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SLIPPED CAPITAL FEMORAL EPIPHYSIS(S.C.F.E.)EPIPHYSIOLYSIS BY PROF. HUSSEIN ABDEL FATTAH
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.
ETIOLOGY • Exact cause is disputed. • Multiple interdependent factors involved. Risk Factors • Overweight. • Abnormally tall child. • Black races. • Endocrinopathies
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.
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
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.
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
Weakening occurs in the hypertrophic zone of the growth plate Slipping occur in this zone
BABY two years traumatic fracture sparation of capital epiphysis RT. United two months later
Traumatic fracture separation capital epiphysis five years old boy L. side Recent united
A.H . 4/93 10/93 Remodelling after slip varies with age, younger is more complete Female age 11 ys Remod.in six m.
D.M.T. F. Age (13 yrs.) 3/90 Missed fourth degree slipage 13 years
D.M.T 10/93 Three & half years later natural healing poor remodeling lack of congruity
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
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
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
16 YS. 95 K. ADIPOSGENITALIA, BILAT. SLIP RT AFTER S.O. LEFT FULLY EXTERNAL ROTATED & SHORTER .
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
First degree slip in lithotomy Lateral view Rt .hip is apparently normal In the A.P. VIEW
Head shaft angle 70 90 Head neck angle
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
C.T. Scan • Demonstrates early slipping • Accurate measurement of angle and degree of slip.the degree of • External femoral rotation at the knee
Treatment • Aim • To stop slipping • To enhance healing • To correct deformities • To avoid complications
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)
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
Pinning • Pin position in the lower and posterior half • Upper and anterior position is dangerous > Penetration and avascular necrosis
Pinning The Other Hip • If painful with no slip • Especially in over weight child • Only 10% of painless other side may slip
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.
SHERBENY pain rt. Hip 30/1o/ 91,acute slip 8/12/91,reduced by traction 3 D.
R.R.S. (F.) B.D. 4/2/1986 age 9 ys. X 6/1995 LEFT MISSED SLIP. RIGHT NORMAL
R.R.S. AFTER REDUCTION BY GRADUAL TRACTION & FIXATION PINS IN GOOD POSITION
H.SHARAWY 12 YRS ACUTE SLIP 5/2/86 1O/2/86 5 DAYS TRACTION Two pins 10/2/86
H.Sharawy.pins left side 5/87 10.88 10. 88
Surgical Treatment • Open Reduction • Dunn (1964) and Dunn & Angle (1978) • High incidence of ischaemic necrosis and chondrolysis • For severe slipping