Epiphysiolysis of the hip joint: diagnosis and treatment

epiphysiolysis of the hip

THEepiphysiolysis is a hip pathology which mainly affects children between 9 and 16 years old. It affects in average 10 teenagers out of 100 and is more frequentand at the garçons than in girls. Without treatment, displacement of the femoral neck continues to occur gradually and can lead to dramatic complications as the avascular necrosis or chondrolysis. To know a bit more about it, read this article till the end.

How to define epiphysiolysis of the hip?

THEepiphysiolysis of the hip ou slipped capital femoral epiphysis is a hip pathology that affects adolescents (between 9 and 16 years old), especially prepubescent boys. Linked to an anomaly of the growth cartilage, it results in a sliding back and down for the head of the femur (upper femoral epiphysis) in relation to the neck of this same bone.

Slippage occurs at the growth plate in the hip joint. The femoral head remains in place in the acetabulum fixed by the round ligament and it is the metaphysis which moves upwards and forwards thus pushing the head backwards and downwards.

This displacement maybe :

  • fast and brutal (lasts less than 3 weeks), in this case we speak ofacute epiphysiolysis;
  • slow and gradual (lasts several months): this is theepiphysiolysis chronic.

The pains are often vague. Radiographically, signs of remodeling are visible.

Acute epiphysiolysis represents 15% of cases of patients who describe coxalgia (hip pain), gonalgia (pain in the knee) or pain resembling that of a fracture.

What are the causes ?

La exact cause epiphysiolysis of the femoral head remains unknown until now. However, this condition is probably two to weakening of the growth plate. Mechanical, hormonal and metabolic factors play an important role in the onset of the disease.

Epiphysiolysis often occurs during the pubertal growth period. She may be due to trauma, a inflammation, complications due to obesity or to changes in blood hormone levels (such as hypothyroidism, low thyroid hormone levels, hyperparathyroidism, growth hormone deficiency, etc.).

There are alsoother risk factors as :

  • the anatomical risk factors such as hip deformities, femoral retroversion or acetabular protrusion ;
  • la radiotherapy (the risk of epiphysiolysis increases in proportion to the dose of radiotherapy received);
  • the kidney disease (eg hyperparathyroidism secondary to renal failure);
  • the taking medication such as steroids ;
  • the history of epiphysiolysis in the in family.

Slipping causes stress in the vessels that supply the femoral head with an increased risk of necrosis (cell death) of the latter. This condition is referred to as hip osteonecrosis (or avascular necrosis).

What are the symptoms ?

Le beginning is often insidious and the symptoms reflect the extent of femoral head slippage.

Le first symptom of epiphysiolysis of the femoral head may be a stiffness or an slight pain in the hip who'sdecreases with rest, but worsens with walking and hip movement. Sometimes the pain may seem to come from the knee or thigh. Pain then radiates to the inner side of the thigh to the knee. It is explained by the irritation of a branch of the obturator nerve which travels in the round ligament.

Has a more advanced stage, the signs may include a pain on passive motion of the hip with limitation of flexion, theabduction (deviation from the axis of the body in a frontal plane) and the internal rotation and lameness, even a inability to walk.

At thephysical examination, hip is in external rotation with an slight shortening of the lower limb, as in fractures of the neck of the femur. A quadriceps amyotrophy (decrease in the volume of the quadriceps muscles) is often found testifying to the chronicity of the disease.

If the diagnosis is late, two types of complications can occur: femoral head necrosis and chondrolysis. Necrosis of the femoral head is due to impaired blood circulation. The bone is then gradually destroyed. As for chondrolysis, it refers to the destruction of the articular cartilage of the hip. osteoarthritis early is the main complication of untreated epiphysiolysis.

How to establish the diagnosis of epiphysiolysis of the hip?

The diagnosis is based above all on the questioning of the doctor who looks for the symptoms and risk factors of epiphysiolysis of the hip joint. After that, you also have to go through an X-ray examination.

La x-ray of both hips (front and side views) allows to visualize growth plate enlargement and posterior and inferior displacement for the femoral head.

THEscan and l'Hip MRI are useful, if the x-rays are normal.

THEscan allows you to search for presence of a possible joint effusion associate.

As for MRI, it not only makes it possible to decide on the presence of femoral head necrosis (damage to the vascularization), but also in relation to the degree and severity of the displacement of the latter. This will guide the surgical management.

How to treat epiphysiolysis of the hip?

Le treatment of epiphysiolysis of the hip is always surgical. Unfortunately there is no no other option possible. THE but is D'prevent slip progression and minimize deformation (to prevent early osteoarthritis, while avoiding avascular necrosis and chrondrolysis).

Le choice of treatment is a function ofamount of slippage, speed of development, acute or chronic character epiphysiolysis and presence or absence of a growth plate.

THEhospitalization is immediate as soon as the diagnosis is established, in order to prevent the child from relying more heavily on the affected lower limb.

The treatment is done in two stages: traction and fixation (surgery).

The bonded traction

Once the diagnosis is made, the inferior member must be absolutely landfilled absolute. A light traction force is applied to the affected limb, using a self-adhesive tape, pending surgery.

Surgery

If you have a insignificant slip, femoral head will be fixed in place by and vis, under radiological control. The screw will be inserted into the neck of the femur, passes through the cartilage and ends in the head of the femur. After the operation, the lower limb is then landfilled during 1 months.

When the slippage is significant (greater than 60°), it will then be necessary reposition the femoral head on the collar, according to Dunn's technique (Dunn's osteotomy). It consists of resecting a corner of the metaphysis to allow the epiphysis to shrink. In post-operative, the lower limb is then landfilled during 3 months.

Evolution and complications

The major complications associated with slipped capital femoral epiphysis are the avascular necrosis and chondrolysis the other complications possible are thelower extremity inequality, femoroacetabular impingement, pseudarthrosis osteotomies and infections.

La avascular necrosis is estimated between 4 and 25% of cases, it is linked to the severity of the epiphyseal tilt and to the unstable character of the epiphysiolysis. It is due to a impaired blood circulation. It causes deformation of the femoral head, a source of osteoarthritis in the medium term. Any attempt at reduction by manipulation or when performing a neck osteotomy increases the risk of necrosis.

La chondrolysis is a destruction of articular cartilage of the acetabulum and the femoral head, it occurs in 30% of cases and especially in the unstable forms.

References

https://www.msdmanuals.com/fr/professional/p%C3%A9diatrie/troubles-osseux-chez-enfant/%C3%A9piphysiolyse-de-la-t%C3%AAte-f%C3%A9morale

https://www.chuv.ch/fr/dfme/dfme-home/enfants-famille/specialites-medicales/chirurgie-de-lenfant-et-de-ladolescent/chirurgie-pediatrique-de-la-hanche/lepiphysiolyse-de-la-tete-femorale

https://www.ultrasoundcases.info/slipped-capital-epiphysis—epifysiolysis-2223/

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