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?
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Slipped Capital Femoral Epiphysis
Overview
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? Condition of the proximal
femoral physis that leads
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to slippage of themetaphysis relative to the
epiphysis
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? Most commonly seen in
adolescent obese males
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? Treatment is usual ypercutaneous pin fixation
Epidemiology
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? Most common disorder affecting adolescent
hips
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? 10 per 100,000(USA)? More common in
? obese children
? males
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? African Americans,Pacific islanders, LatinosEpidemiology
? During period of rapid growth (10-16 years)
? 13 for boys
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? 12 for girls? Associated with puberty
? Left hip is more common
? Bilateral in (~25%)
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Risk factors? Obesity-single greatest risk factor
? Acetabular retroversion and femoral
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retroversionAssociated conditions
? Hypothyroidism -most common etiology of
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nonidiopathic SCFE? Renal osteodystrophy
? Growth hormone deficiency
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? Panhypopituitarism
? Indications for endocrine workup
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? child is < 10 years old? weight is < 50th percentile
? Down syndrome
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Pathophysiology
? Adolescence-perichondrial ring thins and
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weakens? Physis is still vertical in this age group
? Mechanical forces acting on a susceptible
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physis? Slippage occurs though the hypertrophic zone
of the physis
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Pathoanatomy? Angulation-metaphysis translates anterior and
externally rotates
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? Epiphysis remains in the acetabulum
? Periosteum remains intact (chronic SCFE)
? In acute SCFE, periosteum can be partially torn
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Loder Classification? Based on ability to bear weight
? Stable-Able to bear weight with or without
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crutches
? Minimal risk of osteonecrosis (<10%)
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? Unstable-Unable to ambulate (not even withcrutches)
? High risk of osteonecrosis (25-35%)
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? Provides prognostic information
Southwick Slip Angle Classification
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? Based on femoral
epipyseal-diaphyseal
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angle difference? Mild
< 30?
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? Moderate 30-50?
? Severe
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> 50?? Based on the degree of
difference between the
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affected and
unaffected hip
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Grading System -- based onpercentage of slippage
? Grade I 0-33% of slippage
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? Grade II 34-50% of slippage? Grade I I >50% of slippage
Symptoms
? Groin and thigh pain -most common presentation
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? knee pain
? can lead to missed diagnosis
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? Limp? antalgic gait
? externally rotated foot progression angle
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? Patients prefer to sit in a chair with affected leg
crossed over the other
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? Duration? symptoms for weeks to months before diagnosis is made
? Acute on chronic-severe pain,unable to bear weight
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Physical exam
? Abnormal gait
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? antalgic, waddling, externally rotated gait orTrendelenburg gait
? Decreased hip motion
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? Loss of hip IR, abduction, and flexion
? Obligatory external rotation during passive flexion
of hip (Drehmann sign)
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? Weakness
? thigh atrophy
Radiographs
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? AP & frog-leg lateral of right and left hip
? lateral radiograph is best way to identify a
subtle slip
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Radiographs
? Klein's line
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? Line drawn alongsuperior border femoral
neck
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? Will intersect less of the
femoral head or not at
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all in SCFERadiographs
? Epiphysiolysis (growth plate widening or
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lucency)
? Blurring of proximal femoral metaphysis
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(metaphyseal blanch sign of Steel)? seen on AP due to overlapping of the metaphysis
and posteriorly displaced epiphysis
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? MRI
? may help diagnose a preslip condition
Treatment-Stable slip
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? Operative-percutaneous in situ fixation
? indications
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? both stable and unstable slips? one vs. two cannulated screws is controversial
? benefit of 2 screws needs to be considered in
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the face of greater screw related
complications
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? contralateral hip prophylactic fixation-controversial
Treatment
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? Open epiphyseal reduction and fixation? controversial
? unstable and severe slips
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? technique? capital realignment via the modified Dunn
procedure
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Complications? Osteonecrosis of femoral head
? increased risk with unstable slips (~24-47%), most
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common predictor
? operative complication (4-6%)
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? hardware placement in posteriosuperior femoral neckhas the greatest risk of disrupting the vascular supply
? Chondrolysis (0-2%)
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? Residual proximal femoral deformity & limb
length discrepancy
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? Degenerative arthritis