This is the commonest cause of hip pain in the adolescent age group (10-15 years). Males are more frequently affected than females by 2:1. It may be bilateral in 30% of cases. Positive family history, obesity and hormonal abnormalities such as hypogonadism, hypothyroidism and hypopituitarism are well known associations.
The pathology is a stress fracture through the upper femoral growth plate resulting in a progressive slip of the femoral head over the femoral neck. The affected limb shortens and externally rotates as the deformity increases with time.
The Natural History. If this condition is left untreated it may result in severe limb shortening, fixed external rotation and stiffness of the hip. This may then be followed by early onset of osteoarthritis in adulthood. In a small number of cases sudden catastrophic failure of the growth plate may occur, resulting in severe deformity and loss of blood supply to the femoral head (avascular necrosis) with serious long-term sequelae.
In most cases the condition presents with a limp and pain in the hip or groin. However, in 30% of cases the pain may initially be referred to the knee or the thigh creating diagnostic difficulties. To avoid a missed or late diagnosis, it is vital to take radiographs of the hips as well as the knees in any adolescent presenting with thigh or knee pain.
N.B. In this condition the hip radiographs should routinely include 2 views at right angles as in the early stages the classical AP view may appear to be normal . The lateral view usually reveals the slipped epiphysis (see the top radiographs).
Treatment of choice for this condition is insertion of a single cannulated screw percutaneously under X-ray control. With modern techniques this could be achieved using a small stab incision. Postoperative recovery is generally rapid, but a period of protected weigh-bearing with crutches for 6 weeks is recommended.
For severe slips additional procedures in form of open reduction or corrective osteotomies may be necessary. Fortunately this a rare occurrence, especially if this condition has been picked up early before severe deformities have developed.
Prophylactic Fixation of the unaffected hip is a common point of debate. It is recognised that in 30% of cases, slips may occur in both hips.
Onset of symptoms in the unaffected side indicates the need for prophylactic screw fixation. My current practice is also to fix the unaffected hip in cases associated with hormonal abnormalities.
Prognosis of this condition is dependent on the severity and the stability of the slip.
A stable slip is defined as a slip were the individual is able to weight-bear on the affected limb. In unstable slips weight-bearing is not possible due to the severity of symptoms. In general stable slips with slip angles of less than 30° carry excellent long-term prognosis when treated appropriately.
Unstable slips or slips more than 50° carry a more guarded prognosis. Occasionally these cases are complicated by conditions such as avascular necrosis (loss of blood supply to the femoral head) or chondrolysis (loss of cartilage of the head of femur). These complications cause severe deformity or stiffness in the affected hip and result in early osteoarthritis.
Slipped Upper Femoral Epiphysis
Catastrophic Unstable Slip
Screw Stabilisation Under X-Ray Control
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