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SLIPPED CAPITAL FEMORAL EPIPHYSIS (S.C.F.E.) EPIPHYSIOLYSIS BY PROF. HUSSEIN ABDEL FATTAH.

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Presentation on theme: "SLIPPED CAPITAL FEMORAL EPIPHYSIS (S.C.F.E.) EPIPHYSIOLYSIS BY PROF. HUSSEIN ABDEL FATTAH."— Presentation transcript:

1 SLIPPED CAPITAL FEMORAL EPIPHYSIS (S.C.F.E.) EPIPHYSIOLYSIS BY PROF. HUSSEIN ABDEL FATTAH

2 Definition S.C.F.E. is a disorder of the adolescent hip involving progressive displacement of the femoral head in relation to the femoral neck, through the open growth plate, posteriorly and inferiorly. However, the epiphysis actually remain seated in the acetabulum, it is the neck which displaces usually anteriorly and superiorly.

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4 ETIOLOGY Exact cause is disputed. Exact cause is disputed. Multiple interdependent factors involved. Multiple interdependent factors involved. Overweight. Overweight. Abnormally tall child. Abnormally tall child. Black races. Black races. Endocrinopathies Endocrinopathies Risk Factors

5 1 – Biomechanical Factors Change of physeal angle. Change of physeal angle. Increase of physeal activity with growth spurt. Increase of physeal activity with growth spurt. Obesity and lengthening of the neck. Obesity and lengthening of the neck. Abnormal retroversion of the neck. Abnormal retroversion of the neck. Weakness of the fibrocartilagenous perichondrial ring of la Croix. Weakness of the fibrocartilagenous perichondrial ring of la Croix.

6 2 – Endocrine Disorders Harris, (1950) Harris, (1950) Growth HormoneGrowth Hormone Widening of physeal plate and reduction of shearing strength,PITUITARY TUMOURS Widening of physeal plate and reduction of shearing strength,PITUITARY TUMOURS Sex HormonesSex Hormones Reduction of physeal plate and increase of shearing strength Reduction of physeal plate and increase of shearing strength Adiposogenital, PITUITARY DIFFICENCY Adiposogenital, PITUITARY DIFFICENCY

7 3 – Metabolic Factors Decreased Vitamin D activity Decreased Vitamin D activity Rickets Rickets Renal Osteodystrophy Renal Osteodystrophy 4 – Inflammation Morrissy et al, (1983)  Immune complexes in the synovial fluid.  This decreases and disappears when the head is fixed.

8 Blood supply of the proximal end of the femur

9 microstructure of the growth plate

10 Pathology of S.C.F.E. The growth plate is widened and irregular The growth plate is widened and irregular Loose irregular proliferative zone Loose irregular proliferative zone Disarranged and thickened hypertrophic zone Disarranged and thickened hypertrophic zone Chondrocytes are clustered, not columnar Chondrocytes are clustered, not columnar Disturbed endochondral ossification Disturbed endochondral ossification Perichondral fibrous ring of LA CROIX is attenuated Perichondral fibrous ring of LA CROIX is attenuated

11 Weakening occurs in the hypertrophic zone of the growth plate Slipping occur in this zone

12 BABY two years traumatic fracture sparation of capital epiphysis United two months later RT.

13 Traumatic fracture separation capital epiphysis five years old boy L. side Recent united

14 A.H. Remodelling after slip varies with age, younger is more complete Female age 11 ys Remod.in six m. 10/934/93

15 Missed fourth degree slip age 13 years D.M.T. F. Age (13 yrs.) 3/90

16 Three & half years later natural healing poor remodeling lack of congruity D.M.T 10/93

17 Natural History Time of Presentation: Time of Presentation: 1 – Acute Slip:1 – Acute Slip: Less than 2 weeks Less than 2 weeks Pain in knee, hip and thigh Pain in knee, hip and thigh Mild trauma Mild trauma 2 – Chronic slip: More than 3 weeks Vague thigh and knee pain Mild hip symptoms 3 – Acute on Chronic Slip Long duration of symptoms Acute episode of pain and limping

18 Diagnosis 1 – Pain 1 – Pain The commonest presenting symptom:The commonest presenting symptom: Vague in the knee and thigh Vague in the knee and thigh Exaggerated with activity Exaggerated with activity Severe in acute episodes Severe in acute episodes 2 – Limping Antalgic gait in acute conditions Antalgic gait in acute conditions Lurching in long standing conditions Lurching in long standing conditions Leg is externally rotated Leg is externally rotated

19 3- Deromity External rotation of the whole limb Extension and adduction deformity (on examination)Extension and adduction deformity (on examination) Mild shorteningMild shortening 4 – Hip Movements Limited internal rotation, abduction and flexion Limited internal rotation, abduction and flexion Flexion of the hip is accompanied by external rotation and abduction Flexion of the hip is accompanied by external rotation and abduction DIAGNOSIS continued

20 16 YS. 95 K. ADIPOSGENITALIA, BILAT. SLIP RT AFTER S.O. LEFT FULLY EXTERNAL ROTATED & SHORTER.

21 Plain Radiogram (In early slip) (In early slip) Blurring, widening of physeal plateBlurring, widening of physeal plate Decreased height of the epiphysisDecreased height of the epiphysis A line drown along the lat. Neck not crossing the epiphysisA line drown along the lat. Neck not crossing the epiphysis

22 Rt.hip is apparently normal In the A.P. VIEW First degree slip in lithotomy Lateral view

23 X LINES IN NORMAL HIP

24 90 70 Head neck angle Head shaft angle

25 Degree of Slipping 1. Mild: 1. Mild: Slipping of less than 1/3 of epiphysisSlipping of less than 1/3 of epiphysis 2. Moderate: 2. Moderate: Slipping of 1/3 to ½ of epiphysisSlipping of 1/3 to ½ of epiphysis 3. Severe: 3. Severe: Slipping of more than ½ of epiphysisSlipping of more than ½ of epiphysis

26 C.T. Scan Demonstrates early slipping Demonstrates early slipping Accurate measurement of angle and degree of slip.the degree of Accurate measurement of angle and degree of slip.the degree of External femoral rotation at the knee External femoral rotation at the knee

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30 Treatment Aim Aim To stop slippingTo stop slipping To enhance healingTo enhance healing To correct deformitiesTo correct deformities To avoid complicationsTo avoid complications

31 Treatment Non Surgical Treatment Non Surgical Treatment Prolonged traction in internal rotationProlonged traction in internal rotation Immobilization in plasterImmobilization in plaster Manipulative reduction (condemned)Manipulative reduction (condemned) Adjuvant Hormonal Therapy 11 Cases Chorionic Gonadotrophic Hormones. (1500–5000 units/week)

32 Surgical Treatment Epiphyseal Fixation (Pinning) BOYD Epiphyseal Fixation (Pinning) BOYD For mild slips and most moderate slipsFor mild slips and most moderate slips Only one or maximum two pinsOnly one or maximum two pins In mild slips, inserted from lateral approachIn mild slips, inserted from lateral approach In moderate slips, it is inserted from anteriorIn moderate slips, it is inserted from anterior

33 Pinning Pin position in the lower and posterior half Pin position in the lower and posterior half Upper and anterior position is dangerous > Penetration and avascular necrosis Upper and anterior position is dangerous > Penetration and avascular necrosis

34 A.A.Afify M. Lt. Early slip. Rt. N. BILAT.FIX. BY CANULTED SCREWS

35 Pinning The Other Hip If painful with no slip If painful with no slip Especially in over weight child Especially in over weight child Only 10% of painless other side may slip Only 10% of painless other side may slip

36 Preoperative Traction and Pinning In acute and acute on top of chronic cases In acute and acute on top of chronic cases skin Traction in Abduction and internal rotation by a plaster boot and derotation bar for few days. skin Traction in Abduction and internal rotation by a plaster boot and derotation bar for few days. When reduction is achieved pin fixation is done.When reduction is achieved pin fixation is done.

37 SHERBENY pain rt. Hip 30/1o/ 91,acute slip 8/12/91,reduced by traction 3 D.

38 Sherbiny pins after gradual traction with good reduction

39 R.R.S. (F.) B.D. 4/2/1986 age 9 ys. X 6/1995 LEFT MISSED SLIP. RIGHT NORMAL

40 Acute slip before reduction. R.R.S. 11 (YS) 20/2/1997

41 R.R.S. AFTER REDUCTION BY GRADUAL TRACTION & FIXATION PINS IN GOOD POSITION

42 R.R.S. Rt. Hip two pins, Lt. hip remodelled

43 H.SHARAWY 12 YRS ACUTE SLIP 5/2/86 1O/2/86 5 DAYS TRACTION Two pins 10/2/86

44 H.S. Preslip left side 11/86

45 H.Sharawy.pins left side 5/

46 Surgical Treatment Open Reduction Open Reduction Dunn (1964) and Dunn & Angle (1978)Dunn (1964) and Dunn & Angle (1978) High incidence of ischaemic necrosis and chondrolysisHigh incidence of ischaemic necrosis and chondrolysis For severe slippingFor severe slipping

47 Lateral diagram of femoral head showing vascular supply

48 Blood supply of the S.C.F.E. from medial circumflex artery posteriorly

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51 M.S.O. 16YRS.SUDANESE GIANT DURATION TW0 WEAKS SLIP 1O M.P.O. 6/88 OPEN REDUCTION & INTERNAL. FIXATION VIABLE HEAD

52 Implants removed 20/1/

53 O.R. for acute slip 6/90 Osteotomy for chondrolysis 7/91 Mobile hip mild limp, shortening 10/93

54 Trochanteric-Osteotomy Triplane osteotomy (Southwick J.B.J.S 1967 A.V.) Triplane osteotomy (Southwick J.B.J.S 1967 A.V.) Remove Anterior wedge to correct extension. Remove lateral wedge to correct coxa varaRemove Anterior wedge to correct extension. Remove lateral wedge to correct coxa vara Internal rotation to correct ext. rotationInternal rotation to correct ext. rotation

55 Subtrochanteric triplane osteotomy Correction of the head shaft angle Correction of the head shaft angle Fixation by double angle conylar plate Fixation by double angle conylar plate

56 A.E.H. 20/ AGE 16 YS. RT.Gr.4 LT.Gr.1. PIN 11/11/1999 Left hip

57 A.EMAD.H. B.D. 20/12/1983 AGE 16 YS. LEFT. HIP PIN 11/1999 EXTRACTED 2/4/2000. RT. HIP VALGUS DEROTATION OSTEOTOMY 2/4/2000

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61 Complications Ischaemic Necrosis Ischaemic Necrosis A complication of treatment A complication of treatment Forcible ManipulationForcible Manipulation Forcible TractionForcible Traction Cervical OsteotomyCervical Osteotomy Chondrolysis acute cartilage necrosis Chondrolysis acute cartilage necrosis Secondary O.A. Secondary O.A. Within 20 years Within 20 years More with severe deformities More with severe deformities In mild early pinned cases, much less In mild early pinned cases, much less

62 Secondary O.A. Within 20 years Within 20 years More with severe deformities More with severe deformities In mild early pinned cases, much less In mild early pinned cases, much less

63 Presentation of 42 cases 33 M. mean age 14.2 YS. 33 M. mean age 14.2 YS. 9 F. mean age 11.2 YS. never after menarche 9 F. mean age 11.2 YS. never after menarche Degree of Slip Mild1433.3% Moderate1638.1% Severe1228.6% Chronic47.6%Chronic47.6% Acute33.3%Acute33.3% Acute on Chronic19%Acute on Chronic19% Mode of Presentation

64 Side Affected Left side twice the right side in boys, equal in girls Left side twice the right side in boys, equal in girls Bilateral in 20 – 80% Bilateral in 20 – 80% (Weinstein, 1984)(Weinstein, 1984) 51%Hypogonadism Over Weight 18% Abnormally tall 31% Normal Body features

65 Treatment Non Surgical:6 Non Surgical:6 Pinning in-situ:15 Pinning in-situ:15 Traction-Pinning:7 Traction-Pinning:7 S.T.F.O.:12 S.T.F.O.:12 Open Reduction:2 Open Reduction:2

66 Conclusion S.C.F.E. is an ailment of teenagers S.C.F.E. is an ailment of teenagers Knee pain and limp are early complaints Knee pain and limp are early complaints Early diagnosis by hip examination clinically is important Early diagnosis by hip examination clinically is important Plain X-Ray of both hips in A.P. and A.P. Lithotomy position is mandatory Plain X-Ray of both hips in A.P. and A.P. Lithotomy position is mandatory C.T. is helpful for further management C.T. is helpful for further management Early pinning is the best solution Early pinning is the best solution Prophylactic pinning may be done Prophylactic pinning may be done Complications chondrolysis early and late osteoarthritis Complications chondrolysis early and late osteoarthritis Treatment of the predisposing factor is important Treatment of the predisposing factor is important

67 Thank You THANK YOU

68 The Journal of Bone and Joint Surgery American Volume Volume 64-A, No 5 July 1967 Osteotomy through Lesser Trochanter for Slipped Captial Femoral Epiphysis* By Wyane O. Southwick M.D.Y., New Haven Connecticut From the Department of Surgery, Section of Orthopaedic Surgery, Yale University School of Medicine, New Haven

69 Remodeling After Pinning for Slipped Capital Femoral Epiphysis Nathan R. Jones, Dennis C.Paterson, Terence M. Hiller, Bruce K. Foster. Nathan R. Jones, Dennis C.Paterson, Terence M. Hiller, Bruce K. Foster. From Adelaide Children Hospital, South AustraliaFrom Adelaide Children Hospital, South Australia


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