This document discusses slipped capital femoral epiphysis (SCFE), a disorder where the femoral head is displaced from the femoral neck through the growth plate. It covers the etiology, risk factors, classification, signs and symptoms, investigations including x-rays, and treatment options. The main treatment approaches are conservative management with traction or surgical management with in situ pinning to stabilize the epiphysis and promote growth plate closure. The goal of treatment is to prevent further slipping and allow for functional recovery without long-term complications like osteonecrosis.

1. SRI SIDDHARTHA MEDICAL COLLEGE
TUMKUR
Slipped capital femoral epiphysis
CHAIRPERSON: PROF. & HOD Dr. Kiran Kalaiah
MODERATOR: PROF. & HOD Dr. Kiran Kalaiah
SPEAKER: Dr. G. ARUN SIVA RAM
Subject seminar

3. • Slipped capital femoral epiphysis is a disorder in which capital femoral
epiphysis is displaced from the metaphysis through the physeal plate.
• SCFE is actually a misnomer in that the head is held in the acetabulum
by the ligamentum teres,& thus it is actually the neck that comes
upward & outwards while the head remains posterior & downward in
the acetabulum.
• A varus relation exists between the head & neck, but occasionally the
slip is into valgus, with head displaced superiorly & posteriorly in
relation to the neck .

4. Etiology
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

5. 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 12- 18mths
later to 1st (left hip is more common than right).

6. Endocraine factors
• 1) Obesity,
2) Hypogonadal males (adiposogenital syndrome)
• 3) Growth spurt
4) Hypothyroidism (treated or not)
5) GH administration
• Growth hormone stimulate growth of the physis converting cartilage
to bone. Too much unossified cartilage unable to resist stress
imposed by increased body weight .
• No screening unless clinical suspicion

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 shear forces
3.A change in the inclination of the adolescent proximal femoral
physis relative to the femoral neck shaft .

8. Associated conditions with mechanical etiology-
1.Infantile and adolescent blount diasease
2.Patients with peroneal spastic flatfoot and Legg-Calve-Perthes
disease

10. • 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
Pathology

11. • 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.

12. The pathologic changes depend on the stage & degree of displacement.
Pre-slipping stage:
• Physis is widened in zone of hypertrophy.
• Cartilage cells are in disarrayed clusters instead of orderly columns in
this layer.
• Island of unorganized cartilage dispersed irregularly in the proximal
metaphysis.
• Femoral head & acetabulum are normal.
• Synovial membrane is engorged, edematous & swollen.

13. Slipping stage:
• The slip takes place in layer of hypertrophic cartilage cells adjacent to
the zone of provisional calcification.
• The plane of separation is weaving & irregular due to the irregularity
of the contour of the physis.
• The slipping is usually gradual.
• Perichondrium remains attached to the femoral neck, stretching &
elongating as the physis migrates.

14. • In an acute slip the perichondrium is stripped off the neck anteriorly
& inferiorly.
• Capital epiphysis with the acetabulum almost always displace
posteriorly & inferiorly.
• The displaces anteriorly & proximally as a hump.
• Except in acute traumatic slip there is no hemarthosis.

15. Chronic stage
• With healing the inferior angle & anterior portion of the neck
adjacent to the physis is filled with callus.
• When remodeling takes place, the callus becomes incorporated with
the neck.
• The protruding hump becomes round & smooth.
• .

16. • These hump impinges against the anterior & superior margins of
acetabulum & cause limitation of abduction, medial rotation & full
flexion.
• Swelling & edema of the synovial membrane subsides.
• Physis ossifies & there is bony union between the head & the neck.
• Degenerative osteoarthritis sets in the acetabulum

17. • Microscopically Characteristc changes
in PROLIFERATIVE and HYPERTROPHIC ZONES of epiphyses
 chondrocytes number decrease and irregularly arranged
 collagen fibres and Matrix are increased

18. Classification
Temporally, according to onset
• acute
• acute-on-chronic
• chronic
Functionally (Loder classification)
according to ability to WB(weight bear)
• stable
• Unstable
Morphologically, according to extent of displacement

19. Symptoms <2weeks >2 weeks gradual
Xray. displaced epiphysis remodelling and healing
no remodelling noted
ACUTE ON CHRONIC SLIPS: symptoms lasting longer than one month and recent sudden exacerbation
pain after trivial trauma

21. Functional classification
• It is important to determine ability of the patient to bear weight.
According to LODER-
1. "Stable" SCFEs allow the patient
to (walk) with
or without crutches (walking aids).
• 2. "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.

22. Stable unstable
• Wt bearing possible with or
without crutches
• Less severe slips
• Effusion absent
• Good prognosis
• Less chances for avn
• Wt bearing is notpossible
even with crutches
• Slip is more severe
• Effusion is almost always
present
• Bad or worst prognosis
• More chances for avn

23. Radiological classification

25. Categories as per severity of slip
Wilson’s Classification:-
Pre-slip or grade I:
Widening & rarefaction of the physis, but no actual displacement.
Mild slip or grade II:
Femoral head displaces up to one third of the superior metaphyseal width of
the neck
Moderate slip or grade III:
Femoral head displaces greater than one third & less than half of the
superior metaphyseal width of the neck.
Severe slip or grade IV:
Femoral head displaces more than 50% of the superior metaphyseal width of
the neck.

26. PRESLIP: irregularity, widening,and indistinctness of the epiphyseal plate

27. Signs
• Waddling gait is present
• The patient stands with the leg rotated laterally and slightly adducted,
while inspection shows the pelvis to be tilted on the affected side.
• Scoliosis on the affected side is present
• Buttock is atrophied and the gluteal fold is lower than on the normal
side.

28. • On palpation hard mass is felt on which head moves with femur.
• Trochanter is higher than the sound hip
• Adduction and lateral rotation are free but abduction and medial
rotation and extension are greatly restricted.

29. Symptoms
1. Pain : in the groin and around the knee.
2. Antalgic Limp (intermittent).
3. Shortening of the affected limb (1-2 cm).
4. The limb is in external rotation.[frog leg position]

30. 5. Flexion, abduction, medial rotation are limited
6. External rotation, adduction are increased.
7.The presence of hip flexion contracture points towards the possibility
of chondrolysis.
8.Axis deviation – pathognomonic – when hip is flexed, the limb goes
into external rotation

31. Range of motion
• obligatory external rotation: during passive flexion of hip (Drehmann
sign)due to a combination of synovitis and impingement of the
displaced anterior-lateral femoral metaphysis on the acetabular rim.
• loss of hip internal rotation, abduction, and flexion.

32. Stable scfe
History
• vague or dull pain (groin, anteromedial thigh, knee)
• Exacerbated by activity
• Weeks to months
Physical Exam
• Antalgic limp with  ER
• Thigh atrophy
•  hip ROM- loss of IR,ABD, flexion
• Obligate ER with flexion, pain at extreme IR
• Hip flexion contracture (chondrolysis)
• No strenuous maneuvers, i.e. hopping/squatting

33. Unstable scfe
History
• Sudden onset of severe pain
• Minor fall or twisting injury
Physical Exam
• Held in ER
• Refusal to move hip
• Moderate shortening

34. Anterior and Valgus slip
• 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.

35. • 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.

36. 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.

37. • In acute cases it is essential to differentiate between SCFE and type 1
epiphyseal# 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

38. Investigations
X-RAYS-AP VIEW-Trethowan’s sign[kleins line]
Steel metaphysel blanch sign
Sham’s sign
Sapner’s sign
Widening of growth plate
Decrease of epiphyseal height
X-RAY -frog-leg [lowenstein]lateral view
CT-SCAN
MRI SCAN

39. • 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.

40. Metaphyseal blanch sign-Steel sign
A crescent-shaped area of increased density over the metaphysis of the
femoral neck
This density is produced by overlapping of
femoral neck and the posteriorly
displaced capital epiphysis

41. SCHAM SIGN
A) Normal hip, the inferomedial femoral neck overlaps the posterior
wall of the acetabulum- triangular radiographic density
B) Displacement of the capital epiphysis - dense triangle is lost

42. CAPENERS SIGN
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

43. 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]

44. ultra sound :
• Unstable - effusion is present, physeal instability allows reduction , no
metaphyseal resorption or early remodelling .
• Stable - effusion is absent, physeal stability present ,does not allows
reduction , metaphyseal resorption or early remodelling present.
CT-useful in documenting presence of decreased upper femoral neck
antiversion or true retroversion.
• it’s more accurate measure head–neck angle.
• CT is useful in the management of slips.
MRI-useful to assess AVN
can help diagnose a pre-slip condition when radiographs are negative.
Findings:
• growth plate widening. • edema in metaphysis.
• • decreased signal on T1, increased signal on T2.

45. TREATMENT
Goals in treatment
1)To prevent further displacement of the epiphysis
2)To promote closure of the physeal plate.
Long-term goals of treatment include
1)Restoration of a functional range of motion
2)Freedom from pain
3) Avoidance of aseptic necrosis and chondrolysis

46. 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 physis, the only surgical treatment in the
absence of severe degenerative changes is proximal femoral osteotomy.
Indications are functional limitations, unacceptable gait, or cosmetic
deformity

47. Conservative management
• Rest for atleast 12wks and traction can be an alternative to surgical
treatment
• Indicated in – temporary measure before operative treatment
slip due to hypothyroidism
• Rest in spica cast - ⇧ incidence of complications like chondrolysis

49. Surgical management
• Pin in situ
• Reduction and pinning
• Bone peg epiphyseodesis
• Osteotomy
• Reconstruction by arthroplasty, arthrodesis
• Each technique has proponents & opponents, & the choice of t/t
must be individualized for each child, depending on age, type of slip &
severity of displacement

50. In situ pinning
• Goal: To stabilize the epiphysis from further slippage and promote closure
of the proximal femoral physis.
• Internal Fixation [single cannulated screws or pins ( Moore or Knowles) ]
• Conditions to be fulfilled:
Single screw is sufficient and reduce the risk of penetration and AVN.
• The screw should be started on the anterior surface of the proximal femur
to cross perpendicular to the physis. Advance until 5 threads across the
physis and stop at least 5mm from subchondral bone in all views.

51. • Screws are extremely effective for stable SCFEs
• Decreased complications compared to multiple pins, (pin protrusion
& chondrolysis)
• Controversial in the unstable SCFEs
• Some advocate 2 screws
• Others have excellent results with 1 screw
• No biomechanical benefit found with 2 screw

52. • With increasing severity of the slip, the entry point will be found
progressively more superior on the femoral neck.
• After in situ pinning –early wt bearing in stable slips
• after 6-8wks in unstable slips
• Sports activities only after physeal closure.

53. Pin tip be advanced to 8 mm or one third of the femoral head radius
from subchondral bone, whichever projection is the closest. This places
the actual tip 7 to 18 mm from the subchondral bone, leaving a safe
margin.

54. Post operatively:
• ROM exercises begun day after surgery.
• Most patients begin partial wt bearing walking with crutches on day
after surgery.
• Crutches are used for 2 – 3 weeks for stable slip & 6 – 8 weeks for
unstable slips.
• Rigorous sports avoided till physis have closed.

55. When do you fix the other site? (Bilateral in situ
pinning)
Current indications are high risk patients
• (contralateral slip ~ 40-80%):
• initial slip at young age (< 10 years-old).
open triradiate cartilage.
endocrine disorders (e.g. hypothyroidism).
obese males
•Pin if symptoms are present
•Pin if there is known metabolic/endocrine disorders
•Pin if Follow up is unreliable

56. Serious disadvantage is Persistent pin penitration
Adverse affects attributed to unrecognized pin penitration :
•Joint sepsis
•Localised acetabular erosions
•Synovitis
•Post operative hip pain
•Chondrolysis
•Late degenerative osteoarthritis

57. Open reduction
• Tilt in epiphysis may cause early degenerative changes, open
reduction, limited osteotomy & internal fixation may be done if closed
reduction cannot be done.
• Osteonecrosis occurred due to tear in posterior retinacular vessels.

58. BONE PEG EPIPHYSIODESIS:
• Originally described by ferguson & howorth in 1931.
• Following pin insertion many pt developed avn & arthritis of hip.
• To prevent this, bone graft may be inserted through an opening in
femoral neck & across epiphyseal plate.
• Thus securing immobilisation of epiphysis.
• Channel is created in physeal plate through which metaphyseal
vessels gain access to epiphysis.
• Disadvantage- longer opt time, increased blood loss, longer
hospitalisation & longer rehab.

59. Weiner et al

60. Post op
• Spica cast applied for 6weeks.
• Then touch down weight bearing is allowed.
• Mobilized with crutches after 48 – 96 hrs.
• Complete weight bearing is allowed after 10weeks.

61. osteotomy
• Chronic slips produce irregularities in femoral head & acetabulum.
• To restore normal relation, realignment procedure is indicated.
• Two basic types:
close wedge osteotomy: usually near the physis to correct the
deformity.
compensatory osteotomy: through the trochanteric region to produce
deformity in the opposite direction.

64. indications
• To restore the normal relationship of the femoral head and neck
• Delay the onset of degenerative joint disease.
• Prevent further slippage
• Correct preexisting deformity .

65. The goal of preventing further slippage is achieved
• 1)Curetting the physis and securing the capital epiphysis to the neck
• 2) Fixing the capital epiphysis with a bone graft epiphysiodesis or
metallic implant
• 2) Inducing fusion by reorienting the plane of the capital physis into a
more horizontal position

66. CUNEIFORM OSTEOTOMY OF FEMORAL NECK- FISH
TECHNIQUE:
• Indicated in severe chronic or acute on chronic slips.
Fish reported long-term follow up with severe displacement,
requiring osteotomy just distal to physis.
PROCEDURE:
• Place pt supine on operating table.
• Make anterolateral approach to hip.
• Dissect between tensor fasciae latae & gluteus medius to anterior
aspect of capsule of hip joint.
• Incise capsule longitudinally & retract carefully.
• Identify capital femoral epiphysis & projecting part of neck.
• Determine size of wedge by noting degree of slip & position of
epiphysis.

67. • Make base of wedge anteriorly & superiorly for correct positioning of
epiphysis.
• After determining size of wedge, remove bone in small pieces with
osteotome & mallet.
• After removing sufficient bone, reduce the epiphysis by flexion,
abduction, & internal rotation of limb.
• After reduction, fix epiphysis to neck with 3 or 4 pins.
• Donot allow pins to penetrate articular cartilage of epiphysis, but do
• penetrate epiphysis deeply enough to obtain firm fixation.
• Use A-P & frog leg lateral radiographs to determine correct position of
pins.

69. DUNN TECHNIQUE:
• Based on facts- slip of head strips periosteum on back of neck & main
retinacular vessels run up back of neck.
• A lateral approach allows strpping under direct vision & avoid damage
to blood supply.
• Using lateral approach, incise periosteum & elevate posterior vascular
covering of femoral neck.
• Make two osteotomy cuts, one in long axis of neck to remove bony
beak, second at right angles to neck to shorten it by 3-4 mm.
• Appose surfaces of osteotomy, & insert 3 threaded pins up the
femoral neck upto its cut surface.
• Reduce deformity under c-arm & drive pins into femoral head.
• Close the wound in usual manner.

71. Post operatively
• Spica cast applied for 4 weeks.
• Later ROM exercises are begun.
• After 2weeks walking with crutches is allowed.
• After 3 -4 months partial weight bearing allowed.
• Full weight bearing allowed after union is radiologically confirmed.

72. COMPENSATORY BASILAR OSTEOTOMY OF
FEMORAL NECK:
• Described by Kramer et al.
• It corrects varus & retroversion components of moderate or severe
chronic SCFE.
• Line of osteotomy is distal to major blood supply in posterior
retinaculum hence safer than made near physis.
• Threaded pins are used for fixation of osteotomy & epiphysis.
• Both anatomical relationship of proximal femur is restored & further
slipping is prevented.

73. KRAMER ET AL TECHNIQUE
• Determine preop the size of wedge to be removed.
• Approach hip laterally. Begin skin incision 2cm distal & lateral to ASIS
& curve it distally & posteriorly over greater trochanter & distally
along lateral surface of femoral shaft to a point 10cms distal to base
of trochanter.
• Incise longitudinally fascia lata. Develop interval between gluteus
medius & tensor fasciae latae to expose hip jt capsule.
• Incise capsule longitudinally & release widely.
• Reflect distally vastus lateralis to expose base of GT & prox part of
femoral shaft.

74. • Widest part of wedge should be in line with widest part of slip in
anterior & superior aspects of neck.
• Make the more distal osteotomy cut first, perpendicular to femoral
neck & following anterior intertrochanteric line from proximal to
distal.
• Extend this osteotomy cut to posterior cortex.
• Ensure that osteotome does not fully penetrate posterior cortex.
• Drill 1-2, 5mm threaded steinmann pin into femoral neck proximally
to ensure that proximal portion of femur is kept under control before
osteotomy.

75. • Insert several 5mm threaded steinmann pin from outer cortex of
femoral shaft through femoral neck.
• Complete the osteotomy by greensticking posterior cortex and
remove wedge of bone.
• Advance the threaded steinmann pins across the osteotomy site and
physis to prevent further slipping.
• Capsule is closed, clip off the pins close to femur shaft & wound is
closed in layers.

77. EXTRACAPSULAR BASE OF NECK:
• ABRAHAM ETAL reported this surgery.
• Recommended this osteotomy as safe & effective in preventing
further slipping & improving hip ROM in severe chronic slips.
• With severe slip, correction of varus & posterior tilt of femur head is
limited, & complete restoration of normal head – shaft angle may not
be possible.
• Removal of wedge >20mm compromises femur neck length & may
increase femoral anteversion.

78. TECHNIQUE:
• Before surgery, the head-shaft angle is determined on AP radiographs
by measuring the angle formed by the epiphyseal line and the
femoral shaft in the affected limb and comparing it with the
contralateral side (or to 145 degrees).
• The head-shaft angle for posterior tilt or retroversion is determined
on a frog-leg view and compared with the contralateral side (or to 10
degrees).
• The differences between the abnormal and normal angles are used to
determine the size of the wedges removed during osteotomy.

79. • Patient is placed on a fracture table, and maximally internally rotate
the involved limb by gently moving the footplate.
• Obtain permanent anteroposterior and “shoot-through” lateral
radiographs to confirm the chronicity of the slip and to outline the
femoral head better. Prepare and drape the parts.
• Make a standard anterolateral approach.
• Locate the anterior joint tissue or intertrochanteric line between the
gluteus medius and the vastus lateralis muscles.
• Delineate a triangle on the anterior surface of the femoral neck to
indicate the two-plane wedge osteotomy.

80. • Locate the proximal cut by placing a 3 cm long kirschner wire on the
anterior surface of the femur from the lesser to the greater
trochanter at the base of the neck along the edge of the capsule.
Confirm this position by fluoroscopy.
• Wide osteotome used to mark the bone along the K- wire. Externally
rotate the leg, and drill a second kirschner wire in the anteroposterior
plane just distal to the guidewire.
• Place this wire vertical to the anterior surface of the femoral neck.
Rotate the limb internally, and obtain a lateral fluoroscopic view to
confirm correct wire placement.

81. • Begin the second distal osteotomy line from the lesser trochanter to
the growth plate of the greater trochanter. The angle at which this
line is made from the first osteotomy line depends on the amount of
correction needed.
• A 15-mm-wide wedge, measured superiorly to the baseline of the
triangle, is needed.
• Make the osteotomy cuts with a saw, converging them posteriorly to
make a single osteotomy along the posterior cortex. Completely
remove the wedge of bone, especially superiorly, for maximal
correction.

82. • While maintaining traction to prevent proximal migration of the
femur, internally rotate the leg until the wedge closes completely.
• Abducting the leg also helps to close the osteotomy. When the patella
can be internally rotated 15 degrees, adequate correction has been
achieved.
• Fix the osteotomy with three or four cannulated screws . use the first
guidewire to hold the osteotomy temporarily in the desired position.
Use only one screw to span the physis of the femoral head, avoiding
the superolateral quadrant.
• Check alignment and screw placement on permanent radiographs
before closing the wound.
• Close the wound in routine fashion, and apply a sterile dressing.

85. INTERTROCHANTERIC OSTEOTOMY:
• Capital epiphysis slipped chronically & united in poor position, then
trochanteric osteotomy done to produce opposite deformity.
• If physis remains open, need to be fixed with pins or screws.
• To correct coxa vara with some external rotation & hyperextension ,
closing wedge trochanteric osteotomy, with base of wedge laterally is
sufficient.
• To correct coxa vara, hyperextension & moderate or severe external
rotation , ball & socket osteotomy at lesser trochanter can be done.

86. TECHNIQUE
• Make tracings of anteroposterior and lateral radiographs, and
measure them accurately to determine exactly the severity of the
deformity.
• Through a lateral approach , expose the trochanteric region and the
proximal 7.5 to 10 cm of the femoral shaft.
• Insert a guide pin transversely through the femur at the level of the
lesser trochanter, and verify its position by radiographs.

87. • With an osteotome, make reference marks on the trochanter and the
proximal shaft to be used in determining how much to rotate, flex,
and abduct the distal fragment at the time of internal fixation.
• At the level of the lesser trochanter, outline on the bone an
osteotomy convex proximally. Along this outline make multiple holes
in the cortices with a drill, and complete the osteotomy with an
osteotome directed proximally. Now the distal fragment is convex,
and the proximal fragment is concave.
• Abduct, flex, and internally rotate the distal fragment appropriately as
determined before surgery, and fix the fragments with a blade plate
or compression hip screw as in a trochanteric fracture.

89. CHEILECTOMY (OSTEOPLASTY OF FEMORAL
NECK)
• Resection of prominence on anterosuperior aspect of femoral neck
(HERNDONS HUMP) which blocks internal rotation or abduction by
impinging against acetabulum.
• This is combined with intertrochanteric osteotomy when coxa vara &
E.R deformity is severe.
• If epiphysis is still open , epiphysiodesis can be done.
• Excess removal may end up in fracture neck femur & further slipping.

90. Complications
• OSTEONECROSIS
• CHONDROLYSIS
• FEMORAL NECK FRACTURE
• CONTINUED SLIPPING.
• FEMOROACETABULAR IMPINGEMENT (FAI)

91. Osteonecrosis
• Osteonecrosis has been reported to occur in 10% to 40% of patients
with acute unstable SCFE, although more recent reports of in situ
pinning with cannulated screws generally report lower incidences (0%
to 5%).
• Loder et al. suggested that instability may be the best predictor of
osteonecrosis
• 50% of patients with unstable SCFE will develop osteonecrosis

92. chondrolysis
• a joint space less than 3 mm wide (normal 4 to 6 mm) and a
decreased range of motion of the hip joint
• Persistent pin penetration into the joint has been the most frequently
cited cause of chondrolysis
• If severe joint space narrowing persists with limitation of joint
motion, arthrodesis or arthroplasty should be considered.

94. Femoracetabular impingement

96. prognosis
UNTREATED CASES:
• Before skeletal maturity , the disease may progress severely &
acutely.
• At skeletal maturity , risk of late degenerative arthritis appears
directly related to residual deformity.

97. • Pinning insitu provided best long term results , regardless of severity
of slip.
• Long term results worsened with increased severity of slip & when
reduction or realignment had been done.
• Avn & chondrolysis - more likely with increased slip severity or when
osteotomy done , led to poor long term results.

98. Differntial diagnosis
1. TUBERCULOSIS OF HIP –
Adducted & medially rotated , ROM restricted in all directions.
X-ray – extensive demineralisation of femoral head & acetabulum
without epiphyseal displacement.

99. Perthe’s disease
Age – rarely begins after ten yrs.
X-ray – head is not displaced but deformed.

100. CONGENITAL DISLOCATION OF HEAD:
Long history of lameness.
Head of femur palpated outside acetabulum & telescopy test positive
.

103. References
• MERCER ORTHOPAEDIC SURGERY 9th Edition
• CAMPBELL OPERATIVE ORTHOPAEDICS. 12th edition
• TUREK’S PRINCIPLES OF ORTHOPEDICS & ITS APPLICATION 4th Edition
• TACHDJIAN’S PEDIATRIC ORTHOPAEDICS.

104. Thank you