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

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.

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

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.

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

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

Blood supply of the proximal end of the femur

microstructure of the growth plate

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

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

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

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

Remodelling after slip varies with age, younger is more complete A.H . 4/93 10/93 Remodelling after slip varies with age, younger is more complete Female age 11 ys Remod.in six m.

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

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

Natural History Time of Presentation: 1 – Acute Slip: Less than 2 weeks Pain in knee, hip and thigh 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

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

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

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

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

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

LINES IN NORMAL HIP X

Head shaft angle 70 90 Head neck angle

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

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

Treatment Aim To stop slipping To enhance healing To correct deformities To avoid complications

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

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

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

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

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

Preoperative Traction and Pinning 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. When reduction is achieved pin fixation is done.

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

Sherbiny pins after gradual traction with good reduction

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

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

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

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

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

H.S. Preslip left side 11/86

H.Sharawy.pins left side 5/87 10.88 10. 88

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

Lateral diagram of femoral head showing vascular supply

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

OPEN REDUCTION & INTERNAL. FIXATION 4 M .P.O. 6/88 M.S.O. 16YRS.SUDANESE GIANT DURATION TW0 WEAKS SLIP 1O.2.1988 VIABLE HEAD

Implants removed 20/1/1989 1.1989

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

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

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

A.E.H. 20/12.1983. AGE 16 YS. RT.Gr.4 LT.Gr.1. PIN 11/11/1999 Left hip

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

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

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

Presentation of 42 cases Mode of Presentation Degree of Slip 33 M. mean age 14.2 YS. 9 F. mean age 11.2 YS. never after menarche Mode of Presentation Chronic 47.6% Acute 33.3% Acute on Chronic 19% Degree of Slip Mild 14 33.3% Moderate 16 38.1% Severe 12 28.6%

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

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

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

Thank You THANK YOU

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

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