2 DefinitionS.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.
4 ETIOLOGY Risk Factors Exact cause is disputed. Multiple interdependent factors involved.Risk FactorsOverweight.Abnormally tall child.Black races.Endocrinopathies
5 1 – Biomechanical Factors Change of physeal angle.Increase of physeal activity with growth spurt.Obesity and lengthening of the neck.Abnormal retroversion of the neck.Weakness of the fibrocartilagenous perichondrial ring of la Croix.
6 2 – Endocrine Disorders Harris, (1950) Growth Hormone Sex Hormones Widening of physeal plate and reduction of shearing strength,PITUITARY TUMOURSSex HormonesReduction of physeal plate and increase of shearing strengthAdiposogenital, PITUITARY DIFFICENCY
7 4 – Inflammation Morrissy et al, (1983) 3 – Metabolic FactorsDecreased Vitamin D activityRicketsRenal Osteodystrophy4 – Inflammation Morrissy et al, (1983)Immune complexes in the synovial fluid.This decreases and disappears when the head is fixed.
10 Pathology of S.C.F.E. The growth plate is widened and irregular Loose irregular proliferative zoneDisarranged and thickened hypertrophic zoneChondrocytes are clustered, not columnarDisturbed endochondral ossificationPerichondral 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 RT.United two months later
13 Traumatic fracture separation capital epiphysis five years old boy L Traumatic fracture separation capital epiphysis five years old boy L. sideRecentunited
14 Remodelling after slip varies with age, younger is more complete A.H.4/9310/93Remodelling after slip varies with age, younger is more completeFemale age 11 ysRemod.in six m.
15 Missed fourth degree slip age 13 years D.M.T. F. Age (13 yrs.) 3/90Missed fourth degree slip age 13 years
16 D.M.T 10/93Three & half years later natural healing poor remodeling lack of congruity
17 Natural History Time of Presentation: 1 – Acute Slip: Less than 2 weeksPain in knee, hip and thighMild trauma2 – Chronic slip:More than 3 weeksVague thigh and knee painMild hip symptoms3 – Acute on Chronic SlipLong duration of symptomsAcute episode of pain and limping
18 Diagnosis 1 – Pain 2 – Limping The commonest presenting symptom: Vague in the knee and thighExaggerated with activitySevere in acute episodes2 – LimpingAntalgic gait in acute conditionsLurching in long standing conditionsLeg is externally rotated
19 DIAGNOSIS continued 3- Deromity External rotation of the whole limb Extension and adduction deformity (on examination)Mild shortening4 – Hip MovementsLimited internal rotation, abduction and flexionFlexion of the hip is accompanied by external rotation and abduction
20 16 YS. 95 K. ADIPOSGENITALIA, BILAT. SLIP RT AFTER S.O. LEFT FULLY EXTERNAL ROTATED & SHORTER .
21 Plain Radiogram (In early slip) Blurring, widening of physeal plate Decreased height of the epiphysisA line drown along the lat. Neck not crossing the epiphysis
22 Rt .hip is apparently normal First degree slip in lithotomyLateral viewRt .hip is apparently normalIn the A.P. VIEW
30 Treatment Aim To stop slipping To enhance healing To correct deformitiesTo avoid complications
31 Treatment Adjuvant Hormonal Therapy Non Surgical Treatment Prolonged traction in internal rotationImmobilization in plasterManipulative reduction (condemned)Adjuvant Hormonal Therapy11 CasesChorionic Gonadotrophic Hormones.(1500–5000 units/week)
32 Surgical Treatment Epiphyseal Fixation (Pinning) BOYD For mild slips and most moderate slipsOnly one or maximum two pinsIn mild slips, inserted from lateral approachIn moderate slips, it is inserted from anterior
33 Pinning Pin position in the lower and posterior half 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 Especially in over weight childOnly 10% of painless other side may slip
36 Preoperative Traction and Pinning In acute and acute on top of chronic casesskin Traction in Abduction and internal rotation by a plaster boot and derotation bar for few days.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 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
61 Complications Ischaemic Necrosis Chondrolysis acute cartilage necrosis A complication of treatmentForcible ManipulationForcible TractionCervical OsteotomyChondrolysis acute cartilage necrosisSecondary O.A.Within 20 yearsMore with severe deformitiesIn mild early pinned cases, much less
62 Secondary O.A. Within 20 years More with severe deformities In mild early pinned cases, much less
63 Presentation of 42 cases Mode of Presentation Degree of Slip 33 M. mean age YS.9 F. mean age YS. never after menarcheMode of PresentationChronic %Acute %Acute on Chronic 19%Degree of SlipMild %Moderate %Severe %
64 Side Affected Body features Left side twice the right side in boys, equal in girlsBilateral in 20 – 80%(Weinstein, 1984)Body features51% HypogonadismOver Weight18% Abnormally tall31% Normal
66 Conclusion S.C.F.E. is an ailment of teenagers Knee pain and limp are early complaintsEarly diagnosis by hip examination clinically is importantPlain X-Ray of both hips in A.P. and A.P. Lithotomy position is mandatoryC.T. is helpful for further managementEarly pinning is the best solutionProphylactic pinning may be doneComplications chondrolysis early and late osteoarthritisTreatment of the predisposing factor is important
68 The Journal of Bone and Joint Surgery American VolumeVolume 64-A, No July 1967Osteotomy through Lesser Trochanter for Slipped Captial Femoral Epiphysis*By Wyane O. Southwick M.D.Y., New Haven ConnecticutFrom 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.From Adelaide Children Hospital, South Australia