Slipped Capital Femoral Epiphysis SCFE دکتر مظلومی دانشیار ارتوپدی دانشگاه علوم پزشکی مشهد
INCIDENCE AND EPIDEMIOLOGY • The usual deformity consists of an upward and anterior movement of the femoral neck on the capital epiphysis. • The incidence of SCFE varies according to race, sex, and geographic location: The incidence is estimated to be approximately 2 per 100,000 population,
INCIDENCE AND EPIDEMIOLOGY • There is a definite predilection for males to be affected more often than females(5/1), and for the left hip to be affected more often than the right(3/1). • Slipped epiphysis typically occurs during adolescence (boys, 13 to 15 years of age, averaging about 14years; and girls, 11to 13years of age, averaging about 12 years) a period of maximal skeletal growth.
INCIDENCE AND EPIDEMIOLOGY • When SCFE occurs in a juvenile (10 years of age and younger) or in a patient with an open physisolder than 16 years of age, careful assessment for an underlyingEndocrinopathyshould be considered. • Most studies identify bilateral involvement either on initial presentation or subsequently in approximately 20% to 25% of patients
CLASSIFICATION • According to onset of symptoms (acute, chronic, or acute-an-chronic) • functionally, according to the patient's ability to bear weight (stable or unstable) • or morphologically, as to the extent of displacement of the femoral epiphysis relative to the neck (mild, moderate, or severe),
CLASSIFICATION • An acute SCFE has been characterized as one occurring in a patient with prodromal symptoms for 3 weeks or less • Acute slips present as a sudden, dramatic, fracture-like episode occurring after trauma too trivial to cause displacement of the epiphysis as a Salter- Harris type I fracture
CLASSIFICATION • Chronic SCFE is the most frequent form of presentation. Typically, an adolescent presents with a few months history of vague groin pain, upper or lower thigh pain, and a limp. • Radiographs of patients with chronic SCFE show a variable amount of posterior migration of the femoral epiphysis and remodeling of the femoral neck in the same direction
CLASSIFICATION • The acute-on-chronic slipped epiphysis is one in which features of both ends of the spectrum are present • prodromal symptoms have been present for more than 3 weeks with a sudden exacerbation of pain, and radiographic evidence of both femoral neck remodeling and further displacement
Classification • Functional Classification • Patients who were unable to bear weight after the acute episode were identified as having unstable slips. • those who were able to bear weight at the time of presentation to a physician were classified as having stable slips
Morphologic Classification Head-shaft angle mild slips less than 30 degrees from the normal contralateral side moderate slips the angle difference is between 30 and 60 degrees severe slips the angle differs by more than 60 degrees from the contralateral normal side.
ETIOLOGY • Mechanical Factors • THINNING OF THE PERICHONDRIAL RING COMPLEX • RELATIVE OR ABSOLUTE FEMORAL RETROVERSION • CHANGE IN INCLINATION OF THE ADOLESCENT PROXIMAL FEMORAL PHYSIS RELATIVE TO THE FEMORAL NECK AND SHAFT • ASSOCIATED CONDITIONS Blount's disease , peroneal spastic flat foot and Legg-Calve-Perthes disease.
ETIOLOGY Endocrine Factors • The stereotype of an obese, hypogonadal male (the so-called adiposogenital syndrome) presenting with chronic bilateral slipped epiphyses has long stimulated the thought that some alteration in the balance of thyroid, growth, and sex hormones was the cause of slipped epiphysis
CLINICAL FEATURES Stable, Chronic Slipped Capital Femoral Epiphysis • pain in the region of the groin, which may be referred to the anteromedial aspect of the thigh and knee. • The loss of internal rotation on examination, with complaints of pain at the limit of internal rotation, is a key finding in stable SCFE.
Clinical features Unstable Acute or Acute-on-Chronic Slipped Capital Femoral Epiphysis • severe, fracture-like pain in the affected hip region, usually as the result of a relatively minor fall or twisting injury. • the patient unable to bear weight and likely to seek prompt medical attention.
RADIOGRAPHIC FINDINGS Plain Radiography AP and lateral views (Klein's line) on the AP view
TREATMENT STABLE SLIPPED CAPITAL FEMORAL EPIPHYSIS Percutaneous In Situ Fixation with a Fracture Table
treatment Femoral neck osteotomy
COMPLICATIONS Chondrolysis 1- acute cartilage necrosis 2- stiffness and persistent pain in the groin Loss of joint space 3- The incidence of chondrolysis is 1.5%
Avascular Necrosis The most severe complication associated with SCFE is the development of AVN of the epiphysis.