SLIPPED CAPITAL FEMORAL EPIPHYSIS (S.C.F.E.) EPIPHYSIOLYSIS

1. SLIPPED CAPITAL FEMORAL EPIPHYSIS(S.C.F.E.)EPIPHYSIOLYSIS BY 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 • 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 • 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. 3 – Metabolic Factors • Decreased Vitamin D activity • Rickets • Renal Osteodystrophy 4 – InflammationMorrissy 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. side Recent united

14. 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. D.M.T. F. Age (13 yrs.) 3/90 Missed fourth degree slipage 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 • 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. 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: • 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 • 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. 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