SLIPPED CAPITAL FEMORAL EPIPHYSIS

VIVEK PANDEY
 INTRO
• -capital femoral epiphysis is displaced from the
metaphysis through the physeal plate .
• a misnomer in that the head is held in the acetabulum
by the ligamentum teres, and thus it is actually the neck
that comes upward and outward while the head remains
posterior and downward in the acetabulum
• In most cases, a varus relation exists b/w the head and
neck, but occasionally the slip is into valgus, with the
head displaced superiorly and posteriorly in relation to
the neck.
 EPIDEMIOLOGY

• Overall incidence; 2 cases / 100,000.

• Higher in all blacks, esp. black girls.
• Age range of 10 to 14 years in girls (mean, 11.5 years)
and 10 to 16 years in boys (mean, 13.5 years).
• 70 % of affected patients have delayed skeletal
maturation.
• Skeletal age may lag behind chronologic age by as much
as 20 months.
• Male predominance of 2.5:1.
• left hip is twice as often affected as the right hip.
• Other epidemiologic factors may include seasonal
variations and social class.
 EPIDEMIOLOGY

• Affected patients have a tendency toward obesity.

• Almost ½ of affected patients are > 95th percentile in
weight for their age.
• 3/4th of affected boys & ½ of affected girls are above the
90th percentile in weight for their height.

• Incidence of B/L SCFE is 25%. This figure may be low in

that about half of bilateral slips are asymptomatic.
This factor becomes important when considering the
natural history of the disease.
 ETIOLOGY
• The precise etiology is unknown.
a mechanical insufficiency of the proximal femoral
physis to resist the load across it . physiologic loads
across an abnormally weak physis or abnormally high
loads across a normal physis.
• Conditions that weaken the physis include endocrine
abnormalities, systemic diseases (such as renal
osteodystrophy), and previous radiation therapy in the
region of the proximal femur .
• Multiple mechanical factors accounts for abnormally high
loads across the proximal femoral physis in children with
SCFE, including obesity and anatomic variations in the
proximal femoral and acetabular morphology.
• Endocrine Factors

• Estrogen strengthens and Testosterone weakens the physis .These

effects appear to be secondary to the impact that these hormones
have on physeal width since mechanical strength of the physis
varies inversely with physeal width.

• Endocrinopathies account for 5% to 8% of the SCFE cases, SCFE

six times more common in patients who have an endocrinopathy.

• M.C endocrinopathies in children with SCFE are hypothyroidism,

panhypopituitarism, growth hormone (GH) abnormalities, and
hypogonadism include hyperparathyroidism or
hypoparathyroidism .

• most common in children around the time of puberty. It may be that

the abnormalities in the complex interplay of hormones at puberty
puts their hips at risk for SCFE.
Immunology & Genetics

Elevated levels of serum immunoglobulins and the C3

component of complement reported in patients with SCFE .
In patients with chondrolysis, serum immunoglobulin M
(IgM) level was elevated.
Synovial fluid abnormalities were noted.
• SCFE has been reported in identical twins .
• Autosomal dominant inheritance with variable penetrance in
familial cases .
• Some reported association of human leucocyte antigen
(HLA) B12 with SCFE , whereas others have reported an
association of HLA DR4 with SCFE .
Mechanical Factors
Obesity
• Association of SCFE with a decreased femoral ante-version , attributed to
increased shear force across the proximal femoral physis.

• Reduced femoral anteversion has been noted in obese adolescents

compared to adolescents of normal weight . This relative retroversion in
obese adolescents explains the increased incidence of SCFE in this
population group.

• Decrease in the neck shaft angle results in a more vertical physis, -

increase the shear force across the physis.

• Children with deeper acetabuli appear to be at greater risk . The capital

femoral epiphysis anchored more deeply in the acetabulum, forces across
the physis may be exaggerated, especially at the extremes of the range of
motion.
OTHER SYSTEMIC DISEASES

• Radiation therapy to the region of the femoral head also

increases the risk of SCFE .
• Renal osteodystrophy is associated with a 6 to 8 fold
increased risk of SCFE.
• All etiologic agents probably act either by altering the
strength of the zone of hypertrophy or by affecting the shear
stress to which the plate is exposed.
PATHOLOGY
synovium exhibits changes characteristic of synovitis, with hypertrophy and
hyperplasia of the synovial cells, villus formation, increased vascularity, and
round cell infiltration
• Light microscopic studies : physis is widened & irregular, sometimes reaching 12 mm in width (normal is 2.6 to 6 mm).
• Normally, the resting zone accounts for 60 - 70% of the width of the physis, the hypertrophic zone accounts for only 15 - 30% of the width.
• In SCFE, the hypertrophic zone may constitute up to 80% of the physis width.
• L/M :actual slip takes place through the zone of hypertrophy, with occasional extension into the calcifying cartilage. it is apparent that the slip occurs
through the weakest structural area of the plate, the hypertrophic zone.
•
 CLASSIFICATION
On the basis of the patient's history, physical examination, and
radiographs, SCFE can be classified into four categories—
1.Preslip
2.Acute
3.Acute on chronic
4.Chronic.

This traditional classification is being superceded by a more

clinically relevant two group scheme (stable versus unstable),
which is dependent on stability of the hip and relates well to
outcome.
 CLINICAL FEATURES
 PRESLIP PHASE
• C/O initially weakness in the leg or limping on exertion; pain may occur in
the groin, adductor region, or knee with prolonged standing or walking.

• O/E : lack of medial rotation of the hip in extension.

When the affected leg is fixed, the thigh goes into abduction and external
rotation, a sign pathopneumonic for SCFE.

• Radiographically: there is generalized bone atrophy and disuse osteopenia

of the hemipelvis and upper femur only in those patients who limped or
limited their activity.
• Widening, irregularity, and blurring to the physeal plate . The preslip may in
actuality be a minimal slip that is not seen on standard radiograph but may
possibly be seen on CT or MRI scans.
 CLINICAL FEATURES
 ACUTE PHASE
abrupt displacement through the proximal epiphyseal cartilage plate in
which there was a preexisting epiphysiolysis.
Acute slips :10% of the slips .The clinical criterion of having the acute
onset of symptoms for < 2 weeks.
history of mild prodromal symptoms for 1 - 3 mnths before their acute
episode indicates a preslip or mild slip.

Prodromal symptoms : mild weakness, limp, and intermittent groin, medial

thigh, or knee pain are usually followed by H/O minor trauma or of direct
trauma, with immediate increase in pain and inability to use the extremity.
If the patient can walk, it is with difficulty and with a limp. SCFE in the
patient with a history of mild prodromal symptoms may better be classified
as an acute-on-chronic slip.
Antalgic gait. External rotation deformity, shortening, and marked limitation
of motion.
 CLINICAL FEATURES
 CHRONIC SCFE
• groin or medial thigh pain for months to years.
• knee or lower medial thigh pain as their initial symptom. H/O
exacerbations and remissions of the pain or limp.
• O/E: limitation of motion (particularly medial rotation) and
shortening, and most have thigh or calf atrophy.
• The patient with an unstable slip presents much like an acute
trauma patient with the inability to walk even with crutches.
 CLINICAL FEATURES
•
• unstable significant risk of developing aseptic necrosis of the
epiphysis, which generally leads to a poor long-term outcome.

• Stable slips are all others that present with nonacute fracture
like patient is able to walk on the hip even with crutches.
Outcomes of treatment of this group are related to the amount
of displacement and the avoidance of complications of
treatment.
 DIAGNOSIS
Preslip stage -widening and irregularity of the physis with rarefaction of its
juxtaepiphysial portion.
Early diagnosis is made using a Lauenstein (frog-leg) lateral view or true lateral
view of the hip because small slips may be missed on the anteroposterior (AP)
view. A frog-leg lateral view should not be attempted in persons with acute or
unstable slips because it may cause further displacement.

 The Klein line - a line along the superior border of the femoral neck, intersects less of
the femoral head than on the opposite side (Trethowan sign) on the AP radiograph
 Localized rarefaction of the inferior medial metaphysis of the neck.
 The "metaphyseal blanch" of Steel is a crescent-shaped area of increased density
overlying the metaphysis adjacent to the physis on the AP radiograph.
This is an early sign of a posterior slip without significant medial slip and indicates
the need for a lateral radiograph to identify the slip.
 In moderate-to-severe slips, the overlap of the head and the metaphysis is visible.
 Remodeling in chronic slips is seen as callus on the posteroinferior portion of the neck
and rounding-off of the anterosuperior bare area of the neck, which is seen as a
rounded hump.
 DIAGNOSIS

Frog-leg (Lauenstein) lateral view, showing a mild slip that can easily be missed on
an anteroposterior view.
 DIAGNOSIS

Klein line (line drawn along the superior border of the neck intersects less of the
capital epiphysis than on the unaffected side).
 AP radiograph: The Klein line is drawn straight up the superior aspect of
the femoral neck. This should intersect the epiphysis. If not, then it is likely
an SCFE .
 DIAGNOSIS
One classification of displacement is as follows:
• Minimal slip: maximal displacement is less than one-third the
diameter of the neck
• Moderate slip: greater than 1 cm of displacement but less than
half the diameter of the neck
• Severe slip: displacement greater than half the diameter of the
neck
 DIAGNOSIS
• Bone scanning, magnetic resonance imaging (MRI), and computed tomography
(CT) scanning are not routinely performed,

• helpful to confirm the diagnosis of SCFE or more accurately measure the degree of
displacement and epiphyseal perfusion.
– pretreatment MRI in established cases of SCFE has a role with prognostic
implications for the treatment approach and outcome.
– Synovitis, periphyseal edema, and joint effusion are regular features of SCFE;
– MRI contributes to surgical decision-making.
 DIFFERENTIAL DIAGNOSIS

• Perthe’s disease
• Femoral Head Avascular Necrosis
• Femoral Neck Fracture
• Femoral Neck Stress Fracture
• Femur Injuries and Fractures
• Osteitis Pubis
 TREATMENT
Specific goals : to prevent further displacement of the epiphysis and to
promote closure of the physeal plate. Treatment of SCFE should be considered
an emergency.

The patient should not be allowed to bear weight.

Treatment should be initiated immediately.

Delay result in further displacement of the femoral epiphysis with compromise

of the remaining intact blood supply to the epiphysis.

Further displacement leads to increasing deformity and secondary increased

risk of degenerative joint disease .
 TREATMENT

Long-term goals :

restoration of a functional range of motion

freedom from pain
avoidance of aseptic necrosis and chondrolysis.

General principles: reduction of the unstable acute slips and the acute component of
acute-on-chronic slips if displaced more than mildly, followed by stabilization of the
epiphysis.
Stable slips or chronic slips and the chronic component of acute-on-chronic slips should
never be reduced but only stabilized.
runs the risk of aseptic necrosis (the most common cause of a poor result) and long-term
disability.
Acute or unstable slips- aseptic necrosis may occur with the sudden acute
displacement of the epiphysis by interruption of blood supply to the capital
femoral epiphysis.
Reduction attempts of the slip must be gentle.

Skin traction may be used while waiting for the patient to be ready to go to the
operating room. If displacement is mild, no attempt at reduction is done.

•Stabilization of the acute, unstable slip is accomplished by epiphysis pinning.-

large cannulated bone screws or multiple large threaded pins.
•Rapid advance to full weight bearing may then begin.
•All patients must be followed closely until the physeal plate closes.
•Loss of range of motion after treatment may be the first sign of chondrolysis.
•Pain in the other hip (groin, medial thigh, or knee) warrants careful
investigation.
•Most bilateral slips are diagnosed within 1 year of the diagnosis of the initial
slip.
• Pins are generally not removed, but if for some reason removal is considered,
it should be delayed until physeal closure.
Stable or chronic slips should not have attempts at reduction but should be treated by
stabilization procedures primarily, regardless of their degree of displacement.

Stable slips pinned in situ may rapidly advance postoperatively to full weight bearing.

Long-term results of mild and moderate slips are generally good concerning function
and range of motion.

A certain amount of remodeling of the proximal femur can be expected.

Severe slips can also be treated by stabilization procedures primarily.
.Long-termfollow-up studies indicate that the greatest risk to the long-term
outcome of patients with SCFE is the development of aseptic necrosis or
chondrolysis, not malalignment.

 The use of realignment procedures (neck, intertrochanteric, or

subtrochanteric osteotomy or manipulative reductions in chronic slips) is
associated with significantly higher complication rates than pinning in situ
alone.

Realignment procedures :in which restricted range of motion impairs function

after plate physeal closure.

Aseptic necrosis is the most devastating complication of SCFE. It is most

commonly associated—in acute slips and unstable slips—with the abrupt
displacement of the epiphysis disrupting retinacular vessels.

In chronic stable slips, aseptic necrosis can occur as a result of treatment. As
mentioned previously, attempts at reduction of stable or chronic slips, over-
reduction of unstable, acute slips, improper pin placement, and femoral neck
osteotomies are associated with this complication.
.Chondrolysis or cartilage necrosis is often associated with SCFE.

Chondrolysis is manifest clinically by loss of range of motion, pain, limp, and joint
contracture.
Radiographically: loss of joint space, irregularity of the subchondral bone of the femoral
head and the acetabulum, and disuse osteopenia.

It can occur in untreated slips, but this is unusual . The cause of this condition remains
unknown, but it is associated with prolonged immobilization, unrecognized pin
penetration, severe slips, and a long duration of symptoms before treatment.

Treatment of chondrolysis is difficult. Symptomatic treatment should begin immediately

and should include anti-inflammatory agents and bed rest in skeletal traction to relieve
pain and contractures.
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