BILATERAL SLIPPED CAPITAL FEMORAL EPIPHYSIS

CHARLES J. ODGERS IV, M.D., Resident, Orthopaedic Surgery

KIRK DABNEY, M.D., Attending Pediatric Orthopaedic Surgeon

March 19, 1996

CLINICAL CASE PRESENTATION

ORTHOPAEDIC DEPARTMENT

THE ALFRED I. DUPONT INSTITUTE

WILMINGTON, DELAWARE

CASE HISTORY

An 11-year-old boy presented with a one year history of right knee pain. He stated that his knee recently "gave way" when running down the stairs at school. He described his discomfort as a deep achy pain on the medial aspect of his knee. There was no history of trauma, nor had the pain limited his activities until recently. Pt denied numbness, paresthesias, or weakness in his right leg. He denied fevers, chills, and any recent illnesses. He denied history of hip or groin pain.

PHYSICAL EXAM

Examination revealed an obese adolescent male in no acute distress. Height- 149cm(50%) Weight- 59 Kg(>95%). Right knee appeared atraumatic without any areas of point tenderness. There was diffuse pain in the knee with passive ROM. Examination of the hips revealed no tenderness, however there was increased ER and decreased IR of the right hip compared to the left. There were no gait abnormalities.

RADIOGRAPHS

An AP pelvis and frog-leg lateral radiographs of both hips were obtained. On the AP pelvis radiograph, there was notable widening and irregularity of the proximal femoral epiphyseal growth plate, and Klein's line did not intersect the epiphysis. The frog-leg lateral view of the right hip demonstrated an obvious grade 1 slipped capital femoral epiphysis.

FOLLOW-UP

The patient was admitted to the hospital, placed on strict bedrest, and he had an in situ pinning of his right hip the next day. There were no postoperative complications, and he was discharged one day later. By the time of his follow-up visit three weeks later, he was riding his bike and had discarded his crutches. An AP pelvis and frog-leg lateral radiographs of both hips were obtained which were normal. At his three-month follow-up visit, the patient complained of a two week history of vague left hip pain. AP and frog-leg lateral radiographs revealed a grade 1 left slipped capital femoral epiphysis. He had an in situ pinning of his left hip the next day without complications .

DISCUSSION

SCFE- Clinical Presentation

• History- duration of Sx
• Symptoms nonspecific- delay in Dx
• Groin, medial thigh, or knee pain
• Limitation of ROM- esp. IR
• Antalgic limp, abductor lurch
• Always examine other hip

SCFE- Radiographic Presentation

• Radiographic assessment- need AP and lateral views(most important)
• True lateral view better than frog-leg
• Klein's line does not intersect epiphysis on AP view
• Widening and irregularity of physis
• Height of epiphysis decreased in central acetabulum on AP view- epiphysis has slipped posteriorly

Epidemiology of Bilateral SCFE

• Incidence of B/L SCFE ~ 25%(21-37%)- 50% present simultaneously
• Long term studies - identified changes c/w bilateral involvement in 60-80% of pts with known unilateral SCFE( silent slips)
• Incidence of B/L involvement is increased in males, African-Americans, obese pts, and pts with a young age(<13.5yrs. for boys and <11.5 in girls) at initial presentation
• When B/L SCFE occurs sequentially, second slip presents within 18 months of initial slip in 88% of patients

Bilateral SCFE and Endocrine Disorders

• Bilateral SCFE associated with an endocrine disorder ~ 7% of patients
• Hypothyroidism- most common
• Wells and coworkers-prevalence of bilaterality in SCFE associated with endocrine disorders was eventually 100%

Prophylactic Pinning of the Contralateral Hip in Patients with SCFE

• Proponents- Emphasize rate of B/L disease and higher risk of osteoarthritis with the increase in slip severity
• Opponents- Stress that in situ pinning can be associated with severe complications and that many hips would be treated unnecessarily
• Trend- Observation of the unaffected hip

1. Patient should be followed with serial radiographs(AP pelvis and lateral view of hip) every 3-4 months
2. Make pt aware of prodromal symptoms
3. If symptoms develop-return immediately for evaluation

• Exceptions

1. 1. Patient with known metabolic or endocrinologic disorder
2. 2. Patient with inability to obtain timely and appropriate follow-up due to personal or family circumstances

REFERENCES

1. Emery R, Todd R, Dunn D: Prophylactic pinning in slipped upper femoral epiphysis: Prevention of complications. J Bone Joint Surg Br 1990; 72:217-219.
2. Hagglund G, Hansson L, Ordeburg G, Sandstrom S: Bilaterality in slipped upper femoral epiphysis. J Bone Joint Surg Br 1988; 70:179.
3. Klein A, Joplin R, Reidy J, Hanelin J:Roentgenographic features of slipped capital femoral epiphysis. Am J Radiology 1951; 66:361.
4. Loder R, Aronson D, Greenfield M: The epidemiology of bilateral slipped capital femoral epiphysis: A study of children in Michigan. J Bone Joint Surg AM 1993; 75:1141-1147.
5. O'Beirne J, McLoughlin R, Dowling F, et al: Internal fixation using single central pins. J Pediatr Orthop 1989; 9:304-307.
6. Rappaport E, Fife D: Slipped capital femoral epiphysis in growth hormone deficient patients. Am J Dis Child 1985; 139:396-399.
7. Segal L, Davidson R, Robertson W Jr, et al: Growth disturbances of the proximal femur after pinning of juvenile slipped capital femoral epiphysis. J Pediatr Orthop 1991; 11:631-637.
8. Ward W, Stefko J, Wood K,, et al: Fixation with a single screw for slipped capital femoral epiphysis. J Bone Joint Surg Am 1992; 74:799-809.
9. Wells D, King J, Roe T, et al: Review of slipped capital femoral epiphysis associated with endocrine disease. J Pediatr Orthop 1993; 13:610-614.