SCFE, SLIPPED CAPITAL FEMORAL EPIPHYSIS

1. Slipped Capital FemoralSlipped Capital Femoral
EpiphysisEpiphysis
Dr. LOKESH SHAROFF
Orthopedic surgeon ,
Mumbai, India

2. IncidenceIncidence
Annual incidence 2-10 per 100,000Annual incidence 2-10 per 100,000
2.4 M : 1 F2.4 M : 1 F
LEFT > RIGHT HIPLEFT > RIGHT HIP
Boys 13-15 yrs (14)Boys 13-15 yrs (14)
Girls 11-13 yrs (12)Girls 11-13 yrs (12)
presentation outside these ages consider endocrine orpresentation outside these ages consider endocrine or
systemic disorder !!systemic disorder !!

3. IntroductionIntroduction
Obese (50-75% over 95thObese (50-75% over 95th
centile)centile)
Delay in skeletal maturityDelay in skeletal maturity
Bilateral in 17% (50%Bilateral in 17% (50%
present-50% sequential)present-50% sequential)

4. IntroductionIntroduction
femoral neck displace ANTERIORLY ANDfemoral neck displace ANTERIORLY AND
SUPERIORLY with the head in the acetabulum causing anSUPERIORLY with the head in the acetabulum causing an
apparent varus deformityapparent varus deformity

5. AetiologyAetiology
Mechanical factorsMechanical factors
obesityobesity
Increase in femoral retroversionIncrease in femoral retroversion
Vertically oriented physeal plateVertically oriented physeal plate
Thinning of perichondral ringThinning of perichondral ring

6. AetiologyAetiology
InflammatoryInflammatory
synovial hyperplasiasynovial hyperplasia
increase in IG and C3increase in IG and C3

7. AetiologyAetiology
EndocrineEndocrine
Association withAssociation with
Hypothyroidism
Primary hyperparathyroidism
Panhypopituitarism
Hypogonadal conditions
Renal osteodystrophy
GH deficiency and therapy
Rubenstein - taybi syndrome
Klinefelters syndrome

8. PathologyPathology
-Periosteum torn anteriorly-Periosteum torn anteriorly
-Antero-superior part of neck forms a rounded-Antero-superior part of neck forms a rounded
humphump
-area between neck and periosteum posteriorly is-area between neck and periosteum posteriorly is
filled with osseous tissuefilled with osseous tissue

9. HistopathologyHistopathology
-PRE SLIP STAGE - widening of physis-PRE SLIP STAGE - widening of physis
-DISPLACEMENT - occurs through Proliferative-DISPLACEMENT - occurs through Proliferative
and Hypertrophic zonesand Hypertrophic zones
-organisation of chondrocytes changes from-organisation of chondrocytes changes from
columnar to clumpscolumnar to clumps

10. Slipped Capital FemoralSlipped Capital Femoral
Epiphysis classificationEpiphysis classification
According to duration of symptoms--According to duration of symptoms--
Preslip: synovitisPreslip: synovitis
Acute <3wksAcute <3wks
Chronic >3 wksChronic >3 wks
Acute on Chronic >3 wks with furtherAcute on Chronic >3 wks with further
displacement of epiphysisdisplacement of epiphysis

11. Slipped Capital FemoralSlipped Capital Femoral
Epiphysis PresentationEpiphysis Presentation
Physeal stability– Loder classificationPhyseal stability– Loder classification
Stable: can wt bearStable: can wt bear
Unstable : cannot wt. bearUnstable : cannot wt. bear
Acute Slipped Capital Femoral Epiphysis: the Importance of Physeal StabilityAcute Slipped Capital Femoral Epiphysis: the Importance of Physeal Stability
Loder et alLoder et al
JBJS 1993; 75-A:1134-1140JBJS 1993; 75-A:1134-1140

12. Presentation--chronicPresentation--chronic
-often obese and present with pain in the hip (85%) or knee (15%)-often obese and present with pain in the hip (85%) or knee (15%)
—increases in evening or after exertion—increases in evening or after exertion
-Limp-Limp
-thigh atrophy-thigh atrophy
-extremity shortening-extremity shortening
Knee Axilla sign: On attempted flexion of the hip, the patients legKnee Axilla sign: On attempted flexion of the hip, the patients leg
goes into external rotationgoes into external rotation
Internal rotation is lost.Internal rotation is lost.
Abduction and extension is also restrictedAbduction and extension is also restricted

13. Presentation—acute on chronicPresentation—acute on chronic
-sudden onset of pain-sudden onset of pain
-unable to move the limb-unable to move the limb
-unable to bear weight-unable to bear weight
-limb in external rotation-limb in external rotation

14. Presentation --ChondrolysisPresentation --Chondrolysis
-Pain is continous-Pain is continous
-Pain throughout ROM-Pain throughout ROM
-Global restriction of ROM-Global restriction of ROM
-Flexion contracture-Flexion contracture

15. Slipped Capital FemoralSlipped Capital Femoral
Epiphysis RadiologyEpiphysis Radiology
APAP
Physeal wideningPhyseal widening
Steels Metaphyseal Blanch sign (density in neck)Steels Metaphyseal Blanch sign (density in neck)
Klein line/Trethowan signKlein line/Trethowan sign
Schams signSchams sign
Break in Shenton’s lineBreak in Shenton’s line

16. RadiologyRadiology
--Klein's Line:--Klein's Line:
– line drawn along superior border of femoral neck shouldline drawn along superior border of femoral neck should
cross at least a portion of the femoral epiphysiscross at least a portion of the femoral epiphysis
– slip must be suspected if a straight line drawn up lateralslip must be suspected if a straight line drawn up lateral
surface of femoral neck does not touch the femoral headsurface of femoral neck does not touch the femoral head

17. RadiologyRadiology
Metaphyseal blanch sign (STEELS)---Metaphyseal blanch sign (STEELS)---

18. RadiologyRadiology
SCHAMS sign --SCHAMS sign -- The posterior acetabular margin normally cutsThe posterior acetabular margin normally cuts
the medial corner of the metaphysis. In slip the whole metaphysisthe medial corner of the metaphysis. In slip the whole metaphysis
remains lateral to the acetabular margin.remains lateral to the acetabular margin.

19. Slipped Capital FemoralSlipped Capital Femoral
Epiphysis RadiologyEpiphysis Radiology
LateralLateral
Shoot-through/Frog legShoot-through/Frog leg
It shows the bending of the femoral neck and theIt shows the bending of the femoral neck and the
anterior hump of bone growthanterior hump of bone growth
head-shaft angle of SOUTHWICK can be calculatedhead-shaft angle of SOUTHWICK can be calculated

20. RadiologyRadiology
SOUTHWICK’SSOUTHWICK’S
CLASSIFICATIONCLASSIFICATION
calculate the Head-Shaft anglecalculate the Head-Shaft angle
<30--mild<30--mild
30-60--moderate30-60--moderate
>60--severe>60--severe

21. Slipped Capital FemoralSlipped Capital Femoral
Epiphysis RadiologyEpiphysis Radiology
Classification—Classification—
Determined by percentage of displacement of theDetermined by percentage of displacement of the
EPIPHYSIS in relation to the neck, as follows:EPIPHYSIS in relation to the neck, as follows:
grade I (<33%),grade I (<33%),
grade II (33-50%),grade II (33-50%),
grade III (>50%)grade III (>50%)

22. Slipped Capital FemoralSlipped Capital Femoral
Epiphysis TreatmentEpiphysis Treatment
Prevent further slippagePrevent further slippage
Reduce the degree of slippageReduce the degree of slippage
Salvage treatmentSalvage treatment

23. CT--SCANCT--SCAN
--To check HEAD – NECK angle--To check HEAD – NECK angle
--Neck in ante or retroversion--Neck in ante or retroversion
--post-op—whether implant has penetrated into--post-op—whether implant has penetrated into
the jointthe joint
--closure of physis--closure of physis
--compression achieved by screws--compression achieved by screws
--residual deformity--residual deformity

24. ULTRASOUNDULTRASOUND
--to check for joint effusion--to check for joint effusion
--to check for step between femoral neck and--to check for step between femoral neck and
epiphysisepiphysis

25. MRIMRI
--used to asses the pre-slip stage but is expensive--used to asses the pre-slip stage but is expensive

26. BONE SCANBONE SCAN
--Increased uptake in SCFE--Increased uptake in SCFE
--decreased uptake in AVN--decreased uptake in AVN
--increased in the joint space in chondrolysis--increased in the joint space in chondrolysis

27. SCFE Treatment to preventSCFE Treatment to prevent
further slippagefurther slippage
Hip spicaHip spica
Bone peg epiphysiodesisBone peg epiphysiodesis
Pin or screw fixationPin or screw fixation

28. SCFE Treatment to preventSCFE Treatment to prevent
further slippagefurther slippage
THEORIESTHEORIES
--smooth pins– to allow epiphysial growth--smooth pins– to allow epiphysial growth
--threaded pins –to arrest physeal growth--threaded pins –to arrest physeal growth
--single cannulated screw—threads placed across--single cannulated screw—threads placed across
physis to arrest growthphysis to arrest growth
--double screws—for additional rotational stability--double screws—for additional rotational stability
in unstable hipsin unstable hips

29. SCFE Treatment to preventSCFE Treatment to prevent
further slippagefurther slippage
In situ screw or pin fixationIn situ screw or pin fixation
biplane fluoroscopybiplane fluoroscopy
percutaneous techniquepercutaneous technique
Position fixation centrally in headPosition fixation centrally in head

30. SCFE Treatment to preventSCFE Treatment to prevent
further slippagefurther slippage
In situ screw or pin fixation--positionIn situ screw or pin fixation--position
pin must be placed perpendicular to plane of the femoral headpin must be placed perpendicular to plane of the femoral head
starting position anterior of the femoral neck and not lateralstarting position anterior of the femoral neck and not lateral
cortexcortex

31. SCFE Treatment to preventSCFE Treatment to prevent
further slippagefurther slippage
In situ screw or pin fixation—to avoidIn situ screw or pin fixation—to avoid
avoid superior and anterior quadrant of femoral headavoid superior and anterior quadrant of femoral head
following fixation whilst moving hip to ensure no penetrationfollowing fixation whilst moving hip to ensure no penetration

32. SCFE Treatment to preventSCFE Treatment to prevent
further slippagefurther slippage
--BONE GRAFT EPIPHYSIODESIS--BONE GRAFT EPIPHYSIODESIS
Advantages—rapid epiphysial closureAdvantages—rapid epiphysial closure
---no risk of implant penetration into jt.---no risk of implant penetration into jt.
---no reoperation---no reoperation
Disadvantages---infectionDisadvantages---infection
---chondrolysis---chondrolysis
---avn---avn
Uses --- in failed pinning operationUses --- in failed pinning operation

33. SCFE Treatment to ReduceSCFE Treatment to Reduce
degree of slippagedegree of slippage
Closed manipulationClosed manipulation
although after in situ pinning ROM improves this is inalthough after in situ pinning ROM improves this is in
main due to resolution of synovitis and spasm.main due to resolution of synovitis and spasm.
There is little remodellingThere is little remodelling
Closed manipulation >24hrs significantly increases theClosed manipulation >24hrs significantly increases the
risk of osteonecrosisrisk of osteonecrosis

34. SCFE Treatment to ReduceSCFE Treatment to Reduce
degree of slippagedegree of slippage
OsteotomiesOsteotomies
-- to reduce deformity-- to reduce deformity
--to prevent further slipping--to prevent further slipping
--to re-orient and stabilise physis--to re-orient and stabilise physis

35. SCFE Treatment to preventSCFE Treatment to prevent
further slippagefurther slippage
OsteotomiesOsteotomies
1–-dunn’s1–-dunn’s
2—kramer2—kramer
3—barmada3—barmada
4---southwick4---southwick

36. SCFE Treatment to ReduceSCFE Treatment to Reduce
degree of slippagedegree of slippage
OsteotomiesOsteotomies
more distal less correction at primary site of deformitymore distal less correction at primary site of deformity
more proximal more risk of osteonecrosismore proximal more risk of osteonecrosis
used in cases of moderate to severe slipsused in cases of moderate to severe slips

37. SCFE Treatment to ReduceSCFE Treatment to Reduce
degree of slippagedegree of slippage
OsteotomiesOsteotomies
Cuneiform Osteotmy at femoralCuneiform Osteotmy at femoral
physis Fish/ Dunnphysis Fish/ Dunn
--done in severe slips in open--done in severe slips in open
physisphysis
Osteonecrosis 12-35%Osteonecrosis 12-35%
Fish 3.5% osteonecrosis and 11%Fish 3.5% osteonecrosis and 11%
chondrolysischondrolysis

39. Intertrochanteric - SouthwickIntertrochanteric - Southwick
Compensatory osteotomy, the more distal the lessCompensatory osteotomy, the more distal the less
correction at primary source of deformity.correction at primary source of deformity.
Maximum head-shaft correction is 50Maximum head-shaft correction is 50°.°.
Antero-lateral wedge is removed,so flexion and valgus ofAntero-lateral wedge is removed,so flexion and valgus of
distal fragment is achieved .distal fragment is achieved .
Wedge removed -- therefore shorteningWedge removed -- therefore shortening..
Done in severe slipsDone in severe slips

40. SCFE Treatment to ReduceSCFE Treatment to Reduce
degree of slippagedegree of slippage
OsteotomiesOsteotomies
IntertrochantericIntertrochanteric
single, bi or multiple-planesingle, bi or multiple-plane
corrects 45’-50’corrects 45’-50’
low incidence oflow incidence of
osteonecrosis, butosteonecrosis, but
chondrolysis rate 6-50%chondrolysis rate 6-50%

41. SCFE Treatment to ReduceSCFE Treatment to Reduce
degree of slippagedegree of slippage
OsteotomiesOsteotomies
Base of neck—Base of neck—
KRAMER ANDKRAMER AND
BARMADABARMADA
anterior wedgeanterior wedge
removedremoved
corrects 30-50corrects 30-50
for chronic residualfor chronic residual
deformitiesdeformities
moderate to severe scfemoderate to severe scfe

42. SCFE Prophylactic pinning of theSCFE Prophylactic pinning of the
contralateral hipcontralateral hip
FU till skeletal maturityFU till skeletal maturity
Pin if symptoms presentPin if symptoms present
Pin knownPin known
metabolic/endocrinemetabolic/endocrine
disordersdisorders
Pin if FU unreliablePin if FU unreliable

43. SCFE OsteonecrosisSCFE Osteonecrosis
vascular injury, complication of treatmentvascular injury, complication of treatment
increase with severity of slipincrease with severity of slip
increase in acute, unstable slipsincrease in acute, unstable slips
increases with manipulation, pin placement in superior quadrantincreases with manipulation, pin placement in superior quadrant

44. SCFE OsteonecrosisSCFE Osteonecrosis
remove metal workremove metal work
maintain ROMmaintain ROM
shelf acetabuloplastyshelf acetabuloplasty
arthrodesis/THRarthrodesis/THR

45. SCFE ChondrolysisSCFE Chondrolysis
dissolution of articular cartilage with jointdissolution of articular cartilage with joint
stiffness and painstiffness and pain
CauseCause
synovial malnutrition, ischaemia, excessive pressuresynovial malnutrition, ischaemia, excessive pressure
AutoimmuneAutoimmune
Females>malesFemales>males

46. SCFE ChondrolysisSCFE Chondrolysis
incidence 2-20%incidence 2-20%
higher in females, acute and severe slipshigher in females, acute and severe slips
manipulation, prolonged immobilisation, realignmentmanipulation, prolonged immobilisation, realignment
osteotomiesosteotomies
pin penetrationpin penetration
exclude infectionexclude infection

47. SCFE ChondrolysisSCFE Chondrolysis
Non- wt bearing, NSAID, ROMNon- wt bearing, NSAID, ROM
tractiontraction
in pt therapyin pt therapy

48. Thank youThank you