1. SLIPPED CAPITAL FEMORAL EPIPHYSIS (S.C.F.E.) EPIPHYSIOLYSISBY
PROF. HUSSEIN ABDEL FATTAH

2. 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.

4. ETIOLOGY Risk Factors Exact cause is disputed.
Multiple interdependent factors involved.
Risk Factors
Overweight.
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 TUMOURS
Sex Hormones
Reduction of physeal plate and increase of shearing strength
Adiposogenital, PITUITARY DIFFICENCY

7. 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.

8. Blood supply of the proximal end of the femur

9. microstructure of the growth plate

10. 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

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. side
Recent
united

14. 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.

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

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

17. 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

18. 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

19. 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

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 epiphysis
A line drown along the lat. Neck not crossing the epiphysis

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

23. LINES IN NORMAL HIP X

24. Head shaft angle 70 90
Head neck angle

25. 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

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

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

31. 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)

32. 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

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 child
Only 10% of painless other side may slip

36. 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.

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

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

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

44. H.S. Preslip left side 11/86

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

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

47. Lateral diagram of femoral head showing vascular supply

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

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

52. Implants removed 20/1/1989
1.1989

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

54. 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

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

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

57. 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

61. 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

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 menarche
Mode of Presentation
Chronic %
Acute %
Acute on Chronic 19%
Degree of Slip
Mild %
Moderate %
Severe %

64. 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

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

66. 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

67. Thank You
THANK YOU

68. The Journal of Bone and Joint Surgery
American Volume
Volume 64-A, No 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

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