15 Slipped Capital Femoral Epiphysis
Introduction
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I. Slipped Capital Femoral Epiphysis
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Etiology:
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Most common hip disorder affecting adolescents:
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1.5:1 male-to-female ratio:
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i. Unstable slips: 1:1 male-to-female ratio.
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Strong association with socioeconomic level and obesity.
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Bilateral 20 to 80%:
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i. Second slipped capital femoral epiphysis (SCFE) usually occurs within the first year after index slip.
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Racial variability:
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i. Increased incidence in African Americans, Native Americans, Hispanics, and Polynesians.
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Age of onset:
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i. Boys: 12.7 to 13.5 years.
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ii. Girls: 11.2 to 12.1 years.
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Incidence:
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i. 4.8/100,000 (0–16 years of age).
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Pathogenesis:
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Multifactorial and unknown:
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Slippage secondary to collagen disturbance around the pubescent growth spurt: at hypertrophic zone of physis.
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Metabolic, endocrine, and mechanical postulates for cause of SCFE:
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i. Metabolic:
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Serum leptin levels:
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Elevated in obese patients.
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According to Halverson et al, regardless of body mass index (BMI), leptin greater than 4.9 increases the odds ratio of SCFE.
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ii. Endocrine disorders.
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iii. Mechanical factors:
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Obesity:
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Eighty percent of SCFE patients.
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May be due to increased loads on physis, morphology, and endocrine disorders in obese patients.
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Morphology:
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Relative femoral retroversion.
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Acetabular retroversion.
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More vertically orientated physis.
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Histopathology and pathomorphology:
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Proximal capital physiolysis.
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Damage occurs at the zone of provisional calcification (hypertrophic).
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Deformity:
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Anterior translation, external rotation of the femoral neck (metaphysis).
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Posterior, inferior displacement of femoral head (epiphysis).
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Variable posterior tilt of the femoral epiphysis.
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Varus, extension, and external rotation deformity of the femoral neck.
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Rare “valgus slip”:
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i. Anterior, medial neck translation.
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ii. Posterior, valgus inclination of the femoral head.
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Natural history:
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Directly related to degree of slip and durations of treatment:
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According to Loder et al’s retrospective study of 328 “stable” SCFE:
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i. Older children had more severe slip (age):
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Mild: 12.3 years.
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Moderate: 13 years.
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Severe: 13.8 years.
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ii. Duration of symptoms (months):
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Mild: 3.5.
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Moderate: 7.7.
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Severe: 8.8.
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iii. Regression analysis:
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Stable SCFE:
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Two times more likely for moderate or severe slip if older than 12.5 years.
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If duration longer than 2 months, 4.1 times more likely for moderate or severe slip.
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Femoroacetabular impingement (FAI) after SCFE:
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Remodeling occurs at head–neck junction:
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i. Variable degrees.
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ii. Cam morphology occurs.
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iii. Regardless of remodeling, damage to anterior chondrolabral junction.
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Multiple studies report chondrolabral injury even after mild slips.
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Thirty-one percent painful hips in the first decade after pinning.
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Hundred percent decreased head–neck offset = 100% cam morphology:
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i. Less physically demanding lifestyle after remodeling may improve symptoms.
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ii. Recommended to closely monitor SCFE patients in adulthood for FAI syndrome.
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iii. Leads to anterior chondrolabral injury:
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Severity of damage depends on:
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Duration of slip.
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Deformity severity.
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Activity level.
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Damage occurs early:
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Basheer et al reviewed 18 patients at mean 29-month follow-up: significant correlation between outcome scores and time to arthroscopy following SCFE; recommend early FAI treatment after painful presentation.
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Leunig et al found damage in 13 consecutive adolescent SCFE hips with FAI chondrolabral damage when the metaphysis extends beyond the epiphysis.
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iv. FAI syndrome may be risk factor for osteoarthritis.
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Avascular necrosis of the femoral head:
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Devastating and can lead to osteoarthritis.
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Associated with physeal stability.
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Unstable slips are at 9.4 times greater risk.
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Osteoarthritis:
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d. SCFE deformity role in osteoarthritis:
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i. Castañeda et al:
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One hundred and twenty one stable slips treated with pinning at 20-year follow-up.
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Hundred percent had signs of osteoarthritis.
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II. Classification System
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Southwick’s classification system:
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Based on head (epiphyseal)–shaft (diaphyseal) angle ( Fig. 15.1 ).
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Preslip (widening of the physis; no displacement).
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Mild: less than 30 degrees, up to one-third displacement.
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Moderate: 30 to 60 degrees, one-third to one-half displacement.
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Severe: greater than 60 degrees; greater than one-half displacement.
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Loder’s classification system: weight-bearing status:
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Unstable:
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Severe pain.
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Unable to bear weight with crutches:
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i. Fourteen of 30 (47%) unstable hips developed avascular necrosis (AVN).
Fig. 15.1 Frog-leg lateral left hip radiograph of a 9.7-year-old boy who presented with 3 weeks of vague left knee pain, after which he fell and was unable to bear weight. Southwick’s angle is formed by tracing an epiphyseal line (1), a line perpendicular to the epiphyseal line (2), and a line parallel to the center of the femoral shaft (3). The asterisk represents the angle to be measured. Image is classified as a severe slip greater than 60 degrees.
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Stable:
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Can bear weight with or without crutches:
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i. Zero percent of stable slips developed AVN.
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Duration:
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Acute: symptoms less than 3 weeks.
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Chronic: symptoms greater than 3 weeks.
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Acute-on-chronic: acute exacerbation of symptoms in the setting of a chronic slip.
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Prognosis:
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Mild: good prognosis.
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Moderate and severe have increased chance of developing arthritis.
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III. Physeal stability:
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Standard is based on inability to bear weight:
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Ziebarth et al questioned this:
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Retrospective analysis of 82 patients:
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i. Complete physeal disruption observed in 28/82 hips (34%) at surgery.
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ii. Acute versus chronic classification: 82% sensitive and 44% specific.
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iii. Stable versus unstable classification: 39% sensitive and 76% specific.
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iv. Calls into question current SCFE classification systems and there are more unstable hips than expected based on ability to weight bear.
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Anatomical Considerations
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I. Proximal femoral Physis
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Zone of provisional calcification (in hypertrophic zone) is damaged.
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Proximal femur responsible for 3 mm of growth per year.
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II. Blood supply:
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Deep branch of the medial femoral circumflex artery:
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Most important blood supply to the femoral head/epiphysis.
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Lesser contributions from lateral femoral circumflex artery, artery of ligamentum teres.
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History and Physical Examination
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I. History
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Symptoms:
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Vague pain:
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Groin, hip, and knee pain.
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May be severe enough to prevent ambulation.
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Limp:
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Children presenting with knee pain have a longer diagnostic delay than those with hip pain.
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Past medical history: evaluate for endocrinopathy:
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Strong association with SCFE.
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Obesity:
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Increased awareness in all preadolescent patients with pain.
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II. Physical Examination
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No pathognomonic finding for SCFE.
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Gait:
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Antalgic gait.
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Seated or supine:
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Limited flexion and internal rotation (most frequent finding).
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