Slipped Capital Femoral Epiphysis

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This condition involves the medial and posterior slippage of the capital femoral epiphysis along the physeal line. A slipped capital femoral epiphysis has been associated with a high incidence of genetic markers. In one study (Mullaji et al. 1993) the HLA-B27 antigen was positive in 20% of patients with this disorder. This is a disease of childhood and adolescence, with the peak in the early second decade. Involvement is unilateral in the great majority and bilateral in about 20%. Trauma, growth spurt, obesity, and excessive physical activity are suggested as contributing factors. Histo-logically, the main changes are observed in the hypertrophied chondrocytic zone of the growing physeal plate.

Radiographic diagnosis is obvious when slippage is more than moderate in grade (Fig. 13.10A). However, in milder cases the interpretation is not always easy, requiring multiple projections including the frog-leg view. The most characteristic sign is the craniolateral displacement of the proximal femoral metaphysis or the medioposterior dislocation of the capital femoral epiphysis. The displacement remains incompletely corrected after surgery in rare instances (Fig. 13.11A). Other radiographic signs include osteoporosis with a widened physeal line and an irregular metaphyseal margin. Im

Physeal Zone

Fig. 13.11A, B Incomplete correction with mild residual protrusion. A Postoperative anteroposterior radiograph of the right hip in a 16-year-old boy with slipped femoral epiphysis treated with Knowle's pins shows restoration with minimal protrusion deformity (arrow). B Anterior pinhole scintigraph reveals mild protrusion with intense physeal tracer uptake without evidence of vascular compromise (arrow). Note well positioned nails with tracer uptake in creeping new bone formation

Fig. 13.11A, B Incomplete correction with mild residual protrusion. A Postoperative anteroposterior radiograph of the right hip in a 16-year-old boy with slipped femoral epiphysis treated with Knowle's pins shows restoration with minimal protrusion deformity (arrow). B Anterior pinhole scintigraph reveals mild protrusion with intense physeal tracer uptake without evidence of vascular compromise (arrow). Note well positioned nails with tracer uptake in creeping new bone formation

Slipped Capital Femoral Epiphysis

Fig. 13.12A, B Late consequences of improperly treated slipped femoral epiphysis. A Anteroposterior radiograph of the left hip in a 59-year-old man with untreated slippage shows coxa vara deformity with flattened femoral head, widened neck, articular narrowing, and bizarre acetabular hyperostosis (arrow). B Anterior pinhole scintigraph reveals findings of advanced secondary osteoarthritis with intense tracer accumulated in the closed joint and axial dislocation of the crooked femoral neck (arrow)

Fig. 13.12A, B Late consequences of improperly treated slipped femoral epiphysis. A Anteroposterior radiograph of the left hip in a 59-year-old man with untreated slippage shows coxa vara deformity with flattened femoral head, widened neck, articular narrowing, and bizarre acetabular hyperostosis (arrow). B Anterior pinhole scintigraph reveals findings of advanced secondary osteoarthritis with intense tracer accumulated in the closed joint and axial dislocation of the crooked femoral neck (arrow)

mediate or earliest possible surgical restoration is most desirable to prevent disabling deformity that may last for life. When left untreated or inadequately handled, coxa vara deformity with flattened femoral head, widened neck, articular narrowing, and bizarre acetabular hyperostosis become unavoidable (Fig. 13.12A).

99mTc-MDP bone scintigraphy is almost always performed after surgical reduction and refixation. Naturally, the scan shows increased tracer uptake in the repositioned physeal line, reflecting slippage, operative injury, and repair (Fig. 13.10C). Occasional patients, however, may present with residual craniolateral buckling of the proximal femoral metaphysis (Fig. 13.11B). Scintigraphy is an ideal means to obtain information on vascularity and anatomy following surgery and pinning (Figs. 13.10 and 13.11). Bone scanning is ideal for an integrated assessment of the anatomy, vasculariza-tion, metabolic profile, and complication of the capital femoral slippage both treated and untreated (Fig. 13.12).

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