1. Melissa Martinek, DO, PhD
Bio:
Pediatric Orthopaedic Surgery Attending at Dayton Children's
Graduated from Virginia College of Osteopathic Medicine
Orthopaedic Surgery Residency at University Hospitals Regional Medical Center, Richmond Heights, OH
Pediatric Orthopaedic Fellowship – St. Christopher’s Hospital for Children/Philadelphia Shriner’s Hospital
Board Certified -  American Osteopathic Board of Orthopedic Surgery
“I chose Dayton Children’s because of the enthusiasm that exudes from the hospital and their focus on what matters; kids and their families.”

2. Melissa Martinek DO, PhD September 27, 2019
hip pain
Melissa Martinek DO, PhD
September 27, 2019

3. I have no disclosures pertaining to the following topics.

4. Case 1 12 year + 7-month Caucasian female
She comes into outside ED weight bearing with extreme pain in left hip
One-week history of left hip pain
No hx of trauma
No recent illnesses
No fever, chills, pain awaken from sleep
No known allergies
No past medical or surgical history

5. Physical Exam Supine in ED bed not in acute distress LLE
No erythema , ecchymosis or edema of the hip/limb
Pain with Passive ROM and guarding of the left hip
Decreased in flexion, internal rotation, and abduction
Passive knee ROM nonpainful and no effusion
Foot appears mildly externally rotated compared to right side
Neurovascularly intact distally

6. differential diagnosis

7. Next step in the work up?

8. ap left hip

9. lateral left hip

10. contralateral hip

11. Diagnosis = SCFE Now what???? Admit
Bedrest to strict non-weightbearing
NPO based on planned surgical intervention

12. in situ screw fixation

13. scfe Incidence and Epidemiology > in obese
1-7 per 100,000
> in obese
90th to 95th weight percentile for age
Mean age 13.5 years in boys, 11.6 years in girls
Male : Female 2:1
Left > Right
Polynesian highest; African American > Caucasians
Bilateral in % of patients
50% bilateral on initial presentation
Usually occurs in 18mos of first slip
Higher in those with endocrine or metabolic abnormalities

14. slipped capital femoral epiphysis
Misnomer
Femoral neck and shaft displaced relative to the epiphysis
Typical is anterolaterally displaced neck relative to the femoral epiphysis
Although at the physis (growth plate) most occur in adolescence when little growth remains
Etiology
Biochemical and Biomechanical
Thinning of the perichondral ring
Relative or absolute retroversion of the femoral neck
Change in inclination of the adolescent proximal femoral physis
Endocrine
Evaluate is < 10 years of age
Hypothyroidism, renal osteodystrophy, and panhypopituitarism

15. displaced femoral neck

16. histology of scfe Physis (growth plate) is widened
Abnormal chondrocyte maturation
Slip usually occurs through the hypertrophic zone

17. natural history Difficult to predict of non-treated SCFE
Adult reconstructive colleagues
Most cases of degenerative hip arthritis are secondary to under lying structural cause like SCFE
The development of degenerative joint disease (DJD) is relative to the severity of the SCFE

18. scfe classification Onset of Symptoms Acute (< 3 weeks)
Chronic (>3 weeks)
Acute-on-chronic (long standing symptoms with a sudden increase)
Increases risk of osteonecrosis and chondrolysis
Functional classification is best for making treatment decisions and predicting complications such as AVN.
“stable” – full or partial weight bearing , with or without crutches
“unstable” – presents like a femur fracture; unable to weight bear
report of AVN in unstable as high as 47%

19. scfe classification Morphology By displacement of the femoral neck
Width of the femoral neck displaced
Mild 1/3, moderate 1/3-1/2, or severe > 1/2
Difference between epiphyseal shaft angle compared to non- involved side or normal
Mild < 30 degrees, Moderate degrees, Severe > 50 degrees

20. scfe classification Functional Ability to bear weight
Stable or Unstable
Stable - pain and possible limp but able to ambulate without OR with crutches
Unstable - unable to ambulate even with crutches
Why does it matter?
Stable nearly 0% of osteonecrosis
Unstable has 10-50% of osteonecrosis

21. history Hip, groin pain, thigh pain, knee pain May have limp
Maybe exertional
No history of trauma
Variable duration
May have limp

22. physical exam findings
Patient supine look at resting foot position compared to other side
Excessive external rotation
Stable SCFE look at ROM and compare
Slip will have decreased flexion, abduction, and internal rotation as well as guarding
Stable - Antalgic gait, foot external rotated
Unstable – unable to bear weight
Present with knee pain
Normal knee ROM and effusion is absent

23. radiographic findings
Radiographs of pelvis
Anteroposterior (AP)
Frog- leg Lateral
IF unstable cross table lateral
FINDINGS widened physis can be and early sign
Metaphyseal blanch sign of Steel
Crescent shaped double density along the medial femoral neck where the epiphysis overlaps the metaphysis on the radiographs

24. radiographic findings
Klein line
Along superior neck of femur on an AP view in a normal hip should touch some part of the epiphysis
In a SCFE it will not touch

25. lab orders If less than 10 years of age Thyroid function test
Basic chem panal

26. non- op management Historical No role for non-op today Spica cast
Surgical to avoid further slipping and complications

27. surgical management From the office Mainstay is in situ screw fixation
Make Non-weight bearing
NPO
Transfer to ED or direct admit
Plan for surgical intervention
Mainstay is in situ screw fixation
Urgent if stable
Emergent if unstable
Modified Dunn Procedure
Open realignment and femoral neck shortening
Also carries variable high risk of AVN
Prophylactic pinning of contralateral hip
If < 10 years, tri-radiate physis wide open, endocrine abnormality

28. post-operative care No immobilization
NWB to TTWB on crutches for 6 weeks
After 6 weeks gradual return to activities
IF unilateral fixation was performed educate patient and parents on warning signs for the contralateral side
Follow up at regular intervals until skeletally mature

29. outcomes Related to severity of the slip
Results good to excellent in those with mild to moderate slip treated with in situ screw fixation

30. complications Chondrolysis Further slippage
Articular cartilage necrosis of the femoral head
Cause pain and limited motion
Decreased occurrence with screw fixation vs. pins
Risk Factors
Pin/screw crossing the chondral surface
Severe slips
Narrowed joint space < 3mm
Further slippage
Due to improper screw placement
Out of the middle 1/3 of the epiphysis

31. complications Avascular necrosis (Osteonecrosis)
Blood supply to the proximal femoral epiphysis comes from the medial femoral circumflex artery
Travels along the femoral neck
From this is the lateral epiphyseal vessels they enter the epiphysis posterorsuperiorly
There are some other small contributes from
Vessels of the round ligament
Posterior inferior epiphyseal vessels
Injury to the capsular blood supply can result in osteonecrosis
Photo credits:

33. resources
Flynn, J.M., Sankar, W.N. Operative techniques in pediatric orthopaedic surgery. Percutaneous screw fixation o the slipped capital femoral epiphysis. 2nd ed pp
capital-femoral-epiphysis-scfe