Slipped capital femoral epiphysis (SCFE)

SCFE

• Posterior and Medial displacement of the femoral capital epiphysis on the femoral neck through sudden or gradual deformation of the sub-capital growth plate

Incidence

• 3/100,000 in whites

• 7/100,000 in blacks

• Age:– Males 12-16 years– Females 10-14 years

• M-F 2,4-1

• L>R, bilateral in 25%

Etiology

• Mechanical – overload due to obesity, decreased anteversion, changes within physeal plate

• Inflammatory – synovial inflammation?• Hormonal – obesity, hypogonadal features in

boys, secondary and primary hypothyroidism, panhypopituarism, hypogonadal conditions, renal osteodystrophy, growth hormone therapy

• Trauma

Predispositions

• Obesity• Rapid growth• Endocrinopathies

– Hypothyroidism– Renal osteodystrophy– Pituitary deficiency– GH deficiency when treated with GH as this

causes rapid growth

Symptoms

• Limp

• Pain– Groin– Femur– Knee

• Lateral rotation aggravated when hip is flexed

• Decreased internal rotation

Classification

• Acute slip – sudden, severe, fracture-like pain in the upper thigh after trauma

• Chronic slip – a few months history of vague pain in the groin, upper thigh and limp

• Acute on chronic slip – prodromal symptoms with exacerbation of pain

Classification

• 0 – pre slip• I – <30º (mild slip)• II – 30º – 60º (moderate slip)

a – 30º - 40ºb – 40º - 50ºc – 50º - 60º

• III - >60º (severe slip)

Head-neck angle

Southwick- head-shaft angle

Classification - Loder

50%0%Avn

47%96%Good prognosis

More severeLess severeSeverity of slip

ImpossiblePossibleWeight bearing

Unstable Stable

Klein’s Line

Radiographs

Treatment

• Stabilisation of epiphysis and prevention of further slippage

• Stimulation of physeal plate arrest

• Functional improvement by restoration anatomy in severe cases

Treatment

• 0 and I – in situ stabilization

• II - in situ stabilization or inter- , subtrochanteric femoral osteotomy

• III – subcapital femoral neck osteotomy, inter- , subtrochanteric femoral osteotomy

Stabilisation

Stabilisation

Stabilisation

Prognosis

• The majority of patients will be able to return to most sports and activities at approximately 3-6 months post-operatively.

• Removing the hardware is not necessary unless the patient develops pain or there is a problem with the screw itself.

• Because of the high association of bilaterality seen in SCFE (approx 25-40%), patients will need to be closely monitored to ensure that the contralateral hip does not slip.

IRRITABLE HIPIRRITABLE HIP(observation hip, toxic synovitis,

transitory coxitis, coxitis serosa, coxalgia fugax, phantom hip, transient synovitis)

Epidemiology

• Most common cause of hip pain• Reported incidence is 1 in 1000• From 9 months to adolescence (usually

between age 3 and 8 yrs -peak age is 6 yrs)

• More common in boys (2:1)• Whites• Never bilateral

Etiology

• Bacterial/viral infection• Trauma• Allergic reaction

Natural history

• Limited duration of symptoms (average 10 days- may be as long as 8 weeks)

• Recurrence uncommon (< 10%)• May be mild radiographic changes in hip• Coxa magna and femoral neck widening• Association with perthes disease in 1.5%

Symptoms

• Acute hip pain (thigh, groin or knee) • Limp with or without pain• Stance phase shorter for affected limb• Slightly raised temperature • Hip held in flexion, external rotation and

abduction• Protective muscle spasm• One side affected

Diagnosis

• Clinical examination• USG- may show effusion• Rtg- usually normal• Laboratory- may be mild elevation of WBC,

ESR (OB)>20

Differential diagnosis

• Perthes disease• Septic arthritis• Osteomyelitis• Juvenile rhemoatoid arthritis• Slipped femoral epiphysis

Treatment

• Bed rest and analgesia until full ROM achieved

• Non-weight-bearing• Traction only for severe cases • NSAIDs- Naproxen 10mg/kg/d• Partial weight bearing on crutches until limp

resolves