1 Pediatric Orthopedics Rounds Nov 2002 Abdulaziz Al-Ahaideb

2 12 year-old girl with sore left hip Questions

3 History  V.C. 12y.0. girl  c/o painful Lt hip last two weeks. fell 4 days ago. Pain increased but still able to wt bear. It was activity related but never went away with rest  on admission day oct she was about to get on the bus and her leg gave out from under her. She had acute pain in the Lt hip and couldn’t bear weight. Otherwise healthy

4  No constitutional symptoms  No problems in the other joints  Healthy otherwise

5 Physical Examination

6  Couldn’t put weight on the Lt hip  Pain with range of motion  Limitation of internal rotation  Examination of the knee was unremarkable  N/V intact

7  What is the DDx ?

8 Investigations

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10  What would you tell the parents ?  What exactly would you do in the OR ?

11 Intraop. fluoroscopy

12 Postoperative radiographs

13  Is it urgent to take the patient to OR ?  What are the complications of SCFE ? And How to avoid them?

14  What is your postoperative management ?

15 Slipped Capital Femoral Epiphysis  The term is a misnomer because the epiphysis stays in the acetabulum (held by ligamentum teres) and it is the metaphysis that slips  SCFE results from a Salter-Harris–type physeal fracture. In adolescents with SCFE, the epiphyseal growth plate is unusually widened, primarily due to expansion of the zone of hypertrophy

16 Etiology  Vast majority of cases are idiopathic  Associated conditions : Endocrine disorders (e.g. hypothyroidism) Renal osteodystrophy Radiation therapy

17 Etiology  Mechanical factors: Obesity Increased femoral retroversion Deep acetabulum  Hormonal Testosterone reduces physeal strength  SCFE is not a heritable disorder, however, there is a family predisposition

18 Epidemiology  60 % are males  Mean age is 13.5 yrs for boys and 12 yrs for girls  May be bilateral in up to 50 % (esp. in those with endocrine disorders)  Lt hip is more common

19 History  Hip Pain Duration, location Ability to bear weight  Limping  Some patients present with Knee pain  History of injury  Ask about medical problems and their symptoms

20 Physical Examination  Obese children are at higher risk for this problem.  Determine the patient's gait pattern (eg, antalgic, Trendelenburg) and ability to bear weight.  Active and passive range of motion of both hips and knees (usually limited internal rotation)  The lower extremity may rotate externally on gentle passive flexion of the hip when a SCFE is present.  Note any lower extremity deformity, such as external rotation or shortening.

21 DDx  Perthe’s disease  Femoral Head Avascular Necrosis  Femoral Neck Fracture  Femoral Neck Stress Fracture  Femur Injuries and Fractures  Osteitis Pubis

22 Classification  Acute (if less than 3 wks) versus chronic versus acute on chronic (don’t forget pre-slip)  Stable or unstable - Stable patients are able to bear weight on the affected limb with or without crutches or assistive devices. Unstable patients are unable to bear weight due to pain.  Radiographic - Determined by percentage of displacement of the hip in relation to the neck, as follows: grade I ( 50%)

23 Radiography  Klein's Line: line drawn along superior border of femoral neck should cross at least a portion of the femoral epiphysis slip must be suspected if a straight line drawn up lateral surface of femoral neck does not touch the femoral head

24 Management  Goal of treatment is to relieve pain, stop slip progression while avoiding complication, acceleration of epiphysiodesis  The recommended treatment for all types is pinning in situ  Forceful reduction before treatment is not indicated  Pin placement can be done percutaneously with one pin

25 Management  In-situ pinning: Technique: pt supine, percutaneous screw under fluoro, cross physis perpendicularly in both planes and to the centre of epiphysis  Don’t put the screw in superior posterior quadrant

26 Management  Hip spica is a historical treatment.  Open epiphysiodesis with bone grafting  Open reduction and a corrective osteotomy  Compensating base-of-neck osteotomy  Intertrochanteric osteotomy with internal fixation

27 Prophylactic pinning  Prophylactic Pinning of the Contralateral Hip in Patients with SCFE  Proponents- Emphasize rate of B/L disease and higher risk of osteoarthritis with the increase in slip severity  Opponents- Stress that in situ pinning can be associated with severe complications and that many hips would be treated unnecessarily  Trend- Observation of the unaffected hip

28 SCFE  Loder examined two groups early and late in situ pinning and found no difference in rate of AVN

29 Complications  Avascular necrosis Risk factors: acute unstable SCFE, forceful reduction, placement of screw in the superiorposterior quadrant and femoral neck osteotomy It is rare in pts with stable slip  Chondrolysis Risk factors are pin penetration Incidence 5-8 %  Degenerative arthritis

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