SCFE.pptx /slipped capital femoral epiphysis

SCFE

1. S C F E (SLIPPED CAPITAL FEMORAL EPIPHYSIS) DR SHIVENDRA PRATAP SINGH JUNIOR RESIDENT ORTHOPAEDICS DR. RMLIMS LUCKNOW

2. DEFINITION- SCFE terms refers to slippage of the overlying epiphysis of proximal femur posteriorly and inferiorly due to weakness of growth plate in relation to metaphysis SCFE term is misnomer F emoral epiphysis maintains its normal relationship within the acetabulum , and it is femoral neck and the shaft that displace upwards and anteriorly relative to femoral epiphysis and acetabulum

3. EPIDEMIOLOGY- Incidence- 10 per 100,000 more common in obese   children male to female ratio is 2:1 average age range is 12-13 y r  for boys 11-12   yrfor girls occurs when going through puberty Anatomic location- left hip is a more common can be bilateral (arond25%-40%)

4. P athology occurs due to axial and rotational mechanical forces which act on a susceptible physis metaphysis translates anterior and externally rotates epiphysis remains in the acetabulum and lies posterior/inferior to the translated metaphysis

5. CLASSIFICATION Loder Classification Based on ability to bear weight Stable Able to bear weight with or without crutches Minimal risk of osteonecrosis Unstable Unable to ambulate (not even with crutches) High risk of osteonecrosis

6. Temporal Classification Based on duration of symptoms; Acute Symptoms that persist for less than 3 weeks Chronic Symptoms that persist for more than 3 weeks Acute on Chronic Acute exacerbation of long-standing symptoms

7. Southwick Slip Angle Classification   - Epiphyseal- diaphyseal angle can be measured on both AP and frog lateral pelvis radiographs   Slip angle classification is based on the degree of difference between the affected and unaffected hip Southwick Slip Angle Classification Based on femoral epiphyseal- diaphyseal angle difference Mild < 30° Moderate 30-50° Severe > 50°

8. Grading System  Based on percentage of slippage Grade I 0-33% of slippage Grade II 34-50% of slippage Grade III >50% of slippage

9. O bligatory external rotation during passive flexion of hip ( Drehmann sign )

10. RADIOGRAPHY- R ecommended views  - AP & frog-leg lateral of both hips   L ateral radiograph is best way to identify a subtle slip I f slip is unstable, cross-table lateral should be performed instead of frog-leg

11. FINDINGS Klein's line- Seen in AP view line drawn along superior border femoral neck on AP pelvis will intersect less of the femoral head or not at all in a child with SCFE intersects lateral femoral head in a normal hip due to natural lateral overhang of the epiphysis 

12. "S" sign- - line drawn along inferior cortical outline of femur in frog-leg lateral view. N ormally extends from proximal femur head/neck junction to the proximal femoral physis but in SCFE there will be a sharp turn or break in continuity of this line

13. Metaphyseal blanch sign of Steel- Blurring of proximal femoral metaphysics -seen on AP due to overlapping of the metaphysis and posteriorly displaced epiphysis

14. X ray- CT scan- acute / chronic slip MRI- May help  diagnose a preslip condition  when radiographs are negative Findings- Growth plate widening Edema in  metaphysis

15. DIFFERENTIAL- Legg-Calve- Perthes disease  Septic arthritis/transient synovitis Osteomyelitis Developmental dysplasia of hip (DDH)  Traumatic injuries

16. M anagement Conservative management – rest & traction Closed manipulative reduction Operative management- In situ pinning , Open in situ pinning Epiphysiodesis Osteotomies

17. Percutaneous in situ fixation Indications   -   both stable and unstable slips Technique- 2 screw constructs have greater biomechanically stability than the single screw constructs 

18. Modified Dunn procedure- Surgical hip dislocation, open capital realignment and fixation Goal- T o correct the acute proximal femoral deformity and stabilize the epiphysis while protecting the femoral head blood supply  Technique- -surgical hip dislocation using the Ganz technique -Develop retinacular soft tissue flaps -Mobilize epiphysis -Debride metaphysis -Reduce epiphysis to metaphysis -Fixation – using k wires & screws -Postoperatively -touch-down weight bearing for 6 weeks

19. OSTEOTOMY - Flexion intertrochanteric ( Imhauser ) femoral osteotomy Goal- to correct symptomatic proximal femoral deformity in moderate to severe chronic SCFE deformity Technique-   lateral approach supine position straight lateral skin incision from greater trochanter distal down the femoral shaft reflect vastus lateralis to expose lateral femur transverse osteotomy just proximal to lesser trochanter

20. COMPLICATIONS- Osteonecrosis of femoral head   - risk factors initial trauma operative complication Treatment -symptomatic management, core decompression, arthroplasty Contralateral hip SCFE - risk factors  male, obesity, young age of initial slip (< 10 years old, open triradiate cartilage ), endocrine disorders Treatment/prevention- surgical fixation of contralateral hip as needed weight loss programs decreased BMI reduces rates of subsequent contralateral SCFE

21. Chondrolysis   - risk factors unrecognized implant penetration of the articular surface occurring in 0-2% of cases pin placement into the  anterosuperior  quadrant of the femoral head has the highest rate of joint penetration spica cast immobilization Residual proximal femoral deformity & limb length discrepancy Treatment- osteotomy Slip progression Infection   Chronic pain Degenerative arthritis Labral tearing and degeneration

22. THANK YOU