Hip disorders: slipped upper femoral epiphysis
Displacement of the upper femoral
epiphysis on the metaphysis through the hypertrophic zone of the growth plate.
The femoral neck displaces anteriorly and the head remains in the acetabulum.
•
Incidence: the most common adolescent hip
disorder (3:100 000); 25–60%
bilateral.
•
Risk factors: African American, >50% obese
(weight >95th percentile), positive
family history, puberty, boys (12–16yrs) > girls (10–14yrs).
•
Aetiology: unknown, but associated with the
following:
•
Endocrine—hypothyroidism, hypogonadism,
renal osteodystrophy;
•
Mechanical—retroversion of femoral neck or
vertical growth plate;
•
Other—Down syndrome,
radiotherapy/chemotherapy.
Groin, thigh, or knee pain.
Antalgic gait, limited hip fl exion and abduction, flexion into external
rotation, and thigh atrophy.
consider hip pathology in a child
presenting with knee pain.
Characterized by 2 broad types of
children.
•
Obese hypogonadal (low circulating
sex hormones): delayed
skeletal maturation bone age.
•
Tall thin, often boys, post growth
spurt (younger age in girls): overabundance of growth hormones.
This is based on duration of
symptoms.
•
Preslip: wide epiphysis; mild discomfort,
but normal examination; often seen on
contralateral hip.
•
Acute slip: mild symptoms <3wks, then
sudden slippage usually without trauma;
pain so severe child unable to weight bear; usually unstable.
•
Acute on chronic: acute slip on pre-existing chronic
slip; usually have previous symptoms
(pain, limp, out toe gait) for several months; unable to weight bear; usually
unstable.
•
Chronic: most common type; history for
several months; symptoms worsen as
slip progresses; child able to walk with mildly antalgic externally rotated
gait. Usually stable.
•
Slips may be further
sub-classified into stable or unstable (Loder): in an unstable slip’ child unable to weight bear, even with crutches,
and cannot do straight leg raise actively. These have increased risk of AVN.
•
X-Ray: AP pelvis and frog lateral hips.
Widening of physis, Klein’s line intersects
lateral capital epiphysis on AP.
•
MRI: useful in pre-slip diagnosis, and
evidence of AVN.
•
Endocrine tests: if appropriate, e.g. thyroid
function.
The aim is to prevent further
‘slippage’ and to minimize complications. Operative
Usually pin in situ (to encourage the proximal femoral epiphysis to close,
hence preventing further slippage); usually not reduced as manipulation may
increase the incidence of avascular necrosis. Prophylactic pinning of opposite
hip is controversial. It is recommended in younger children and those with
endocrinopathy.
•
Chondrolysis (degeneration of the
articular cartilage of the hip with narrowed joint space, pain, decreased
motion): associated with
more severe slips; occurs more
frequently among African American children and females; associated with pins
protruding out of the femoral head.
Osteonecrosis/avascular
necrosis (higher incidence in unstable hips): due to injury to retinacular
vessels (at time of slip or manipulation) or compression from intracapsular
haematoma. Commonly leads to degenerative joint disease. Avascular necrosis
uncommon in stable slips.
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