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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
- males 12-15
- fem 10-14
- (80% of SCFE cases occur during adolescent growth spurt)
3 things SC is associated with?
- delayed bone age
- African Americans
% 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?
- mechanical factors
- endocrine imbalance
- genetic influence
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
- antalgic gait
- 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
- min: less than 1/3 diameter of fem neck
- mod: 1/3 - 1/2
- severe: 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
- 20% bilat
attributes of kids who get LCPD
- small for age (89% have delayed bone age)
- lower socioeconomic
- lower birth wts
- breech births
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
- portion of fem head protruding anterolat & inf
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
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
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)
- 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
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)
- onset >8y/o
- incongruency noted at skeletal maturity
3 principles of treating LCPD
- relieve symptoms
- maintain shape of fem head
techniques for releif of symptoms for LCPD
- limit activities
- 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
- acetabular 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
- >6 y/o
- 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