5. Race/Ethnicity
RRF, Caucasians
at 1.0
5.6 – Polynesians
3.9 – Blacks
2.5 – Hispanics
RRF 9.6 - India*
5
*Y. J. Lim, F. Kagda, K. S. Lam et al., “Demographics and clinical presentation of slipped capital femoral epiphysis in
Singapore: comparing the East with the West,” Journal of Pediatric Orthopaedics B, vol. 17, no. 6, pp. 289–292, 2008.
6. Gender & Age
Male predominence, 90% → 60% ↓
Indo-Mediterranean's – 90% male*
Polynesians – M:F equal*
Age- Prepubescence & Early Adolescence
13.5 yrs → 12.0 yrs in boys
12 yrs → 11.2 yrs in Girls
??????
Early maturation
Obese children present early
6
* R. T. Loder, “The demographics of slipped capital femoral epiphysis: an international multicenter
study,” Clinical Orthopaedics and Related Research, no. 322, pp. 8–27, 1996.
7. Symptom Duration
Stable SCFE (Avg) – 4 to 5 mths
4.5 mths – Boys
3.6 mths – Girls
7
* R. T. Loder, T. Starnes, G. Dikos, and D. D. Aronsson, “Demographic predictors of severity of stable slipped capital
femoral epiphyses,” Journal of Bone and Joint Surgery, American, vol. 88, no. 1, pp. 97–105, 2006.
Symptom duration as a function of slip severity
8. Body weight, Obesity, BMI
Majority are Obese
◦ > 50% are > 95th percentile weight for age
Age at Diagnosis - ↓ with ↑ obesity
◦ 12.4 yrs – Obesity (95th percentile)
◦ 14.3 yrs – Others (< 10th percentile)
BMI (Avg)
◦ 25 to 30 kg/m2 or
◦ > 85thpercentile
B/L SCFE (31.1) v/s U/L SCFE (26.8)
8
* R. T. Loder, “The demographics of slipped capital femoral epiphysis: an international multicenter study,” Clinical
Orthopaedics and Related Research, no. 322, pp. 8–27, 1996.
9. Seasonal Variation
Latitude north of 40 ̊- Late Summer &
Autumn months
9
N. Maffulli and A. S. Douglas, “Seasonal variation of slipped capital femoral epiphysis,” Journal of
Pediatric Orthopaedics B, vol. 11, no. 1, pp. 29–33, 2002.
10. Bilaterality
Overall – 18 to 50%
M/C Africans (34%) v/s Asians (18%), Hispanics (17%),
White (7%)
Rx affect risk of B/L involvement †
36% - In-situ pinning
7% - spica cast
Close attention “MANDATORY”
B/L SCFE *
50% to 60% - Simultaneous SCFE
80% to 90% - Sequential SCFE within 18 mths
10
*R. T. Loder, D. D. Aronson, and M. L. Greenfield, “The epidemiology of bilateral slipped capital femoral epiphysis: a study of
children in Michigan,” Journal of Bone and Joint Surgery, American, vol. 75, no. 8, pp. 1141–1147, 1993.
† J. M. Hurley, R. R. Betz, R. T. Loder, R. S. Davidson, P. D.nAlburger, and H. H. Steel, “Slipped capital femoral epiphysis: the
prevalence of late contralateral slip,” Journal of Bone and Joint Surgery, American, vol. 78, no. 2, pp. 226–230, 1996.
11. Predictors of risk of B/L
involvement
Young age
Modified Oxford Hip bone age < 16
Endocrine cause
Obesity
Tri-radaite cartilage fusion – Risk 4%
↑ Post slope angle epiphysis (>12) - ↑ Risk
11
T. A. Bidwell and N. S. Stott, “Sequential slipped capital femoral epiphyses: who is at risk for a second
slip?” Aus NZ Journal of Surgery, vol. 76, no. 11, pp. 973–976, 2006.
12. Classification
Traditional classification
◦ Based on History, Duration of symptoms,
Examination, Radiography
Pre-slip
Acute slip - < 3wks symptom
Chronic slip - > 3 wks symptom
Acute on chronic - > 3wks symptom +
Acute slip
12
13. Classification
Kullio et al given a classification
◦ Based on USG findings
Acute
Effusion without Metaphyseal remodeling
Chronic
No Effusion with Metaphyseal remodeling
13
14. Classification
Loder`s Classification
◦ Based on ability to bear weight
Stable slip
◦ able to bear weight with or without crutches
◦ No AVN
Unstable slip
◦ unable to bear weight, with or without crutches
◦ 47% incidence of AVN 14
18. Pathology
Slipping in hypertrophic
Zone of physis
Zone of hypertrophy is
widened and composed of
chondrocytes in disarrayed
clusters instead of orderly
columns
Chondrocytes of the
hypertrophied zone at
the cleft (C) region are
in disordered clusters
and irregular columns
18
19. Watch it in Pre-slip
Weakness in lower extremity
Limping
Exertional pain
◦ Felt as referred pain at groin, thigh or
knee
O/E –
◦ ↓ IR (most consistent finding)
19
22. Chronic Slip
M/C type – 85%
Pain in groin, thigh or knee - > 3
wks
Walks with limp
Knee pain delays diagnosis –
46%
O/E –
Antalgic gait
Loss of IR, Abd & flexion
LLD – severe cases
With flexion – spontaneous Abd
+ ER
22
23. Acute on chronic slip
Prodromal symptom > 3 wks
Sudden exacerbation of pain
Precludes weight bearing
Imp ????
S/d be differentiated from Acute slip
Attempted reduction - ↑ AVN
23
29. Severity of SCFE
Frog-leg lateral pelvis radiograph of a patient with a 44°
slipped capital femoral epiphysis (moderate), with an
epiphyseal-shaft angle of 56° on the right and of 12° on the
left (56° – 12° = 44°).
29
31. Role of other investigation
Bone scan
Increased Uptake – Chondrolysis
Decreased Uptake – AVN
USG
Early slips – Effusion + Step b/n neck &
epiphysis
Severity of slippage
MRI - early AVN
31
32. Natural History of SCFE
All slips
STOPS
Gradual displacement
Physis closure
Degree of slip
Timing of cessation
SHORTTERMCOURSELONGTERMCOURSE
Premature 2 ͦ Osteoarthritis
α to Severity
Resultant deformity
32
33. What should be our GOALS?
Detect early → Deformity (↓) → 2 ͦ OA (↓)
Prevent further slippage → Severity (↓) → 2 ͦ OA (↓)
Avoid complications → 2 ͦ OA (↓)
33
34. How can we detect early ?
Meticulous History taking
Proper Examination
Proper Investigations and their analysis
34
35. Differential Diagnosis
Fractures
•Significant trauma
•↑ Soft tissue shadow
•Displacement any
direction
•Trivial trauma
• No Soft tissue
shadow
•Displacement post-inf
direction
Perthes disease
•Sclerosis, cyst,
collapse of head
•MRI - ↑&↓ signal
intensity T2 & T1
•Displaced epiphysis
•Remodeling changes
Osteomyelitis
•↑ WBCs, ESR, CRP
Fever
•MRI - ↑ signal
intensity T2 / Intra-
osseous/subperiostea
l abscess
•Normal
•No fever
•No abscess
SlippedCapitalFemoral
Epiphysis
35
37. How can we prevent further slippage?
Stable SCFE
(Chronic)
Unstable SCFE
(Acute)
1.In-situ pinning
2.Epiphysiodesis
3.Femoral Osteotomies without surgical dislocation
4.Surgical dislocation of the hip with modified Dunn
osteotomy, reduction, and fixation
(5. Urgent reduction, fixation
and arthrotomy)
37
38. In Situ pin or screw fixation
• Percutaneous - Acute and chronic slips
◦ Mild
◦ Moderate
◦ Some severe
Open
◦ More severe Acute &
◦ Acute on chronic slip
38
39. In Situ pin or screw fixation
Technical Aspect
Supine position
◦ Fracture table
◦ Radiolucent table
top
Entry point
◦ Mark trajectory
lines AP & Lateral
views
39
40. In Situ pin or screw fixation
Technical Aspect
Intersection of line
Pass guide wire
Pass drill bit over
wire
Insert cannulated
screw
Insertion of Guide wire
Measurement & Drilling
Insertion of Screw40
41. Ideal Placement of screw
Entry point
◦ Anterior femoral neck
Extent
◦ 8mm
◦ ⅓ Femoral head radius
No.of screws
◦ 1- Chronic
◦ 2- Acute
Placement
◦ perpendicular to physis
◦ centre of epiphysis
Pin penetration
◦ Rotating fluoroscopic beam
Ideal position
41
42. Osteotomy
Closing wedge osteotomy (femoral
neck)
Cuneiform osteotomy
Subcapital realignment of
epiphysis
Base of neck osteotomy
Compensatory osteotomy
(Trochanter)
Imhauser/ Southwick
osteotomy
42
43. Rate of complications α Proximity
of the osteotomy
◦ Highest -osteotomies at the apex
(intracapsular in the superior neck)
◦ Lowest -osteotomies performed
extracapsularly in the
intertrochanteric area
Severity of 2 ͦ compensating
deformity α Distal the corrective
osteotomy
43
44. Cuneiform osteotomy of the
femoral neck (FISH)
44
Exposure & capsule incision Osteotomy
Removal of wedge of bone
More bone removed Realignment Fixation
45. Cuneiform osteotomy of the femoral
neck (DUNN)
45
Osteotomy of GT
Elevation of synovium
Removal of callus
Osteotomy Line Realignment Fixation
51. Spica Cast
Used as an Adjunct
Also definitive management of slipped
epiphysis
Complications
Pressure sores
Chondrolysis
51
52. Spica Cast
Little indication - modern management
Reserved for the occasional desperate
situation
Very young patients
Chronic renal failure
52
53. Conclusions: A systematic review of the literature
recommends on the basis of level of evidence that
the best treatment for a stable SCFE is single screw
in situ fixation and for unstable SCFEs urgent gentle
reduction, decompression, and internal fixation.
53
55. Most common
complaints are
Excessive external
rotation,
Limitation of flexion,
Trendelenburg lurch,
Combination of these
Residual Deformity after Closure of the Physis
(Femeroacetabular Impingement)
55
56. TREATMENT
Osteoplasty of the femoral neck
May be done in conjunction with fixation of the epiphysis (usually epiphysiodesis)
or independently, after closure of the physis
56
57. TREATMENT
Intertrochanteric repositioning osteotomy performed for complaints of restricted flexion
and internal rotation after in situ fusion. A, Before intertrochanteric osteotomy.
B, After intertrochanteric osteotomy. The patient was pleased with the more functional
position of the hip arc of motion, with increased flexion and internal rotation.
Intertrochanteric repositioning osteotomy
57
60. Etiology
Unknown, but theories says…….
Loss of synovial fluid - ↓ Nutrition
Autoimmunity - ↑ IgM & C₃
Metallic Implant penetration
Impingement of labrum & acetabulum
(“Pistol grip deformity”)
60
61. Clinical features
Persistent pain – groin/upper thigh
Flexion, Abduction & ER
ROM- painful/decreased in all
planes
Walking/activities-adversely
affected
Radiography
Loss of joint space > 50%
Joint space of 3mm/less
Bone scan
Increased uptake-seldom
necessary
61
62. Natural History
Pain + Restriction ROM + ↓ joint
space
6 wks to 4 mths – after treatment
6 to 12 mths – max ↓ joint space
Reconstitute (variable extent) – 3 yrs
62
63. Treatment
Non-specific & supportive
Rule out
Infection – Hip aspiration
Implant penetration – CT scan
Supportive care
Modification of activities
Use of crutches
Gentle ROM Ex
Anti-inflammatory medications
63
64. AVN
Severe complication
Occur with/without Rx
M/C occur
Closed/open reduction of unstable slips
Osteotomy of the femoral neck
Less
Open epiphysiodesis
In situ pinning of stable slips
64
65. How it occurs?
Unstable slips- tearing of the
periosteum →lateral epiphyseal
arterial system damage
Forcible reduction → tear the posterior
periosteum
During surgery→ direct injury to the
periosteum
Intra-articular tamponade by traumatic
effusion
65
66. How they present?
Can occur – few wks/ 1yr/ 18mths
Increasing pain + deformity + loss of
motion
Develop progressive deformity and
restriction of motion
Radiography- Two patterns of
distribution
Total head necrosis
Partial (or segmental) necrosis
66
67. TREATMENT
Prevention - ↓ surgeon's control
How?
◦ Open reduction
◦ Femoral neck osteotomies
◦ Manipulation of stable slips
◦ Forcible manipulation of unstable slips
67
68. TREATMENT
Educate the patient - potential outcome
Ascertain metallic implants 2 ͦ
encroachment
Remove the implant
Physis not fused – Manipulate/Reinsert
Intertrochanteric osteotomy - little pain +
deformity + poor functional position
Arthroplasty or Hip fusion - Debilitating
pain with progressive radiographic
changes
68
69. Contralateral Slips
B/L Slips
◦ Simultaneous – 50% to 60%
◦ Subsequent – 80% to 90%
Castro et al – 2335 times risk
Rx controversial
Indication
◦ Age
◦ Endocrine cause
◦ Follow up not feasible
◦ Posterior slope angle >12 deg
◦ Young obese children
70. Conclusion
SCFE is not an uncommon disease
Most commonly occurs in Adolescent obese
male, involving left hip
Take meticulous history, do proper
examination, get proper investigations
Detect early, intervene early and avoid
complications
In-situ fixation gold standard surgical option
stable SCFE
Surgical dislocation with modified Dunn
osteotomy provides promising result by
reducing the Incidence of AVN
70
Anteroposterior radiographic appearance of a normal hip and a hip with mild chronic slipped capital femoral epiphysis. A, Normal hip. A line drawn parallel to the superior femoral neck (Klein's line) will intersect the lateralmost portion of the capital femoral epiphysis. B, Hip with mild chronic slip. Klein's line does not intersect the capital epiphysis (Trethowan's sign). Lateral radiographs will confirm the diagnosis.
Metaphyseal blanch sign of Steel in slipped capital femoral epiphysis. A crescent-shaped area of increased density lies over the metaphysis of the femoral neck adjacent to the physis. This density is produced by overlapping of the femoral neck and the posteriorly displaced capital epiphysis on the anteroposterior view of the hip.
Scham's sign of slipped capital femoral epiphysis. A, In the normal hip, the inferomedial femoral neck overlaps the posterior wall of the acetabulum, producing a triangular radiographic density on the anteroposterior view. B, With displacement of the capital epiphysis, this dense triangle is lost because this portion of the femoral neck is located lateral to the acetabulum.
Radiographic appearance of slipped capital femoral epiphysis (SCFE) on presentation. A, Appearance of acute SCFE on a frog-leg lateral view. The displacement of the epiphysis is suggestive of a Salter-Harris type I fracture of the upper femoral physis. There are no secondary adaptive changes noted in the femoral neck. B, Frog-leg lateral radiographs in a patient with many months of thigh discomfort and a chronic slipped epiphysis. Adaptive changes in the femoral neck predominate, and the epiphysis is centered on the adapted femoral neck. C, Frog-leg lateral radiographs of a patient with acute-on-chronic SCFE. The patient had several months of vague thigh pain, with sudden, severe exacerbation of that pain. The acute displacement of the epiphysis is evident. Unlike in acute SCFE (see A), secondary adaptive remodeling changes are also present in the femoral neck, beyond which the epiphysis has acutely displaced.
