etiology, clinical features, investigations to be done and management

1. Slipped capital femoral
epiphysis
Presenter- Dr.Madhukar

2. INTRODUCTION
• The capital femoral
epiphysis is unique.
• It is one of the few
epiphysis in the body
that is inside the joint
capsule.

3. Definition
• SCFE term refers to slippage of the overlying
epiphysis of proximal femur posteriorly and
inferiorly due to weakness of the growth plate in
relation to metaphysis.
• Although this disorder is termed slipped capital
femoral epiphysis(SCFE), this is a misnomer. The
femoral epiphysis maintains its normal
relationship within the acetabulum, and it is the
femoral neck and the shaft that displace upwards
and anteriorly relative to the femoral epiphysis
and acetabulum.

4. Epidemiology
• Incidence is 2-3 per 100,000 population.
• Most common in adolescent period with rapid growth
plate (boys 10-16yrs; girls 12-14yrs)
• Very early onset <10yrs and very late onset >16yrs
should be evaluated for endocrine disorders.
• Males have 2.4 times the risk as females.
• Obesity is a risk factor because it places more shear
forces around the proximal growth plate in the hip.
• Bilateral slippage is common of which 2nd slip is about
12-18 months later to the 1st (left is effected 1st before
right)

5. Etiology
• Local trauma
• Obesity
• Endocrine disorders (like primary or secondary
hupoparthyroidism, adiposogenital
dystrophy(hypogonodal male)
• Growth hormone deficiency
• Atypical SCFE is associated with renal failure,
radiation therapy.

6. Pathology
• The epiphysis slowly displaces inferiorly and
posteriorly with the femoral neck shifting upward and
rotating anteriorly to the anterverted position thus
resulting in varus deformity, adduction and external
rotation of the femur.
• The displacement takes place through the layer of
hypertrophied mature cartilage cells adjacent to the
calcified cartilage zone
• The interval produced by separation becomes filled
with fibrous tissue, embryonic cartilage and callus
particularly at the posterior and inferior angle

7. Abduction and internal rotation of the hip are
greatly limited by 2 factors
- large hump formed by the fibrous cartilage
overgrowth about the anterior exposed portion
of the neck impinges against the anterior and
superior margins of the acetabulum
-The capital epiphysis is fixed posterior and inferior
where further outward movement is limited by
its impingement against capsule

8. Classification
• Based on symptoms
-acute
-chronic
-acute on chronic
• Functional classification
-stable
-unstable
• Depending on head shaft angle
-mild
-moderate
-severe

9. • Acute slip: sudden onset of usually severe
symptoms that have been present for less
than 2 weeks.x-ray shows displacement
without any bone healing
• Chronic slips –gradual onset and symptoms
of more than 2weeks duration some bony
healing and remodeling along the medial
femoral neck usually seen on x -rays

10. • Acute on chronic—symptoms lasting longer
than one month and a recent sudden
exacerbation of pain after a relatively trivial
injury
• Pre-slip– essentially an x-ray finding
manifested by irregularity widening and
indistinctness of the epiphyseal plate

11. • Depending on head shaft angle

13. Mild slipping – exist when the neck is displaced less than
1/3 rd of the diameter of the femoral head or when the
head shaft angle deviates from normal by 30 degrees
or less on both a,p and lateral views
Moderate slipping—when neck is displaced between 1/3
rd and ½ the diameter of femoral head or angle
deviation between30-60 degrees
Severe slipping:
when the neck is displaced more than half the
diameter of the head or deviation of the head shaft
angle of more than 60 degrees than normal

15. Loders classification
stable unstable
• Wt bearing possible with or
without crutches
• Less severe slips
• Effusion absent
• Good prognosis
• Less chances for avn
• Wt bearing is not possible
even with crutches
• Slip is more severe
• Effusion is almost always
present
• Bad or worst prognosis
• More chances for avn

17. Clinical features
• The onset is insidious
• Course is slowly progressive
• Symptoms:-
• Pain in the groin and around the hip
• Antalgic limp
• Sortening of the affected limb
• Limb may be in external rotation
• Flexion, abduction, internal rotation are limited.
• External rotation, adduction are increased.
• Axis deviation(pathognomic) – when hip is flexed,
the limb goes into external rotaion.

18. Hip flexion and external rotation are limited and with
flexion of the affected hip, the limb rotates externally.

19. • Preslipping stage :
• At first slight discomfort develops about the
groin usually after activity and it subsides by
rest this may be associated with slight
stiffness and an occasional limp
• The pain may radiate along antero-medial
thigh and to the inner aspect of the knee

20. • Chronic slipping stage:
• An antalagic limp becomes pronounced and
persistent .
• The findings include tenderness about the hip
and limitation of motion abduction and internal
rotation
• the limb gradually develops an adduction and
external rotation deformity
• when hip is flexed the external rotation deformity
is accentuated

21. • Stage of fixed deformity
-Pain and muscle spasm disappear but the
limp,external rotation, adduction and
shortening persists
• Signs:
-The patient is likely to be a boy between age of
10-17 years or a girl between 11 and 13 in
whom menstruation has not at started

22. • The radiographic abnormalities that may be
seen in SCFE depend on the degree of
displacement of the capital epiphysis.
• The AP radiograph of the hip, supplemented
by a frog-lateral view, is usually sufficient to
make a correct diagnosis.
• Several diagnostic indicators of SCFE have
been identified on the anteroposterior
projection of the hip

23. • The TRIANGLE SIGN OF CAPENER may
be of value in recognizing early SCFE.
• On a plain film of the normal adolescent hip,
an intracapsular area at the medial aspect of
the femoral neck is seen overlapping the
posterior wall of the acetabulum, creating a
dense triangular shadow-triangle of capener
• In most cases of SCFE, this triangle is lost.

25. • In a later stage, periarticular osteoporosis
becomes apparent, as do widening and
blurring of the physis and a decrease in height
of the epiphysis
• Moreover, as the disease progresses, slippage
of the capital epiphysis can be identified by
the absence of an intersection of the epiphysis
with a line drawn tangent to the lateral cortex
of the femoral neck

27. Metaphyseal blanch sign of steel
• In Ap view- crescent shaped area of increased
density overlying the metaphysis adjacent to
the physis.
• This increased density is due to the
overlapping of the femoral neck and the
posteriorly displaced capital epiphysis.

29. • Chronic stages of this disorder exhibit reactive
bone formation along the superolateral aspect
of the femoral neck, along with remodeling;
this creates a protuberance and broadening of
the femoral neck, which gives it a “pistol-grip”
appearance known as a HERNDON HUMP.

32. Radiological appearances
- Preslipping stage-indicated by the absence of the
normal shoulder on the upper aspect of the neck and
head [TRETHOWAN’S SIGN] in which a line called KLEINS
LINE ,drawn along the superior surface of the neck
will pass above the femoral head rather than through
the head
-The head is more or less sickle shaped instead of
hemispherical and its height is diminished
-The epiphyseal is widened and rarefaction or even
streaks of sclerosis may be seen underneath it

34. • Early stage
-The head of the femur lies in the acetabulum
but it is rotated so that its lower and laterally.
-The head is slightly displaced in relation to the
neck

35. • Advanced stage:
-The femoral head is atrophic especially in its
projecting lower half and it has now become
so rotated and displaced that only a small
anterior portion is actually in the acetabulum
-The projecting lower edge of the head is now
curved laterally and upwards and is in contact
with the lower border of the neck

36. -The head is often completely separated from
the neck and lies loose in the acetabulum
except for the displacement, the contour of
the bones is normal but the joint margins and
the joint space may be hazy from the
extravasation of blood.

37. • CT SCANS
Are valuable in visualizing early slipping.CT
provides the most accurate measurement of
the extent of epiphyseal displacement and
angulation

38. Diagnosis
• Diagnosis is a combination of clinical suspicion plus
radiological investigations.
• 20-50% cases of scfe are misdiagnosed on their 1st
presentation to a medical facility.
• This is because the common symptom is knee pain.
This is a referred pain from the hip.
• The symptom complex consist of-
• A limp of spontaneous onset(without apparent cause)
• Pain referred to the knee in obese adolescent.
• Characteristic radiographic appearance.

39. Differential diagnosis
1. Tuberculosis of hip
-Attitude- adducted and medially roated
-Movements-restricted in all directions atrophy
is greater
-Hip is more sensitive and painful even at rest
radiographs show extensive demineralization
of the femoral head and acetabulum without
any epiphyseal displacement

40. 2. Perthes disease
-History : limitations of movement slight atrophy
and shortening are identical with those of mild
epiphyseal coxa vara the chief points of difference
-age: perthes diseases rarely begins after the
tenth year while slipped capital femoral epiphysis
begins before it
-X-ray: in perthes the head is not displaced
but actually deformed

41. Difference between SCFE and
PERTHE’S
SCFE PERSTHE’S
age- 10-14 yrs
Late onset 14-16 yrs
4-7 yrs
Late onset 7-10 yrs
Thin and tall adolscent or short
obese individuals
Occurs in normal child
Presents as pain with slippage
and limping nated later satge
Initially child limps and then at
later stages complaints of pain
Limb may externally roated but
no fixed flexion deformity
Fixed flexion deformity is noted

42. 3. Congenital dislocation of hip
-Usually present since birth.
-Head of the femur may be palpated outside
the acetabulum.
-Telescopy present in majority of the case.

43. Prognosis
The second hip becomes affected in about 1 in 4
cases
• The end result depends to a certain extent on
the degree of displacement of the head
• In early case where there is minimal slipping
the end result is completely satisfied
• Good results can be achieved with good
reduction provided avascular necrosis avoided

44. • Good results can be achieved even with up to
50% displacement of the head if good
reduction is followed by corrective osteotomy
• Some patients with a displaced epiphysis after
treatment develop avascular necrosis cartilage
necrosis and arthritic changes during adult life

45. Management
• Conservative management- rest and traction
• Closed manupulative reduction
• Operative management
insitu pinning -open instiu pinning
-Bone peg Epiphysiodesis
-Osteotomies
-

46. Closed reduction
• Manipulative reduction has been reported for
acute and acute on chronic slips with
moderate and sever displacement.
• An association of avascular necrosis with
manipulative reduction has been reported.

47. -The development of avascular necrosis may be
related to severity of the slip rather than to
the manipulative reduction provided that only
a very gentle reduction is performed. This is
performed with the patient on a fracture table
and internal rotation alone usually is sufficient
to obtain adequate reduction

48. -Longitudinal traction is applied to counteract
the muscle spasm straight longitudinal
traction especially when combined with
medial rotation will effectively reduce the
displacement of an acute slip and this can be
followed by internal fixation

49. The aim of surgery are
• To prevent further slip
• To reduce the displacement
• To effect early closure of the epiphyseal plate

50. Internal fixation
• In situ pin or screw fixation
Percutaneous in situ pinning is currently the
most often used treatment for mild moderate
and some severe acute on chronic slipped
capital femoral epiphysis
Open in situ pinning may be indicated for more
severe acute or acute on chronic slipping

51. Percutaneous in-situ pinning
• Although earlier reports indicated that two or
three pins were necessary for stability and
results of multiple pinning generally have
been satisfactory
• Reports now recommend the use of a single
larger diameter central pin or screw because
single pin insertion is technically simpler than
insertion of multiple pins but this is still
surgeon dependent

52. • Whether pins or cannulated hip screws are
used, they should not be removed for at least
12 months or until the physis closes.
• Persistent pin penetration has been the most
serious disadvantage of in situ pinning.
• Adverse effects attributed to unrecognized pin
penetration include joint stiffness.

53. • The pins should be placed in the femoral neck
and into the centre of the head in the safe
zone to avoid pin penetration.
• Lehman et al and Shaw recommended the use
of cannulated hip screw with injection of radio
opaque dye to detect pin penetration.
• The pin tip is to be advanced to 8mm or1/3rd
of the radius of the femoral head from the sub
chondral bone.
• This places the actual tip 7 to 18 mm from the
subchondral bone, leaving a safe margin.

55. Open in situ pinning
• Technique (Morrissy):
• Place the patient on the fracture table with
the affected leg abducted 10 to 15 degrees
and internally rotated as for as possible
without force. This brings the femoral neck as
close as possible parallel to the floor to assist
in obtaining true anterior and lateral image
views after standard preparation and draping
under image control insert a k-wire

56. • Through the antero-lateral area of the thigh
down to the femoral neck, adjusting the guide
wire on the antero-posterior projection to
determine the axis of the femoral neck and
obtain a lateral view to determine the amount
of posterior inclination needed.
• When the starting point and the posterior
inclination have been estimated, insert the
guide through a small puncture wound.

57. • Advance the guide wire to the physis and
confirm placement in the central axis of the
femoral head by intensification. If the position
is correct advance the guide assembly across
the plate until the proper depth is reached
determine the correct screw length by
passing a guide wire of identical length
advance correct length screw over the guide
pin and then remove the pin.

58. • Use both anteroposterior and lateral views to
conform that the screws do not penetrate the
joint and close the stab wound with a single
subcuticular suture .
• If two screws are deemed necessary for an
acute slip the first screw should lie in the
central axis of the femoral head and the
second below it avoiding the superolateral
quadrant .
• The second screw should stop at least 8mm
from the subchondral bone

59. • After treatment
• Range of motion exercises are to begin the day
after surgery .
• Partial weight bearing is allowed for most of the
patients on first day using crutches.
• Crutches are used until all signs of synovitis are
gone and motion is free and painless .all vigorous
activities are forbidden until the physis have
closed .
• The screws are removed after physeal closure has
been demonstrated.

60. • Prophylactic pinning of the contra-lateral hip
is performed in rare instances such as In high
risk non complaint patients or patients with
epiphysio-lysis from irradiation therapy or
renal failure .

61. Bone peg epiphysiodesis
- Described by Ferguson and Howorth in 1931
-Reported complications after pin or screw
penentration into the joint increased its
popularity
-There is rapid physeal closure and low
incidence of complications especially in
chondro-lysis

62. • Disadvantages
Graft insufficency leading to increase in severity
of slip and failure of physeal fusion
• Longer opreating time
• Increased blood loss
• Longer hospitalization
• Longer rehabilitation

63. • Spica cast immobilization may be necessary to
present further slip
• Post operative complication
• -avascularnecrosis
• -chondro-lysis
• -infection
• -lengthy immobilization
• -heterotopic ossification

64. Technique of bone peg epiphysiodesis
through anterolateral apporach(wenier
etal)
-Make a mid lateral incision beginning 4 to 5
inches below the level of the greater
trochanter in the lateral mid line of the upper
portion of the thigh,proceeding proximally to
the greater trochanter and then angling
obliquely to the antero-superior iliac spine

66. - Muscles are split and retracted capsule of the hip
joint is exposed and opened in an H shape
fashion
- If bony hump present on the antero-lateral meta-
physeal region resulting from slip remove it with
an osteotome
- Make a square or rectangular window in the
anterior surface of femoral neck insert a large
hollow drill through the window and drill it across
the physis into the epiphysis under image
intensifier

67. -Remove a cylindrical core consisting of
metaphyseal bone physis and a portion of the
epiphyseal bone there by guaranting passage
of the drill across the physis and into the
epiphysis enlarge the cylindrical tunnel with a
curret and remove more of the physis remove
sections of cortico-cancellous bone from the
outer layer of ilium and sand witch them
together and drive this composite bone peg
across the physis into epiphysis

68. After treatment
Spica cast applied in acute slips for six weeks
and then touch down wait bearing is allowed
Chronic slips are ambulated on crutches after 48
to 96 hrs of bed rest
Weight bearing can be started at approximately
10 weeks

69. -In an effort to simplify bone peg epiphysiodes schmidt et
al developed a percutaneuos fluoroscopically guided
technique using cortical allograft inserted through a
hole drilled in the lateral femoral cortex passed
through the femoral neck and across the physis
-Procedure is similar to the percutaneous pin fixation
except that rather than cannulated screw a 10mm
reamer is inserted over the guide pin and a tunnel is
reamed
-Reamed tunnels is filled with a cortical strut allograft.
-operative time the and morbedity similar to single screw
fixiation

70. Osteotomy
-Chronic slips with moderate or severe
displacement produce perment irregularities
in the femoral head and acetabulum and
some form of reconstructive procedure often
is indicated the goals of any osteotomy are-
Restoration of the normal relationship of
the femoral head and neck
Dealy of the onset of degenerative joint
disease

71. There are two basic types of osteotomy
• Closing wedge osteotomy through the femoral
neck usually near the physis to correct the
deformity and
• Compensetory osteotomy through the
trochanteric region to the produce deformity
in the opposite direction

72. Four femoral neck osteotomies are described
• The technique of fish
• The technique of dunn just distal to the
slip(subcapital).
• The base of neck technique of kramar et al.
• The technique of abraham et al.
• The itertrochantric osteotomy by southwick.
Compensatory osteotomies in the trochanteric
region as well as partial cheilectomy to reduce
deformity

74. Cuneiform osteotomy of the femoral
neck(fish)
-Reduction by a cuneiform osteotomy made just
distal to the physis and internal fixation may
be necessary for a severe chronic or acute on
chronic slip.
-The reported incidence of avascular necrosis
and chondrolysis after this procedure have
been exceptionally high

75. • Technique
-Place the patient supine make an anterolateral approach
to the hip
-Open the capsule longitudinally determine the size of
the wedge to be removed by noting the degree of slip
and the position of the epiphysis make the base of the
wedge anteriorly and superiorly for correct positioning
of the epiphsysis after removing sufficient bone
-Reduce the epiphsysis by flexion abduction and internal
rotation of the limb after reduction fix the epiphysis to
the neck with 3 or 4 pins

76. Cuneiform osteotomy of femoral neck
{fish}

77. After treatment
-The patient should be free in bed with the
involved limb supported on pillows
-When comfortable he is allowed out of bed
using crutches with only touch down weight
bearing of the involved limb
-Full weight bearing is permitted after x-rays
show the osteotomy to be completely healed
at approximately 5 months pins are removed
full activity allowed 2 months later

78. Cuneiform osteotomy of femoral neck
(dunn)
-Dunn described an osteotomy for severe
chronic slips in chidern with open physis he
emphasized that this procedure should not be
done if the physis is closed

80. • The slip of the femoral head strips the
periosteum from the back of the femoral neck
and beak of new bone is laid down beneath it
• The main retincular blood supply runs of the
femoral neck a lateral apporach allows
stripping of the periosteum and its contained
vessels under direct vision to avoid damaging
the blood supply to the femoral head

81. • Technique
-Through a lateral approach make an incision in the
periosteum and elevate the posterior vascular
covering of the femoral neck make to osteotomy
cuts one in the long axis of the neck to remove
the bony beak and the second at right angles to
the neck to shorten it by 3 to 4 mm. appose the
surface of the osteotomy and insert three
threaded pins up the femoral neck to its cut
surface.

82. -Reduce the deformity and conform position on
x ray. In the lateral view the head should
appear to sit squarely on the neck but in AP
view the head should be tilted into about 20
degrees of valgus when reduction is
satisfactory drive the pins into the femoral
head close the wound in layers

83. • After treatment
-A cast is applied from the nipple line to the toes on
the affected side holding the extremity in the
nuetral roatatoin and abduction and to above
knee on the opposite side.
-Cast is removed at 4 weeeks and active and passive
motions are begun after two weeks crutch
walking is allowed at 3 to 4 months after surgery
partial weight bearing is permitted full weight
-Bearing permitted only after x-ray evidence of
union of osteotomy

84. Compensatory basilar osteotomy of
femoral neck
-Kramer et al described a compensatory
osteotomy of the base of the femoral neck
that corrects the varus and retoversion
components of moderate or severe chronic
slipped capital femoral epiphysis

85. -They suggested that it is safer than an
Osteotomy made near or at the physis
because the line of the osteotomy is distal to
the major bloood supply in the posterior
retinacuium.
-Threaded pains are used for fixation of the
osteotomy and the epiphysis not only is the
anatomical relationship of the proximal femur
restored but also futher slipping is prevented

86. • Technique
-Determine preoperatively the size of the wedge
to be removed by measuring the head-neck
angle on AP radiograph and confirmed at
surgery by measuring the width of the callus
by direct inspection.

87. -Part of wedge will be in line with the widest part of the
slip in the anterior and superior aspects of the neck
make the more distal osteotomy cut first perpendicular
to the femoral neck and following the anterior
intertrochanteric line from proximal to distal extended
this osteotomy
-Cut to the posterior cortex but leave this cortex intact
(this will permit the greenstick fracture in the posterior
cortex when closed)make the second osteotomy cut
directed obliquely so that its cutting edge stays distal to
the posterior retinacular blood supply.

88. -Drill one or two 5mm threaded steinmann pins
into the femoral neck proximally to ensure
that the proximal portion of the femur is kept
under control before completing the
osteotomy
-Complete the osteotomy by medial rotation nd
abduction of the distal segment.
-Advance the threaded steinmann across the
osteotomy site and physis to prevent for the
slipping

90. After treatment
Bed rest for 2 to 3 weeks followed by non weight
bearing
partial weight bearing is allowed depending on
the stability of the osteotomy
stienmenn pins should be removed only after
physis has fused

91. Extra capsular base of neck osteotomy
• Extra capsular base of neck osteotomy
• Abraham et al recommended this osteotomy as
safe and effective in preventing furthur slipping
and improving hip range of motion in pts with
severe chronic slip
• They noted that with severe slips the amount of
correction of varus and posterior tilt of the
femoral head is limited and complete restoration
of normal head shaft angle may not be possible

92. • Removal of a wedge larger than 20 mm
compromises femoral neck length and may
greately increase femoral antversion
• Also pinning across the osteotomy site becomes
more difficult when correction of more than 55
degrees of varus or valgus is attempted
• These same restrictions also are applicable to
intra capsular base of neck osteotomies and
southwick procedure

93. • Before surgery the head shaft angle is
measured on lateral films by measuring the
angle formed by epiphyseal line and the
femoral shaft in the affected limb and
comparing it with normal limb
• The head shaft angle for posterior tilt or
retroversion is measured on frog lateral view
and compared with normal side
• The difference between normal and abnormal
angles are used to determine the size of
wedge removed during osteotomy

94. • Make a standard anterolateral approach mark
the anterior joint line or intertrochantric line
• Delineate a triangle on the anterior surface of
the femoral neck to indicate the two plane
wedge osteotomy
• Locate the proximal cut by placing a 3cm long
k wire on the anterior surface of the femur
from the lesser to greater trochanter at the
base of the neck along the edge of the capsule
confirm position by c-arm

95. • Externally rotate the leg and drill a second K wire on
the AP plane just distal to the guide wire
• Begin the second osteotomy line from the lesser
trochanter to the growth plate of the greater trochanter
• Make a single osteotomy along the posterior cortex and
completely remove the wedge and by maintaining
traction internally rotate or abduct the leg to close the
osteotomy.
• Use cannulated screws to hold the osteotomy, use only
one screw to span the physis of the femoral head
avoiding superolateral quadrant .

97. Southwick’s intertrochantric
osteotomy
 This is measured biplane intertrochanteric
osteotomy in which degree of correction is
accurately pre determined before surgery.
 Osteotomy through the trochanter is most useful
when the head has slipped from 30-70d is
considered minimum and is fixed insitu with
threaded pins
 Initially the limitation of joint movement due to
muscle is overcomed by longitudinal traction in
mild abduction and an internal rotation strap for
few days.

99. • The X-ray measurements are made on both AP
and frog leg lateral views.
• AP view gives the degree of varus deformity.
• Frog leg lateral view gives the measure of
posterior tilting.
• Measurements are made by template models
on X-ray prior to surgery.

100. Complications
1.Avascular necrosis :
• More common with moderate and severe slips and less
common with mild slips.
• Avn is common following femoral neck osteotomy33%,Open
reduction with knowles pin- 27%, less common with in situ
fixation – 1.5% and after trochanteric osteotomy – 10%.
• AVN probably results from interruption of retrograde blood
supply and is apparently influenced by the original injury.
• Forceful repetitive manipulatations, open reductions,
osteotomies of femoral neck and superolateral placement of
pins.

101. 2. Chondrolysis:
• Sometimes termed as ‘acute cartilaginous necrosis’ is
an affection of the hip joint characterized
pathologically by rapid loss of articular cartilage and
clinically by development of continuous pain and
severe restriction of motion.

102. • A joint space that measured less than 3mm width
and decreased range of motion are required for
the diagnosis.
• Occurs more often in females and black.
• More common following trochanteric osteotomy-
59%, open reduction -55%. Femoral neck
osteotomy – 37%, pin protruding into the joint –
51%. It is usually diagnosed within the first 6-9
months of observation

103. • The joint space is rapidly lost and severe limitation of
movement is present.
• Subsequently the width of the joint space usually increases
slowly and range of motion also increases slightly.
• If severe joint space narrowing persists with limitation of joint
motion arthrodesis or arthroplasty should be considered.
• Conservative treatment by bed rest , traction.
• Usually the joint goes to ankylosis

104. 3. Osteorthritis :
• Normally pressure forces of weight bearing are widely
distributed over the femoral head.
• In coxa vara pressure forces are concentrated over a smaller
area causing degeneration of cartilage and incongruous joint
surfaces.
• The time required for these changes to develop was long and
varied from 18 months to 4 years after onset.

105. 4. Fractures:
• Fractures can occur just distal to the knowles pins. So the pins
should be removed after the epiphyseal plate has fused.
• Over reaming of the femoral neck also cause a stress fracture.
5. Continued slipping:
• In case of conservative treatment or in which pins were not
placed far enough proximally or removed before the physis
had completely fused.

106. THANK YOU