HSS spring SCFE & LCPD

• displacement of fem head on fem neck at physeal plate
• epiphysis slips down and back in rel to neck of femur

1/100,000

• 2 to 1
• males 12-15
• fem 10-14
• (80% of SCFE cases occur during adolescent growth spurt)

• obesity
• delayed bone age
• African Americans

• 25%
• and half of those present initially bilat, the other half have a sequential onset

• trauma
• 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

• pain in hip or groin
• referred pain in the knee
• antalgic gait
• changes in ROM
• x-ray

limited abd, flex, IR (often leg is  maintained in ER)

(flex hip and it'll automatically go into ER)

• 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

• traction -- IR
• this will decrease muscle spasms and soft tissue contractures

• reattach fem head to neck
• using pins, plates screws, bone grafts...

• AVN
• chondrolysis

• 1.5-15%
• 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

rapid progressive narrowing of hip joint w decreased ROM 2/2 loss of articular cartilage

chondrolysis 3x more often then AVN

• NWB - TTWB w crutches
• initially only amb bed to chair, progressing w MD's orders

for ROM and strengthening, follow MD's orders

• idiopathic
• self-limiting disease of the hip
• starts w avascular necrosis of fem head --> osteonecrosis of fem capital epiphysis --> resorption, collapse, repair

medial femoral circumflex artery (same one that causes AVN in SCFE post-op)

unknown, but some guesses - subchondral fracture, microtrauma, infection, congenital vascular irregularities, thrombotic vascular insults, synovitis

• 3-13 yrs, but most often at 4-8
• 4 to 1, m to f
• 20% bilat

• small for age (89% have delayed bone age)
• lower socioeconomic
• lower birth wts
• breech births
• ADHD

• condensation
• fragmentation
• reossification
• remodeling

• portion of head becomes necrotic
• bone growth stops 2/2 lack of blood supply
• high risk for deformity if not treated

• fem head is smaller
• med jt space seems wider

2: fragmentation

• 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

epiphysis appears fragmented

• 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 of fem head and acetabulum as the fem head grows
• they'll retain any residual deformity from the repair process

• manga - widening of head and neck
• breva - shortening

these are residual deformities seen if LCPD isn't managed

• classic sign of LCPD
• portion of fem head protruding anterolat & inf

• small in stature
• normal labs
• x-rays dependant on stage
• thigh, calf, tush atrophy (prob bc of antalgic gait)
• painful limp
• pos trendelenburg sign

• 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

LCPD

adductors and ilipsoas

IR and abd

legl lenght discrepancy 1-2 cm 2/2 collapse of fem head

• 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

• onset <6 y/o
• tx started < 8 y/o
• early stage of LCPD

• extensive involvement of fem head (type 3 and 4)
• onset >8y/o
• incongruency noted at skeletal maturity

• relieve symptoms
• maintain shape of fem head
• containment

• limit activities
• traction
• P/NWB w crutches
• NSAIDs

• 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

Scottish Rite brace - puts the kid in abduction, still allows wt bearing

6-18 months - worn full time until reossification of lat epiphysis occurs

• proximal femoral varus osteotomy
• acetabular osteotomy
• combined pelvic and femoral osteotomy

• stage 1 or 2
• 60-66% have good results
• must have good ROM, round fem head, good joint congruency

• provides containment by redirecting the acetabulum for better ant and lat coverage
• 75%

• >6 y/o
• mod to severe involvement but only minimal head deformity

folks w poor prognosis, where one procedure alone can't get adequate coverage of fem head

minimizes leg shortening, varus deformity, abd weakness

• spica
• ~6 weeks

follow MD's orders for wt-bearing, A/AAROM, strengthening

emphasis on hip abd ROM and strenght