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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.”
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Melissa Martinek DO, PhD September 27, 2019
hip pain Melissa Martinek DO, PhD September 27, 2019
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I have no disclosures pertaining to the following topics.
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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
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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
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differential diagnosis
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Next step in the work up?
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ap left hip
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lateral left hip
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contralateral hip
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Diagnosis = SCFE Now what???? Admit
Bedrest to strict non-weightbearing NPO based on planned surgical intervention
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in situ screw fixation
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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
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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
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displaced femoral neck
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histology of scfe Physis (growth plate) is widened
Abnormal chondrocyte maturation Slip usually occurs through the hypertrophic zone
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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
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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%
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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
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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
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history Hip, groin pain, thigh pain, knee pain May have limp
Maybe exertional No history of trauma Variable duration May have limp
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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
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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
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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
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lab orders If less than 10 years of age Thyroid function test
Basic chem panal
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non- op management Historical No role for non-op today Spica cast
Surgical to avoid further slipping and complications
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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
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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
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outcomes Related to severity of the slip
Results good to excellent in those with mild to moderate slip treated with in situ screw fixation
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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
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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:
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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
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