SLIPPED CAPITAL FEMORAL EPIPHYSIS

CASE SUMMARY
Patients name : Soh Chee Roon
Age / Race / Sex : 11 years old / Malay / Boy
Orthopedic no. : !""/ #
$he %oy &as re'erred to orthopedic clinic on 1!
th
March ## %y a general practitioner
&ith a presenting complaint o' le't groin pain 'or the past ( months. $he groin pain
&as mild to moderate in se)erity especially on &al*ing. +e had a 'all &hile r,nning
prior to that. +e had no similar pro%lems in the past. $here &as no other pain
else&here.
On examination- he &as o%ese. +e &as a%le to %ear &eight %,t &ith a limping gait. +e
*ept his leg externally rotated. $here &as a limitation o' motion o' his le't hip
especially a%d,ction and extension. $here &as one cm shortening o' his le't lo&er
lim%.
A plain radiograph sho&ed slipped capital 'emoral epiphysis grade 1o' his le't hip. A
+ip ,ltrasonography sho&ed no .oint e'',sion. +e &as re'erred to the Pediatric ,nit
'or screening o' endocrine a%normalities. $he in)estigation res,lt sho&ed no
a%normality.
+e ,nder&ent in sit, single cann,lated scre& 'ixation o' le't hip on /
th
March ##.
+e had preoperati)e s*in traction o' the a''ected lim% 'or a 'e& days prior to the
s,rgery.
$he patient &as positioned on a 'ract,re ta%le or radiol,cent ta%le in the s,pine
position to allo& sim,ltaneo,s %iplane anteroposterior and lateral 'l,oroscopic
imaging. $o determine the starting point- a g,ide0pin is placed on the s*in o)erlying
the proximal part o' the 'em,r and- ,nder anteroposterior 'l,oroscopic g,idance- the
153
pin is positioned s,ch that it pro.ects o)er the center o' the 'emoral nec* and head-
crossing the physis in a perpendic,lar 'ashion. Once this pin position has %een
o%tained- a mar*ing pen is ,sed to dra& a line on the s*in re'lecting the pin position
on the anteroposterior image. $he same proced,re &as ,sed 'or the lateral
'l,oroscopic image- and a t&o0centimeter s*in incision is made at the intersection o'
the t&o lines. $he g,ide0pin is ad)anced 'reehand thro,gh the so't tiss,es to engage
the anterolateral 'emoral cortex. $he position and ang,lation o' the g,ide0pin are
ad.,sted- &ith 'l,oroscopic g,idance- to o%tain the proper alignment %e'ore the g,ide0
pin is drilled into the %one. 1t is ideal to ad)ance the g,ide0pin into the center o' the
'emoral head- perpendic,lar to the physis- as seen on %oth the anteroposterior and the
lateral 'l,oroscopic images on the 'irst attempt- since m,ltiple drill0holes can &ea*en
the %one- ca,sing a 'ract,re thro,gh an ,n,sed hole. A'ter the appropriate scre&
length has %een determined- a 2.(0millimeter stainless0steel cann,lated scre& is
placed o)er the g,ide0pin and is ad)anced ,ntil / threads engage the epiphysis. $he
scre& sho,ld not %e le't protr,ding %eyond the lateral aspect o' the 'emoral sha't-
&here it can %e toggled %y the so't tiss,es- leading to scre& loosening. A'ter s,rgery-
the patient %egins partial &eight0%earing &ith ,se o' cr,tches and grad,ally ad)ances
to ',ll &eight0%earing as tolerated. Most patients can &al* &itho,t cr,tches &ithin
t&o to 'o,r days.
$he pain resol)ed and his le't hip range o' motion &as normal &hen he &as 'ollo&ed
,p ( months postoperati)ely.
DISCUSSION
Slipped capital 'emoral epiphysis 3 SC45 6 is a &ell *no&n disorder o' the hip in
adolescents that is characteri7ed %y displacement o' the capital 'emoral epiphysis
'rom the metaphysis thro,gh the physis. $he Incidence o' SC45 is %et&een 10(:1##
### in the Ca,casian and more in %lac* pop,lation 2: 1## ###. $he %oy is more
commonly a''ected as compared to girl &ith a ratio o' 0/: 1.$he age o' onset 'or
%oys 31(01/ years old6 is m,ch later than in girls 31101( years old6- &hich occ,r
154
d,ring the gro&th sp,rt$here is no local data to date regarding the pre)alence o'
SC45 in Malaysia.
$he hip disorder sho,ld %e s,spected in a %oy &ithin the adolescent age gro,p &hen
he presented &ith hip- thigh and *nee pain.
$he immediate etiology o' slipping is mechanical. $he 'emoral head or epiphysis is
held in the aceta%,l,m %y the ligament,m teres. $he metaphysis in 'act is one that
mo)es ,p&ard and o,t&ard &hile the epiphysis remains in the aceta%,l,m. 1n most
patients- there is an apparent )ar,s relationship %et&een the head and the nec* 3the
epiphysis seem to %e displaced posterior and in'erior in relati)e to the nec* o' 'em,r6-
%,t occasionally the slip is into a )alg,s position. 1n the )ast ma.ority o' cases- the
etiology is ,n*no&n / idiopathic. SC45 does not appear to %e a herita%le disorder. $he
com%ination o' %oth mechanical and %iochemical 'actors ha)e %een proposed as the
etiology o' idiopathic SC45 &hich may res,lts in a &ea*ened physis &ith s,%se8,ent
'ail,re 39oder et al- ###6.
Mechanical 'actors associated &ith the disorder are o%esity- increased 'emoral
retro)ersion and increased physeal o%li8,ity 3more )ertical6. :itadai et al 31;;#6 ha)e
sho&n the association %et&een children &ith SC45 and a deeper aceta%,l,m 3a mean
center0edge angle o' <i%erg o' (2 degrees compared &ith a mean o' (( degrees in
control s,%.ects- a greater co)erage o' the 'emoral head yields more shear stress
across the physis6. A ( dimensional analysis %ased on comp,ted tomography on
patients &ith SC45 %y :ordelle et al 3##16 re)ealed an association %et&een the
disorder &ith red,ced 'emoral ante)ersion and red,ced 'emoral sha't nec* angle.
+o&e)er they 'o,nd that SC45 has no in'l,ence on aceta%,l,m de)elopment.
Biochemical 'actors are also li*ely in)ol)ed. SC45 is a disease o' p,%erty- &hen
many hormonal changes occ,r. $he presences o' perichondral ring and
transepiphyseal collagen 'i%ers gi)e strength to physis. $he physis strength decreases
d,ring period o' gro&th sp,rt. $he associated increased in physiological acti)ity o'
the physis and &idening o' the physis res,lts in a rapid longit,dinal gro&th in
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response to gro&th hormone. $he e''ects o' the gonadotropins on the physis may
explain the male predominance o' SC45= estrogen red,ces physis &idth and increases
physis strength- &hereas testosterone red,ces physis strength. $his pro%a%ly explains
&hy the disorder is commoner in %oys and extremely rare in girls a'ter menarche. $he
other hormonal disorders s,ch- as excessi)e gro&th hormone secretion-
hypoparathyroidism- hypopit,itarism and hypothyroidism may %e associated &ith
SC45 39oder et al- ###6.
An 1diopathic SC45 is the diagnosis made. $here &as no associated hormonal
im%alance / disorder 'o,nd.
$he Pathology o' the disease is centered in the region o' physis. $he normal gro&th
plate is di)ided into a. the reser)e or resting 7one %. the proli'erating 7one c. the
mat,rity 7one d. 7one hypertrophic 7one and e. the calci'ying 7one. Ro,tine
histological e)al,ation and electron microscopy st,dies o' SC45 demonstrated a
de'iciency and a%normality in the s,pporting collageno,s and proteoglycan
'rame&or* o' the physis. Both the hypertrophic and the proli'erati)e 7ones are
a%normal. Patient &ith SC45 has a &idened physis region. $he hypertrophic 7one is
&idened to "#0!# percent o' gro&th plate as compared to (# percent in normal person.
$he plane o' the slip passes thro,gh the di''erent 7one o' physis and extending to&ard
the metaphysic. $he physeal disr,ption leads to premat,re physis ',sion- &hich-
,s,ally occ,r in 10 years 39oder et al- ###6.
$he Clinical Preentation )aries &ith the type o' slip. 1t can %e di)ided into preslip
3">6- ac,te slip 311>6- chronic slip 3"#>6 and ac,te on chronic slip 3(>6.
Preslip: the child complains o' some degree o' groin and thigh pain especially
on prolonged standing or &al*ing. 1t is associated &ith limitation o' internal
rotation.
Ac,te slip: $he pain present in less than three &ee*s d,ration &ith
demonstra%le external rotation de'ormity- shortening- and mar*ed limitation o'
motion secondary to pain on physical examination. $he child is ,na%le to %ear
&eight.
156
Chronic slip characteri7ed %y intermittent groin and thigh or *nee pain 'or
se)eral &ee*s or months. Physical examination ,s,ally demonstrates an
antalgic gait- limitation o' 'lexion- internal rotation and a%d,ction. $he leg
,s,ally externally rotated.
Ac,te on chronic slip patient s,dden &orsening o' a chronic hip/ thigh / *nee
pain.
$he classi'ication descri%ed a%o)e depends on the memory o' the child or parent- or
%oth- and may %e inacc,rate= it also does not gi)e a prognosis &ith regard to the
potential 'or a)asc,lar necrosis. $&o ne&er and more clinically ,se',l classi'ications-
one clinical and one radiographic- depend on physeal sta%ility. 9oder et al 31;;(6
di)ided SC45 into sta%le or ,nsta%le. $he clinical classi'ication depends on the a%ility
o' the child to &al*. $he SC45 is considered sta%le &hen the child is a%le to &al*
&ith or &itho,t cr,tches- and it is considered ,nsta%le &hen the child cannot &al*
&ith or &itho,t cr,tches. $he radiographic classi'ication depends on the presence or
a%sence o' a hip e'',sion on ,ltrasonography. 1' the ,ltraso,nd demonstrates the
a%sence o' metaphyseal remodeling and the presence o' an e'',sion- an ac,te e)ent is
li*ely to ha)e occ,rred and the SC45 is considered ,nsta%le. 1' the ,ltraso,nd
demonstrates metaphyseal remodeling and the a%sence o' an e'',sion- an ac,te e)ent
has not occ,rred and the slipped capital 'emoral epiphysis is considered sta%le.
?nsta%le slipped capital 'emoral epiphyses ha)e a m,ch higher pre)alence o'
a)asc,lar necrosis 3,p to /# >in some series6 compared &ith sta%le slipped capital
'emoral epiphyses 3nearly # percent6. $he high rates o' complications &ith ,nsta%le
slips are most li*ely secondary to )asc,lar in.,ry ca,sed at the time o' the initial
displacement.
Considering the a%o)e disc,ssion- the %oy &as ha)ing a chronic and sta%le slip type
o' SC45.
$he Radiological Ae!ent sho,ld %egin &ith a plain radiograph. An
anteroposterior 3AP6 and lateral 'rog position o' the pel)is are ,s,ally
s,''icient39oder et al- ###6.
157
On AP "ie#$
$he physis loo*s &ider and irreg,lar.
$retho&ans sign 3in 5nglish literat,re6 or :leins line 3 in the American
literat,re6 signi'ies a line that is dra&n along the s,perior %order o' the nec*.
@ormally the line passes thro,gh the head. 1n a slip- the line remains s,perior
to the head
1n a grad,al/ sta%le slip- there are radiographic signs o' s,perior and anterior
remodeling on the 'emoral metaphysis and o' periosteal ne& %one 'ormation at
the epiphyseal0metaphyseal .,nction posteriorly and in'eriorly.
$he metaphyseal %lanch sign o' Steel is a do,%le density seen at the le)el o'
the metaphysis on an anteroposterior radiograph= the do,%le density re'lects
the posterior cortical lip o' the epiphysis as it is %eginning to slip posteriorly
and is radiographically s,perimposed on the metaphyseal density.
On lateral "ie#$
$he angle %et&een the 'emoral nec* to the epiphyseal %ase 3epiphyseal0sha't angle as
descri%ed %y So,th&ic*6 is normally ;#A the on the 'rog0leg lateral radiograph. 1n a
slip- the angle decreases.
$he degree o' slippage is generally graded according the amo,nt o' the head
displacement in proportion to the &idth o' the 'emoral nec* on AP or 9ateral )ie&.
Preslip 3Brade 16: $here is a &idening and rare'action o' the physis &itho,t
displacement.
Mild Slip 3Brade 116: $he 'emoral head is displaced ,p to 1/( o' the 'emoral
nec* on AP )ie& or C (#A tilt on lateral )ie&.
Moderate slip 3Brade 1116: $he 'emoral head slipped 1/( to /( o' the 'emoral
nec* on AP )ie& or %et&een (#A0/#A tilt on lateral )ie&.
Se)ere slip 3Brade 1D6: $he 'emoral head is displaced E /( o' the 'emoral
nec* n AP )ie& or E /#A tilt on lateral )ie&.
158
A %one can and a !agnetic reonance i!aging scan allo& earlier diagnosis o'
a)asc,lar necrosis and chondrolysis. An &ltraonogra'hy can %e ,sed to )is,ali7e an
e'',sion in the hip 3a sign o' an ,nsta%le slipped capital 'emoral epiphysis6 and
remodeling o' the 'emoral nec* 3a sign o' a sta%le slipped capital 'emoral epiphysis6.
$&o ma.or iss,es arise &hen SC45 is le't ,ntreated. $he head may slip ',rther 3as
long as the physis remained open6 and the hip may de)elop early degenerati)e .oint
disease in ad,lt li'e. +o&e)er- not many long term st,dies to date a)aila%le to
associate the ris* o' de)eloping early osteoarthrosis and SC45. +ips &ith a se)ere
SC45 and those &ith a)asc,lar necrosis or chondrolysis ,ndergo more rapid
deterioration &ith degenerati)e changes.
$he most important priority in the treat!ent o' a patient &ith a SC45 is to pre)ent
progression o' the slip &itho,t ca,sing additional harm 3an a)asc,lar necrosis and
chondrolysis o' the 'emoral head6.
$he c,rrent treatment methods 'or a patient &ith a ta%le (chronic) SCFE incl,de:
1. immo%ili7ation in a hip0spica cast-
. in sit, sta%ili7ation &ith single or m,ltiple pins or scre&s-
(. open epiphyseodesis &ith iliac crest or allogenic %one gra't-
F. open red,ction &ith a correcti)e osteotomy :
thro,gh the physis and internal 'ixation &ith ,se o' m,ltiple pins-
compensating %ase0o'0nec* osteotomy &ith in sit, sta%ili7ation o' the
slipped capital 'emoral epiphysis &ith ,se o' m,ltiple0pin 'ixation- and
intertrochanteric osteotomy &ith internal 'ixation.
39oder etal- ###6
$he treatment in a hi' 'ica sho,ld %e considered as an alternati)e 'or patient &ith
sta%le SC45. $he hip spica a)oids the complications associated &ith an operati)e
proced,re. 1t is also pro)ides prophylactic treatment o' the contralateral hip. Bet7 et al
31;;#6 reported a high rate o' complications 'ollo&ing hip spica. $he slip progressed
159
in t&o hips 3/ percent6 and chondrolysis de)eloped in se)en 31; percent. $he hip0
spica cast is di''ic,lt to %e maintained especially i' the patient is o%ese. $he ,se o' hip
spica is not recommended.
In Sit& Sta%ili*ation #ith Ue o+ Single cann&lated cre# in the center o' the
epiphysis- perpendic,lar to the physis is pre'era%le.
$he %lind spot- &hich is an area that cannot %e )is,ali7ed &ith the ,se o'
anteroposterior and tr,e lateral radiograph- is o'ten the site o' ,nrecogni7ed pin
protr,sion. Pin protr,sion can %e associated &ith the de)elopment o' chondrolysis and
s,%chondral %one changes. <ith m,ltiple pins- the possi%ility that one or more &ill
protr,de into the .oint is increased.
$he res,lts o' single0scre& 'ixation in patients &ith slipped capital 'emoral epiphysis
ha)e %een grati'ying and a lo& pre)alence o' additional slippage and o'
complications. Aronson and Carlson 31;;"6 and <ard et al 31;;6 reported excellent
or good res,lts in ;/ percent and ; percent- respecti)ely- in patients &ith slipped
capital 'emoral epiphysis treated &ith single0scre& 'ixation. A perc,taneo,s in sit,
'ixation ,sing t&o threaded Steinmann pins is associated &ith a high complication
rate 3Bla*e et al- 1;;"6. $he complication incl,des progressi)e slippage= &o,nd
in'ection one had a %ro*en portion o' pin d,ring remo)al. $here &as no case o'
implant 'ail,re and chondrolysis.
$he most important contri%,tion to the %lood s,pply to the 'emoral head is 'rom the
lateral epiphyseal )essels. $he lateral epiphyseal )essels enter the 'emoral head in the
posteros,perior 8,adrant and anastomose &ith the )essels 'rom the ro,nd ligament at
the .,nction o' the medial and central thirds o' the 'emoral head. $he ideal position
'or a scre&- there'ore- is in the central area or ne,tral 7one o' the 'emoral head. 1' a
pin is placed in the posteros,perior 8,adrant- the ris* o' damage to the epiphyseal
%lood s,pply is increased
160
An o'en e'i'hyeodei #ith Iliac cet or allogeneic %one gra+t is another option to
',se the physis. $he proced,re a)oids the complications associated &ith internal
'ixation- incl,ding ,nrecogni7ed pin protr,sion- damage to the lateral epiphyseal
)essels- and hard&are 'ail,re. $he s,rgical techni8,e in)ol)es an anterior ilio'emoral
expos,re o' the hip .oint. A rectang,lar &indo& o' %one is remo)ed 'rom the anterior
aspect o' the 'emoral nec*. A hollo& mill is ,sed to create a cylindrical t,nnel across
the physis- and m,ltiple corticocancello,s strips o' iliac crest %one gra't are dri)en
into the t,nnel as %one pegs across the proximal 'emoral physis. +o&e)er- the
'ixation pro)ided %y the iliac crest %one gra't is not as sec,re as that achie)ed %y
internal 'ixation. Rao et al 3 1;;"6 reported disco,raging res,lt &ith s,ch proced,re.
Complications s,ch as progressi)e slip- an a)asc,lar necrosis and chondrolysis &ere
reported in signi'icant n,m%er.
An o'en red&ction #ith correcti"e oteoto!y can %e per'ormed to correct the
de'ormity o' 'emoral nec*. $he correcti)e osteotomy carries the ris* o' a)asc,lar
necrosis to the 'emoral head.
$he pre)alence o' %ilateral slipped capital 'emoral epiphysis has %een reported to
range %et&een / and F# > in many series. +o&e)er- recent st,dies &ith 'ollo&0,p
into ad,lthood ha)e demonstrated pre)alence as high as "( percent 3+,rley et al-
1;;"6. $his &ide range may %e related to the )aria%ility in the radiological criteria
,sed to e)al,ate the hips- in the d,ration o' 'ollo&0,p- in the presence o' symptoms in
the contralateral hip. $he ris* o' de)eloping a slip m,st %e &eighed against the ris*s
o' an additional operation o' a contra0lateral seems to %e a normal side, Pro'hyla-i
'inning o' the opposite hip may %e considered in a high ris* gro,p o' patient s,ch as
o%ese child &ith endocrine a%normalities and a yo,nger age %oy at the time o' initial
slip is predicti)e o' contralateral slip 3Stasi*elis et al- 1;;" 6.
$&o main co!'lication may occ,r in SC45.
1. A)asc,lar necrosis: $he ris* o' de)eloping AD@ is higher in ,nsta%le SC45
as compared to sta%le SC45 &hich is rare.$he 'actors responsi%le 'or the
de)elopment o' AD@ are:
161
an ac,te ,nsta%le SC45
o)erred,ction o' an ac,te SC45-
attempts at red,ction o' the chronic component o' an ac,te0on0chronic
SC45-
placement o' pins in the s,perolateral 8,adrant o' the 'emoral head-
'emoral nec* osteotomy. $he 're8,ency o' AD@ is increased i' a
c,nei'orm or %asilar nec* osteotomy is per'ormed prior to physeal
. Chondrolysis is de'ined as narro&ing o' the .oint space to at least one0hal' o'
that in the contralateral hip in ,nilateral cases and as narro&ing o' the .oint
space to less than ( mm in %ilateral cases. $he pre)alence o' chondrolysis in
patients &ith a SC45 is / to 2 percent. Ris* 'actors leading to chondrolysis
incl,de:
immo%ili7ation in a cast-
,nrecogni7ed permanent pin penetration-
se)ere SC45- and
prolonged symptoms %e'ore treatment.
$he treatment selected in this patient- in sit, pinning &as the %est s,rgical option 'or
him as the case o' chronic- sta%le SC45. $he patient has to %e 'ollo&ed ,p reg,lar
inter)al to detect a possi%ility o' de)eloping the contralateral slip and those
complications descri%ed a%o)e associated &ith in sit, pinning o' the a''ected hip.
CONCLUSION
$he diagnosis o' slipped capital 'emoral epiphysis sho,ld %e r,led o,t in
adolescent presenting &ith hip/ thigh/ *nee pain. Plain radiograph is ,s,ally s,''icient
to ma*e the diagnosis and grade the se)erity. ?tmost importance is to classi'y the slip
&hether it is sta%le or ,nsta%le. $his simple classi'ication has prognostic in'ormation
regarding the ris* o' de)eloping a)asc,lar necrosis.
162
Regardless o' the se)erity o' the slip- in sit, pinning pro)ides the %est long0term
',nction- the lo&est ris* o' complications- and the most e''ecti)e delay o'
degenerati)e arthritis. Many patients &ith a slipped capital 'emoral epiphysis respond
&ell to this treatment- as seen at the time o' long0term 'ollo&0,p- i' the slipped capital
'emoral epiphysis is mild or moderate in se)erity- good congr,ity is maintained
%et&een the 'emoral head and the aceta%,l,m- and a)asc,lar necrosis and
chondrolysis do not de)elop.
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