Coupon Accepted Successfully!


Pathogenesis and Pathology

  1. Slip occurs through hypertrophic zone of growth plate classically in obese hypogonadal male (adiposogenital syndrome)
  2. Normally, pitutary growth hormone activity stimulates rapid growth and increased physeal hypertrophy during puberty (adolescent growth spurt).
  3. This is balanced by increasing gonadal hormone activity, which promotes physeal maturation & epiphyseal fusion. So growth hormone excess & or hypogonadism is provocative of SCFE.
  4. Physeal disruption leads to premature fusion of epiphysis-usually with in 2 years of the onset of symptoms.
  5. Bone remodeling may cause permanent external rotation deformity and apparent coxa vara.
  6. Chondrolysis & AVN are possible complications 

Clinical Picture

  1. An adolescent child (boys 13-15 & girls 11- 13) typically overweight or very thin and tall presents with pain some times in the groin, but often only in thigh (anteromedial aspect) & knee
  2. Antalgic limp, with the affected side held in a position of increased external rotation, (turning out of leg).
  3. Restriction of internal rotation, abduction & flexion actually represents a change in location of a relatively preserved arc of motion rather than a loss of motion. So hip extension,  external rotation and adduction are increased.
  4. A classical sign is tendency of thigh to rotate in to progressively more external rotation, as the affected hip is flexed.
  5. Slipping usually occurs as a series of minor events rather than a sudden, acute episode. Patient with unstable acute or acute on chronic SCFE characteristically present with sudden onset of severe, fracture like pain usually as a result of a relatively minor fall or twisting injury.
  6. Chondrolysis complicating SCFE presents with more continuous pain, hip held in an external rotated position at rest, with flexion contracture and global restriction of hip motion. The patient usually complain of pain through out the arc of motion rather than just at its extremes.
  7. 20% cases will have evidence of contralateral slip. 60% of patients will have B/L involvement when associated with endocrinopathies. 




Plain radiography (x- ray)

  1. Widening & irregularity physis with rarefaction in its juxta epiphyseal portion (earliest sign)
  2. A line drawn tangential to superior femoral neck (klein’s line) on AP view will intersect a portion the lateral capital epiphysis normally. With typical posterior displacement of capital epiphysis this line will intersect a smaller portion of the epiphysis or not at all – Trethowans sign.

  3. Tc 99 scan show increased uptake in capital femoral physis in SCFE, decreased uptake with in epiphysis is highly specific for AVN. When chondrolysis is present, there is increased uptake of isotope on both sides of the joint.
  4. MRI can help in diagnosis 


  1. SCFE is usually a progressive disease endocrinopathies that requires prompt surgical treatment. Because the changes in the chronic form occurs so slowly it is impossible to manipulate the femoral head into a better position. So treatment consists fixing the slip in its current position & preventing progression
  2. This is done by inserting one or more screws or pins across the growth plate (pinning in Situ)
  3. Acute slips, if unstable may be gently reduced before fixation but it increases the chances of AVN. 

Developmental Dysplasia of Hip (DDH)

  1. Risk factors are - Faulty intrauterine position (breech), Familial, First born, Female child, oligohydramnios.
  2. Caucasians & Native Americans have higher incidence as compared to Blacks & Asians.
  3. DDH is often associated with torticollis & metatarsus adductus & oligohydramnios ( intrauterine crowding)
Clinical Feature:
Abduction is limited (especially in flexion)
Asymmetric thigh folds
Short limb as shown by
Higher buttock folds
Galeazzi or Allis signi.e. lowering of knee on affected side in a lying child with hip & knees flexed
Trendelenberg’s test, telescopy & vascular sign of Narath is positive
Diagnostic tests for infants

Fig: Causes of difficult reduction / No reduction

Barlow’s Test

  1. 1° part — In position of 900 flexion of hips & knees, now the hip is adducted & pushed. And this will lead to dislocation of hip (but not if already dislocated)
  2. IInd part — Now the hip is abducted & pulled. This will cause ‘clunc’ indicating reduction of hip.

Ortolani’s Test

  1. It is similar to 2” part of Barlow’s test
  2. Some consider only 1st part as Barlow’s test
    Mnemonic: “ORAB” i.e. Ortolani test — Reduction Abduction 

Radiological Features


Fig: USG in DDH (Alpha Angle Normal >60o)

  1. In Von Rosen’s view following parameters should be noted
    1. Perkin’s line — Vertical line drawn at the outer border of acetabulum
    2. Hilgenreiner’s line — Horizontal line drawn at the level of tri-radiate cartilage  Normally the head lies in the lower and inner quadrant formed by two lines (Perkin’s & Hilgenreiner’s). In DDH the head lies in outer & upper quadrant
    3. Shenton’s line - Smooth curve formed by inferior border of neck of femur with superior margin of obturator foramen --Shenton’s line is broken
    4. Acetabular index — Normally is ≤ 300
    5. CE angle of Wiberg — normal value is 15-30°  
  2. Delayed appearance & retarded development of ossification of head of femur
    1. Sloping acetabulum
    2. Superior & lateral displacement of femoral head.
    3. 80% of cases of DDH occur in girls
    4. DDH is more common in first born children as primigravida uterus and abdominal muscles are unstretched and subject the fetus to prolonged periods of abnormal positioning. This positioning tends to force the fetus against the mother’s spine, limiting motion of hip, Particularly hip abduction, This crowding phenomenon’ is the cause of its association with torticollis & metatarsus adductus.
    5. Oligohydramnios causes limited fetal mobility and thus increases risk of DDH. Breech presentation is another strong association factor. But the twin pregnancy does not increase the risk.
    6. An inferior capsule of hip assumes hourglass shape and may prevent a successful closed reduction.  

Clinical Presentation of Bilateral DDH

  1. In a bilateral dislocation the gait is described as ‘duck like waddle’ or ‘sailor’s gait’and consists of an inclination to the side on which the weight is born (lurching gait on both side). In unilateral cases the child lurches towards affected side. This is known as abductor lurch or Trendelenburg gait.
  2. Lordosis is Particularly noticeable in bilaterai cases & is often presenting complaint.
    In b/l cases legs appear too short for the body, the perineal space is broadened, the trochanter are unduly prominent, and the buttocks broad & flat. In uniateral cases one leg is short which can be demonstrated by Galeazzi/ Allis test.
  3. In b/l case there is no asymmetry on abduction; & flexed knees are at the same level. Combined abduction is limited but this is difficult to detect because the limitation is symmetrical.
  4. Klisic test can recognize b/l DDH, in which the examiner places the 3rd finger over greater frochanter & index finger on the ASIS. An imaginary line drawn between these fingers Should point to the umblicus. When hip is dislocated the more proximal greater frochanter causes the line to point about half way between the umblicus & pubis.
  5. In bilateral cases trendelenburg sign is Positive on both sides and shenton’s line is broken bilaterally.  

Treatment Plan of DDH

  1. Neonate & Young Child (1-6 month)

  1. Pelvic harness 6 week after  hip reduces, is treatment of choice
  2. Ilfeld - craig splint, Von - Rosen splint and Frejka pillow& triple diapers can also be used. 
  1. 6-18 months
  1. Traction/close reduction, if successful - cast for 3 months
  2. If close reduction is unsuccessful due to interposition of hourglaes capsule; open reduction is performed by medial approach in <12 months old & by anterolateral approach in children >12 months old. 
  1. 18-36 months
    1. Open reduction  (antero lateral approch) & femoral shortening  
  2. More than 3 years
    1. Reduction+femoral shortening+pelvic osteotomy

Test Your Skills Now!
Take a Quiz now
Reviewer Name