PERTHES DISEASE & SLIPPED

CAPITAL FEMORAL EPIPHYSIS

Dr. Gulzar Saeed
MBBS FCPS
Professor & Head
Department of Orthopedic Surgery
FRPMC Karachi
 PERTHES DISEASE
Legg-Calve-Perthes Disease is an idiopathic
avascular necrosis of the proximal femoral
epiphysis in children.
 PERTHES DISEASE

• Affects 1 in 10,000 children

• 4-8 years is most common age of presentation
• Male to female ratio is 5:1
• Higher incidence in urban areas and among lower
socioeconomic class
• Bilateral in 12%
 PERTHES DISEASE
RISK FACTORS

• Positive family history

• Low birth weight
• Abnormal birth presentation
 ETIOLOGY
PATHOPHYSIOLOGY

• Disruption of blood supply to femoral head- osteonecrosis-

revascularization with subsequent resorption and later collapse-
creeping substitution - remodelling after collapse
• Controversial aetiology
• Thrombophilia has been reported to be present in 50% of patients
• Up to 75% of affected patients have some form of coagulopathy
• Repeated subclinical trauma and mechanical overload lead to bone collapse and repair
(multiple-infarction theory)
• Maternal / passive smoking
 CATTERALL CLASSIFICATION

Based on degree of head involvement

• Group I- Involvement of the anterior epiphysis only
• Group II- Involvement of the anterior epiphysis with a
central sequestrum
• Group III-Only a small part of the epiphysis is not
involved
• Group IV-Total head involvement
 CATTERALL
CLASSIFICATION
• Group I- Involvement of the
anterior epiphysis only
• Group II- Involvement of
the anterior epiphysis with a
central sequestrum
• Group III-Only a small part
of the epiphysis is not
involved
• Group IV-Total head
involvement
 PRESENTATION

• Symptoms: insidious onset- may cause painless limp-

intermittent hip, knee, groin or thigh pain
• Physical exam- hip stiffness- loss of internal rotation and
abduction-gait disturbance-antalgic limp-Trendelenburg
gait (head collapse leads to decreased tension of
abductors)-limb length discrepancy.
 IMAGING

• Radiographs: AP of pelvis and frog leg laterals-medial joint space

widening (earliest) from less ossification of head-irregularity of femoral
head ossification-decreased size of ossification center
• sclerotic appearance-cresent sign (represents a subchondral fracture)
• Bone scan: can confirm suspected case of LCPD-decreased uptake (cold
lesion) can predate changes on radiographs ;provides information on
extent of femoral head involvement
• MRI : early diagnosis revealing alterations in the capital femoral
epiphysis and physis ;more sensitive than radiograph
PERTHES DISEASE- IMAGING
PERTHES DISEASE- IMAGING
 TREATMENT
• TREATMENT GOALS
• Resolution of symptoms: NSAIDs, traction, crutches, restoration of range of motion
• Physic al therapy ,
• containment of hip
• Improve range of motion, bracing, proximal femoral osteotomy, pelvic osteotomy
• Ensure that femoral head is well seated in acetabulum
 TREATMENT
• Nonoperative: observation alone, activity restriction (non-weightbearing), and physical
therapy (ROM exercises)
• Indications: children < 8 years of age
• Operative: femoral and/or pelvic osteotomy
• indications: children > 8 years of age,
• technique: proximal femoral varus osteotomy to provide containment
• pelvic osteotomy: Salter or triple innominate osteotomy
• Shelf arthroplasty may be performed to prevent lateral subluxation and resultant lateral
epiphyseal overgrowth
 SLIPPED CAPITAL FEMORAL EPIPHYSES

A condition of the proximal femoral physis that

leads to slippage of the metaphysis relative to the
epiphysis, and is most commonly seen in adolescent
obese males
 SLIPPED CAPITAL FEMORAL
EPIPHYSES
• Occurs due to axial and rotational mechanical forces which act on a
susceptible physis
• Metaphysis translates anterior and externally rotates epiphysis remains
in the acetabulum and lies posterior/inferior to the translated
metaphysis
• Increased risk in adolescence because: the perichondrial ring thins and
weakens, physis is still vertical in this age group (160° at birth to 125° at
skeletal maturity), which results in increased shearing forces
 SLIPPED CAPITAL FEMORAL
EPIPHYSES
• Associated conditions: endocrine disorders
• Hypothyroidism. labs: elevated TSH
• renal osteodystrophy. labs: elevated BUN and creatinine
• growth hormone deficiency
• panhypopituitarism
• endocrine workup indicated if child is < 10 years old
 SLIPPED CAPITAL FEMORAL
EPIPHYSES: PRESENTATION
• History: most commonly atraumatic, although some present after an
injury. pain has often been present for several months
• Symptoms: pain in hip (52%), groin (14%) and thigh (35%)
• knee pain: 15-50% present with knee pai
• physical exam – inspection-abnormal gait / limp-antalgic, waddling,
externally rotated gait or Trendelenburg gait-abnormal leg alignment
• loss of hip internal rotation, abduction, and flexion
 IMAGING
• Radiographs: recommended views :AP & frog-leg lateral of both hips
• Lateral radiograph is best way to identify a subtle slip
• findings
• Klein's line: line drawn along superior border femoral neck on AP pelvis will intersect less
of the femoral head or not at all in a child with SCFE intersects lateral femoral head in a
normal hip due to natural lateral overhang of the epiphysis .evaluate for asymmetry between
sides
• "S" sign: line drawn along inferior cortical outline of femur in frog-leg lateral view normally
extends from proximal femur head/neck junction to the proximal femoral physis but in
SCFE there will be a sharp turn or break in continuity of this line
• epiphysiolysis (growth plate widening or lucency)
• findings
• Klein's line
• line drawn along superior border femoral neck on AP pelvis
• will intersect less of the femoral head or not at all in a child with SCFE
• intersects lateral femoral head in a normal hip due to natural lateral overhang of the epiphysis
• evaluate for asymmetry between sides
• "S" sign
• line drawn along inferior cortical outline of femur in frog-leg lateral view
• normally extends from proximal femur head/neck junction to the proximal femoral physis but in
SCFE there will be a sharp turn or break in continuity of this line
• epiphysiolysis (growth plate widening or lucency)
S.U.F.E
 TREATMENT

• Operative: percutaneous in situ fixation

• indications : both stable and unstable slips
• Outcomes: good or excellent outcomes in >90% of cases
• open epiphyseal reduction and fixation
• indications (controversial): unstable and severe slips
THANK YOU