Slipped epiphyses and Perthes

1
Slipped epiphyses and Perthes

• Mr Neeraj Garg
• Royal Liverpool Childrens Hospital

2
Slipped Capital Femoral Epiphysis Epidemiology

• Incidence 2 100,000
• Skeletally immature
• Obese
• Boys 1.5 1 Girls
• Boys age 13 Girls age 12
• LgtR (esp. in boys)
• Black gt White
• Bilateral involvement 37

Kelsey. Pediatrics 1973 51 1042-1050 7
Loder et al. JBJS 1993 75-A 1141-114
3
Slipped epiphysis Aetiology

• Vulnerable or widened physis
• Adolescence !
• Hypothyriodism
• Growth Hormone
• Sex hormones
• Renal osteodystrophy
• Radiation

Goldman et al. Radiology 1978 126
333-339. Skinner Clin. Orthop., 135 90-92,
1978.
4
Slipped epiphysis Aetiology

• Mechanical factors
• Trauma
• Obesity
• Femoral retroversion

Gelberman et al. JBJS 1986 68-A 1000-1007.
5
Slipped epiphysis Clinical Presentation

• Obese
• Pain in groin/Knee
• External rotation and abduction with flexion
• Limited Abd/IR
• Increased ER
• Ext Rot Gait

6
Slipped epiphysis Radiographic Classification

• Displacement
• Mild up to 1/3 displaced
• Moderate up to 1/2 displaced
• Severe over 1/2 displaced

7
Slipped epiphysis Clinical Classification

• Stable Chronic
• Unstable-Acute

8
Slipped epiphysis Treatment

• Single 6.5 mm Cannulated Screw

9
Slipped epiphysis Complication
chondrolysis(Acute Cartilage Necrosis)

• Aetiology unknown
• Can occur without treatment
• Persistent Pin Penetration
• Transient Pin Penetration
• Auto immune process postulated
• Antigen - Chondromuco-protein immune complexes in
  synovial fluid

Warner et al. JPO(B) 1996 (5) 168-172 Lubicky.
JPO(B) 1996 (5) 162-167
10
Perthes Disaese

• Perthes 1913
• Self limiting non inflammatory condition
• Degeneration Regeneration
• Sclerosis
• Fragmentation
• Re-ossification
• Healing

11
Perthes Epidemiology

• Usually occurs age 3 -12 years
• Most common age 5 - 7 years
• Bilateral in 10 - 20
• Boy 3-5 1 Girl
• Familial in 8-12
• (Wansbrough et al. JBJS 1959, 41-A 135-146.)

12
Perthes Aetiology

• Unknown
• Genetic Factors
• No strong supportive evidence
• Environmental Factors
• High incidence in inner city Liverpool
• Low Socio-economic status
• Hall et al BMJ 19832871757-1759

13
Perthes Prognostic Factors

• Extent of epiphyseal involvement
• Age at onset of disease
• Sex

14
Perthes Differential Diagnosis

• Septic arthritis
• Transient synovitis
• Slipped femoral epiphysis
• MED/SED
• Systemic Steroids
• Abnormal Coagulation
• Sickle cell
• Thalassaemia
• Leukaemia

• Lymphoma
• ITP
• Haemophilia

15
Perthes Investigation

• Bloods FBC, ESR, CRP, Blood Culture
• Radiographs
• Ultrasound Scan
• Bone Scan
• Decreased bone scan uptake before radiographic
  changes

(Rutskii el al Ortop Travmatol Protez
19891035-39)
16
Perthes Investigation MRI

• Earlier diagnosis than plain radiography
• More information regarding extent of necrosis
  than bone scanning

(Henderson et al. JPO 1990 10 287-297)
17
Perthes Treatment

• Observation
• Containment
• Brace
• Femoral osteotomy
• Pelvic osteotomy