Talk of Dr John on SCFE

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Information about Talk of Dr John on SCFE

Published on March 21, 2014

Author: johnebnezar


Coxa Vara and Slipped CAPITAL FEMORAL EPIPHYSIS: DR JOHN EBNEZAR VICE PRESIDENT OF THE INDIAN ORTHOPEDIC ASSOCIATION MBBS, D’ORTHO, DNB (Ortho), MNAMS (Ortho), DAC, DMT, (Diploma In Sports Medicine-Australia), INOR Fellow (UK), ( Phd ) Yoga Chief Orthopedic And Spine Surgeon, Expert In Holistic Orthopedics Parimala Health Care Services ® (An ISO 9001:2000 Hospital) Bilekahalli,Bannerghatta Road,Bangalore 560076. Contact No’s : 080-26581231/080-26583117/09986015128 Email:,, Coxa Vara and Slipped CAPITAL FEMORAL EPIPHYSIS About Dr John Ebnezar Website: : Vice President of the Indian Orthopedic Association Author of 19 books in Orthopedics (A World Record) President, Karnataka Chapter, Neuro Spinal Surgeons Association of India Chairman, Indian Orthopedic Association’s Patient Education and Professionalism Committee Former Assistant Professor in Orthopedics, Devraj Urs Medical College, Kolar Former Senior Specialist in Orthopedics, Bangalore Medical College About Dr John Ebnezar Website: COXA Vara -Introduction : COXA Vara - Introduction At Birth, Normal Femoral Neck Shaft Angle 160* which decreases to 125* in adult life. PowerPoint Presentation: Femoral Neck Shaft Angle – When it deviates from normal, what is the result? Term used to describe a reduced angle between neck and shaft of femur less than 120* Coxa Vara - Definition : Coxa Vara - D efinition It is an abnormality of the proximal end of femur, which is characterized by decreased neck shaft angle Normal coxa vara is due to differential growth pattern of capital femoral and greater trochanteric epiphysis. In coxa, valga the neck shaft angle is increased Types: Types Congenital Acquired PowerPoint Presentation: The term congenital coxa vara has been applied to two types of coxa vara seen in infancy and childhood. Classification : Classification Congenital Acquired: Congenital coxa vara . Congenital short femur with coxa vara . Congenital bowed femur with coxa vara . Part of generalized skeletal dysplasias : This is seen in mucopolysaccharidosis , multiple epiphyseal dysplasias , achondroplasia , cleidocranial dysostosis , etc. According to the site of disturbance. Capital coxa vara : Eg Perthes ’ disease, chondro-osteodystrophy , cretinism, septic arthritis of hip, etc. Epiphyseal coxa vara : Slipped capital femoral epi­physis . Cervical coxa vara : This is seen in malunited trochanteric fracture, pathological hip conditions like: Children: Rickets, bony dystrophies, etc. Adults: Osteomyelitis , osteoporosis, Paget’s disease, fibrous dysplasia, etc. Types of congenital Coxa Vara: Types of congenital Coxa Vara The First Type The Second Type Is Present At Birth, Is Rare, And Is Associated With Other Congenital Anomalies, Such As Proximal Femoral Focal Deficiency Or Anomalies In Other Parts Of The Body Such As Cleidocranial Dysostosis. Usually Not Discovered Until The Child Is Walking Is More Common Than The First And Is Associated With No Other Abnormality Except Possibly A Congenitally Short Femur. Preoperative radiograph shows neck-shaft angle of less than 90 degrees bilaterally at age 5 years. : Preoperative radiograph shows neck-shaft angle of less than 90 degrees bilaterally at age 5 years. Congenital Coxa Vara : Congenital Coxa Vara Rare Defect of endochondral ossification in the medial part of femoral neck When child starts to crawl or stand, femoral neck bends and with continued weight bearing, it further collapses, increasingly into varus and retroversion Condition is bilateral in about one third of cases Clinical Features : Clinical Features Small Stature Limp Bow leg Waddling Gait Upward Shift Of Greater Trochanter Decreased Rotation And Abduction Of Hip Pain Stiffness Flexion Contractures . Plain X-ray: Femoral Neck In Varus And Abnormally Short, Often There Is Separate Fragment Of Bone In A Triangular Notch On The Inferomedial Surface Of The Femoral Neck Due To Distorted Anatomy,difficulty In Measuring Neck Shaft Angle. Neck shaft angle is less than 90°, length of the neck is decreased, Head is unusually translucent, Plain X-ray Other Reliable Radiological Parameters: Other Reliable Radiological Parameters A alternative is to measure Hilgenreiner’ s epiphyseal angle – angle subtended by a horizontal line joining the centre of tri-radiate cartilage of each hip and another parallel to the physeal line Normal angle is 30*. With Bilateral Coxa Vara: With Bilateral Coxa Vara Patient May Not Be Seen Until He Or She Presents As A Young Adult With Osteoarthritis What is Fairbank’s Triangle?: What is Fairbank’s Triangle? The epiphyseal plate may be too vertical. There may be a separate triangle of bone in the inferior portion of the metaphysis, called Treatment – 2 O’s : Treatment – 2 O’s Observation: If Epiphyseal angle is between 40-60* Regular follow-up for monitoring any progression Operation: If Epiphyseal angle > 60* If Shortening is progressive Deformity correction is by Subtrochanteric Valgus Osteotomy Other Indications for surgery: Other Indications for surgery Coxa Vara Deformity Is Progressive Painful Unilateral Associated With Leg-length Discrepancy When The Neck-shaft Angle Is 110 Degrees Or Less The treatment of choice: The treatment of choice Subtrochanteric osteotomy : to place the femoral neck and head in an appropriate valgus position with the shaft of the femur. Surgery can be delayed until the child is 4 or 5 years old to make internal fixation easier. Bilateral Subtrochanteric Osteotomies And Internal Fixation With Pediatric Hip Screw : Bilateral Subtrochanteric Osteotomies And Internal Fixation With Pediatric Hip Screw Acquired coxa vara : Acquired coxa vara Develops if femoral neck bends or breaks Mechanical Coxa Vara Severe shortening of femoral neck Relative overgrowth of greater trochanter During weight bearing abductor muscles are at a mechanical disadvantage and patient walks with trendelenburg’s gait. Acquired Coxa Vara - Causes: Acquired Coxa Vara - Causes During childhood Rickets bone dystrophies Perthe’s Disease. In adolescence Epiphysiolysis Causes At any age: Causes At any age Osteomalacia Fibrous dysplasia Pathological fracture Aftermath of infection Malunited fractures Paget’s disease. Treatment : Treatment Corrective valgus osteotomy - only if there is marked shortening or intolerable discomfort. Distal transposition of greater trochanter - In case of disproportionate high greater trochanter. Disadvantages of Coxa Vara : Disadvantages of Coxa Vara Normal apposition between joint surfaces is lost. Trochanter is displaced upwards, impinges on the side of pelvis. Marked shortening of the limb. Waddling gait. COXA VALGA: COXA VALGA Increase In Femoral Neck Shaft Angle more then 135* is termed as Coxa Valga It is less common than coxa vara Causes of Coxa Valga: Causes of Coxa Valga Slipped Capital Femoral Epiphyses Poliomyelitis Slipped Capital Femoral Epiphysis (Syn: Epiphyseal Coxa Vara; Adolescent Coxa Vara) : Slipped Capital Femoral Epiphysis ( Syn : Epiphyseal Coxa Vara ; Adolescent Coxa Vara ) Slipped capital femoral epiphysis (SCFE) occurs during adolescent rapid growth period when epiphyseal plate is weak and the capital epiphysis is displaced down and back Epiphysiolysis of the caput femoris Sliding at the level of the epiphysis Müller first described it in the year 1889. Limping Child - Main Diagnoses: Limping Child - Main Diagnoses In Study of Total number of cases: Retrospective review of medical records of all patients aged 0 – 15 years who presented to Cork University Hospital with acute atraumatic limp, hip or knee pain over a 3 year period, 304 cases 2 31 Transient synovitis 30 S lipped capital femoral epiphysis 15 Infection – 10 septic arthritis 5 osteomyelitis 9 Legg-Calve- Perthes ’ disease 19 other – Includes Toddler’s #, Osteochondritis Dissecans, Eosinophilic Granuloma Of Ischium Epidemiology SCFE : Epidemiology SCFE Boys : girls = 3 : 1 Adolescents in period of fast growth(10-17y) Most common hip abnormality presenting in adolescence 2 per 100.000 in the general population 10 per 100.000 in the USA Slipped Capital Femoral Epiphysis : 9 yrs-end of growth Obesity in 50% Increased frequency with endocrine disorders; hypothyroid, renal disease, GH: Sex hormone imbalance Slipped Capital Femoral Epiphysis Aetiology of SCFE: Aetiology of SCFE Unknown Broadening of the epiphysis in the hypertrophic zone (80% hypertrophic compared to 15-30% normally) Locally higher levels of immunoglobulin's and complement factors Shear forces cause fractures at the hypertrophic zone Stress on the hip causes the epiphysis to move posteriorly and medially Multifactor Aetiology : Multifactor Aetiology Higher risk Endocrine (hypothyroidism, hypogonadism , renale osteodystrophy , panhypopituitarism and growth hormone treatment) Body type: Female slender build/Male obesity type Radiotherapy in the hip area - higher risk Trauma – trivial or none at all Obesity Hormones Oestrogen narrows and strengthens the epiphysis Testosterone • In low doses weakens the epiphysis • In high doses strengthens the epiphysis Genetic predisposition ( autosomal dominant pattern) Environmental factors Left hip involved in 58 % of the cases. Theories of causations : Theories of causations Harris hormonal theory: Due to hormonal imbalance between the increased growth hormone and decreased sex and thyroid hormone. Traumatic theory: Epiphyseal line is the weakest part of the normal adolescent bone. Theory of periosteal thinning: Periosteum, which is thick in children, thins out during adolescence. Onset SCFE : Onset SCFE Acute or chronic Pre slip (6% ) - Here X-rays show wide irregular epiphysis Acute (11%) – Sudden onset, period up to 3 wks Chronic (60%) – Duration is more than 3 weeks Acute on chronic (23%) – Symptoms are present for one month and there is recent sudden increase in pain following trivial injury. Classification of Slipping: Classification of Slipping Mild (51%) Neck displaced less than 1/3 of head Head shaft angle is less than 30 deg Moderate Slip (22%) Neck displaced more than 1/3 to ½ of the head Head shaft angle is more than 30-60 deg Severe Slipping (17%) Neck displaced more than ½ of the head Neck shaft angle is more than 60 degrees Symptoms SCEF : Symptoms SCEF Pain around the knee or the hip Limping Not able to ambulate Not able to weight bare External rotation deformity Shortening of the leg Slipped Capital Femoral Epiphysis: Unstable: sudden, severe pain with limp Stable: limp with variable medial knee or anterior thigh pain 36% will later involve opposite side Restricted internal rotation, abduction, flexion Slipped Capital Femoral Epiphysis Clinical stages in SCFE Pre-slipping Stage Chronic Slipping Stage Stage of fixed deformity: Clinical stages in SCFE Pre-slipping Stage Chronic Slipping Stage Stage of fixed deformity Pre-slipping Stage: Pre-slipping Stage Discomfort in the groin Stiffness Limp No objective finding Medial rotation of the hip is decreased Chronic Slipping Stage: Chronic Slipping Stage Clinical features Antalgic gait Pain in the groin Antalgic gait Varus , adduction and external rotation deformity is present Abduction decreased and adduction increased Internal rotation decreased and external rotation increased External rotation is increased Chronic Slipping Stage: Chronic Slipping Stage Trendelenberg Gait is positive Chronic Slipping Stage: Chronic Slipping Stage Trendelenberg Test is positive Meet the Pioneer - Trendelenburg: In 1895 Fredrich Trendelenburg described a clinical sign useful for detecting the function of hip abductor muscle with special reference to CDH and progressive muscular dystrophy Meet the Pioneer - Trendelenburg Trendelenberg test: Requirements Tests the abductor mechanism of the hip that consists of Fulcrum –hip joint Lever arm- Head, neck Power-abductors Free Abduction/ Adduction Of 20 Deg. Able To Stand On Affected Limb For > 30 Sec. Age > 5 Years. Trendelenberg test Pre-requisites Step 1 - Performing A Standard Trendelenburg Test: Step 1 - Performing A Standard Trendelenburg Test Examiner Stands Behind The Pt Step 2: Step 2 Pt Is Asked To Raise One Leg Off The Ground With Hip Flexed Between 0-30 Degrees And To Balance Herself Step 3: Step 3 The Pt Is Asked To Raise The Non-stance Side As High As Possible Note: Drop less than 5 degrees is normal. Only if the drop is more than 5 degrees it is considered abnormal. The patient should be able to hold the pelvis steady for 30 secs. If unable to hold for more than 30 secs it is positive. False positive in 10% of the patients. Positive Trendelenberg test: Standing on the normal side Positive Trendelenberg test Standing on the affected side Stage of Fixed Deformity: Stage of Fixed Deformity No pain No spasm Limb shortening Adduction and external rotation deformity Screening test- Allis or Galeazzi Sign: Screening test- Allis or Galeazzi Sign Hip is flexed to 60 degrees Knee flexed to 90 degrees Feet made level at the heels Normal - Both the knees are at the same level Knee level if short – Shortening is in the femur Knee or the leg is pushed forwards – Shortening is in the leg Apparent measurement: Apparent measurement Shows compensation that pt has developed to conceal any fixed deformity Here both limbs should be kept parallel to each other Measured from xiphisternum or umbilicus to medial malleolus True Measurements - In standing position: True Measurements - In standing position The Block Test: Done In ambulatory patients For Shortening of the limb Patient stands close to the wall ASIS is at a lower level Instruct the patient to move the limb up ASIS starts moving upwards When the ASIS comes to the horizontal level Insert measured wooden block beneath the foot to keep it level Now measure the height of the block The measure is the limb length discrepancy MEASUREMENTS True shortening: MEASUREMENTS True shortening Square the pelvis ASIS  MEDIAL JOINT LINE KNEE  MEDIAL ALLEOLUS BRYANTS TRIANGLE:  BRYANTS TRIANGLE A - Draw a line connecting the GT and ASIS B – Line perpendicular from ASIS towards the bed C– Line connecting GT and line B Nelaton’s Line: Nelaton’s Line Patient lies on the normal side Hip and knee flexed to 90 degrees Line drawn from the Sharp bony point on the ischial tuberosity to the ASIS This line should just touch the trochanter No need of comparison with the other side NORMAL TROCHANTER TIP ABNORMAL Other Important Qualitative lines: Shoemakers Line Other Important Qualitative lines Chiene’s Test RIGHT TROCHANTER MIGRATED UP RIGHT TROCHANTER MIGRATED UP Bilateral SCFE : Bilateral SCFE Bilateral 20-25% 50% (of 25%) on presentation 88% (of 25%) within 18 months from presentation Bilateral Boys Afro-Americans Obesity BMI in patients with SCFE : BMI in patients with SCFE The mean BMI of patients with bilateral disease was significantly greater than that of patients with unilateral disease. Patients with unilateral involvement who progressed to bilateral disease had a significantly greater average BMI than patients who did not progress. Elevated BMI is associated with SCFE, especially bilateral SCFE. Investigations - SCFE : Investigations - SCFE X ray AP, Lateral or Frog leg view Posterior position of the epiphysis on the axial view Broad and irregular epiphysis “Blanch sign of Steel”: a crescent-shaped area of increased density overlying the metaphysis adjacent to the epiphyseal plate Line of Klein (straight line along) does not cross the lateral part of the epiphysis Slipped Capital Femoral Epiphysis: 61 Slipped Capital Femoral Epiphysis Radiographic Changes : Radiographic Changes Early changes Late changes Marginal blurring of the proximal metaphysis Lower margin of metaphysis is included within the acetabulum normally but excluded in the early epi­physeal slip. Trethovan’s line is present Depth of epiphysis is reduced. There is a step between the metaphysis and the epiphysis Trethovan’s sign is present. Head is atrophic. Neck shaft angle is less than 90°. New bone formation is seen at the anterior superior part of the neck. Joint space is usually clear. Shenton’s line is broken. Other Investigations: Other Investigations • Ultrasound helps to confirm the diagnosis • CT-scan measures dislocation • MRI helps in early diagnosis in the pre slip stage Principles of treatment: Principles of treatment If epiphysis has begun to displace, there is no safety until the epiphyseal line has fused. When there is minor displacement: epiphysis is fused at once by pining in displaced position. Acute major slip: Emergency reduction is done under (GA) or reduction is obtained by traction and fixed with pins. Irreducible displacement: This is treated by open reduction and cervical osteotomy . Old fixed displacement: This is treated by a corrective osteotomy at the inter- trochanteric or sub­trochanteric level. Treatment SCFE : Treatment SCFE Prevent further slip Percutaneous fixation (one screw 6,5-7,5 mm) Within 24 to 48 hours Repositioning (one try) – Manipulation of the fracture frequently results in osteonecrosis and chondrolysis because of the tenuous nature of the blood supply. Preventive pinning of the other side? - Depending on the possible cause (high BMI, underlying disease) Slipped Capital Femoral Epiphysis – Fixation in situ: 66 Slipped Capital Femoral Epiphysis – Fixation in situ Complications SCFE : Complications SCFE Premature closing of the epiphysis AVN or Osteonecrosis – 31% after forced closed reduction of the slip – 0-5% in percutanous fixation with screws Chondrolysis Osteo arthrosis Outcome depends on nature of the slip and age of onset Salvage procedures: osteotomy , arthrodesis , THR SCFE : SCFE Early Gentle Treatment Beware Of The Cause Slipped Capital Femoral Epiphysis: Slipped Capital Femoral Epiphysis Slip of the upper femoral ephiphysis either gradual or sudden More common in unduly fat and sexually underdeveloped Seen in adolescent age group Seen more in boys as compared to girls Hormonal influence Xray : Xray AP view growth plate displaced Trethowans sign Lat angulation of neck Trethowans sign: Trethowans sign On AP view : A line drawn along superior surface of the neck passes above the head unlike in a normal hip where it passes bisecting the head. PowerPoint Presentation: In some cses Endocrine disorder Boys Both sides in 30% of cases Trauma Clinical Presentation: Clinical Presentation Leg externally rotated Shortening Limited abduction and Ext. rotation Increase Adduction and external rotation Clinical tests: Clinical tests Apparant lengthening of involved limb, Positive leg- Axilla sign ( on passive flexion of hip and knee, lower limb will point towards ipsilateral axilla) X-Ray Pelvis with Both Hips AP : X-Ray Pelvis with Both Hips AP On AP view of Pelvis with both hips, increase in neck shaft angle is seen. Treatment: Treatment Acute slip closed reduction and pinning Gradual and less than 1/3 fix in-situ If More osteotomy Prophylactic pinning on opposite side Medial closed femoral osteotomy or lateral open wedge osteotomy Recommended reading: Recommended reading Apley’s System of Orthopaedics & Fractures Essential Orthopaedics ( J. Maheshwari ) John Ebnezar Textbook of orthopeadics For Further reading Text Book Of Orthopedics, IV Edition, Jaypee: For Further reading Text Book Of Orthopedics, IV Edition, Jaypee From Clinical Examination of Orthopedics IV Edition, Jaypee: From Clinical Examination of Orthopedics IV Edition, Jaypee

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