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Slipped Capital Femoral Epiphysis SCFE
Slipped Capital Femoral Epiphysis SCFE
George SM Dyer, Harvard Medical School Year-IIIGillian Lieberman, MD
George SM Dyer, Harvard Medical School Year-IIIGillian Lieberman, MD
George DyerGillian Lieberman, MD
January 2001
22
What is it?What is it?
•
In a person with an open femoral physis, mild trauma shifts the femoral head in relation to the femoral neck
•
Femoral head
slips posteriorly
and medially
•
In a person with an open femoral physis, mild trauma shifts the femoral head in relation to the femoral neck
•
Femoral head
slips posteriorly
and medially
http://www.packardchildrenshospital.org/health/orthopaedics/scfe.htm
George DyerGillian Lieberman, MD
33
Simplified Concept of SCFESimplified Concept of SCFE
George DyerGillian Lieberman, MD
44
Simplified Concept of SCFESimplified Concept of SCFE
Open physisOpen Open physisphysis Slipped physisSlipped Slipped physisphysis
George DyerGillian Lieberman, MD
55
EpidemiologyEpidemiology
•
Incidence 30/100,000•
Age: 10 -
15 yrs
•
Boys > girls•
Blacks > whites
•
More common in overweight children
•
Incidence 30/100,000•
Age: 10 -
15 yrs
•
Boys > girls•
Blacks > whites
•
More common in overweight children
George DyerGillian Lieberman, MD
66
History and Differential DiagnosisHistory and Differential Diagnosis
•
Ernst Mueller, 1889•
Described it pathologically using dissected specimens
•
“There occurs in young individuals aged 14-18, without trauma to the hip, a limp, a weariness, and gradual shortening of the affected limb”
•
Ernst Mueller, 1889•
Described it pathologically using dissected specimens
•
“There occurs in young individuals aged 14-18, without trauma to the hip, a limp, a weariness, and gradual shortening of the affected limb”
•
Distinguished by Mueller from other hip disorders of the young
•
Congenital Hip Dysplasia
•
Legg-Calve-Perthes
disease•
Can be related to renal osteodystrophy, especially if bilateral
•
Distinguished by Mueller from other hip disorders of the young•
Congenital Hip Dysplasia
•
Legg-Calve-Perthes
disease•
Can be related to renal osteodystrophy, especially if bilateral
George DyerGillian Lieberman, MD
77
Radiologic StudiesRadiologic Studies
•
Plain Film Projections•
Posterior-Anterior•
Frog-leg Lateral
•
CT•
May resolve finer anatomy (Guzzanti
V, Falciglia
F, 1991)
•
MR•
Most sensitive for small changes in soft tissues (Umans
H, et al. 1998)
•
But diagnosis is still most often made on plain film
•
Essential
to recognize
•
Plain Film Projections•
Posterior-Anterior•
Frog-leg Lateral
•
CT•
May resolve finer anatomy (Guzzanti
V, Falciglia
F, 1991)
•
MR•
Most sensitive for small changes in soft tissues (Umans
H, et al. 1998)
•
But diagnosis is still most often made on plain film
•
Essential
to recognize
George DyerGillian Lieberman, MD
88
Radiographic FindingsRadiographic Findings
•
It’s easy when the findings are clear…
•
It’s easy when the findings are clear…
http://www.aafp.org/afp/980501ap/loder.html
George DyerGillian Lieberman, MD
99
Radiographic Findings in SCFERadiographic Findings in SCFE
•
Klein’s Criteria (1951)•
Earliest: Widened and irregular growth plate, compared to contralateral
hip Increased lucency
medially
•
Angulated contour of femoral head, then becomes rounded with adaptation•
Periosteal
proliferation at inferior, posterior margins and further slippage create “crow’s beak”
•
Klein's Line•
Line drawn along superior border of femoral neck should cross at
least a portion of the femoral epiphysis (Klein, 1951)
•
Most sensitive indicator of a mild slip on plain filmClassification
Grade I: displacement of epiphysis less than 30% of width of femoral neckGrade II: slip between 30%-60%Grade III: includes slips of greater than 60% the width of neck
•
Klein’s Criteria (1951)•
Earliest: Widened and irregular growth plate, compared to contralateral
hip Increased lucency
medially•
Angulated contour of femoral head, then becomes rounded with adaptation•
Periosteal
proliferation at inferior, posterior margins and further slippage create “crow’s beak”
•
Klein's Line•
Line drawn along superior border of femoral neck should cross at
least a portion of the femoral epiphysis (Klein, 1951)
•
Most sensitive indicator of a mild slip on plain filmClassification
Grade I: displacement of epiphysis less than 30% of width of femoral neckGrade II: slip between 30%-60%Grade III: includes slips of greater than 60% the width of neck
George DyerGillian Lieberman, MD
1010
Klein’s LineKlein’s Line
Courtesy of Dr. Carlo Buonomo, Children’s Hospital, Boston
Klein’s line demonstrates
slipped femoral head on right, normal on left
Klein’s line demonstrates
slipped femoral head on right, normal on left
George DyerGillian Lieberman, MD
1111
Importance of the Frog Leg: Patient DG: Is There a Slip?
Importance of the Frog Leg: Patient DG: Is There a Slip?
Courtesy of Dr. Carlo Buonomo, Children’s Hospital, Boston
George DyerGillian Lieberman, MD
1212
Patient DG: Frog LegPatient DG: Frog Leg
Courtesy of Dr. Carlo Buonomo, Children’s Hospital, Boston
Klein’s line demonstrates
slipped femoral head bilaterally
Klein’s line demonstrates
slipped femoral head bilaterally
George DyerGillian Lieberman, MD
1313
Comparison PatientsComparison Patients
•
Now it’s time to practice finding SCFE in other patients•
For each, identify whether there is a slip on the right side, the left side, or both sides
•
Now it’s time to practice finding SCFE in other patients•
For each, identify whether there is a slip on the right side, the left side, or both sides
George DyerGillian Lieberman, MD
1414
Patient JB: 15 year old boy Is the Slip on the Right, the Left,
Or Bilateral?
Patient JB: 15 year old boy Is the Slip on the Right, the Left,
Or Bilateral?
Courtesy of Dr. Carlo Buonomo, Children’s Hospital, Boston
George DyerGillian Lieberman, MD
1515Courtesy of Dr. Carlo Buonomo, Children’s Hospital, Boston
Klein’s line demonstrates
slipped femoral head bilaterally
Klein’s line demonstrates
slipped femoral head bilaterally
Patient JB: Frog leg view Is the Slip on the Right, the Left,
Or Bilateral?
Patient JB: Frog leg view Is the Slip on the Right, the Left,
Or Bilateral?
George DyerGillian Lieberman, MD
1616Courtesy of Dr. Carlo Buonomo, Children’s Hospital, Boston
Klein’s line demonstrates
slipped femoral head on right
Klein’s line demonstrates
slipped femoral head on right
Patient MC Is the Slip on the Right, the Left,
Or Bilateral?
Patient MC Is the Slip on the Right, the Left,
Or Bilateral?
George DyerGillian Lieberman, MD
1717
Patient KG: 11 year old girl Is There a Slip?
Sometimes Klein’s Line is Equivocal
Patient KG: 11 year old girl Is There a Slip?
Sometimes Klein’s Line is Equivocal
Courtesy of Dr. Carlo Buonomo, Children’s Hospital, Boston
George DyerGillian Lieberman, MD
1818Courtesy of Dr. Carlo Buonomo, Children’s Hospital, Boston
Patient KG: Frog leg view Is the Slip on the Right, the Left,
Or Bilateral?
Patient KG: Frog leg view Is the Slip on the Right, the Left,
Or Bilateral?
George DyerGillian Lieberman, MD
1919
When Klein’s Line Fails, Try Capener’s
Sign
When Klein’s Line Fails, Try Capener’s
Sign
•
On PA, ischium
and femoral head overlap to yield crescent of double density
•
SCFE reduces overlap area•
Sometimes more sensitive than Klein’s line alone
•
On PA, ischium
and femoral head overlap to yield crescent of double density
•
SCFE reduces overlap area•
Sometimes more sensitive than Klein’s line alone
Courtesy of Dr. Carlo Buonomo, Children’s Hospital, Boston
George DyerGillian Lieberman, MD
2020Courtesy of Dr. Carlo Buonomo, Children’s Hospital, Boston
Capener’s
sign suggests slipped left
and normal right
Capener’s
sign suggests slipped left
and normal right
Patient KG: Capener’s
Sign Is the Slip on the Right, the Left,
Or Bilateral?
Patient KG: Capener’s
Sign Is the Slip on the Right, the Left,
Or Bilateral?
George DyerGillian Lieberman, MD
2121Courtesy of Dr. Carlo Buonomo, Children’s Hospital, Boston
Capener’s
sign suggests slipped right
and normal left
Capener’s
sign suggests slipped right
and normal left
Patient MG: Is the Slip on the Right, the Left, Or Bilateral?
Patient MG: Is the Slip on the Right, the Left, Or Bilateral?
George DyerGillian Lieberman, MD
2222Courtesy of Dr. Carlo Buonomo, Children’s Hospital, Boston
Klein’s line demonstrates
slipped left
and normal right
Klein’s line demonstrates
slipped left
and normal right
Patient MO: Is the Slip on the Right, the Left, Or Bilateral?
Patient MO: Is the Slip on the Right, the Left, Or Bilateral?
George DyerGillian Lieberman, MD
2323Courtesy of Dr. Carlo Buonomo, Children’s Hospital, Boston
Klein’s line demonstrates
slipped left
and normal right
Klein’s line demonstrates
slipped left
and normal right
Patient MT: Is the Slip on the Right, the Left, Or Bilateral?
Patient MT: Is the Slip on the Right, the Left, Or Bilateral?
George DyerGillian Lieberman, MD
2424Courtesy of Dr. Carlo Buonomo, Children’s Hospital, Boston
Klein’s line demonstrates
slipped left
and normal right
Klein’s line Klein’s line demonstrates demonstrates
slipped leftslipped left
and and normal rightnormal right
Patient RW: Is the Slip on the Right, the Left, Or Bilateral?
Patient RW: Is the Slip on the Right, the Left, Or Bilateral?
George DyerGillian Lieberman, MD
2525Courtesy of Dr. Carlo Buonomo, Children’s Hospital, Boston
Klein’s line demonstrates
slipped right
and normal left
Klein’s line demonstrates
slipped right
and normal left
Patient SP: Is the Slip on the Right, the Left, Or Bilateral?
Patient SP: Is the Slip on the Right, the Left, Or Bilateral?
George DyerGillian Lieberman, MD
2626
ComplicationsComplications
Deformityas bones grow
Deformityas bones grow
Acute cartilage necrosis (chondrolysis)
Acute cartilage necrosis (chondrolysis)
Avascular
Necrosis (AVN)
Avascular
Necrosis (AVN)
Time
•
If undetected, SCFE has disabling sequelae•
If undetected, SCFE has disabling sequelae
George DyerGillian Lieberman, MD
2727
Tenuous Blood Supply of Femoral HeadTenuous Blood Supply of Femoral Head
•
Arterial supply to the head of the femur is from the medial and lateral circumflex arteries, distally, and from the foveal
artery in the ligamentum
teres, proximally •
All three are threatened by SCFE•
Shift of the femoral head in relation to the femoral neck can shear the circumflex arteries
•
The displacement of the femoral head within the acetabulum
often shears or damages the ligamentum
teres
•
The result is avascular
necrosis of the femoral head
•
Arterial supply to the head of the femur is from the medial and lateral circumflex arteries, distally, and from the foveal
artery in the ligamentum
teres, proximally•
All three are threatened by SCFE•
Shift of the femoral head in relation to the femoral neck can shear the circumflex arteries
•
The displacement of the femoral head within the acetabulum
often shears or damages the ligamentum
teres
•
The result is avascular
necrosis of the femoral head
George DyerGillian Lieberman, MD
2828
Progression of AVN in a Sickle-Cell Patient
Progression of AVN in a Sickle-Cell Patient
http://gait.aidi.udel.edu/res695/homepage/pd_ortho/educate/clincase/clcsimge/sickle1.jpg
Age Age Age Age Age Age
Progressive Progressive
•
This patient does not have SCFE, but the pathologic changes of AVN would look similar to those pictured here
•
This patient does not have SCFE, but the pathologic changes of AVN would look similar to those pictured here
George DyerGillian Lieberman, MD
2929
Treatment by Femoral Head FixationTreatment by Femoral Head Fixation
Femoral head pinned for
reduction and stability
Femoral head pinned for
reduction and stability
http://www.aafp.org/afp/980501ap/loder.html
•
If detected early, standard-of-care treatment for SCFE is fixation of the femoral head
•
If detected early, standard-of-care treatment for SCFE is fixation of the femoral head
George DyerGillian Lieberman, MD
3030
Early Detection Leads to Better OutcomesEarly Detection Leads to Better Outcomes
Excellent % Good % Fair % Poor %Early Treatment 72 14 4 10Delayed < 3 mo 67 20 7 6Delayed 3-6 mo 64 12 12 12Delayed >6 mo 36 9 49 9Delayed >9 mo 28 18 18 36
(Cowell, 1966)(Cowell, 1966)
•
It is crucial to detect even subtle indication of SCFE because early detection leads to much better long-term outcome
•
It is crucial to detect even subtle indication of SCFE because early detection leads to much better long-term outcome
George DyerGillian Lieberman, MD
3131
SummarySummary
•
Devastating if missed, essential
to recognize
•
Diagnosis is still most often made on plain film
•
When SCFE is in question, get a frog leg
•
Look for Klein’s line and Capener’s
sign
•
Devastating if missed, essential
to recognize
•
Diagnosis is still most often made on plain film
•
When SCFE is in question, get a frog leg
•
Look for Klein’s line and Capener’s
sign
George DyerGillian Lieberman, MD
3232
ReferencesReferences
•
Mueller E. Ueber
die Verbiegung
des Schenkelhalses
im
Wachstumsalter, Eine
neus
Krankheitsbild. Beitraege
zur
Klinische
Chirurgie
1889; 4: 137. Transby
Bick EM, Clin
Orthopedics 1966; 48: 7-10
•
Klein A, Joplin RJ, Reidy
JA, Havelin
J. Roentgenographic
features of slipped capital femoral epiphysis. Am J Roentgenography
1951; 66: 361-364
•
Umans
H, Liebling
MS, Moy L, Haramati
N, Macy NJ, Pritzker
HA. Slipped capital femoral epiphysis: a physeal
lesion diagnosed by MRI, with radiographic and CT correlation. Skeletal Radiol
1998 Mar;27(3):139-44
•
Guzzanti
V, Falciglia
F. Slipped capital femoral epiphysis: comparison of a roentgenographic
method andcomputed
tomography in determining slip severity. J Pediatr
Orthop
1991 Jan-Feb;11(1):6-12
•
Stanitski
CL, Litts
CS, Stanitski
DF J Pediatr
Orthop
Tibial
torsion in chronic, stable slipped capital femoral epiphyses: evaluation by CT scan. 1997 Sep-Oct;17(5):657-8
•
Cowell
H. Significance of early diagnosis and treatment of slipped capital femoral epiphysis. Clin
Orthopedics 1966; 48: 89-94
•
Slipped capital femoral epiphysis. Wheeless
on-line textbook of orthopedics. http://www.medmedia.com/05/314.htm
•
Mueller E. Ueber
die Verbiegung
des Schenkelhalses
im
Wachstumsalter, Eine
neus
Krankheitsbild. Beitraege
zur
Klinische
Chirurgie
1889; 4: 137. Transby
Bick EM, Clin
Orthopedics 1966; 48: 7-10
•
Klein A, Joplin RJ, Reidy
JA, Havelin
J. Roentgenographic
features of slipped capital femoral epiphysis. Am J Roentgenography
1951; 66: 361-364•
Umans
H, Liebling
MS, Moy L, Haramati
N, Macy NJ, Pritzker
HA. Slipped capital femoral epiphysis: a physeal
lesion diagnosed by MRI, with radiographic and CT correlation. Skeletal Radiol
1998 Mar;27(3):139-44•
Guzzanti
V, Falciglia
F. Slipped capital femoral epiphysis: comparison of a roentgenographic
method andcomputed
tomography in determining slip severity. J Pediatr
Orthop
1991 Jan-Feb;11(1):6-12•
Stanitski
CL, Litts
CS, Stanitski
DF J Pediatr
Orthop
Tibial
torsion in chronic, stable slipped capital femoral epiphyses: evaluation by CT scan. 1997 Sep-Oct;17(5):657-8
•
Cowell
H. Significance of early diagnosis and treatment of slipped capital femoral epiphysis. Clin
Orthopedics 1966; 48: 89-94•
Slipped capital femoral epiphysis. Wheeless
on-line textbook of orthopedics. http://www.medmedia.com/05/314.htm
George DyerGillian Lieberman, MD
3333
AcknowledgementsAcknowledgements
•
Thanks to Ms. Beverlee
Turner for her invaluable technical assistance in preparing this presentation for publication on the internet
•
Special thanks to Dr. Carlo Buonomo, Children’s Hospital Boston, for his expert instruction on reading pelvic plain film, and for generously allowing access to his teaching collection
•
Larry Barbaras and Ben Crandall our webmasters
•
Thanks to Ms. Beverlee
Turner for her invaluable technical assistance in preparing this presentation for publication on the internet
•
Special thanks to Dr. Carlo Buonomo, Children’s Hospital Boston, for his expert instruction on reading pelvic plain film, and for generously allowing access to his teaching collection
•
Larry Barbaras and Ben Crandall our webmasters
George DyerGillian Lieberman, MD