SLIPPED CAPITAL FEMORAL EPIPHYSIS - By Dr. Lokesh Sharoff
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Transcript of SLIPPED CAPITAL FEMORAL EPIPHYSIS - By Dr. Lokesh Sharoff
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Slipped Capital Femoral Slipped Capital Femoral EpiphysisEpiphysis
Dr. LOKESH SHAROFFOrthopedic surgeon , Mumbai, India
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IncidenceIncidence
Annual incidence 2-10 per 100,000Annual incidence 2-10 per 100,000
2.4 M : 1 F2.4 M : 1 FLEFT > RIGHT HIP LEFT > RIGHT HIP
Boys 13-15 yrs (14)Boys 13-15 yrs (14)
Girls 11-13 yrs (12)Girls 11-13 yrs (12)presentation outside these ages consider endocrine or presentation outside these ages consider endocrine or systemic disorder !!systemic disorder !!
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IntroductionIntroduction
Obese (50-75% over 95th Obese (50-75% over 95th centile)centile)
Delay in skeletal maturityDelay in skeletal maturity
Bilateral in 17% (50% Bilateral in 17% (50% present-50% sequential)present-50% sequential)
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IntroductionIntroduction
femoral neck displace ANTERIORLY AND femoral neck displace ANTERIORLY AND SUPERIORLY with the head in the acetabulum causing an SUPERIORLY with the head in the acetabulum causing an apparent varus deformityapparent varus deformity
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AetiologyAetiology
Mechanical factorsMechanical factorsobesityobesity
Increase in femoral retroversionIncrease in femoral retroversion
Vertically oriented physeal plateVertically oriented physeal plate
Thinning of perichondral ringThinning of perichondral ring
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AetiologyAetiology
InflammatoryInflammatorysynovial hyperplasiasynovial hyperplasia
increase in IG and C3increase in IG and C3
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AetiologyAetiology
EndocrineEndocrineAssociation withAssociation with
Hypothyroidism Primary hyperparathyroidism
Panhypopituitarism Hypogonadal conditions Renal osteodystrophy GH deficiency and therapy
Rubenstein - taybi syndrome Klinefelters syndrome
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PathologyPathology
-Periosteum torn anteriorly-Periosteum torn anteriorly-Antero-superior part of neck forms a rounded -Antero-superior part of neck forms a rounded humphump-area between neck and periosteum posteriorly is -area between neck and periosteum posteriorly is filled with osseous tissuefilled with osseous tissue
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HistopathologyHistopathology
-PRE SLIP STAGE - widening of physis-PRE SLIP STAGE - widening of physis-DISPLACEMENT - occurs through Proliferative -DISPLACEMENT - occurs through Proliferative and Hypertrophic zonesand Hypertrophic zones-organisation of chondrocytes changes from -organisation of chondrocytes changes from columnar to clumpscolumnar to clumps
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Slipped Capital Femoral Slipped Capital Femoral Epiphysis classificationEpiphysis classification
According to duration of symptoms--According to duration of symptoms--
Preslip: synovitisPreslip: synovitis
Acute <3wksAcute <3wks
Chronic >3 wksChronic >3 wks
Acute on Chronic >3 wks with further Acute on Chronic >3 wks with further displacement of epiphysisdisplacement of epiphysis
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Slipped Capital Femoral Slipped Capital Femoral Epiphysis PresentationEpiphysis Presentation
Physeal stability– Loder classificationPhyseal stability– Loder classification
Stable: can wt bearStable: can wt bear
Unstable : cannot wt. bear Unstable : cannot wt. bear Acute Slipped Capital Femoral Epiphysis: the Importance of Physeal StabilityAcute Slipped Capital Femoral Epiphysis: the Importance of Physeal Stability
Loder et alLoder et al
JBJS 1993; 75-A:1134-1140JBJS 1993; 75-A:1134-1140
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Presentation--chronicPresentation--chronic
-often obese and present with pain in the hip (85%) or knee (15%)-often obese and present with pain in the hip (85%) or knee (15%)—increases in evening or after exertion—increases in evening or after exertion
-Limp-Limp
-thigh atrophy-thigh atrophy-extremity shortening-extremity shortening
Knee Axilla sign: On attempted flexion of the hip, the patients leg Knee Axilla sign: On attempted flexion of the hip, the patients leg goes into external rotationgoes into external rotation
Internal rotation is lost. Internal rotation is lost.
Abduction and extension is also restrictedAbduction and extension is also restricted
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Presentation—acute on chronicPresentation—acute on chronic
-sudden onset of pain-sudden onset of pain -unable to move the limb-unable to move the limb
-unable to bear weight-unable to bear weight
-limb in external rotation-limb in external rotation
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Presentation --ChondrolysisPresentation --Chondrolysis
-Pain is continous-Pain is continous
-Pain throughout ROM -Pain throughout ROM
-Global restriction of ROM-Global restriction of ROM
-Flexion contracture-Flexion contracture
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Slipped Capital Femoral Slipped Capital Femoral Epiphysis RadiologyEpiphysis Radiology
APAPPhyseal wideningPhyseal widening
Steels Metaphyseal Blanch sign (density in neck)Steels Metaphyseal Blanch sign (density in neck)
Klein line/Trethowan signKlein line/Trethowan sign
Schams sign Schams sign Break in Shenton’s lineBreak in Shenton’s line
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RadiologyRadiology
--Klein's Line:--Klein's Line:– line drawn along superior border of femoral neck should line drawn along superior border of femoral neck should
cross at least a portion of the femoral epiphysiscross at least a portion of the femoral epiphysis– slip must be suspected if a straight line drawn up lateral slip must be suspected if a straight line drawn up lateral
surface of femoral neck does not touch the femoral headsurface of femoral neck does not touch the femoral head
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RadiologyRadiology
Metaphyseal blanch sign (STEELS)---Metaphyseal blanch sign (STEELS)---
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RadiologyRadiology
SCHAMS sign -- SCHAMS sign -- The posterior acetabular margin normally cuts The posterior acetabular margin normally cuts the medial corner of the metaphysis. In slip the whole metaphysis the medial corner of the metaphysis. In slip the whole metaphysis remains lateral to the acetabular margin.remains lateral to the acetabular margin.
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Slipped Capital Femoral Slipped Capital Femoral Epiphysis RadiologyEpiphysis Radiology
LateralLateralShoot-through/Frog legShoot-through/Frog leg
It shows the bending of the femoral neck and the It shows the bending of the femoral neck and the anterior hump of bone growthanterior hump of bone growth
head-shaft angle of SOUTHWICK can be calculatedhead-shaft angle of SOUTHWICK can be calculated
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RadiologyRadiology
SOUTHWICK’S SOUTHWICK’S CLASSIFICATIONCLASSIFICATION
calculate the Head-Shaft anglecalculate the Head-Shaft angle<30--mild<30--mild30-60--moderate30-60--moderate>60--severe>60--severe
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Slipped Capital Femoral Slipped Capital Femoral Epiphysis RadiologyEpiphysis RadiologyClassification—Classification—
Determined by percentage of displacement of the Determined by percentage of displacement of the EPIPHYSIS in relation to the neck, as follows:EPIPHYSIS in relation to the neck, as follows:
grade I (<33%), grade I (<33%),
grade II (33-50%), grade II (33-50%),
grade III (>50%)grade III (>50%)
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Slipped Capital Femoral Slipped Capital Femoral Epiphysis TreatmentEpiphysis Treatment
Prevent further slippagePrevent further slippage
Reduce the degree of slippageReduce the degree of slippage
Salvage treatmentSalvage treatment
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CT--SCANCT--SCAN
--To check HEAD – NECK angle --To check HEAD – NECK angle --Neck in ante or retroversion--Neck in ante or retroversion--post-op—whether implant has penetrated into --post-op—whether implant has penetrated into the jointthe joint--closure of physis--closure of physis--compression achieved by screws--compression achieved by screws--residual deformity--residual deformity
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ULTRASOUNDULTRASOUND
--to check for joint effusion--to check for joint effusion
--to check for step between femoral neck and --to check for step between femoral neck and epiphysisepiphysis
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MRIMRI
--used to asses the pre-slip stage but is expensive--used to asses the pre-slip stage but is expensive
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BONE SCANBONE SCAN
--Increased uptake in SCFE--Increased uptake in SCFE--decreased uptake in AVN--decreased uptake in AVN--increased in the joint space in chondrolysis --increased in the joint space in chondrolysis
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SCFE Treatment to prevent SCFE Treatment to prevent further slippagefurther slippage
Hip spicaHip spica
Bone peg epiphysiodesisBone peg epiphysiodesis
Pin or screw fixationPin or screw fixation
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SCFE Treatment to prevent SCFE Treatment to prevent further slippagefurther slippage
THEORIESTHEORIES--smooth pins– to allow epiphysial growth--smooth pins– to allow epiphysial growth--threaded pins –to arrest physeal growth--threaded pins –to arrest physeal growth--single cannulated screw—threads placed across --single cannulated screw—threads placed across physis to arrest growthphysis to arrest growth--double screws—for additional rotational stability --double screws—for additional rotational stability in unstable hipsin unstable hips
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SCFE Treatment to prevent SCFE Treatment to prevent further slippagefurther slippageIn situ screw or pin fixationIn situ screw or pin fixation
biplane fluoroscopybiplane fluoroscopy
percutaneous techniquepercutaneous technique
Position fixation centrally in headPosition fixation centrally in head
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SCFE Treatment to prevent SCFE Treatment to prevent further slippagefurther slippage
In situ screw or pin fixation--positionIn situ screw or pin fixation--positionpin must be placed perpendicular to plane of the femoral headpin must be placed perpendicular to plane of the femoral head
starting position anterior of the femoral neck and not lateral starting position anterior of the femoral neck and not lateral cortexcortex
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SCFE Treatment to prevent SCFE Treatment to prevent further slippagefurther slippage
In situ screw or pin fixation—to avoidIn situ screw or pin fixation—to avoidavoid superior and anterior quadrant of femoral headavoid superior and anterior quadrant of femoral head
following fixation whilst moving hip to ensure no penetrationfollowing fixation whilst moving hip to ensure no penetration
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SCFE Treatment to prevent SCFE Treatment to prevent further slippagefurther slippage
--BONE GRAFT EPIPHYSIODESIS--BONE GRAFT EPIPHYSIODESIS
Advantages—rapid epiphysial closure Advantages—rapid epiphysial closure ---no risk of implant penetration into jt. ---no risk of implant penetration into jt. ---no reoperation ---no reoperationDisadvantages---infectionDisadvantages---infection ---chondrolysis ---chondrolysis ---avn ---avnUses --- in failed pinning operationUses --- in failed pinning operation
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SCFE Treatment to Reduce SCFE Treatment to Reduce degree of slippagedegree of slippageClosed manipulationClosed manipulation
although after in situ pinning ROM improves this is in although after in situ pinning ROM improves this is in main due to resolution of synovitis and spasm. main due to resolution of synovitis and spasm. There is little remodellingThere is little remodelling
Closed manipulation >24hrs significantly increases the Closed manipulation >24hrs significantly increases the risk of osteonecrosisrisk of osteonecrosis
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SCFE Treatment to Reduce SCFE Treatment to Reduce degree of slippagedegree of slippage
OsteotomiesOsteotomies -- to reduce deformity-- to reduce deformity
--to prevent further slipping--to prevent further slipping--to re-orient and stabilise physis--to re-orient and stabilise physis
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SCFE Treatment to prevent SCFE Treatment to prevent further slippagefurther slippage
OsteotomiesOsteotomies1–-dunn’s1–-dunn’s2—kramer2—kramer3—barmada3—barmada4---southwick4---southwick
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SCFE Treatment to Reduce SCFE Treatment to Reduce degree of slippagedegree of slippage
OsteotomiesOsteotomiesmore distal less correction at primary site of deformitymore distal less correction at primary site of deformity
more proximal more risk of osteonecrosismore proximal more risk of osteonecrosis
used in cases of moderate to severe slipsused in cases of moderate to severe slips
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SCFE Treatment to Reduce SCFE Treatment to Reduce degree of slippagedegree of slippage
OsteotomiesOsteotomiesCuneiform Osteotmy at femoral Cuneiform Osteotmy at femoral
physis Fish/ Dunnphysis Fish/ Dunn
--done in severe slips in open --done in severe slips in open physisphysis
Osteonecrosis 12-35% Osteonecrosis 12-35%
Fish 3.5% osteonecrosis and 11% Fish 3.5% osteonecrosis and 11% chondrolysischondrolysis
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Intertrochanteric - SouthwickIntertrochanteric - Southwick
Compensatory osteotomy, the more distal the less Compensatory osteotomy, the more distal the less correction at primary source of deformity. correction at primary source of deformity.
Maximum head-shaft correction is 50Maximum head-shaft correction is 50°.°.Antero-lateral wedge is removed,so flexion and valgus of Antero-lateral wedge is removed,so flexion and valgus of distal fragment is achieved .distal fragment is achieved .
Wedge removed -- therefore shorteningWedge removed -- therefore shortening..Done in severe slips Done in severe slips
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SCFE Treatment to Reduce SCFE Treatment to Reduce degree of slippagedegree of slippage
OsteotomiesOsteotomies
IntertrochantericIntertrochantericsingle, bi or multiple-planesingle, bi or multiple-plane
corrects 45’-50’corrects 45’-50’
low incidence of low incidence of osteonecrosis, but osteonecrosis, but chondrolysis rate 6-50%chondrolysis rate 6-50%
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SCFE Treatment to Reduce SCFE Treatment to Reduce degree of slippagedegree of slippage
OsteotomiesOsteotomiesBase of neck—Base of neck—
KRAMER AND KRAMER AND BARMADABARMADA anterior wedge anterior wedge removedremoved
corrects 30-50corrects 30-50for chronic residual for chronic residual deformitiesdeformitiesmoderate to severe scfemoderate to severe scfe
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SCFE Prophylactic pinning of the SCFE Prophylactic pinning of the contralateral hipcontralateral hip
FU till skeletal maturityFU till skeletal maturity
Pin if symptoms presentPin if symptoms present
Pin known Pin known metabolic/endocrine metabolic/endocrine disordersdisorders
Pin if FU unreliablePin if FU unreliable
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SCFE OsteonecrosisSCFE Osteonecrosis
vascular injury, complication of treatmentvascular injury, complication of treatment
increase with severity of slipincrease with severity of slip
increase in acute, unstable slipsincrease in acute, unstable slips
increases with manipulation, pin placement in superior quadrantincreases with manipulation, pin placement in superior quadrant
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SCFE OsteonecrosisSCFE Osteonecrosis
remove metal workremove metal work
maintain ROMmaintain ROM
shelf acetabuloplastyshelf acetabuloplasty
arthrodesis/THRarthrodesis/THR
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SCFE ChondrolysisSCFE Chondrolysis
dissolution of articular cartilage with joint dissolution of articular cartilage with joint stiffness and painstiffness and pain
CauseCausesynovial malnutrition, ischaemia, excessive pressuresynovial malnutrition, ischaemia, excessive pressure
AutoimmuneAutoimmune
Females>malesFemales>males
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SCFE ChondrolysisSCFE Chondrolysis
incidence 2-20%incidence 2-20%higher in females, acute and severe slipshigher in females, acute and severe slips
manipulation, prolonged immobilisation, realignment manipulation, prolonged immobilisation, realignment osteotomiesosteotomies
pin penetrationpin penetration
exclude infectionexclude infection
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SCFE ChondrolysisSCFE Chondrolysis
Non- wt bearing, NSAID, ROMNon- wt bearing, NSAID, ROM
tractiontraction
in pt therapyin pt therapy
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Thank youThank you