Hip problems

Slipped Capital Femoral Epiphysis

Perthes Disease
Developmental Dysplasia of Hip
Slipped Capital
Femoral Epiphysis
I ntroduction
The most common hip abnormality
presenting in adolescence and a
primary cause of early osteoarthritis.
SCFE is a Salter-Harris type 1
fracture through the proximal
femoral physis.
The femoral head gradually slip
posteriorly, medially and intefriorly
with respect to the neck.
I ncidence
Incidence is 1 case per 100,000 people.
SCFE occurs most frequently in
adolescents
overweight boys
African American children
Left hip more common than right.
Bilateral involvement 20-40%



Unknown!

Any condition that
decreases physeal
strength

Increased shear forces due
to obesity
weight during growth
spurt=strain on growth plate
More vertical proximal
femoral physis
Retroversion shear
forces with walking
Disease processes that
weaken physis
Hypothyroidism
Renal disease
Hypogonadism
Hypopituitarism
GH deficiency
treated with HGH
<10 years of age
Other factors that
contribute
Marfans disease
Posttransplant
medications
Radiation therapy
Etiology
Clinical presentation
Clinical presentation often is misleading, with
only 50% of patients presenting with hip pain
and 25% presenting with knee pain.
Antalgic limp: Knee pain; 46%
Severe pain= unable to walk
Extremity: externally rotated/adducted/ shortened
Lack of Internal Rotation
Flex hip externally rotate


Symptoms and Clinical Findings
Antalgic limp: Knee pain; 46%
Severe pain= unable to walk
Extremity: externally rotated/adducted/
shortened
Lack of Internal Rotation
Flex hip externally rotate


Radiology
Diagnosis is made using AP pelvis
and lateral frog-leg radiographs.
Abduction of the femur for the frog-
leg view may result in increased
slippage and should be performed
with caution.
Radiographs
AP
May not detect the slip!
Widening early dz
Irregular growth plate
Steels metaphyseal
blanching
No remodeling: acute
unstable
Change in Kleins line




















Line is not intersecting any
part of the head









Radiology Signs
Loss of triangular sign of
capener
Blurring of physis
Relative decreased
height of epiphysis
Loss of intersection of
epiphysis by lateral
cortical line of femoral
neck.
Radiographs
Head-Shaft angle by Southwick,
Determine degree of slip/stability on
frog-leg lateral
Angle between femoral head and
shaft (HSA)
HSA of affected side minus HSA of
nl side
Determine long-term px
Mild: 1-29
Mod: 30-60
Severe: >60
CT Scan
Assess magnitude of deformity
Post-op check of physeal
closure
MRI
Dx of AVN or chrondrolysis
13-year-old female adolescent
anteroposterior pelvic view: increased opacity of her right
metaphysis and the subtle widening of the physis
14-year-old male adolescent who came to the emergency
department with complaints of thigh and knee pain
A relatively subtle medial slip at AP view.
A more obvious posterior slip at frog-leg lateral view
Classification
Traditional Classification
Fahey and OBrian, 1965
no rationale for this selection of time
Acute < 3 weeks of symptoms
Chronic > 3 weeks of symptoms
Acute on Chronic > 3 weeks of symptoms +
sudden exacerbation
Surgical Treatment
Goals:
1. primum non nocere
2. Pain relief
2. Prevent slip progression
3. Accelerate epiphsiodesis
4. Avoid AVN and chondrolysis


Situ - Pinning I n
Single-screw in-situ
High success rate
Low incidence of slippage
Minimal complications with proper
placement
Placement of single screw
1980s: Morrissey
Center of femoral head/ to physis
Enhance rate of physeal closure (Ward, JBJS,
1992)
Avoid posterosuperior quadrant (Brodetti,
J BJ S, 1960)
Injury to lateral epiphyseal vessels= AVN
Situ - Pinning I n
Placement of single screw
Proper start point important
anterior on neck
pin start below lesser troch: fx
incidence
Multiple drill holes weaken bone
5 screw threads into the epiphysis

Op - Pre
Screw
Placement
2-Bone-Graft Epiphysiodesis
3-Osteotomy
Complication
AVN
Chondrolysis
Continued Slip
Because of smooth pins
Poor primary fixation: not
perpendicular to physis
Pin Breakage: unstable fixation
Subtrochanteric fracture
OA/Pistol grip deformity
LEGG-CALVE-
PERTHES
DISEASE
Perthes Disease
Perthes Disease
Idiopathic Avascular Necrosis of Capital
Femoral Epiphysis (CFE)

An ischaemic episode of the lateral epiphyseal
arteries initiates avascular necrosis of the
capital femoral epiphysis. The lateral
epiphyseal arteries supply an extensive area
of the capital femoral epiphysis.

Cause is unknown
Perthes Disease
More common in boys than girls 4-5:1
Age range 3-11yo more usually 5-6 yo
Often lower socio-economic groups
(?nutrition factors)
Perthes in Lt.
femoral head
Perthes Disease
Etiology
interruption of blood supply to CFE
ossification ceases temporarily
articular cartilage continues to grow
(nourished by synovial fluid)
subchondral bone is revascularised
and becomes weak
results in subchondral fracture which
can allow the femoral head to become
flattened and mis-shapen
Perthes Disease
Signs & Symptoms
Limp
Pain in knee, thigh
hip ROM abduction & internal
rotation
Affected leg may become shorter and
thinner over time
Physical Exam - Shows
1. Decrease ROM in hip abduction and internal
rotation.
2. Hip stiffness
3. Knee pain
X-rays: Four stages
1. Synovitis
2. Aseptic necrosis- increased joint space and
small femoral head
3. Fragmentation - increased bone density
4. Residual - increased bone density
Perthes Disease
Radiograph: LCP

Perthes Disease
Management:
Many (approx 60%) do well without treatment of any kind,
especially younger boys under 5 years of age.
Some (approx. 15%) do badly even with active
management.
Remaining 25% benefit from active management.
Factors that determine which group children will fall into
has been difficult to determine.
Following principles are generally agreed.
Management Principles
reduce hip irritability, pain and spasm if present
prevent deformity of the femoral head (reduces risk for
osteoarthritis in later years)
Congruity of hip joint.
Perthes Disease
Rest in bed with pain relief
Traction to relieve muscle spasm
Slings/springs to regain ROM
Containment of femoral head in
acetabulum through
use of abduction brace (eg. Scottish
Rite or Toronto). Continue to
ambulate.
surgically increasing acetabular
coverage (innominate and/or varus
osteotomy) followed by period in
broomstick plasters.
Perthes Disease
Avoid high impact activities eg running,
jumping until fem. head is healed.
Hydrotherapy may also be useful.


Recovery is a slow process
(2-5 years) therefore chn. need
emotional support and reassurance
that they will recover and be able to
resume "normal" activities.
ysplasia D evelopmental D
ip H of
DDH
ysplasia D evelopmental D
ip H of the
Femoral head has an abnormal relationship
with acetabulum
Includes unstable, subluxated (excessive
movement in the socket), and dislocated hips
Risk Factors
Female
Breech
Family History

DDH
Recommendations
Serial physical screening exams
Hip imaging for females born breech
(120/1000)
Optional imaging for males born breech
(26/1000)
Optional imaging for females with FH
If positive Ortalani or Barlow on initial PE, refer
to orthopedic doctor
If exam is equivocal (soft clicks)check in 2
wks
DDH
Developmental Dysplasia of the Hip
CDH
Congenital Dislocation of the Hip
DDH
Radiological
Diagnosis
classic features
increased acetabular index (
n=27, >30-35 dysplasia)
disruption shenton line ( after
age 3-4 should be intact on all
views)
absent tear drop sign
delayed appearance ossific
nucleus and decreased
femoral head coverage
failure medial metaphyseal
beak of proximal femur ,
secondary ossification center
to be located in lower inner
quadrant
center-edge angle useful after
age 5 ( < 20) when can see
ossific nucleus
Physical findings
Girl
Asymmetrical skin folds
Limited abduction
Short leg
Pistoning
Ortolanis sign
Barlows sign
DDH
X-ray findings
Delayed appearance of ossific nucleus
Small ossific nucleus
Dysplastic acetabulum
Proximal displacement of femur
DDH
DDH
Treatment
0 : Pavlik harness
1: Closed reduction, cast
1 - 5 or 8: Open reduction, pelvic
osteotomy
Older: Leave dislocated

Pavlik Harness
Check at 3 weeks to confirm reduction
Adjust position every 6 12 weeks
Continue until the hips are clincally and
radiologically normal

Management of DDH
Newborn
Splintage in abduction (Pavlik harness)
6 - 18 months
Closed reduction - Traction
Splintage
Open reduction and Splintage
Late diagnosed dislocations
Persistent dislocation in adults
Treatment of DDH
- weeks 6 Neonate to - Group I
positive Ortolani and Barlows tests
and skin fold discrepancies. Also
dislocated side can be extended all
the way down to the level of the
exam table, because it is lacking the
normal hip flexion tightness that
newborn have. Refer this child to
Orthopedics for treatment most likely
with a Pavlik harness.
Treatment of DDH
Hip - months 12 - weeks 6 - Group II
capsular and soft tissue have now
tightness up and the Ortolani test
may not be positive. Will see limited
abduction in this age and skin fold
asymmetry. Again referral to Ortho
for treatment with Pavlik harness,
traction, adductor tenotomy, or
closed reduction.
Treatment of DDH
- years 3 - months 12 - Group III
Walking with a painless limp.
Galeazzi sign positive, and limited
abduction. X-rays positive by this
age. Again referral to Ortho for
possible treatment by arthrography,
traction, adductor tenotomy, open
reduction, and pelvic versus femoral
osteotomy.
Treatment of DDH
years to skeletal 3 - Group IV
maturity- Same as group III and X-ray
is positive. Referral to Ortho for
treatment. Usually need to have
surgery to corrected at this age.
FYI - Bilateral dislocations over 6
years old and unilateral over 8 years
old do better left ALONE.