deformity
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NON OPERATIVE
Traction and spica cast immobilisation
Prevents further slipping
Results in premature physeal closure
More complications
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MILD SLIPS Deformity is minimal
Insert one or two screws or threaded pins along the femoral neck and into the epiphysis
Now recommended – single larger diameter central pin or screw
Pins should not be removed for atleast 12 months or until epiphysis closes
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MODERATE SLIPS
Fix epiphysis in situ – short threaded pins
After 1 year, if deformity present, corrective osteotomy done
Alternatively bone graft epiphyseodesis
Trim anterosuperior metaphysis to prevent impingement
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SEVERE SLIPS
Open reduction by Dunn’s Method – small segment of femoral neck is removed to reposition the epiphysis, once reduced it is held by 2 or 3 pins.
Alternatively, fix epiphysis followed by compensatory intertrochanteric osteotomy
1. Tri plane osteotomy 2. Geometric flexion osteotomy
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PROPHYLACTIC PINNING
It is done for contralateral slips Indicated in rare instances High risk Non compliant patients Patients with epiphysiolysis from renal failure orirradiation therapy
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CLOSED REDUCTION
Done in severe acute unstable slips
Technically difficult or impossible to pin in situ
Earlier- Internal rotation alone Gradual reduction by skin traction and
internal rotation over 3-4 days
Avascular necrosis more
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OPEN REDUCTION
Dunn’s in severe acute or chronic slip
Heyman – Herndon epiphysiodesis procedure in moderate slips
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BONE PEG EPIPHYSIODESIS
Done by using hollow mill to create tunnel across physis, sandwiched iliac bone grafts driven across the physis
More complications than in situ pinning
Disadvantages-graft insufficiency, longer operating time,increase blood loss
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OSTEOTOMY
A CLOSING WEDGE OSTEOTOMY-through femoral neck
• Cuneiform Osteotomy femoral neck (Fish)• Cuneiform Osteotomy femoral neck
(Dunn)• Compensatory Basilar Osteotomy of
femoral neck• Extracapsular Base-of-neck osteotomy
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B. Compensatory osteotomy Intertrochanteric osteotomy
C. Cheilectomy resection of the part impinging
against acetabulum
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COMPLICATIONS
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AVACULAR NECROSIS
More common in-
Unstable (acute) slips Forceful repetitive manipulation Open reduction Osteotomy of femoral neck Superolateral placement of pins
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CHONDROLYSIS
More common in- Pin penetration into joint Trochanteric osteotomy, open reduction, femoral neck osteotomy Closed reduction and pin fixation
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Joint space <3mm wide and decreased range of motion of hip joint
Fibrous ankylosis follows
Treatment- intraarticular cortisone injecton
surgical manipulation
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FEMORAL NECK FRACTURE
Thermal injury caused by reaming of femoral neck before screw insertion.
Prevention- avoid unnecessary drilling, pins removed after
physeal fusion
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COXA VARA
Head slips backwards-femoral neck retroversion
Secondary effectsa. External rotation deformity of hipb. Shortening of femurc. Secondary osteoarthritis
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CONTINUED SLIPPING
If not treated Screws not placed proximally enough Removed before complete fusion of
physis
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THANK YOU