SLIPPED CAPITAL FEMORAL EPIPHYSIS

1. Dr Varun Sapra

2.  SCFE –
 Femoral neck and shaft displace relative to the
femoral epiphysis and the acetabulum
Misnomer as neck displaces relative to the epiphysis
 Usually, upward & anterior
 Head remains posterior and downward in the
acetabulum.
INTRODUCTION

3.  Femoral epiphysis displacing relative femoral neck:-
i) Posterior-a varus relation M.C
ii) Forward (anteriorly)
iii) Laterally (into a valgus position)
DISPLACEMENTS

4. Dispalcement

5. THE PHYSIS

6. PATHO-ANATOMY

7. 1 Reserve Zone-
 Composed of chondrocytes
 Type II collagen is present in its highest amount
 Oxygen tension is low
2 Proliferative Zone.
 Chondrocytes form matrix
 Oxygen tension is high
 Rich vascular supply.
 The majority of the longitudinal growth of the growth plate
occurs in this zone.
Growth plate

8.  The zone is avascular,
 low oxygen tension (similar to the reserve zone).
 Chondrocytes prepare matrix for mineralization and
calcification.
 Slip occurs through the weakest structural area of
the plate, the hypertrophic zone.
3 Hypertrophic Zone

9.  Varies according to race, sex, geography
 Estimated 2 per 100,000
 Males > females (male to female ratio is 2:1)
 left > right
 During adolescence, max skeletal growth
boys 13-15 years, avg 14
girls 11-13 years, avg 12
associated with puberty
 Bilateral - 20-25 %
 When bilateral slips occur, the second slip usually occurs
within 12 to 18 months of the initial slip.
Incidence/Epidemiology

10.  Often unknown
 Majority are normal by current endocrine work-up
 Etiologic –
Altering the strength of the zone of hypertrophy
Affecting the shear stress to the plate
 1)Endocrine
 2)Mechanical
ETIOLOGY

11.  Predisposing features:
-thinning of perichondral ring complex
-retroversion of femoral neck
-change in inclination of prox femoral physis relative to
femoral neck/shaft
Mechanical Factors

12.  Fibrous band that encircles physis at cartilage-bone
interface
 Acts as limiting membrane,
 mechanical support to physis
 Thins rapidly with maturation  strength
1) Perichondral Ring Thinning

13. 2) Retroversion of Femoral Neck
 Relative or femoral retroversion
 Physis more susceptible to AP shearing forces
3)Inclination
Increased slope of proximal femoral physis on both affected
and non-affected sides
Increased obliquity
Patients with a slipped epiphysis have a slope 11 degrees more
on the affected side and 5 degrees more on the unaffected side

14. 1) Obesity,
2) Hypogonadal males (adiposogenital syndrome)
3) Growth spurt
4) Hypothyroidism (treated or not)
5) GH administration
6) CRF
Growth hormone - stimulate growth of the physis converting cartilage
to bone. too much un-ossified cartilage unable to resist stress
imposed by increased body weight
No screening unless clinical suspicion
Endocrine Factors

15.  Periosteum stripped from ant/inf surface of femoral
neck
 Area btw neck & post periosteum fills with callus &
ossifies
 Anterosuperior neck forms “hump”(remodel)
Acute slips will have hemarthrosis
PATHOLOGY-GROSS

16. -Edematous synovial membrane,periosteum,capsule
 Light microscopic - physis is widened and irregular
Resting zone -60 to 70% of the width of the physis,
Hypertrophic zone -15 to 30%.
 SCFE, the hypertrophic zone may constitute up to
80% of the physis width.
Microscopic

17.  A,Slipping hypertrophied zone of the physis
 B The zone of hypertrophy is widened
 C The chondrocytes of the hypertrophied zone at
the cleft


18.  Temporally, according to onset
acute
acute-on-chronic
chronic
 Functionally, according to ability to WB(weight bear)
stable
unstable
 Morphologically, according to extent of displacement
CLASSIFICATION

19. CLASSIFICATION
Based on Duration of slip

21. STABLE UNSTABLE
Weight bearing Possible Not possible
Severity of slip Less severe More severe
Effusion Absent Present
Good prognosis 96% 47%
AVN 0% 50%

22. Preslip phase-
i)Weakness in the leg
ii) limping on exertion;
iii)On physical examination,
Lack of medial rotation of hip , hip in extension.
Affected leg is fixed, the thigh goes into abduction
and external rotation
CLINICAL FEATURES

23. i)The clinical criterion- acute onset of symptoms < 2 weeks
ii)Prodromal symptoms - weakness, limp, and intermittent groin,
medial thigh, or knee pain
Uable to weight bear.
iii) Antalgic gait
iv) An external rotation deformity
v) Shortening
vi) limitation of motion.
The greater the amount of slip, the greater is the restriction of
motion.
Unstable Acute or Acute-on-Chronic Slipped
Capital Femoral Epiphysis

24. i)Groin or medial thigh/knee pain for months to years.
ii)Exacerbations and remissions of the pain or limp
iii)Limitation of motion(particularly medial rotation) the
leg fixed external rotation
iv) Increased- hip extension
external rotation
adduction
Decreased
flexion , internal rotation ,abduction
CHRONIC SLIP/ STABLE SLIP

25. v) Antalgic limp
vi)Local tenderness over the hip joint
vii)Shortening
viii)Thigh or calf atrophy.
ix) Hip flexion contracture -Chondrolysis.
Stable, Chronic Slipped Capital Femoral Epiphysis

26. DISORDER AGE SEX BILATERAL
DDH 0-2yrs FEMALES
1:4
20%
PERTHES
DISEASE
4-6yrs MALES
5:1
10%
SCFE 10-15yrs MALES
2:1
25-40%
Causes of Limp & Hip, Thigh or Knee Pain in
Children

27.  1)X-RAY-
Frog-leg lateral accentuate the deformity
Lateral view the best to detect the slip - head is
posterior in relation to the neck
DIAGNOSIS

28. PRE-SLIP
 The earliest radiographic change widening and
irregularity of the physis

29. Klein's line

30.  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
Metaphyseal blanch sign-Steel sign

31. 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

33. 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

34.  Acute- little or no of the femoral neck
 Chronic-remodeling of the femoral neck
Remodeling

35. Southwick Classification
lateral epiphyseal-shaft angle (LESA).

37.  mild slips- <30 degree
 moderate slips -30 - 60 degrees
 severe slips- >60 degrees
 Normal values 145 degrees - AP
 10 degrees posterior on the frog-leg lateral

38. Epiphysis relative to the metaphyseal
width

39.  More accurate in the measurement of the head–neck
angle
 Demonstrating penetration of the hip joint by
fixation devices
 Confirm closure of the proximal femoral physis
 Assess the severity of residual deformity of the
upper femur
II) CT SCAN

40.  Measurement of the head–neck angle on computed
tomography (CT) scan

41.  3)Technetium-99 Bone Scan
 Increased uptake -involved hip,
 Decreased uptake -AVN,
 Increased uptake in the joint space - chondrolysis.
 4) Ultrasonography
5) Magnetic Resonance Imaging

42.  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
TREATMENT

43. 1. Absolute Bed Rest
2. Traction
3. Hip Spica Cast
1)NON OPERATIVE TREATMENT

44. • Bilateral BK cast
• Holding the hips in Abd & IR
• Weight bearing not allowed usually for 3 - 4 months
Spica Cast immobilization

45. i)Percutaneous and open in situ pinning
ii)Open reduction and internal fixation
iii) Epiphysiodesis
iv)Osteotomy
v)Reconstruction by arthroplasty, arthrodesis, or
cheilectomy
2)OPERATIVE TREATMENT

46.  Single
 Central pin- the screw in the center of the femoral
head
 DISADVANTAGE
Persistent pin penetration
.
In Situ Pin or Screw Fixation

47.  AFTER TREATMENT
 Range-of-motion exercises - begun the day.
 Unstable slips- partial weight bearing 6 to 8 weeks.
 sports and other activities forbidden until physes
have closed.
 The screws removed after physeal closure

48.  A, Anterior approach to hip and H-shaped capsular
incision.
 B, Use of hollow mill to create tunnel across physis
 C, Sandwiched iliac bone grafts are driven across
physis.
Bone Peg Epiphysiodesis

49.  A portion of the residual physis is removed and a
dowel or “peg” of autologous bone graft (ipsilateral
iliac crest) is inserted into the epiphysis.
 In unstable slips, supplementary internal fixation,
postoperative traction, or spica cast immobilization
for 3 to 8 weeks until early stabilization has occurred

50.  Disadvantages
1)Graft insufficiency
2)Increase in severity of slip
3)Failure of physeal fusion
4)longer operating time, increased blood loss, longer
hospitalization, and longer rehabilitation.

51.  AFTER TREATMENT
 In acute slips - spica cast for 6 weeks
 In chronic slips weight bearing started at
approximately 10 weeks.

52. OSTEOTOMY

53.  There are two basic types of osteotomy:
 1)Closing wedge osteotomy through the femoral
neck - correct the deformity.
 2)Compensatory osteotomy through the trochanteric
region - produce a deformity in the opposite
direction

54. OSTEOTOMY

55.  To restore the normal relationship of the femoral
head and neck
 Delay the onset of degenerative joint disease.
 Prevent further slippage
 Correct preexisting deformity .
INDICATIONS

56. 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
The goal of preventing further slippage is
achieved

57.  Trapezoidal osteotomy of the femoral neck
 Referred as “an open replacement of the displaced
femoral head”
 should not be done if the physis is closed.
 Reduce the capital femoral epiphysis on the femoral
neck by resecting a portion of the superior femoral
neck.
 Advantage - the deformity itself is corrected
Results.
 High risk of complications, AVN and chondrolysis.
1) Dunn Procedure

59.  Indicated to correct residual deformity after closure
of the physis.
 corrects the varus and retroversion components of
moderate or severe chronic SCFE.
 Pose less risk to interruption of the blood supply to
the femoral head than the Dunn procedure
 Osteotomy held with threaded Steinmann pins,
which extended into the capital epiphysis if the
physis is still open
2)Base-of-Neck Osteotomy (Kramer and
Barmada Procedures).

60.  Barmada's group –
 Extracapsular base-of-neck osteotomy performed
slightly more distally
 Recommended for moderate to severe chronic SCFE
with a greater than 30-degree head–shaft angle on
lateral radiographs.

62.  Preferable method to correct deformity associated with SCFE
Southwick osteotomy –
chronic or healed slips with head–shaft deformities between 30 and
70 degrees
 Biplane osteotomy
 Performed at the level of the lesser trochanter.
Imhauser's procedure - Intertrochanteric
 COMPLICATIONS
I)Chondrolysis
2)Post operative narrowing of joint space
4)Intertrochanteric Osteotomy
(Imhauser/Southwick Procedure).

64.  Not performed routinely.
 Symptomatic slipping of the contralateral slip after
unilateral treatment - 12.5%
 Asymptomatic slipping of the contralateral hip has -
40%.
Prophylactic Pinning of Contralateral Slips

65.  Indications-
High-risk
Noncompliant patients
Epiphysiolysis from irradiation therapy
Metabolic or endocrinopathic
Renal failure.
Children younger than 10 years at the time of
presentation

66. 1)CHONDROLYSIS
Occasionally referred to as “acute cartilage necrosis”
NATURAL HISTORY
 Symptoms develop between 6 weeks and 4 months
after treatment,
 Progressive joint space narrowing occurs, maximum
reduction - 6 to 12 months of onset of symptoms.
COMPLICATIONS

68. EPIDEMIOLOGY
Spontaneously
Depends on mode of treatment
1.5% percutaneous in situ pinning
50% - spica cast.
 Pin penetration of the joint
 Intertrochanteric osteotomy.
Girls are more likely to be affected than boys.

69.  CLINICAL FEATURES
 Stiffness
 Pain in the groin or upper thigh.
 Walking affected.
 The hip held in flexion, abduction, and external rotation.
 There is substantial reduction in the arc of motion of the
hip in all planes, and motion is usually painful.

70.  Radiographically,
Loss of joint space.
The radiographic criterion - loss of more than 50% of
the joint space
or an absolute measurement of 3 mm or less.(normal-
4-6mm)
 A technetium bone scan shows increased uptake in
an affected joint space.

71.  ETIOLOGY
 Etiology is not known various theories-
1) Lack of synovial fluid production- failure of nutrition
of articular cartilage
2) Autoimmune - Produce an antigen
3) Metallic implant penetration
4) Impingement - labrum and acetabulum by
anterior “pistol grip” deformity of the femoral neck

72. 1)CT of the hip to confirm that no implant
encroachment is present.
2) Aspiration of the hip to rule out a low-grade
infection.
3)If pin penetration has occurred, the implant must
be removed or replaced if the physis is not fused.
4)Supportive care
5) Muscle releases or capsulotomy,
6) Arthrodesis or total joint arthroplasty.
TREATMENT

73.  Generalized osteopenia
 and narrowing of the cartilage space.

74.  Axhausen in 1924 used the term aseptic necrosis
Without treatment
 Acute displacement (unstable slip).
 Closed or open reduction of unstable slips
 Osteotomy of the femoral neck.
 Intertrochanteric osteotomy.
 lowest open epiphysiodesis or in situ pinning of
stable slips
AVASCULAR NECROSIS

75.  The blood supply to the femoral head is interrupted,
 The lateral epiphyseal arterial system may be
damaged
EPIDEMIOLOGY

76.  RADIOGRAPHIC FINDINGS AND CLINICAL
FEATURES
 Two patterns of distribution are typically seen:
Total head necrosis
Partial (or segmental) necrosis
 Affected epiphysis first fails to become osteopenic
 Resorption of the necrotic bone
 collapse of the affected portion of the epiphysis.

77.  TREATMENT
 1)prevention.
 2)Implant removal
 3) Joint arthroplasty (total or partial) or hip fusion
 4)Hip arthrodesis

79.  10% to 15% of patients with SCFE
 Osteonecrosis is rare in untreated patients
 Results from interruption of the retrograde blood
supply by the original injury (superior retinacular
artery of the medial circumfl ex femoral)
1) unstable (acute) slips,
2) forceful repetitive manipulations
3) open reduction, or
4) osteotomy of the femoral neck.
5) Superolateral placement of pins
3) OSTEONECROSIS

80. Anterior physeal separation.
a sign indicating a high rise for avascular
necrosis
separation of the anterior lip of the
epiphysis from the metaphysis

81. ETIOLOGY
i) Fixation of SCFE with multiple pins
ii) Unused drill holes
iii) After nail removal
iv) Thermal injury caused by reaming of the femoral
neck
.
Femoral Neck Fracture

82. Subtrochanteric fracture,
Transverse fractures
Immediate ORIF with a hip screw and a long side
plate
Femoral neck fracture
less common
spica casting
weight relief alone
Vascularized pedicle bone graft

83. The complication can be decreased by
avoiding drilling unnecessary holes in the bone
avoiding overzealous reaming of the femoral neck
 Untreated Slipped Capital Femoral Epiphysis
 i)Severe degree and that degenerative arthritis
 ii)AVN
 iii)Chondrolysis

84.  The displacement is either superior and posterior
Increased femoral anteversion.
 Clinical picture
 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
Treatment
1)in situ pinning.
2)limited open approach for in situ pinning-valgus slip
2)Open bone graft epiphysiodesis -if percutaneous pinning is inadvisable or
unsuccessful
ANTERIOR AND VALGUS SLIPS

85. THANK YOU