Download MBBS Orthopaedics PPT 16 Scfe Vs Lecture Notes

A 14-year-old athletic male with a medium build presents with 3 weeks of atraumatic

--- Content provided by FirstRanker.com ---

left hip and thigh pain. For that last 12 hours, he has been unable to bear weight, even

with crutches. He denies right hip pain. He has obligatory external rotation of the left

hip upon flexion. Radiographs are seen in figures A, B. What is the best next step?

--- Content provided by FirstRanker.com ---

Slipped Capital Femoral Epiphysis


Overview

--- Content provided by FirstRanker.com ---

? Condition of the proximal

femoral physis that leads

--- Content provided by FirstRanker.com ---

to slippage of the

metaphysis relative to the

epiphysis

--- Content provided by FirstRanker.com ---

? Most commonly seen in

adolescent obese males

--- Content provided by FirstRanker.com ---

? Treatment is usual y

percutaneous pin fixation

Epidemiology

--- Content provided by FirstRanker.com ---

? Most common disorder affecting adolescent

hips

--- Content provided by FirstRanker.com ---

? 10 per 100,000(USA)
? More common in

? obese children
? males

--- Content provided by FirstRanker.com ---

? African Americans,Pacific islanders, Latinos
Epidemiology

? During period of rapid growth (10-16 years)
? 13 for boys

--- Content provided by FirstRanker.com ---

? 12 for girls
? Associated with puberty
? Left hip is more common
? Bilateral in (~25%)

--- Content provided by FirstRanker.com ---

Risk factors

? Obesity-single greatest risk factor
? Acetabular retroversion and femoral

--- Content provided by FirstRanker.com ---

retroversion
Associated conditions

? Hypothyroidism -most common etiology of

--- Content provided by FirstRanker.com ---

nonidiopathic SCFE

? Renal osteodystrophy

? Growth hormone deficiency

--- Content provided by FirstRanker.com ---

? Panhypopituitarism

? Indications for endocrine workup

--- Content provided by FirstRanker.com ---

? child is < 10 years old

? weight is < 50th percentile

? Down syndrome

--- Content provided by FirstRanker.com ---

Pathophysiology

? Adolescence-perichondrial ring thins and

--- Content provided by FirstRanker.com ---

weakens

? Physis is still vertical in this age group
? Mechanical forces acting on a susceptible

--- Content provided by FirstRanker.com ---

physis

? Slippage occurs though the hypertrophic zone

of the physis

--- Content provided by FirstRanker.com ---

Pathoanatomy

? Angulation-metaphysis translates anterior and

externally rotates

--- Content provided by FirstRanker.com ---

? Epiphysis remains in the acetabulum
? Periosteum remains intact (chronic SCFE)
? In acute SCFE, periosteum can be partially torn

--- Content provided by FirstRanker.com ---

Loder Classification

? Based on ability to bear weight

? Stable-Able to bear weight with or without

--- Content provided by FirstRanker.com ---

crutches

? Minimal risk of osteonecrosis (<10%)

--- Content provided by FirstRanker.com ---

? Unstable-Unable to ambulate (not even with

crutches)

? High risk of osteonecrosis (25-35%)

--- Content provided by FirstRanker.com ---

? Provides prognostic information


Southwick Slip Angle Classification

--- Content provided by FirstRanker.com ---

? Based on femoral

epipyseal-diaphyseal

--- Content provided by FirstRanker.com ---

angle difference

? Mild

< 30?

--- Content provided by FirstRanker.com ---

? Moderate 30-50?

? Severe

--- Content provided by FirstRanker.com ---

> 50?

? Based on the degree of

difference between the

--- Content provided by FirstRanker.com ---

affected and

unaffected hip

--- Content provided by FirstRanker.com ---

Grading System -- based on

percentage of slippage

? Grade I 0-33% of slippage

--- Content provided by FirstRanker.com ---

? Grade II 34-50% of slippage
? Grade I I >50% of slippage
Symptoms

? Groin and thigh pain -most common presentation

--- Content provided by FirstRanker.com ---

? knee pain

? can lead to missed diagnosis

--- Content provided by FirstRanker.com ---

? Limp

? antalgic gait

? externally rotated foot progression angle

--- Content provided by FirstRanker.com ---

? Patients prefer to sit in a chair with affected leg

crossed over the other

--- Content provided by FirstRanker.com ---

? Duration

? symptoms for weeks to months before diagnosis is made

? Acute on chronic-severe pain,unable to bear weight

--- Content provided by FirstRanker.com ---

Physical exam

? Abnormal gait

--- Content provided by FirstRanker.com ---

? antalgic, waddling, externally rotated gait or

Trendelenburg gait

? Decreased hip motion

--- Content provided by FirstRanker.com ---

? Loss of hip IR, abduction, and flexion
? Obligatory external rotation during passive flexion

of hip (Drehmann sign)

--- Content provided by FirstRanker.com ---

? Weakness

? thigh atrophy
Radiographs

--- Content provided by FirstRanker.com ---

? AP & frog-leg lateral of right and left hip
? lateral radiograph is best way to identify a

subtle slip

--- Content provided by FirstRanker.com ---

Radiographs

? Klein's line

--- Content provided by FirstRanker.com ---

? Line drawn along

superior border femoral

neck

--- Content provided by FirstRanker.com ---

? Will intersect less of the

femoral head or not at

--- Content provided by FirstRanker.com ---

all in SCFE

Radiographs

? Epiphysiolysis (growth plate widening or

--- Content provided by FirstRanker.com ---

lucency)

? Blurring of proximal femoral metaphysis

--- Content provided by FirstRanker.com ---

(metaphyseal blanch sign of Steel)

? seen on AP due to overlapping of the metaphysis

and posteriorly displaced epiphysis

--- Content provided by FirstRanker.com ---

? MRI

? may help diagnose a preslip condition
Treatment-Stable slip

--- Content provided by FirstRanker.com ---

? Operative-percutaneous in situ fixation

? indications

--- Content provided by FirstRanker.com ---

? both stable and unstable slips

? one vs. two cannulated screws is controversial

? benefit of 2 screws needs to be considered in

--- Content provided by FirstRanker.com ---

the face of greater screw related

complications

--- Content provided by FirstRanker.com ---

? contralateral hip prophylactic fixation-

controversial
Treatment

--- Content provided by FirstRanker.com ---

? Open epiphyseal reduction and fixation

? controversial
? unstable and severe slips

--- Content provided by FirstRanker.com ---

? technique

? capital realignment via the modified Dunn

procedure

--- Content provided by FirstRanker.com ---

Complications

? Osteonecrosis of femoral head

? increased risk with unstable slips (~24-47%), most

--- Content provided by FirstRanker.com ---

common predictor

? operative complication (4-6%)

--- Content provided by FirstRanker.com ---

? hardware placement in posteriosuperior femoral neck

has the greatest risk of disrupting the vascular supply

? Chondrolysis (0-2%)

--- Content provided by FirstRanker.com ---

? Residual proximal femoral deformity & limb

length discrepancy

--- Content provided by FirstRanker.com ---

? Degenerative arthritis