Disorders of Growth and Development in the Extremities

Paul D. Sponseller

2.1 Introduction

A summary of important pediatric conditions is provided in this and the following two chapters, focusing on concepts and key points. Principles and specific treatment details are covered more extensively in standard texts. Other major topics are covered in Chapter 5 (skeletal syndromes), Chapter 6 (neuromuscular disorders), and Chapter 7 (trauma) of this book.

2.2 Lower-Limb Length Inequality

2.2.1 Principles

1. 
   

   Inequalities of lower-limb length of up to 1.0 to 1.5 cm are within normal variation of the population.

   
   
2. 
   

   Inequalities of less than 2.5 cm do not cause back pain or noticeable limp.

   
   
3. 
   

   Length inequalities are a much less common cause of limp than are joint disorders (contracture, pain) or muscle weakness.

   
   
4. 
   

   The gait disturbance caused by inequality of limb length is usually subtle and consists of pelvic drop and compensatory knee flexion of the long limb and ankle equinus of the short limb.

   
   
5. 
   

   Most congenital inequalities of limb length behave in a proportionate fashion with growth; that is, the ratio of the short leg to the long leg remains constant.

2.2.2 Congenital Causes

1. 
   

   Congenital short femur, proximal focal femoral deficiency, tibial or fibular hemimelia, hemiatrophy, hemihypertrophy. Multiplier method predicts final discrepancy (see Chapter 1).

   
   
2. 
   

   Systemic disorders: Ollier disease, fibrous dysplasia, osteochondromatosis, osteogenesis imperfecta, cerebral palsy. Multiplier method is not always predictive because of progressive deformity.

2.2.3 Acquired Causes

1. 
   

   Developmental dysplasia of the hip (DDH; length difference resulting from growth disturbance or osteotomy).

   
   
2. 
   

   Legg–Calvé–Perthes disease (may be up to 4 cm if proximal femoral physeal growth slows early).

   
   
3. 
   

   Blount disease.

   
   
4. 
   

   Trauma (fracture overlap, growth arrest).

   
   
5. 
   

   Osteomyelitis with physeal arrest.

   
   
6. 
   

   Foot deformities.

2.2.4 Measurement

1. 
   

   Block method: Palpate height of iliac crests in standing patient. Add height to short limb by measured blocks until equal. This is a good screening method to determine whether further, more precise measurements are needed. Although not as precise for long bones as radiographic measurements, it does take into account all factors, such as contracture and shortening occurring within the foot or pelvis (▶ Fig. 2.1).

   
   
2. 
   

   Tape method: Measure from inferior margin of the anterior superior iliac spine (ASIS) to the medial malleolus. This method can be inaccurate in overweight patients or in those who have had anterior hip surgery and does not include foot discrepancies.

   
   
3. 
   

   Scanogram: Images of hips, knees, and ankles are taken in one position alongside a radiographic ruler. This method does not account for foot discrepancies or contracture.

   
   
4. 
   

   Computed radiograph: Computes lengths and angles of segments. This method may be used with low-dose radiography such as EOS.

   
   
   
   

   

   
   

   Fig. 2.1 The standing block test: a block is added under the short limb (B) until the pelvis is palpated to be level A.

2.2.5 Treatment

1. 
   

   If discrepancy is less than 2.5 cm in a mature person, no treatment is needed.

   
   
2. 
   

   2.5 to ~4 cm: Leg lift or epiphyseodesis or shortening of corresponding long segment.

   
   
3. 
   

   Approximately greater than 4 cm: Limb lengthening if no contraindications or combination of lengthening and shortening and lift.

   
   
   
   

   
   

   Bibliography

   
   

   
   

   1. Escott BG, Ravi B, Weathermon AC, et al. EOS low-dose radiography: a reliable and accurate upright assessment of lower-limb lengths. J Bone Joint Surg Am 2013;95(23):e1831–e1837

   
   

   2. Paley D, Bhave A, Herzenberg JE, Bowen JR. Multiplier method for predicting limb-length discrepancy. J Bone Joint Surg Am 2000;82-A(10):1432–1446

   
   

   3. Sabharwal S, Zhao C, McKeon JJ, McClemens E, Edgar M, Behrens F. Computed radiographic measurement of limb-length discrepancy. Full-length standing anteroposterior radiograph compared with scanogram. J Bone Joint Surg Am 2006;88(10):2243–2251

2.3 Developmental Dysplasia of the Hip

2.3.1 Principles

Developmental dysplasia of the hip is caused by forces acting on the hip in utero. The risk is increased by abnormalities of connective tissue. DDH is a spectrum, from hips that are subluxatable or dislocatable (Barlow positive) to dislocated (Ortolani positive). The combined incidence is 2 to 5 per 1,000.

All hips should be physically screened by a knowledgeable examiner at birth and again within the first few months of life. The infant should be made as quiet and comfortable as possible for the examination, using warmth, contact, low light, feeding, or a pacifier. Abnormal physical signs that are marked with an asterisk (*) below should prompt reexamination or ultrasound, with treatment if these are abnormal.

2.3.2 Risk Factors in History

The following factors increase the risk of hip dysplasia in descending order and should prompt reexamination or ultrasound:

1. 
   

   Positive family history of DDH.

   
   
2. 
   

   Breech position at the end of gestation (5% are unstable). A breech female should have a screening ultrasound.

2.3.3 Physical Examination for Developmental Hip Dysplasia in the Newborn

1. 
   

   Appearance at rest: The dysplastic hip is more adducted at rest in unilateral cases and may have a deeper or extra high fold proximally.

   
   
2. 
   

   *Asymmetric passive abduction: Dislocated hip will lack passive abduction compared with the normal side (▶ Fig. 2.2a).

   
   
3. 
   

   *The Barlow test will cause pistoning of the proximal femur if dislocatable (▶ Fig. 2.2b).

   
   
4. 
   

   *The Ortolani test will cause a “clunk” as a dislocated hip is relocated. Examine each hip separately; stabilize the pelvis with the other hand (▶ Fig. 2.2c). The Ortolani and Barlow tests are for translation of the femur. A “click” per se is not a positive test; only 1% of patients with a click have dysplasia. A click may come from the patella or the meniscus of the knee as well as from the fascia lata or a synovial fold in the hip.

   
   
5. 
   

   Proximal location of greater trochanters is a helpful sign in diagnosing a patient with bilateral irreducible hip dislocations. Also, the femoral head may cause a prominence superiorly.

   
   
6. 
   

   Significant foot deformity or torticollis may increase the risk of hip dysplasia and should prompt a careful examination of the hips.

   
   
   
   

   

   
   

   Fig. 2.2 (a) Asymmetric abduction; left side is dysplastic. (b) Barlow test (done on one hip at a time). (c) Ortolani test.

2.3.4 Evaluation of the Older Child for Developmental Dysplasia of the Hip

In the older child with hip dysplasia, the signs progressively change. Reducibility of the hip in the awake patient is lost after about 3 months, and one must rely more on indirect signs:

1. 
   

   Asymmetric passive abduction.

   
   
2. 
   

   Galeazzi test will show thigh shortening on the side that is dislocated (▶ Fig. 2.3a). The pelvis should be kept horizontal during this test.

   
   
3. 
   

   Leg-length discrepancy.

   
   
4. 
   

   Trendelenburg gait.

   
   
5. 
   

   Palpable femoral head posterior to the acetabulum.

   
   
6. 
   

   Nélaton line (an imaginary line between the ASIS and the ischium) should project superior to the trochanter (▶ Fig. 2.3b).

   
   
7. 
   

   Klisic line between the greater trochanter and the ASIS should project cephalad to the umbilicus (▶ Fig. 2.3c).

   
   
8. 
   

   Increased lumbar lordosis in stance (if bilateral) is due to posterior displacement and mechanical disadvantage of hip abductors.

   
   
   
   

   

   
   

   Fig. 2.3 (a) Galeazzi sign shows apparent thigh shortening on dysplastic side (right). (b) If dislocated, the greater trochanter will lie proximal to Nélaton line (anterior superior iliac spine to ischium). (c) Klisic line in the normal hip falls above the umbilicus.

2.3.5 Imaging

2.3.5.1 Ultrasonography

The role of ultrasound in the diagnosis of dysplasia varies regionally. Its benefit is its ability to show cartilage and other soft tissues, as well as observe stability in response to stress. Interpretation of an ultrasound considers both static and dynamic findings.

The ultrasound view is named according to the direction of the transducer: transverse or coronal—and the position of the hip: neutral or flexion. The highest frequency possible (3–7 MHz) will give the best resolution, but this must usually be reduced with age to obtain adequate penetration.

Coronal View

In this view, the landmarks are similar to those seen on a plain radiograph, when the transducer is in the mid acetabular plane. By convention, the lateral wall of the ilium is displayed horizontally.

1. 
   

   The stability and gross appearance are the most important features.

   
   
2. 
   

   The following other parameters should be checked (▶ Fig. 2.4):

   
   
   
   
   1. 
      

      Femoral head coverage: The percent of the femoral head medial to the outer line of the ilium. This should be greater than 50%.

      
      
   2. 
      

      Alpha angle, or acetabular roof line, between the lateral ilium and the bony acetabular roof. It is analogous to the acetabular index and should be greater than 60 degrees.

      
      
   3. 
      

      Beta angle, or slope of the labrum versus the lateral wall of the ilium. It should be less than 55 degrees, indicating a downward slope of the labrum.

      
      
      
      

      

      
      

      Fig. 2.4 Drawings of ultrasound images. (a) Coronal view. FhC, femoral head coverage; α angle, acetabular roof line; β angle, slope of labrum. (b) Transverse view. Note the “U” formed by the metaphysis and the acetabulum. h, head of femur; i, ischium; m, metaphysis of femur.

Transverse View

In this view, the hip is flexed and the transducer is placed posterolaterally in the transverse plane of the body. The combination of echoes from the femoral metaphysis and the acetabulum normally form a “U.” When dislocated, the femoral head comes to lie lateral and posterior to the acetabulum, and the U is disrupted.

2.3.5.2 Radiographic Evaluation

1. 
   

   Grades of hip dislocation according to Tönnis indicate the position of the ossific nucleus relative to the Perkin vertical line (p) and the Hilgenreiner horizontal line (h) (▶ Fig. 2.5):

   
   
   
   
   1. 
      

      Nucleus medial to Perkin line.

      
      
   2. 
      

      Nucleus lateral to Perkin line.

      
      
   3. 
      

      Nucleus at Hilgenreiner line.

      
      
   4. 
      

      Nucleus above Hilgenreiner line.

   
   
2. 
   

   The acetabular index is the angle formed between the Hilgenreiner line and the inner and outer borders of the acetabular roof (▶ Fig. 2.6a, right hip). It is useful in assessing hip development in early years, before the center of the femoral head can be accurately identified. The normal values are shown in ▶ Fig. 2.6b.

   
   
3. 
   

   Center edge angle (CEA) of Wiberg:

   
   
   
   
   1. 
      

      CEA measures the coverage of the femoral head by the acetabulum (▶ Fig. 2.6a, left hip). Long-term follow-up studies by Wiberg have shown a correlation between development of symptoms after maturity and CEA below 20 degrees.

      
      
   2. 
      

      Normal values—lower limit of normal:

      
      
      
      
      1. 
         

         5 to 8 years: 19 degrees.

         
         
      2. 
         

         9 to 12 years: 25 degrees.

         
         
      3. 
         

         13: 26 degrees.

         
         
      4. 
         

         Less precise under 5 years.

         
         
         
         

         

         
         

         Fig. 2.5 (a) Tonnis grades of hip dislocation based upon position of femoral epiphysis. p, perkins line; h, horizontal line at outer edge of acetabulum. (b) For young patients who do not have an ossific nucleus, the IHDI (international hip dysplasia institute) grades are used, referencing the femoral metaphysis.

         
         
         
         

         

         
         

         Fig. 2.6 (a) Acetabular index (A.I.) measurement (right hip) and measurement of center edge angle (CEA) of Wiberg (left hip). (b) Acetabular index normal values for age. MV, mean value; s, one standard deviation; 2s, two standard deviations. (b is used with permission from Tonnis D. Normal values of the hip joint for the evaluation of x-rays in children and adults. Clin Orthop Relat Res 1976;119:41 (Fig. 2).)

2.3.6 Management of Hip Dysplasia

▶ Fig. 2.7 is a general algorithm for the management of dysplasia. Guidelines given may be modified based on individual factors.

2.4 Legg–Calvé–Perthes Disease

Legg–Calvé–Perthes disease (idiopathic avascular necrosis [AVN] of the immature femoral head) is most commonly seen in children aged 4 to 10 years. Five percent of patients develop bilateral involvement, but this is usually at different times (asynchronous). Synchronous involvement should suggest the possibility of skeletal dysplasia, hypothyroidism, or steroid use.

2.4.1 Symptoms

1. 
   

   Minimal or no history of trauma.

   
   
2. 
   

   Stiffness.

   
   
3. 
   

   Intermittent mild pain or no pain at all.

2.4.2 Signs

1. 
   

   Mild Trendelenburg gait.

   
   
2. 
   

   No pain with gentle motion.

   
   
3. 
   

   Limitation of abduction and internal rotation.

2.4.3 Imaging

1. 
   

   Chronological sequence (Waldenstrom; ▶ Fig. 2.8):

   
   
   
   
   • 
     

     Sclerosis of epiphysis:

     
     
     
     
     1. 
        

        No loss of height.

        
        
     2. 
        

        Loss of height.

     
     
   • 
     

     Fragmentation:

     
     
     
     
     1. 
        

        One to two fissures.

        
        
     2. 
        

        Advanced fragmentation.

     
     
   • 
     

     Early healing:

     
     
     
     
     1. 
        

        Early new bone laterally.

        
        
     2. 
        

        New bone greater than one-third of epiphysis.

     
     
   • 
     

     Complete healing.

   
   
2. 
   

   Staging:

   
   
   
   
   1. 
      

      Catterall (▶ Fig. 2.9):

      
      
      
      
      1. 
         

         Central anterior involvement of head only.

         
         
      2. 
         

         Greater central head involvement but intact medial and lateral column.

         
         
      3. 
         

         Lateral three quarters of femoral head involved with only intact medial column; metaphyseal reaction.

         
         
      4. 
         

         Whole-head involvement, with metaphyseal reaction and remodeling of epiphysis.

      
      
   2. 
      

      Herring lateral pillar classification predicts flattening during healing (▶ Fig. 2.10):

      
      
      
      
      1. 
         

         Lateral pillar is intact without radiographic change.

         
         
      2. 
         

         Lateral pillar is collapsed, but height is still greater than 50%.

         
         
      3. 
         

         Lateral pillar is collapsed to less than 50% of original height.

   
   
3. 
   

   Prognostic signs:

   
   
   
   
   1. 
      

      “Head-at-risk signs” of Catterall:

      
      
      
      
      1. 
         

         Lateral calcification.

         
         
      2. 
         

         Lateral subluxation.

         
         
      3. 
         

         Gage sign: lucency proximal and distal to lateral physis.

         
         
      4. 
         

         Metaphyseal reaction.

         
         
      5. 
         

         Horizontal physis (meaning limb is adducted).

      
      
   2. 
      

      Epiphyseal extrusion (▶ Fig. 2.11) greater than 20% carries poor long-term prognosis.

      
      
   3. 
      

      Mose sphericity: Deviation of head periphery from a perfect sphere by more than 3 mm on anteroposterior (AP) and lateral radiograph carries poor long-term prognosis.

      
      
   4. 
      

      Stulberg rating (used after healing) assesses femoral head sphericity and its congruency with the acetabulum. There are five different stages; these have been correlated with long-term outcome (▶ Fig. 2.12).

   
   
4. 
   

   Arthrogram, magnetic resonance imaging (MRI): These are not routinely indicated but may be helpful in selected cases. Perfusion MRI may help establish degree of AVN.

   
   
   
   

   

   
   

   Fig. 2.8 Waldenstrom chronological stages of Perthes: I, sclerosis of epiphysis; II, fragmentation; III, early healing; IV, complete healing.

   
   
   
   

   

   
   

   Fig. 2.9 Catterall classification of Perthes disease as viewed from above.

   
   
   
   

   

   
   

   Fig. 2.10 (a–c) Herring lateral pillar classification of Perthes.

   
   
   
   

   

   
   

   Fig. 2.11 Measurement of epiphyseal extrusion = a-b / c-d. (Used with permission from Green NE, Beauchamp RD, Griffin PP. Epiphyseal extrusion as a prognostic index in Legg-Calve-Perthes disease. J Bone Joint Surg Am 1981;63(6):902 (Fig. 1).)

   
   
   
   

   

   
   

   Fig. 2.12 Stulberg rating of outcome of healed Perthes. Stages I and II are spherical and congruent and have a low likelihood of degenerative joint disease. Stages III and IV are aspherical and congruous and have a risk of degenerative joint disease by middle age. Stage V is aspherical and incongruous, and there is a risk of degenerative joint disease before age 50 years. (Used with permission from Stulberg SD, Cooperman DR, Wallensten R. The natural history of Legg-Calve-Perthes disease. J Bone Joint Surg Am 1981;63(7):1095–1108.)

2.4.4 Differential Diagnosis

1. 
   

   Hypothyroidism.

   
   
2. 
   

   Multiple epiphyseal dysplasias.

   
   
3. 
   

   Spondyloepiphyseal dysplasia.

   
   
4. 
   

   Meyer dysplasia (bilateral synchronous early childhood AVN; better prognosis).

   
   
5. 
   

   Storage disorder (Gaucher disease, mucopolysaccharidoses).

   
   
6. 
   

   AVN following trauma, steroids, sickle cell infarct, DDH treatment.

2.4.5 Treatment

1. 
   

   There is no consensus on a protocol. However, many hips have a poor long-term outcome, and some hips appear to be helped by treatment. Containment is indicated if several of the following features are present:

   
   
   
   
   1. 
      

      Head involvement greater than 50% (Catterall 3–4, Herring B or B/C border).

      
      
   2. 
      

      Age over 8 years.

      
      
   3. 
      

      No collapse or extrusion.

   
   
2. 
   

   Containment options:

   
   
   
   
   1. 
      

      Abduction brace or Petrie casts.

      
      
   2. 
      

      Femoral varus osteotomy.

      
      
   3. 
      

      Iliac rotational osteotomy or augmentation.

      
      
   4. 
      

      Combinations of b and c.

   
   
3. 
   

   Late options:

   
   
   
   
   1. 
      

      Epiphysiodesis for leg length inequality greater than 2 cm.

      
      
   2. 
      

      Valgus osteotomy for symptomatic hinge abduction.

      
      
   3. 
      

      Trochanteric transfer for persistent abductor weakness.

      
      
   4. 
      

      Epiphyseal osteotomy for femoral incongruity.

      
      
      
      

      
      

      Bibliography

      
      

      
      

      1. Herring JA, Kim HT, Browne R. Legg-Calve-Perthes disease. Part I: Classification of radiographs with use of the modified lateral pillar and Stulberg classifications. J Bone Joint Surg Am 2004;86-A(10):2103–2120

      
      

      2. Herring JA, Kim HT, Browne R. Legg-Calve-Perthes disease. Part II: Prospective multicenter study of the effect of treatment on outcome. J Bone Joint Surg Am 2004;86-A(10):2121–2134

      
      

      3. Hyman JE, Trupia EP, Wright ML, et al; International Perthes Study Group Members. Interobserver and intraobserver reliability of the modified Waldenström classification system for staging of Legg-Calvé-Perthes disease. J Bone Joint Surg Am 2015;97(8):643–650

      
      

      4. Joseph B, Nair NS, Narasimha Rao K, Mulpuri K, Varghese G. Optimal timing for containment surgery for Perthes disease. J Pediatr Orthop 2003;23(5):601–606

2.5 Transient Synovitis of the Hip

2.5.1 Overview

1. 
   

   Transient synovitis of the hip is characterized by the acute onset of monarticular hip pain, limp, and restricted motion.

   
   
2. 
   

   It is the most common cause of hip pain in children.

   
   
3. 
   

   Child is usually 1 to 4 years of age, but any age can be affected.

   
   
4. 
   

   Synovitis must be distinguished from septic arthritis (Kocher’s clinical practice guideline).

   
   
5. 
   

   Gradual but complete resolution over several days to weeks is the norm.

   
   
6. 
   

   Cause is unknown, but it may be immune mediated.

2.5.2 Diagnosis

1. 
   

   A diagnosis of exclusion.

   
   
2. 
   

   Acute onset of unilateral hip pain in an otherwise healthy child; often after respiratory illness.

   
   
3. 
   

   The patient may be afebrile or have a low-grade fever.

   
   
4. 
   

   Laboratory values are nonspecific and are often within normal limits.

   
   
5. 
   

   Kocher’s criteria to distinguish septic arthritis from transient synovitis:

   
   
   
   
   1. 
      

      Refusal to bear weight.

      
      
   2. 
      

      Temperature greater than 38.

      
      
   3. 
      

      WBC greater than 12,000.

      
      
   4. 
      

      ESR greater than 40.

2.5.3 Physical Examination

1. 
   

   Limp and antalgic gait are common.

   
   
2. 
   

   Most patients can bear weight on the involved extremity with assistance.

   
   
3. 
   

   Hip is held in a flexed, externally rotated position. Restricted range of motion, especially abduction and rotation; slow movement is better.

   
   
4. 
   

   Pain is not as great as with septic arthritis.

2.5.4 Laboratory Tests

1. 
   

   Laboratory tests are usually nonspecific and within normal limits, but they may help rule out other diagnoses.

   
   
2. 
   

   Peripheral WBC count is normal to slightly elevated.

   
   
3. 
   

   ESR averages 20 mm/hour but may be slightly higher.

   
   
4. 
   

   Blood culture, rheumatoid factor, and Lyme titers results are usually within normal limits.

   
   
5. 
   

   Aspiration of joint fluid is not needed if presentation is typical. If done, results are nonspecific.

2.5.5 Imaging

1. 
   

   Plain films of the hip: AP and lateral views.

   
   
2. 
   

   In transient synovitis, they are normal but can help rule out other diagnoses.

   
   
3. 
   

   Ultrasound may be used to assess for effusion and to guide aspiration if infection cannot be ruled out clinically.

   
   
4. 
   

   MRI is needed only in cases of persistent pain.

2.5.6 Differential Diagnosis

1. 
   

   Septic arthritis.

   
   
2. 
   

   Osteomyelitis in the femoral neck or pelvis.

   
   
3. 
   

   Tuberculous arthritis.

   
   
4. 
   

   Psoas abscess.

   
   
5. 
   

   Other muscle infection about the hip.

   
   
6. 
   

   Juvenile rheumatoid arthritis.

   
   
7. 
   

   Idiopathic chondrolysis.

   
   
8. 
   

   Acute rheumatic fever.

   
   
9. 
   

   Legg–Calvé–Perthes disease.

   
   
10. 
    

    Tumor.

    
    
11. 
    

    Sacroiliac joint infection.

2.5.7 Treatment

1. 
   

   Bed rest at home if diagnosis is clear, or in hospital if further workup is needed.

   
   
2. 
   

   Nonsteroidal anti-inflammatory drugs (NSAIDs).

   
   
3. 
   

   Prompt improvement should be seen: if not, then look for other diagnoses.

   
   
4. 
   

   Activity as tolerated when clinically improved.

2.5.8 Prognosis

Good; no clear evidence of increased risk of AVN.

2.6 Slipped Capital Femoral Epiphysis

2.6.1 Background

1. 
   

   Incidence: 2 to 10 per 100,000:

   
   
   
   
   1. 
      

      Higher rate in males than in females.

      
      
   2. 
      

      Higher in African Americans.

      
      
   3. 
      

      20% of patients have bilateral involvement at presentation.

      
      
   4. 
      

      20% of patients become more bilateral later.

   
   
2. 
   

   Etiologic factors:

   
   
   
   
   1. 
      

      Obesity.

      
      
   2. 
      

      Trauma: Mild or severe.

      
      
   3. 
      

      Endocrine disorders: Hypothyroidism, hypogonadism, rickets, renal failure.

      
      
   4. 
      

      Down syndrome.

      
      
   5. 
      

      Family history.

      
      
   6. 
      

      Radiation.

2.6.2 Classification

1. 
   

   Loder classification:

   
   
   
   
   1. 
      

      Stable: Able to bear weight (even with crutches).

      
      
   2. 
      

      Unstable: Unable to bear weight.

   
   
2. 
   

   Chronological:

   
   
   
   
   1. 
      

      Acute: Symptoms of less than 3 weeks’ duration.

      
      
   2. 
      

      Chronic: Symptoms for 3 weeks or longer.

   
   
3. 
   

   Severity:

   
   
   
   
   1. 
      

      Grade I: Less than 33% slip of epiphysis on metaphysis.

      
      
   2. 
      

      Grade II: 33 to 50% slip.

      
      
   3. 
      

      Grade III: More than 50% slip.

      
      
   4. 
      

      “Pre-slip”: Symptoms are present in patient at risk, but no observable slip is seen; MRI may be positive.

2.6.3 Clinical Presentation

1. 
   

   Age 9 to 14 years, most common.

   
   
2. 
   

   Antalgic limp.

   
   
3. 
   

   Pain in the thigh, knee, or hip.

   
   
4. 
   

   Leg externally rotated during gait and at rest.

   
   
5. 
   

   Internal rotation less in flexion than in extension.

   
   
6. 
   

   Seasonal variation: Highest rates in September, lowest in March because of sunlight and vitamin D cycles (delayed effects).

   
   
7. 
   

   Age–weight test: If younger than 10 or older than 16 years or weight is less than 50th percentile, then suspect nonidiopathic slip and perform an endocrine workup.

   
   
8. 
   

   Height test: If height is below 10th percentile for age, risk of atypical slip is increased, perform an endocrine workup.

2.6.4 Imaging

1. 
   

   Slip is best seen on lateral view.

   
   
2. 
   

   AP view:

   
   
   
   
   1. 
      

      Physeal widening, irregularity.

      
      
   2. 
      

      Decreased epiphyseal height.

      
      
   3. 
      

      “Klein line”: Line on lateral femoral neck with slipped capital femoral epiphysis (SCFE) transects less than 20% of epiphysis in child older than 10 years.

      
      
   4. 
      

      Chondrolysis-joint space narrowing may be seen before treatment (rare).

2.6.5 Treatment

1. 
   

   Immediate weight relief (bed rest).

   
   
2. 
   

   Traction for acute slip for comfort or reduction if severe (optional).

   
   
3. 
   

   Fixation in situ:

   
   
   
   
   1. 
      

      Single screw is centrally placed within physis.

      
      
   2. 
      

      Second screw may be used if first is not perfect or if slip is severe.

   
   
4. 
   

   Realignment: Main indication is the patient who is dissatisfied with limb deformity resulting from slip; it is not commonly needed.

   
   
   
   
   1. 
      

      Open realignment and pinning of acute slip (± surgical dislocation).

      
      
   2. 
      

      Cuneiform osteotomy just below physis.

      
      
   3. 
      

      Base of neck osteotomy: some series show high AVN rate.

      
      
   4. 
      

      Subtrochanteric osteotomy (Southwick).

   
   
5. 
   

   Prophylactic contralateral pinning:

   
   
   
   
   1. 
      

      Cost–benefit studies show prophylactic pinning is justifiable (at the surgeon’s discretion).

      
      
   2. 
      

      Main indication is a patient in whom diagnosis of late contralateral SCFE may be missed as a result of impaired communication or follow-up.

      
      
   3. 
      

      Also valid option in patients with SCFE before growth spurt (in girls younger than 10 years, in boys younger than 12 years).

      
      
   4. 
      

      If triradiate cartilage is closed or in a girl older than 13 years or in a boy older than 14 years, then there is a low risk of subsequent slip (~7%).

2.6.6 Complications

1. 
   

   Chondrolysis: Affects 5% or less and usually improves with time and physical therapy.

   
   
2. 
   

   AVN:

   
   
   
   
   1. 
      

      Greater in unstable or acute slips.

      
      
   2. 
      

      May be focal or complete.

      
      
   3. 
      

      Some healing is possible in young patients.

      
      
   4. 
      

      Some patients can function for 10 to 20 years with AVN before salvage is needed.

      
      
      
      

      
      

      Bibliography

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