adolescent coxa vara
TRANSCRIPT
ADOLESCENT COXA VARA
It is also known as Slipped Capital Femoral Epiphysis
Or Epiphysiolysis
It is displacement of the proximal femoral epiphysis
WHO?
•10 – 16 yrs•Boys•Obese or tall & thin•Blacks•Left > Right
WHY?
MOSTLY MULTIFACTORIAL
Local trauma
Obesity
Endocrine disease (hypothyroidism, hypopituitarism, chronic renal disease)
Genetic
CLINICAL FEATURES
H/O Injury
Pain in groin thigh or knee
Limp
On Examination
Leg is externally rotated
1-2cm short
Limitation of flexion, abduction and internal rotation
Classic Sign – there is increasing external rotation as the hip is flexed
INVESTIGATIONS
RADIOLOGICAL FEATURES
XRAY
In AP view-Normal head-shaft angle is 1450
In Lateral view-Normal head-shaft angle is 1700
Lateral view – most reliable sign – femoral epiphysis is tilted backwards
AP view – a line drawn on the superior surface of the neck remains superior to the
head instead of passing through it (TRETHOWAN’S SIGN)
CT SCAN
It is helpful to confirm the diagnosis in early, mild slipping
X ray-
Trethowan’s Sign positive
CLASSIFICATION
DurationA. Acute slips – sudden onset of severe
symptoms, <2 weeks, Xray shows no evidence of bone healing
B. Chronic slips – gradual onset, >2 weeks, Xray shows some bony healing and remodelling along postr. and med. femoral neck
C. Preslip – Xray finding of irregularity, widening and indistinctness of physis
D . Acute on Chronic – symptoms >1 month, recent exacerbation of pain following trivial trauma
BASED ON XRAY
MILD (GRADE I) - Neck displaced <1/3rd of diameter of femoral head, angle deviation <300
MODERATE (GRADE II) – Displacement btw 1/3rd and 1/2, angle deviation btw 300 and 600
SEVERE (GRADE III) – Displacement >1/2, angle deviation more than 600.
TWO PART CLASSIFICATION
UNSTABLE – Severe pain prevents walking even with crutches
STABLE – Walking is possible with orwithout crutches
TREATMENT
AIMS
Preserve epiphyseal blood supply
Stabilize the physis
To correct any residual deformity
NON OPERATIVE
Traction and spica cast immobilisation
Prevents further slipping
Results in premature physeal closure
More complications
MILD SLIPS Deformity is minimal
Insert one or two screws or threaded pins along the femoral neck and into the epiphysis
Now recommended – single larger diameter central pin or screw
Pins should not be removed for atleast 12 months or until epiphysis closes
MODERATE SLIPS
Fix epiphysis in situ – short threaded pins
After 1 year, if deformity present, corrective osteotomy done
Alternatively bone graft epiphyseodesis
Trim anterosuperior metaphysis to prevent impingement
SEVERE SLIPS
Open reduction by Dunn’s Method – small segment of femoral neck is removed to reposition the epiphysis, once reduced it is held by 2 or 3 pins.
Alternatively, fix epiphysis followed by compensatory intertrochanteric osteotomy
1. Tri plane osteotomy 2. Geometric flexion osteotomy
PROPHYLACTIC PINNING
It is done for contralateral slips Indicated in rare instances High risk Non compliant patients Patients with epiphysiolysis from renal failure orirradiation therapy
CLOSED REDUCTION
Done in severe acute unstable slips
Technically difficult or impossible to pin in situ
Earlier- Internal rotation alone Gradual reduction by skin traction and
internal rotation over 3-4 days
Avascular necrosis more
OPEN REDUCTION
Dunn’s in severe acute or chronic slip
Heyman – Herndon epiphysiodesis procedure in moderate slips
BONE PEG EPIPHYSIODESIS
Done by using hollow mill to create tunnel across physis, sandwiched iliac bone grafts driven across the physis
More complications than in situ pinning
Disadvantages-graft insufficiency, longer operating time,increase blood loss
OSTEOTOMY
A CLOSING WEDGE OSTEOTOMY-through femoral neck
• Cuneiform Osteotomy femoral neck (Fish)• Cuneiform Osteotomy femoral neck
(Dunn)• Compensatory Basilar Osteotomy of
femoral neck• Extracapsular Base-of-neck osteotomy
B. Compensatory osteotomy Intertrochanteric osteotomy
C. Cheilectomy resection of the part impinging
against acetabulum
COMPLICATIONS
AVACULAR NECROSIS
More common in-
Unstable (acute) slips Forceful repetitive manipulation Open reduction Osteotomy of femoral neck Superolateral placement of pins
CHONDROLYSIS
More common in- Pin penetration into joint Trochanteric osteotomy, open reduction, femoral neck osteotomy Closed reduction and pin fixation
Joint space <3mm wide and decreased range of motion of hip joint
Fibrous ankylosis follows
Treatment- intraarticular cortisone injecton
surgical manipulation
FEMORAL NECK FRACTURE
Thermal injury caused by reaming of femoral neck before screw insertion.
Prevention- avoid unnecessary drilling, pins removed after
physeal fusion
COXA VARA
Head slips backwards-femoral neck retroversion
Secondary effectsa. External rotation deformity of hipb. Shortening of femurc. Secondary osteoarthritis
CONTINUED SLIPPING
If not treated Screws not placed proximally enough Removed before complete fusion of
physis
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