HSS spring SCFE & LCPD

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HSS spring SCFE & LCPD
2013-04-29 10:20:06

HSS spring SCFE & LCPD
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  1. what's slipped capital femoral epiphysis? (SCFE)
    • displacement of fem head on fem neck at physeal plate
    • epiphysis slips down and back in rel to neck of femur
  2. incidence of SCFE
  3. m:f of SCFE, and age for each
    • 2 to 1
    • males 12-15
    • fem 10-14
    • (80% of SCFE cases occur during adolescent growth spurt)
  4. 3 things SC is associated with?
    • obesity
    • delayed bone age
    • African Americans
  5. % that have bilat issues
    • 25%
    • and half of those present initially bilat, the other half have a sequential onset
  6. true etiology of SCFE is unknown, but 4 factors maybe involved?
    • trauma
    • mechanical factors
    • endocrine imbalance
    • genetic influence
  7. acute SCFE
    caused by a traumatic shear force on the growth plate, and the fem head suddenly separates with a crack in the epiphyseal cartilage --> immediate severe pain

    20% of SCFE cases are acute
  8. chronic SCFE
    increased shear forece exerted over time to make a gradual slip -- seen in obese kids

    can be a big load on a normal plate, or a normal load on a weak epiphyseal plate
  9. clinical presentation of SCFE
    • pain in hip or groin
    • referred pain in the knee
    • antalgic gait
    • changes in ROM
    • x-ray
  10. changes in ROM seen in SCFE
    limited abd, flex, IR (often leg is  maintained in ER)

    (flex hip and it'll automatically go into ER)
  11. SCFE classification system
    • I think it's the Wilson or Wheeless ststen
    • based on amount of slip of head from neck
    • min: less than 1/3 diameter of fem neck
    • mod: 1/3 - 1/2
    • severe: slipped greater than 1/2 the neck's diameter
  12. pre-op tx for SCFE
    • traction -- IR
    • this will decrease muscle spasms and soft tissue contractures
  13. SCFE operation
    • reattach fem head to neck
    • using pins, plates screws, bone grafts...

    • AVN
    • chondrolysis
  14. how often do you see AVN post op of SCFE?
    • 1.5-15%
    • involves entire fem head
    • more common in acute SCFE, esp after manipulation
    • medial femoral circumflex artery
  15. chondrolysis def
    acute cartilage necrosis

    mostly in mod or severe SDVE, may be 2/2 pin penetration
  16. results of chondrolysis after SCFE
    rapid progressive narrowing of hip joint w decreased ROM 2/2 loss of articular cartilage
  17. SCFE complications - which do you get more?
    chondrolysis 3x more often then AVN
  18. what kind of wt bearing is ok for the first 3-6 weeks post op of SCFE?
    • NWB - TTWB w crutches
    • initially only amb bed to chair, progressing w MD's orders

    for ROM and strengthening, follow MD's orders
  19. Legg Calve Perthes Disease aka coxa plana
    what is it?
    • idiopathic
    • self-limiting disease of the hip
    • starts w avascular necrosis of fem head --> osteonecrosis of fem capital epiphysis --> resorption, collapse, repair
  20. principle vessel involved in Legg Calve Perthes Disease
    medial femoral circumflex artery (same one that causes AVN in SCFE post-op)
  21. why does AVN happen in LCPD?
    unknown, but some guesses - subchondral fracture, microtrauma, infection, congenital vascular irregularities, thrombotic vascular insults, synovitis
  22. when do kids get LCPD? which age is most common? male to fem ratio? % bilat?
    • 3-13 yrs, but most often at 4-8
    • 4 to 1, m to f
    • 20% bilat
  23. attributes of kids who get LCPD
    • small for age (89% have delayed bone age)
    • lower socioeconomic
    • lower birth wts
    • breech births
    • ADHD
  24. 4 stages of LCPD
    • condensation
    • fragmentation
    • reossification
    • remodeling
  25. condensation in LCPD
    • portion of head becomes necrotic
    • bone growth stops 2/2 lack of blood supply
    • high risk for deformity if not treated
  26. how will condensation in LCPD look on x-ray?
    • fem head is smaller
    • med jt space seems wider
  27. in which stage is revascularization of fem head initiated in LCPD
    2: fragmentation
  28. fragmentation stage in LCPD
    • necrotic bone is reabsorbed and fragmented
    • revascularization of fem head is initiated
    • new bone is being formed on old
    • still, big risk of deformity if not treated
  29. x-rays in fragmentation stage of LCPD?
    epiphysis appears fragmented
  30. reossification stage of LCPD
    • fem head begins to reossify
    • fem head and neck may demonstrate changes in structure and shape
    • bone density returns to normal on x-ray
    • no further deformity will develop
  31. remodeling stage of LCPD
    • remodeling of fem head and acetabulum as the fem head grows
    • they'll retain any residual deformity from the repair process
  32. coxa magna vs coxa breva
    • manga - widening of head and neck
    • breva - shortening

    these are residual deformities seen if LCPD isn't managed
  33. sagging rope sign
    • classic sign of LCPD
    • portion of fem head protruding anterolat & inf
  34. clinical presentation of kid w LCPD
    • small in stature
    • normal labs
    • x-rays dependant on stage
    • thigh, calf, tush atrophy (prob bc of antalgic gait)
    • painful limp
    • pos trendelenburg sign
  35. what's the pain like in LCPD?
    • painful limp
    • referred pain to groin, med thigh, or knee
    • pain increases w activity and decreases w rest
    • tender over ant and post hip joint capsule
  36. which of these will give a pos trendeleneburg?
  37. which muscles spasm in LCPD
    adductors and ilipsoas
  38. ROM limitations in LCPD
    IR and abd

    legl lenght discrepancy 1-2 cm 2/2 collapse of fem head
  39. how to classify LCPD (not the stage system, but by type)
    • type 1: involves <25% of ant fem head, an no collapse or fragmentation
    • type 2: 25-50% of ant fem head with collapse of involved portion
    • type 3: 50-75% of fem head is involved, there's collapse w sequestration of involved portion, and there's metaphyseal involvement
    • type 4: involves entire head, involves collapse, sequestration, and displacement of fem head, extensive metaphyseal involvement
  40. favorable prognosis for LCPD if...
    • onset <6 y/o
    • tx started < 8 y/o
    • early stage of LCPD
  41. poor prognosis for LCPD if...
    • extensive involvement of fem head (type 3 and 4)
    • onset >8y/o
    • incongruency noted at skeletal maturity
  42. 3 principles of treating LCPD
    • relieve symptoms
    • maintain shape of fem head
    • containment
  43. techniques for releif of symptoms for LCPD
    • limit activities
    • traction
    • P/NWB w crutches
    • NSAIDs
  44. containment for LCPD
    • it's the "cornerstone of treatment"
    • puts the fem head in acetabulum in right space to allow proper molding

    must be in stage 1 or 2
  45. a brace used for containment in LCPD
    Scottish Rite brace - puts the kid in abduction, still allows wt bearing
  46. how long to wer containment brace for LCPD (non-operative)
    6-18 months - worn full time until reossification of lat epiphysis occurs
  47. 3 surgical options for LCPD
    • proximal femoral varus osteotomy
    • acetabular osteotomy
    • combined pelvic and femoral osteotomy
  48. femoral varus osteotomy for LCPD - done when? quality of results? who can get it?
    • stage 1 or 2
    • 60-66% have good results
    • must have good ROM, round fem head, good joint congruency
  49. acetabular osteotomy for LCPD  -- does what? % good results?
    • provides containment by redirecting the acetabulum for better ant and lat coverage
    • 75%
  50. who should get an acetabular osteotomy for LCPD
    • >6 y/o
    • mod to severe involvement but only minimal head deformity
  51. combined pelvic and femoral osteotomy - for whom?
    folks w poor prognosis, where one procedure alone can't get adequate coverage of fem head

    minimizes leg shortening, varus deformity, abd weakness
  52. post-op containment for LCPD - what kid of cast? how long?
    • spica
    • ~6 weeks
  53. emphasis of PT post op of LCPD
    follow MD's orders for wt-bearing, A/AAROM, strengthening

    emphasis on hip abd ROM and strenght