HSS spring SCFE & LCPD
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HSS spring SCFE & LCPD
HSS spring SCFE LCPD
HSS spring SCFE & LCPD
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
incidence of SCFE
m:f of SCFE, and age for each
2 to 1
(80% of SCFE cases occur during adolescent growth spurt)
3 things SC is associated with?
delayed bone age
% that have bilat issues
and half of those present initially bilat, the other half have a sequential onset
true etiology of SCFE is unknown, but 4 factors maybe involved?
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
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
clinical presentation of SCFE
pain in hip or groin
referred pain in the knee
changes in ROM
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)
SCFE classification system
I think it's the Wilson or Wheeless ststen
based on amount of slip of head from neck
: less than 1/3 diameter of fem neck
: 1/3 - 1/2
: slipped greater than 1/2 the neck's diameter
pre-op tx for SCFE
traction -- IR
this will decrease muscle spasms and soft tissue contractures
reattach fem head to neck
using pins, plates screws, bone grafts...
how often do you see AVN post op of SCFE?
involves entire fem head
more common in acute SCFE, esp after manipulation
medial femoral circumflex artery
acute cartilage necrosis
mostly in mod or severe SDVE, may be 2/2 pin penetration
results of chondrolysis after SCFE
rapid progressive narrowing of hip joint w decreased ROM 2/2 loss of articular cartilage
SCFE complications - which do you get more?
chondrolysis 3x more often then AVN
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
Legg Calve Perthes Disease aka coxa plana
what is it?
self-limiting disease of the hip
starts w avascular necrosis of fem head --> osteonecrosis of fem capital epiphysis --> resorption, collapse, repair
principle vessel involved in Legg Calve Perthes Disease
medial femoral circumflex artery (same one that causes AVN in SCFE post-op)
why does AVN happen in LCPD?
unknown, but some guesses - subchondral fracture, microtrauma, infection, congenital vascular irregularities, thrombotic vascular insults, synovitis
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
attributes of kids who get LCPD
small for age (89% have delayed bone age)
lower birth wts
4 stages of LCPD
condensation in LCPD
portion of head becomes necrotic
bone growth stops 2/2 lack of blood supply
high risk for deformity if not treated
how will condensation in LCPD look on x-ray?
fem head is smaller
med jt space seems wider
in which stage is revascularization of fem head initiated in LCPD
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
x-rays in fragmentation stage of LCPD?
epiphysis appears fragmented
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
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
coxa magna vs coxa breva
manga - widening of head and neck
breva - shortening
these are residual deformities seen if LCPD isn't managed
sagging rope sign
classic sign of LCPD
fem head protruding anterolat & inf
clinical presentation of kid w LCPD
small in stature
x-rays dependant on stage
thigh, calf, tush atrophy (prob bc of antalgic gait)
pos trendelenburg sign
what's the pain like in LCPD?
referred pain to groin, med thigh, or knee
pain increases w activity and decreases w rest
tender over ant and post hip joint capsule
which of these will give a pos trendeleneburg?
which muscles spasm in LCPD
adductors and ilipsoas
ROM limitations in LCPD
IR and abd
legl lenght discrepancy 1-2 cm 2/2 collapse of fem head
how to classify LCPD (not the stage system, but by type)
of ant fem head, an
collapse or fragmentation
of ant fem head with
of involved portion
of fem head is involved, there's
of involved portion, and there's
displacement of fem head, extensive metaphyseal involvement
favorable prognosis for LCPD if...
onset <6 y/o
tx started < 8 y/o
early stage of LCPD
poor prognosis for LCPD if...
extensive involvement of fem head (type 3 and 4)
incongruency noted at skeletal maturity
3 principles of treating LCPD
maintain shape of fem head
techniques for releif of symptoms for LCPD
P/NWB w crutches
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
a brace used for containment in LCPD
Scottish Rite brace - puts the kid in abduction, still allows wt bearing
how long to wer containment brace for LCPD (non-operative)
6-18 months - worn full time until reossification of lat epiphysis occurs
3 surgical options for LCPD
proximal femoral varus osteotomy
combined pelvic and femoral osteotomy
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
acetabular osteotomy for LCPD -- does what? % good results?
provides containment by redirecting the acetabulum for better ant and lat coverage
who should get an acetabular osteotomy for LCPD
mod to severe involvement but only minimal head deformity
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
post-op containment for LCPD - what kid of cast? how long?
emphasis of PT post op of LCPD
follow MD's orders for wt-bearing, A/AAROM, strengthening
emphasis on hip abd ROM and strenght