9/7/14

1

Evaluation  of  a  child  with  a  limp  /  Slipped  

Capital  Femoral  Epiphysis  (SCFE)  

 Lee  S.  Segal,  MD  

Chief,  Division  of  Pediatric  Orthopedics  American  Family  Children’s  Hospital  

Department  of  Orthopedics  and  Rehabilitation,    University  of  Wisconsin  School  of  Medicine  and  

Public  Health      Madison,  WI  

Evaluation  of  a  child  with  a  limp  /  Slipped  Capital  Femoral  Epiphysis  (SCFE)  

 

I  have  no  financial  relationships  related    

to  disclose  

Introduction  

•  common  presentation  to  pediatric  orthopaedic  office  

•  limp  can  be  caused  by  pain,  weakness,  or  mechanical  factors  

•  requires  thorough  history  and  physical  examination  

 

Evaluation  of  the  limping  child  

narrow  differential  dx  based  upon    

1.  Gait  2.  Location  3.  Age  

– Toddler  (<4y)  – Child  (4-­‐10y)  – Adolescent  (>10y)  

4.  Pain  

Normal  gait   Abnormal  gait    

•  Trendelenburg    •  equinus              (toe-­‐walking)  

•  circumduction/  vaulting  

•  steppage    

9/7/14

2

Non-­‐antalgic  gait  

•  Equinus:    CP,  congenitally  tight  heel  cord,  LLD,  clubfoot  

•  Trendelenberg:    LCP,  DDH,  SCFE,  Muscular  dystrophy  

•  Circumduction/Vaulting:    CP,  LLD,  any  stiffness  of  ankle/knee  

•  Steppage:    CMT,  CP,  Spina  Bifida    

History  

•  Is  limp  associated  with  or  without  pain?  •  PQRST-­‐  characterize  pain  

– Provokes,  Palliates  – Quality  – Radiate,  Referred  – Severity  – Timing  

•  PMH  •  Family  history  

Physical  examination  

•  gait  •  table-­‐top  exam  (supine,  prone)  

•  Take  age  of  child  into  consideration  with  exam  

 

Imaging  •  radiographs  

(comparison,  oblique)  

•  bone  scan  •  ultrasound    •  CT    •  MRI    

 

•  CBC  with  Diff  •  ESR  /  CRP  •  Lyme  titer  •  rheum  (ANA,  RF)  •  joint  aspiration        (cell  count,  etc)  

Lab  tests   Critical  Questions  Flynn  J,  Widmann  RF:  The  Limping  Child:  Evaluation  and  Diagnosis.    JAAOS  2001  

•  Is  the  limp  due  to  pain?  •  Did  the  pain  occur  suddenly  or  gradually,                        

or  has  it  always  been  there?  •  Is  the  child  systemically  ill?  •  Does  the  child  exhibit  a  specific  gait  pattern?  •  Can  the  pain  be  localized?    

9/7/14

3

Toddler  (<4y)  •  Toddler’s  fracture    •  DDH  •  osteomyelitis,  septic  

arthritis  •  JA,  Lyme  •  tumor  (benign/

malignant)  •  Non-­‐accidental  trauma  

DDH:  3+8  month  old  ♀  

In  toddler,  not  uncommon  to  present  with  a  LLD  and  limp  

Risk  Factors  •  4  “F’s”:  Breech,  +FH,  1st  born,  

female  (6:1)  •  Uterine  compression  syndrome  •  Associated  structural  

abnormalities  •  Ethnic  groups  •  *  majority  of  infants  with  DDH  

don’t  have  a  risk  factor  •  *  safe  swaddling  

Treatment  depends  on  age  of  presentation  

0-­‐6  months    •  Pavlik  harness  6-­‐18  months  •  Hip  arthrogram,  +/-­‐  

adductor  tenotomy,  closed/open    reduction  and  hip  spica  cast  for  12-­‐18  weeks  

>  3  years  late  discovery  DDH  

open  reduction  with  femoral  shortening  +  pelvic  osteotomy

Child  (4-­‐10y)  •  Pediatric  bone  and  

joint  infection  /  synovitis  

•  Legg-­‐Calve-­‐Perthes  •  fracture  •  OCD  •  Foreign  body  •  Tumor  •  Lyme  disease    

•  Transient  synovitis  •  Septic  arthritis  •  Osteomyelitis  

9/7/14

4

Transient  Synovitis  •  Hip  joint  most  often  affected  •  Mild  pain  ,  fever,  stiffness,  lab  abnormalities        

(T<101,  ESR<  50,  WBC<  15,000)  •  Tolerate  movement  of  hip  if  done  cautiously  •  U/S  shows  minimal  fluid  in  joint  •  TX-­‐  Rest  and  NSAIDS  •  Improvement  is  usually  within  a  few  days  to  2  wks  •  Wax  and  wane,  recurrence  

Septic  arthritis  hip  joint  commonly  involved  

§  Child  appears  toxic,  irritable  §  Severe  pain  with  joint  ROM  §  U/S  demonstrate  joint  effusion  §  Neonate  often  has  multiple  

joint  involvement,  may  not  mount  inflammatory  response  (fever,  ESR,  WBC)  

§  Don’t  want  to  miss  septic  hip,  severe  sequelae  

§  Confirm  with  aspiration  

normal  

fluid  

Transient  synovitis  vs  septic  arthritis  of  hip  

Prediction  of  septic  arthritis  is  93%  with  3  or  more  of  the  following  (Kocher  criteria)  

•  Fever  •  NWB  

•  ESR  >40  • WBC  >12,000                                                                                      

      *  Does  not  replace  the  clinical  exam    

Septic  arthritis  of  the  hip  

•  Infant  with  septic  arthritis  of  the  left  hip  

•  Hip  held  rigidly  in  the  classic  position  of  flexion,  abduction,  and  external    rotation  

•  position  that  maximizes  capsular  volume  

•  Infant  relatively  comfortable  as  long  as  the  hip  remains  immobile  in  this  position  

Septic  Arthritis  

•  Diagnosis  is  made  via  hip  joint  aspiration  (US  or  in  OR)  

•  Treatment  is  drainage  and  irrigation,  followed  by  antibiotics  

•  Early  treatment  is  important  for  a  good  result  

•  Identify  the  cause,  determine  which  antibiotic,  duration,  route  

Legg–Calve-­‐Perthes  Disease  

•  Most  common  in  children  4  to  8  yrs  old  

•  Males  >  females  affected  Insidious  limp  is  most  common  presentation  

•  Limited  hip  abduction  and  internal  rotation  on  exam  

9/7/14

5

LCP  -­‐  etiology  Unknown  –  source  of  frustration,  

2  prevailing  theories    

(1)  disruption  of  blood  supply    *  disturbance  clotting  mechanism    *  hyperviscosity            Factor  Leiden  V,  Protein  S  and  C  deficiency  

(2)  underlying  systemic  disorder    primary  disorder  of  epiphyseal  cartilage?    delayed  skeletal  maturation,  shorter  stature,  ADHD  

Perthes  Disease  temporal  classification  -­‐  xray  

Initial Fragmentation Reossification Healed 9 Mo 32 Mo 10 yr

classification  

Extent  of  involvement  

• Catterall  • Lateral  Pillar  

prognosis  

•  Age  at  presentation  (<6  years)  •  Extent  of  involvement    •  Perfusion  MRI    •  Duration  of  disease  process  •  Clinical  ROM  

Treatment  principles  goal  –  maintain  sphericity  femoral  head  

•  Maintain  ROM  (PT,  NSAID,  petrie  casts)  •  Containment  (bracing  vs  surgery)  •  If  >6  yo  or  lateral  pillar  B/C,  hip  subluxation,  other  

treatment  may  be  considered  (femoral  or  pelvic  osteotomy)  

•  Long  term  prognosis  depends  on  residual  femoral  head  deformity  

Adolescent  (>10  yrs)  CITMAT  

•  Sports  -­‐  related  stress  fractures  (overuse,  repetitive),  OCD  

•  Transitional:  SCFE,  tarsal  coalition,  Osgood-­‐Schlatter      

•  Inflammation:  Juvenile  arthritis,    •  Infection:  Osteomyelitis,  Lyme  

disease  •  Tumor  

9/7/14

6

The  limping  child  

•  Common  musculoskeletal  presentation  

•  Determine  gait  pattern,  associated  with  or  without  pain,  age  of  child,  and  localization  

•  Establish  differential  DX,  choose  appropriate  studies  to  confirm  diagnosis  

•  Be  familiar  with  treatment  with  relation  to  condition  

Slipped  Capital  Femoral  Epiphysis  (SCFE)  “the  unsolved  adolescent  hip  disorder”  

•  Most  common  adolescent  hip  disorder  

•  Missed  or  delay  in  diagnosis  

•  Asymptomatic,  chronic  SCFE  “tilt  deformity”  

•  Etiology  remains  unknown  

etiology  remains  unknown  

mechanical

genetic

inflammatory trauma

endocrine

Missed  or  delay  in  diagnosis  

Kocher  et  al  Pediatrics  2004  •  Median  delay  8  weeks    •  Significant  relationship:  delay  in  dx  à  

increase  slip  severity  Matava  JPO  1999  •  Isolated  distal  thigh  or  knee  pain  

common  presentation  •  Leads  to  higher  rates  of  missed  dx,  

unnecessary  x-­‐rays,  and  more  severe  slips  

Silent  slip     Silent slip

9/7/14

7

Silent  slip   Silent  slip  à  tilt    /  pistol  grip  deformity  

Clinical  presentation  

•  May  complain  of  hip,  thigh,  or  knee  pain  (Hilton’s  Law)  

•  Extremity  externally  rotated  •  +  roll  test  •  +/-­‐    ability  to  WB    •  **  Any  older  child  or  adolescent  

with  knee  pain  has  a  SCFE  until  proven  otherwise  

Treatment  goals  

•  Preventing  progression  of  the  slip  

•  Promote  closure  of  the  growth  plate  

•  Minimizing  risks  of  AVN  /  chondrolysis  

•  Prophylactic  pinning  of  contralateral  hip  controversial  in  NA  

Narrow  age  range  at  presentation  

•  Males    -­‐        12.7  yrs  •  Females    -­‐    11.6  yrs  •  Beyond  this  range  (+/-­‐  2  yrs)  –  consider  endocrine  or  systemic  disorder  (atypical)  

Atypical  SCFE  

•  Below  10th  percentile  for  height  for                              chronologic  age  

•  Bilateral  presentation  •  Juvenile  •  Consider  associated  endocrine  disorder  :  

hypothyroidism  (esp.  if  <  10)  •  pituitary  and  parathyroid  abnormalities  •  VDRR  •  Radiation  exposure  •  GH  treatment  

Renal  osteodystrophy

9/7/14

8

smooth  k-­‐wires/semitubular  plate  (1996)  

kidney  transplant  (2005)

Epidemiology  

•  Incidence  -­‐  2/100,000  •  Ethnic  variation  •  Seasonal  variation  •  Geographic  variation      (40o  latitude)  

•  Bilateral  25%  (?)  

40o

classification  

•  Traditional  (temporal)  – Acute,  acute  on  chronic,  chronic  

•  Physeal  stability  •  Severity  of  slip  

Acute  SCFE  

•  Onset  <  3  weeks  •  Epiphyseal  displacement  

without  remodeling  •  High  risk    AVN  >15%  

Physeal  stability  

Loder  et  al  JBJS  75A,  1993  •  Clinical  evaluation  •  Unstable  -­‐  “patient  presents  with  

severe  hip  pain,  and  is  unable  to  walk  with  or  without  crutches,  regardless  of  the  duration  of  symptoms”  

•  Fluoroscopic  evaluation  •  *prognostic  importance  

pathophysiology  

•  Direction  of  slip  •  True  posterior  •  Hypertrophic  zone  of  physis  

9/7/14

9

Torsional  basis  /  SCFE  

•  Both  coronal  +  sagittal  planes  of  shear  loading  

•  Displacement  of    CFE    resolved  by  common  torsional  force    

torsional basis of SCFE

radiographs  **  must  obtain  both  AP  and  

frog-­‐lateral  x-­‐rays  of  the  pelvis  

•  AP  radiograph  -­‐  Difficult  to  recognize  minimal  slip  

Clues  •  Klein’s  line  •  Decreased  epiphyseal  

height  •  Blanch  sign  

AC 7-7-97

AC 9-30-1997 Goals  of  Treatment  (older)  

•  Prevent  further  slip*    •  Promote  premature  physeal  closure*  •  Minimize  risks  associated  with  SCFE  

Evolving  concepts  with  SCFE  

•  FAI  –  femoral  acetabular  impingement    

9/7/14

10

treatment  •  Always  consider  dx  •  Don’t  send  home  •  Differentiate  stable  vs.  

unstable  •  Do  not  allow  further  

ambulation  •  Surgical  “urgency”  •  standard  of  care  North  

America  :  in-­‐situ  single  screw  fixation  

NORTH  AMERICA  •  CANNULATED  SCREW  

FIXATION/single  •  B/L  INCIDENCE  25%      •  OBSERVE  

CONTRALATERAL  HIP  

GERMANY  •  K–WIRE  FIXATION  •  B/L  INCIDENCE  75%    •  STABILIZE  

CONTRALATERAL  HIP  

Entry  site  different  than  pinning  hip  fracture  

9/7/14

11

9/7/14

12

risks  • AVN  • chondrolysis  

•  Unstable  •  Slip  severity  •  Iatrogenic    •  Segmental  vs  global  

pitfalls  

a.  Growth  disturbance  /  premature  closure  b.  Subtrochanteric  fracture  c.  Strip  screws  upon  attempt  to  remove  

a.  

b.  

c.   Pin  in  situ  for  severe  SCFE  In  past  used  to  consider  osteotomies  to  compensate  for  deformity  

osteotomies  

AVN  risk    higher    closer  to  deformity  

A C

New  concepts  

•  Contralateral  hip  –  prophylactic  stabilization  

•  Femoral  acetabular  impingement  (FAI)  

•  Open  surgical  hip  dislocation  

9/7/14

13

Femoral  Acetabular  Impingement  (FAI)  

CAM  FAI  

Open  surgical    hip  dislocation  Preserve  blood  supply  

Surgical  hip  dislocation  protects  blood  supply  to  femoral  head  

summary  

•  Any  adolescent  with  knee  pain  is  a  SCFE  until  proven  otherwise  

•  Always  obtain  x-­‐ray  of  pelvis  •  Always  obtain  2  views  (AP/Frog)  •  Surgical  “urgency”  –  don’t  send  home  •  Delay  in  Dx  increases  risk  of  slip  severity  

Thank  you