E-mail
Case: SCFE Complication
Reported by Myles Clough
, Orthopaedic Surgeon, Kamloops, BC, Canada
A 10 year old girl presented to an orthopaedic colleague on Sept 22nd with a complaint of right hip pain. Xray (1) showed quite a subtle slip (SCFE = Slipped Capital Femoral Epiphysis). After some heartsearching about treating such a young patient, he fixed the epiphysis in situ with a single cannulated screw (2,3). She was doing well until October 14th. She got tied up on her crutches and fell down two steps. She has a sub-trochanteric fracture commencing at the screw hole. (4)
Figure 1
Figure 2
Figure 3
Figure 4
Is anyone familiar with this as a complication of treatment of SCFE? I would assume that putting in more screws would make this more rather than less likely.
My plan of management is to do a Dynamic Hip Screw fixation. After reduction and prior to taking out the current screw I will put in 2 new K wires to try to prevent rotation as the old screw is backed out. Then I plan to pass a wire up the current cannulated screw, back it out and use the wire to guide the reamer for placing the lag screw. I don't plan to advance it any further than the current position of the screw. The rest of the operation should be straghtforward, attaching the lag screw to the side plate.
Would anyone treat this patient with closed reduction and traction? Any other internal fixation? Flexible IM rods? Any comments about my proposed treatment?
I have told the family that this situation increases the risk of AVN - any comments on that?
Comments
FROM: Rene Hartel
Perhaps an 90 degrees adolescent blade plate is a better option with less risk of an AVN? The DHS is a big thing for this little head. Biomechanically the blade plate is in theory better than the DHS for this fracture.
Rene Hartel
CH Argentan, France
FROM: Angel Peiró M.D.
> Is anyone familiar with this as a complication of treatment of SCFE?
----Yes I have a similar case (below). The contralateral side was pinned prophylactically.
> Any comments about my proposed treatment?
----I agree, but we use another nail-plate (RAB).
> I have told the family that this situation increases the risk of AVN - any comments on that?
-----Probably No
Regards,
Angel Peiró M.D.
Valencia, Spain
FROM: Dr. Freih Odeh Abu Hassan, MD(Orth.), FRCS(Eng), FRCS(Tr&Orth)
This complication usually happen when the registrar or the resident made multiple holes by the K.wire in the lat. cortex trying to localize the center of the neck.
The problem of these fractures it extends above the lesser trochanter. If you can put DHS this will be excellent but the entry of the DHS will be below or at the fracture site and this is difficult to hold the fracture very well.
I would suggest to leave the screw in place and put Buttress T-plate after reduction of the fracture with 3 screws above the fracture and 4-5 below, followed by NWB for 6 weeks.
The risk of AVN is possible.
I did find in my collections one similar case of yours (below).
Best Luck,
Dr. Freih Odeh Abu Hassan, MD(Orth.), FRCS(Eng), FRCS(Tr&Orth)
Assistant Professor of Orthopedics & Pediatric Orthopedics Surgery
University of Jordan, Amman, Jordan
Summary/Outcome
I really appreciate the helpful suggestions from the list. Rene Hartel suggested a paediatric condylar blade plate. Dr Gonzales showed a similar case treated the way I was planned to, but his case had healed the epiphysis. Dr Abu Hassan suggested a T plate. The difficulty with the blade plate idea is that there may not be room to put the blade in front or behind the existing screw. I will have that on hand (and T plates) as I like the idea of leaving the epiphysis alone and not changing the screw. Another thought is "Schulies" which convert a standard plate into something more like a condylar plate. Follow-up will be provided.
I did a quick check into Medline and found this complication is reported but very rare. (1/308 hips reported from Toronto by Riley et al 1990). Canale et al (1994) also described it as a complication of unused drill holes. I wasn't present at the original surgery but the surgeon is a consultant with 15 years experience. Nonetheless, it isn't only residents who make extra drill holes and this case may serve to emphasize that we shouldn't.
Right hip, AP, post operation
By 6 weeks post operation, the fracture is well healed. The patient is comfortable. She has lost external rotation. Internal rotation is similar to the normal left side. She has been allowed to bear weight and undertake physiotherapy. She is not tender over the plate but I anticipate that it will cause crepitus when she externally rotates the hip. Follow-up in six months with a view to removing all the hardware if the epiphysis is fused.
Nov 28th 2000 (6 weeks post operation), showing the fracture to be well healed.
7 months after the initial presentation of the right side, she presented again with left hip pain. Xray showed a minimal slip and this side has been fixed in situ with a single cannulated screw. The epiphysis of the right hip is not yet fused.
Bibliography
Canale ST, Azar F, Young J, Beaty JH, Warner WC, Whitmer G. Subtrochanteric fracture after fixation of slipped capital femoral epiphysis: a complication of unused drill holes. J Pediatr Orthop. 1994 Sep-Oct;14(5):623-6.
Karr RK, Schwab JP. Subtrochanteric fracture as a complication of proximal femoral pinning. Clin Orthop. 1985 Apr;(194):214-7.
Aronson DD, Carlson WE. Slipped capital femoral epiphysis. A prospective study of fixation with a single screw. J Bone Joint Surg Am. 1992 Jul;74(6):810-9.
Morrissy RT, Busch MT. Windshield-wiper loosening: a complication of in situ screw fixation of slipped capital femoral epiphysis. J Pediatr Orthop. 1994 Jul-Aug;14(4):549-50.
Howorth B. The drilling operation for slipping of the capital femoral epiphysis. Clin Orthop. 1966 Sep-Oct;48:75-7.
Canale ST, Casillas M, Banta JV. Displaced femoral neck fractures at the bone-screw interface after in situ fixation of slipped capital femoral epiphysis. J Pediatr Orthop. 1997 Mar-Apr;17(2):212-5.
Jeffery RS, Hollis S. Fixation with a single screw for slipped capital femoral epiphysis. J Bone Joint Surg Am. 1993 Aug;75(8):1255-6.
Denton JR. Fixation with a single screw for slipped capital femoral epiphysis. J Bone Joint Surg Am. 1993 Mar;75(3):469.
Hoffmann R, Sudkamp NP, Schutz M, Raschke M, Haas NP. Current status of therapy of subtrochanteric femoral fractures. Unfallchirurg. 1996 Apr;99(4):240-8. Review. German.
Riley PM, Weiner DS, Gillespie R, Weiner SD. Hazards of internal fixation in the treatment of slipped capital femoral epiphysis. J Bone Joint Surg Am. 1990 Dec;72(10):1500-9.
Maletis GB, Bassett GS. Windshield-wiper loosening: a complication of in situ screw fixation of slipped capital femoral epiphysis. J Pediatr Orthop. 1993 Sep-Oct;13(5):607-9.
Wiss DA, Matta JM, Sima W, Reber L. Subtrochanteric fractures of the femur. Orthopedics. 1985 Jun;8(6):793, 797-800.
Denton JR. Progression of a slipped capital femoral epiphysis after fixation with a single cannulated screw. A case report. J Bone Joint Surg Am. 1993 Mar;75(3):425-7.
Warner JG, Bramley D, Kay PR. Failure of screw removal after fixation of slipped capital femoral epiphysis: the need for a specific screw design. J Bone Joint Surg Br. 1994 Sep;76(5):844-5.
Kibiloski LJ, Doane RM, Karol LA, Haut RC, Loder RT. Biomechanical analysis of single- versus double-screw fixation in slipped capital femoral epiphysis at physiological load levels.
Morrissy RT. Slipped capital femoral epiphysis technique of percutaneous in situ fixation. J Pediatr Orthop. 1990 May-Jun;10(3):347-50.
Richards BS. Slipped capital femoral epiphysis. Pediatr Rev. 1996 Feb;17(2):69-70.
Bianco AJ Jr. Treatment of slipping of the capital femoral epiphysis. Clin Orthop. 1966 Sep-Oct;48:103-10.
Baynham GC, Lucie RS, Cummings RJ. Femoral neck fracture secondary to in situ pinning of slipped capital femoral epiphysis: a previously unreported complication. J Pediatr Orthop. 1991 Mar-Apr;11(2):187-90.
Folsch CO, Kunze K. Osteosynthesis of subtrochanteric femoral fractures with the dynamic condyle screw. Zentralbl Chir. 1993;118(6):357-60. German.
