Limp: Non-infectious HipMichael Peyton, MD

Slipped Capital Femoral Epiphysis (SCFE)

Pathology

Femoral head (epiphysis) of the

proximal femur displaces on the

femoral neck due to weakness in the

hypertrophic zone of the growth plate

(physis)

Slipped Capital Femoral Epiphysis (SCFE)

Contributing Factors

● Obesity / Puberty

○ Inc stress across physis

○ Inc prevalence younger

● Metabolic derangement

○ Inherently weakening physis

Epidemiology

● Pre- / Adolescent (Puberty)

● 1.5 Male > F

● Greater in black, Hispanic,

Polynesian, Native Americans

Slipped Capital Femoral Epiphysis (SCFE)

Presentation

● Groin/hip or knee pain

○ Acute vs Chronic (>3wk)

● Painless limp with external rotation

of the affected leg

● Limited hip ROM - decreased

internal rotation, flexion,

abduction

● Obligatory external rotation with

passive hip flexion

Slipped Capital Femoral Epiphysis (SCFE)

Unstable SCFE

● Unable to bear weight

● High risk for osteonecrosis

● Risk of early osteoarthrosis

Imaging Evaluation

● AP and frog-leg lateral XR

● MRI - only if not seen on XR with

high suspicion or risk of

contralateral slip

● CT - only for presurgical planning

Klein Lines - line extended from lateral cortex that intersects femoral epiphysis

Slipped Capital Femoral Epiphysis (SCFE)

Lab Evaluation

Consider for:

● < 10 years old

● Weight < 50%ile

● Suspected endocrine

○ Hypothyroidism - thyroid function

○ Osteodystrophy of chronic renal failure - BUN and Cr

Slipped Capital Femoral Epiphysis (SCFE)

Treatment

● Stabilize physis with

percutaneous in situ fixation

● Contralateral tx for high risk pt

Prognosis

● Leg length discrepancy

● Osteonecrosis

● Osteoarthritis

● Impingement

● 45% require total hip

replacement by 50 yo

Legg-Calve-PerthesPathology

Idiopathic osteonecrosis of the

femoral capital (head) epiphysis

Disruption of Blood Supply -> Bone

Resorption -> Femoral Head

Weakening and Flattening ->

Reossification -> Growth Resumption

Epidemiology

● School aged (4-8 yo)

● 3:1 M:F

● Bilateral in 10-15%

Legg-Calve-Perthes

Possible Risk Factors

● Collagen type II mutations

● Coagulation abnormalities

● Microtrauma from repetitive hip

loading and extreme hip flexion

(gymnast and dancers)

● Venous congestion

● Hyperactive behavior (ADHD)

Legg-Calve-Perthes

Presentation

● Painless limp

● Referred pain to knee (femoral n.),

medial thigh (obturator n.), buttock

(sciatic n.)

● Limited hip abduction and internal

rotation

● Weak quadriceps and hip

abductions from atrophy

Limited ABduction of left hip

Limited internal rotation of left hip

Limited internal rotation of left hip (prone)

Legg-Calve-Perthes

Imaging Evaluation

● AP pelvic and bilateral frog-leg

● MRI - accurate for early dx

Early signs - flattening of left femoral head and subchondral sclerosis

Later signs - extrusion of femoral head laterally, not contained by acetabulum

Legg-Calve-Perthes

Diagnosis of Exclusion

Consider other diseases causing osteonecrosis of femoral head

● Sickle cell disease

● Lupus

● Chemotherapy

● Long-term steroid use

Legg-Calve-Perthes

Treatment and Prognosis

● Early referral to peds ortho

● Tx varies, but no cure

● Goal: maintain shape to prevent

degenerative changes and loss

of hip ROM

Developmental Dysplasia of the Hip (DDH)

● Ranges from mild acetabular

dysplasia to frank hip dislocation

● RF: breech, female, firstborn, family

hx, oligohydramnios; prolonged

swaddle

● Tx goal: maintain concentric

reduction of the femoral head in the

acetabulum to allow continued

normal development of the hip

Developmental Dysplasia of the Hip (DDH)

Hip Exam: Newborn

● Barlow: adduct hip midline and apply posterior force

○ → + clunk from subluxation

○ +Barlow = femoral head rests in acetabulum, but pathologic instability

● Ortolani: after Barlow maneuver, abduct the hips while applying anterior-

directed pressure at the greater trochanters

○ → + if femoral head relocates (clunk)

○ +Ortolani = femoral head is dislocated at rest

● Sensitivity 54%

Developmental Dysplasia of the Hip (DDH)

Hip Exam: older infant or walking child

● Leg length discrepancy

● Thigh-fold asymmetry

● Limited hip abduction

● Galeazzi sign

● Trendelenburg gait or Waddling Gait

US is useful in neonate with little

ossification of the acetabulum and

no ossification center of the

femoral head (<3 mo)

Screening US for < 6 mo with 1 or

more significant risk factors

Evidence is used to support treating hip dislocation (Ortolani+)

while observing milder instability (Barlow+)

Hip Trauma

Traumatic Hip Dislocation (usually posterior)

● < 10 yo = due to low injury sports, trip, or fall

● > 10yo = high energy MVA

● Urgent closed reduction → open if intraarticular fragment following reduction

Fractures to consider in high energy mechanism

● Femoral head, neck

● Proximal femur physis

● Pelvic ring

● Acetabular (lower incidence compared to adults due to cartilaginous

acetabulum and ligamentous laxity)