By Dr.

Ashesh Desai
 Definition

• Disorder of the proximal femoral physis

• Slippage of metaphysis anteriorly & superiorly

• posteroinferior displacement of femoral head in
relation to neck

• Relative to the epiphysis,which remains

anatomically positioned in the
acetabulum(misnomer).
 Epidemiology
• Usually occur just before puberty and may show
evidence of endocrine abnormalities.
• Age:
-Males 12-16 years
-Females 10-14 years
• M:F-2.5:1
• Left>Right
• Bilaterality : 25%
• Familial : 5%
 Aetiology
• Risk factor:(Spear;1982)

-Physeal height
-Planar physis
-Load
-Abnormal physeal inclination
-Deficient physeal component
-Obesity -
- decreased femoral anteversion ,
- increase shear stress on the physis.
Endocrine: Hypothyroidism
Hyperparathyroidism
Hypoestrogenic state
Panhypopituitarism
Cryptorchidism
Genetic :Down,klienfelter ,marfan
Iatrogenic :Growth hormone therapy
Radiation or chemotherapy.
Metabolic :Renal osteodystophy,Rickets
 Theory
• Growth hormone stimulate the growth of
physis.
• Sex hormones play a part in converting
cartilage to bone.
• If the sex hormone fails to keep up,there is too
much un-ossified cartilage to resist stress
imposed by increase body weight.
 Pathology
• Resembles a stress fracture.
• During growth the proximal femoral epiphysis
becomes increasingly more oblique and therefore
more liable to displaced following injury.
• Slip is associated with
 Increased width of physis.
 Reduction in the proportion of resting zone
 Increased size of the hypertrohic zone.
 Slip occur between the proliferative and
hypertohic zone.
 Hypertrophic Zone
Zone of Provisional
calcification
Zone of
ossification
 Clinical presentation
• An overweight child
• Poorly localised groin,thigh, or knee pain
• Limp
• History of minor trauma
• Age usually is 11-14 years
 Clinical examination
• Leg-shortened and externally rotated
• Restricted flexion,abduction,internal rotation
of affected hip
• Additional external rotation when the hip is
flexed further
 Classification-Loder

Stable Unstable
weight bearing Possible Not possible
severity of slip Less More
Good prognosis 96% 47%
Avascular necrosis Rare-0% 50%
• Chronological
• 1.Acute slip :sudden,severe,fracture like pain
in upper thigh after trauma. short priod(<3
weeks)

• 2.Chronic slip:groin pain,medial thigh and

knee pain(>3 weeks)

• 3.Acute or chronic slip: prodromal symptoms

with exacerbation of pain
 Grading

• Angular displacement(Southwick angle)

• Grade 1-pre slip
• Grade 2- (mild slip)<30 degree
• Grade 3-(moderate slip)30-60 degree
• Grade 4- (severe slip)over 60 degree
• Severe slips likely to be unstable.
 Extent of displacement
Head-shaft angle
(southwick)...

AP view N-145 deg

slip-<120 deg

Lat view N-10 deg

Mild-<30 degree
Moderate-30 to 60 degree
Severe->60 degree
 Investigation
• Plain X-rays (AP and lateral views)
1.Very often seems to be normal
2.Positive trethowan sign (Klein’s line)
3.Decreased in epiphyseal height
4.Capener’s sign
5.Widening and irregularity of the physeal line
6.Metaphyseal blanch sign of steel
7.Scham’s sign
Frog leg lateral view-most sensitive
 Klein’s line
• Line drawn along the superior margin of the
neck should intersect epiphysis (usually 20%
of femoral head lateral to this line.)
 Capener’s sign
• In pelvic AP view in the normal hip, the
posterior acetabular margin cuts across the
medial corner of the upper femoral
metaphysis.

• With slipping,the entire metaphysis is lateral

to the posterior acetabular margin.
 Metaphyseal blanch sign of steel
• Crescent shaped increased density lies over
metaphysis of the femoral neck adjacent to
physis.
 Scham’s sign/Loss of capener triangle
• In the normal hip the inferomedial femoral
neck overlaps the posterior wall of the
acetabulum producing triangular radiographic
density.
• With displacement of capital epiphysis this
dense triangle is lost.
 CT scan
• less indication for CT in SCFE
• Absolute indications are
1.Checking pin penetration following
treatment
2.Confirm closure of physis
3.Check the severity of residual
deformity during the planning for
reconstructive osteotomy
 Bone scan
• Tec 99 bone scan –
Increased uptake in the involved side
Decreased uptake in presence of AVN
Significant uptake in the joint space is seen
in chondrolysis
 USG
• For joint effusion in early slip
 Treatment
• Aim-
1.To prevent progression of slip without
complication.
2.Stabilization of epiphysis and prevention of
further slippage
3.Stimulation of physeal plate arrest
4.Functional improvement by restoration
anatomy in severe cases.
 Initial treatment options for stable
SCFE
1.In situ pinning
2.Bone graft epiphysiodesis
3.Osteotomy
4. Hip spica cast
 In situ pining
• Insitu pinning first described by ‘TELSON’
(threaded pins )
• Single cannulated ,6.5 mm pin into femoral
epiphysis from the base of ant femoral neck
for stable slip .
• For unstable slips 2 pins may be applied
 Technique of percutaneous in situ
fixation
• Patient – on fracture
table
• Affected leg is held in
extension and neutral
to slight internal
rotation with
unaffected limb in
flexion and abduction
(permit fluroscopic
imaging)
 The ideal placement of single cannulated screw is as
close to the centre of the capital epiphysis as possible
and as perpendicular to physis as possible
 The entry point of the guide wire must be at the base of the
femoral neck and is directed posteriorly into the centre of the
epiphysis
position checked with C arm
Length of the screw required is measured
Bone is drilled and tapped
• The screw is inserted over the guide wire
Guide wire is removed and position
checked with C arm
For unstable cases
 Treatment as per grades
• Grade 1 – In situ stabilization

• Grade 2 – In situ stabilization or inter-

subtrochanteric femoral osteotomy

• Grade 3 – Subcapital femoral neck

osteotomy,or inter-subtrochanteric osteotomy
 Prophylactic pinning of contralateral
hip
• Upto 25% of cases are bilateral
• Consider for patients with:
Endocrinopathy
<10 years of age
Presence of open triradiate cartilage.

-There is <4% chances of contralateral slip in

patients with closed triradiate.
 Complication
• Osteonecrosis of head of femur-
 Incidence decreased by pinning in situ and the
use of narrow threaded pins.
 Use only one pin and certainly not more than 2
 More common in unstable SCFE
 May be related to-
1.Hemarthrosis and increased joint pressures
leading to temponade.
2.Direct vascular damage.
3.Vessel kinking or spasm.
• Chondrolysis-Rapid and progressive loss of
articular cartilage
Affects about 8%.
Majority associated with pin penetration.
Weight relief may restore the joint space ,but
ROM may not return.
Treatment-Remove the pin,mobilise the
joint,may require capsulotomy and
manipulation under anaesthesia.
 Take home message
• Early diagnosis-High index of clinical suspicion
• Always – PBH Frog leg lateral view
• Treatment – Surgery must
• Pinning in situ
• Don’t try to reduce – high chance of AVN
• Regular follow up to diagnose contralateral
SCFE as earliest.
Thank you…