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Andi Rahmat Hidayat C 111 07 104 Advisor: dr. Andi Sirfa dr. Helmiyadi Kuswardhana Supervisor: dr.

Henry Yurianto, M.Phill, PhD, Sp.OT Orthopaedic and Traumatology Department Medical Faculty of Hasanuddin University Makassar 2012

BACKGROUND
Slipped capital femoral epiphysis (SCFE) is a common

hip disorder in adolescents. SCFE is characterized by posteroinferior displacement of the capital femoral epiphysis on the metaphysis through the physis.

INCIDENCE & EPIDEMIOLOGY


Vary incidence for each country 0.2 per 100,000 in eastern Japan to as high as 10 per 100,000 in the northeastern United States

Racial differences in the prevalence of SCFE : 1.0 for Caucasians, 4.5 for Pacific Islanders, 0.5 for Indonesian-Malay peoples

Boys accounts 60% for all cases

INSIDENS & EPIDEMIOLOGY


The mean age at diagnosis 13.5 years boys and 12.0 years girls Half of adolescents with SCFE are above the 95th percentile in weight for their age. Bilateral involvement in as many as 63% of patients.

ETIOLOGY
Biomechanical
Obesity Femoral retroversion Trauma

Biochemical
Hormonal Imbalance

PATHOLOGY
Femoral head in contact with acetabulum Femoral shaft and neck rotate externally
Head moves posteriorly

Neck moves cephalad

CLASSIFICATION SOUTHWICK METHOD OF MEASURING HEAD-SHAFT ANGLE DIFFERENCE

<30o 30 -60o >60o

: Mild : Moderate : Severe

DEGREE OF SLIP

CLASSIFICATION ACCORDING TO THE ONSET


Pre Slipped Acute SCFE

Chronic SCFE

Acute on chronic SCFE

CLASSIFICATION ACCORDING TO THE ONSET


Pre Slip SCFE Symptom Weakness in the lower extremity, or exertional pain in the groin, thigh, or knee. Sign Decreased internal rotation

CLASSIFICATION ACCORDING TO THE ONSET


Acute SCFE
Symptom 10-15% of patients with SCFE Symptoms < 3 weeks Severe pain that made the child unable to walk or stand. Physical Examination Alterations in gait, including a limp on the affected side, external rotation of the leg, and trunk shift. Hip motion is limited, especially internal rotation and abduction, due to pain.

CLASSIFICATION ACCORDING TO THE ONSET


Chronic SCFE

Symptom
85% of SCFE Patient Pain in the groin,thigh, or knee and walks with a limp. The duration of symptoms, although variable, lasts >3

weeks. Symptoms often last for several months to years.

CLASSIFICATION ACCORDING TO THE ONSET


Chronic SCFE Physical Examination
Antalgic gait, with loss of hip internal rotation, abduction, and

flexion. When flexed up, the hip tends to move in an externally rotated position. There is a shortening of the affected leg. Atrophy of the thigh muscle may be noted

CLASSIFICATION ACCORDING TO THE ONSET


Acute on Chronic SCFE
Acute on Chronic SCFE occurs when the patient with

chronic SCFE develops a sudden acute exacerbation of pain that precludes walking

CLASSIFICATION ACCORDING TO FUNCTION

Stable SCFE

Unstable SCFE

CLASSIFICATION ACCORDING TO FUNCTION

Stable Weight Bearing Severity of slip Effusion Good Prognosis AVN Weight bearing possible Less severe Absent 96% 0%

Unstable Weight bearing not possible More severe Present 47% 50%

DIAGNOSIS
Physical Examination
History Taking Imagine

Diagnosis

IMAGINE
X-ray
AP and frog-leg lateral pelvis radiographs demonstrate the

posteroinferior displacement of the epiphysis relative to the metaphysis. Kleins line :


Patients with SCFE : Trethowans sign

IMAGINE
The second classification method measures the epiphyseal

shaft angle on the frog-leg lateral pelvis radiograph.

The degree of slip is classified as : Mild (<30), Moderate (30 to 50), Severe (>50)

MANAGEMENT
Initial Treatment
Single screw fixation Bone Graft epiphysiodesis In situ fixation with multiple pins Hip spica cast

Late Treatment
Intertrochanteric osteotomy

Open Surgical Dislocation With Femoral Neck Osteoplasty

MANAGEMENT
Single Screw Fixation
Percutaneous

placement with minimal soft-tissue injury High success rate and patient satisfaction rate A low incidence of slip progression, osteonecrosis, and chondrolysis. Karol et al reported that singlescrew fixation was 77% as stable as double screw fixation.

MANAGEMENT
Bone Graft Epiphysiodesis
Avoid

the complication associated with internal fixation including unrecognized pin

Unacceptable rate of re-slippage


Other disadvantages : increased

blood loss, a longer duration of anesthesia, and a larger scar

MANAGEMENT
In situ fixation with multiple pins
Multiple pins are placed in the posterosuperior

quadrant, the lateral epiphyseal vessels may be damaged. the frequency of complications with multiple pins is too high and do not recommend multiple pin fixation for the management of SCFE

MANAGEMENT

MANAGEMENT
Hip Spica Cast Not Recommended Pressure sores, Chondrolysis, Further slip after spica removed

MANAGEMENT
Prophylactic Fixation of the Contralateral Hip
The risk of contralateral SCFE developing in a patient

with unilateral SCFE is reported to be 2,335 times higher than the risk of initial SCFE. Prophylactic fixation of the contralateral hip was beneficial to the long-term outcome of that hip.

MANAGEMENT

A severe slip can be treated by fixing it and then performing a compensatory osteotomy. Wedges are cut based laterally and anteriorly so as to permit valgus, flexion and rotation at the osteotomy.

COMPLICATION
OSTEONECROSIS
Associated with manipulation of SCFE
Risk Factors : Severity of slip, reduction attempts, multiple screws,

high osteotomies.
On physical examination, Loss of hip motion, internal rotation,

Radiographs Collapse of the epiphysis with cyst formation Sclerosis develop after a few months

COMPLICATION
CHONDROLYSIS Rapid progressive loss of articular cartilage (joint space on xray) which is associated with pin penetration and multiple pin fixation. The incidence of chondrolysis in patients with SCFE ranges from1.8% to 55%, The diagnosis is confirmed by radiographs demonstrating a joint space reduction >50% a joint space <3 mm. Incidence now less with single pin fixation and reported to not occur with temporary penetration of the guide wire during screw fixation. Thought to be in autoimmune phenomenon.

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