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MANIPULATIVE REDUCTION FEMORAL EPIPHYSIS O'Brien

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					MANIPULATIVE                                                   REDUCTION                                         IN        SLIPPED                                 UPPER                      FEMORAL                              EPIPHYSIS

                                                                              T. J.            FAIRBANK,                        CAMBRIDGE,                              ENGLAND



             Recent                 papers                on      the        treatment                      of      slipped                  upper                femoral              epiphysis                have          been       concerned
almost   exclusively   with                                           various       open                     surgical    procedures.                                           Little  emphasis       has                          been given to
the place of manipulative                                                 reduction,                        which,    while accepted                                           as proper    treatment                              for the recent
acute             slip,            has         been          regarded                    almost               as one                  of the                surgical                deadly            sins       when            applied            to any
patient              seen               at a later                stage.
             Arbitrary                        time        limits            have           been             set,         varying                     from         a few           days          up     to three               weeks         from             the
acute     episode,                            beyond       which                        manipulative                                reduction   should     not be attempted.                                                          Hall (1957)
concluded         that                         manipulation                             had been                    found               to be a relatively    safe and effective                                                       method     of
reducing                     the         deformity                    in      patients                 soon              after              an         acute            episode,              and          should             be     reserved                for
them.              Both                 he     and        Durbin                  (1960)             found               that          in hips                   which          had          been         manipulated                    the        results
were          worse                than         in those              that          had        not,         although                    Durbin                    was        prepared                to try gentle                 manipulation
in patients                     with            50 per cent                       or more                  of displacement                                   : he made                 no mention                      of the         duration                of
symptoms       in his patients.    In Newman’s         (1960)     series of sixty hips all six successfully                                                                                                                                replaced
by       manipulation    did well, but again      the duration           of symptoms      was not given.                                                                                                                               Fahey      and
O’Brien     (1965),    in a review    of the literature        on       acute  slips,” agreed  with many                                         “                                                                                      authors      in
recommending         that closed    reduction    should       be avoided      if more   than two or three                                                                                                                               weeks     had
elapsed                 since            the         acute         episode.                    The           only          patient                    with          a poor             result          in their            ten       patients               was
treated              in a plaster                         after            closed             reduction.                            Their             review             showed                generally                poor         results           from
this       form              of immobilisation,                                     only            475            per     cent             giving                satisfactory                  results           compared                 with             625
per       cent          of      satisfactory                      results               when          internal                  fixation                    was        used.          These           figures           may          be compared
with          those                in        Jerre’s           (1950)               series            of         twenty-four                           successful                   reductions                   in     which            there          were
ten        cases              of         ischaemic                    necrosis,                  whereas                   this             complication                            arose            in only             seven           hips          when
attempted                      reduction                     in a further                      ninety-three                           patients                   had         been        unsuccessful.                        Reposition                    was
achieved                  in only two ofthe    eighty-three                                                        hips         “     which                 on     admission                   did        not    present             fracture-like
symptoms                     and signs.”    it is noteworthy                                                               that             the          manipulation                           was         sufficiently               forceful               to
fracture                the        shaft            of the         femur                in one             instance.                   Jerre            also           noted          that         the late           results        deteriorated
in      accordance                           with      the        degree                ofdisplacement                                that            remained.                     Bianco            (1965)            was        in substantial
agreement                       with            Fahey              and            O’Brien,                  and           in         a total                of     397         hips          with         slipped          epiphyses                   at     all
stages             seen            at the              Hospital                   for         Special               Surgery                  manipulation                             was           attempted                 in only            twenty-
seven             and         was            successful                 in only               thirteen,                  with          three            poor            results          (Jacobs                1968).           There           appears
to      be        general                    agreement                     that          after         manipulative                                   reduction                 immobilisation                           in a hip                spica            is
inefficient                   and            possibly              dangerous.
             The             object             of this               contribution                           is to             suggest                  that           manipulative                       reduction                can         be      done
safely          in many    patients     with                                      longstanding                       trouble,                          even when there has been no acute episode,
with         little danger      of ischaemic                                         necrosis                    ; and that                          the results are at least as good as those after
the       major               operations                       that         would                otherwise                     be required.                              The          only          published              support               for        this
view that the writer      has found   comes       from Vaughan-Jackson               (1956),     who reported         twelve     hips
with symptoms        of up to seven months’         duration,      seven of them with no acute incident,                   reduced
or improved       by very gentle    manipulation.             With    one exception,         in which       avascular      necrosis
followed    displacement      of the epiphysis           by the nail,     his results          were   satisfactory;        but the
follow-up                     was             in many                 cases             too         short           for         it to be certain                               that          this      complication                      would              not
occur.
             In      the           writer’s                view            there              are      only              two           contra-indications                                     to      attempting                   manipulative
reduction:                         1) bony                fusion             of the                 epiphysis                   in malposition;                                 and          2) inability                 on the           surgeon’s
part         to be gentle                           and        to “know                        when              to stop.”

252                                                                                                                                                                    THE     JOURNAL               OF      BONE        AND       JOINT         SURGERY
                               MANIPULATIVE             REDUCTION        IN        SLIPPED         UPPER    FEMORAL      EPIPHYSIS   253




                                            FIG.   I                                                              FIG.   2




                                            FIG.   5                                              FIG.    6
               Case      1-Severe      degree      of   epiphysiolysis        in     a   patient  Symptoms
                                                                                                     aged   14.    eight months,
               worse      for two weeks.          Figures   1 and 2-Before       reduction.     Figure      3-Six      weeks after
               reduction.       Figure    4-Three       and a half months    after reduction.       Figures      5 and 6-Three
                              years later. Trivial Symptoms       only, with slight restriction     of movement.



VOL.       51 B,   NO.    2,   MAY   1969
       D
254                                                                        T. J. FAIRBANK




                                     FIG.    7                                                                     FIG.     8




                                                   FIG.        II                                                                            FIG.     12
 Case     2-Epiphysiolysis            in a patient             of 14, fourteen          months’    symptoms           since   football      injury,       worse    for two
 weeks.       Figures       7 and     8-Before            reduction.           Figure      9-Two        months        after   reduction.           Figure       10-Eight
 months       after     reduction.       Figures          11  and      12-Twelve           years   later.      Almost       normal       shape       of femoral       head.
                                                                             No symptoms.




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                                         MANIPULATIVE                         REDUCTION                     IN SLIPPED                   UPPER            FEMORAL                    EPIPHYSIS                                         255

                                                                                                            MATERIAL
           During              the fifteen                years         1950-64                  thirty-two               patients                 were           seen      with           thirty-five            hips         affected
by upper   femoral   epiphysiolysis:                                                   an      incidence                  of roughly                     one per 150,000     of the population
served.  The condition       is therefore                                                   rare in the                   Cambridge                      area.  Early  diagnosis,   so vital for
efficient treatment,          depends     on the quality      of the general                                                                             practitioner       service.                            But only               one
in two general       practitioners       is likely to see a single example                                                                                 during     his practising                             lifetime,             and
in these   circumstances            it is excusably    difficult    to preserve                                                                             a mind       constantly                             suspicious               of
vague           pains          in the            knee,          thigh          or hip             of an adolescent.
           The         treatment                 these        hips received   is shown    in Table  I.                                                    “     Pre-slip       refers  “to a painful    hip
without               detectable                 shift       of the epiphysis     but with widening                                                           and irregularity        of the epiphysial
plate considered                           confirmatory                      of the diagnosis.
Sex and age-In                              this small                  series    one-third    of the                                  patients            were           girls            with       an      average            age       of
eleven          and      a halfyears,                     that        ofthe            boys         being          thirteen              and        a halfyears.                       There           was      no significant
difference               in sex or age                      incidence                  between                those           treated              by manipulative                                reduction              and       those
treated          by other                  means.
                                                                                                             TABLE               I
                                                                     SUMMARY                OF TREATMENT                      IN THIRTY-FIVE                       HIPS




                                                                     Condition              and method               of treatment                                   Number             of

                                                         Pre-slip,           treated             by traction             for three            months                             1

                                                         Pre-slip,           pinned          .          .            .             .           .              .                  1

                                                         Mild        slip,     pinned             without          reduction                   .              .                  8

                                                         Manipulative                  reduction              and        pinning               .              .              16

                                                        Intertrochanteric                        osteotomy                         .           .              .                  1

                                                        Cervical             wedge          osteotomy                .           .             .              .                  8



Duration                of         symptoms-Of                           the          sixteen               hips         treated              by         manipulative                         reduction                four         were
“     acute,”           with            two       weeks’             premonitory                        symptoms                        in    two         of       them.               In         all but        one of these
four       the        slip     was             almost        complete.                      Reduction                    performed                      in each             instance                 within       seventy-two
hours           was      apparently                     perfect,              one       being           over-reduced                          at first.
           In     the remaining      twelve    patients symptoms                                                                   were             “    chronic,”                    on only    two occasions
starting          with minor    trauma,     and had been present                                                                 for two,                four, four,                  four, five, six and seven
weeks,      and               three,    three,    six,                   eight and                  fourteen     months.      In this group    the degree      of slip was
categorised                   as slight      in two,                     moderate                   (more    than    1 centimetre     slip in either  direction)      in six
and        severe             in        four      hips.            In        all     four           “   severe            “     slips         there               had       been            some           exacerbation                    of
symptoms,                    with          minor           trauma              in one              instance              only,           about            two           weeks          before              admission              (Figs.
    1 to 6).      These             four         patients            include            those           with        the longest                     “    chronic             “       history          ; the exacerbation
in each          case              had not               been sufficient  to immobilise                                                the patient                   but         had caused                     the      doctor     to
seek        further                advice,              and is presumably      evidence                                                of further                   shift         or at least                    of      persisting
instability        at the epiphysial                                    plate (Figs.    7 to                        12). In three     of the eight “mild                                                      slips pinned                 in
situ”       (Table    I) reduction                              had        been attempted                           without  success;     the patients had                                                    had symptoms
for      one,         four         and          six months.

                                                                                                        TECHNIQUE
           Attempts                 at gradual                reduction                 by traction                      have          been        abandoned                         as often          futile         and      always
wasteful              of time.
       The            patient              is placed               on        an orthopaedic                         table              with        the     pelvis           held            down           by an assistant;
traction              is applied                  by      the        surgeon                with            the     hip         and           knee            flexed         90 degrees,                      and        the      thigh

VOL.       51 B,        NO.        2,     MAY      1969
256                                                                                       T.     J.   FAIRBANK


slowly           and           steadily           rotated            medially          and        then       abducted            and        finally            extended.               The       surgeon
may        be firm              but       never        forceful.             Rarely       does        the        surgeon       feel that                reduction             has    occurred.



                 i#{149}’




                                               tWIG.     13                                                                                FIG.          14




                                                              FIG.      17                                                                 FIG.          18
                               Case       3-Over-reduction                   in a case       of epiphysiolysis             in a patient           of     14, with symptoms
                               of five weeks’ duration.                      Figures      13 and         14-Before           reduction.                Figures   15 and 16-
                                       Over-reduction.                       Figures      17 and         18-Correct            reduction               and fixation.


           The          foot      is then          attached            to the footpiece                  in abduction                and      medial               rotation          with      moderate
traction             and         radiographs                  are taken.              If reduction               is successful,             fixation               is obtained          with      Austin

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                                     MANIPULATIVE                    REDUCTION                   IN      SLIPPED               UPPER      FEMORAL              EPIPHYSIS                                       257

Moore’s              pins,       which            are      now       preferred               to the             Smith-Petersen                    nail       used         earlier.            The    surgeon
must          not     waste          time;         the      sooner          the        leg can            be removed                   from        its position                  of medial           rotation
and      abduction        the better;                        the position                  menaces                 the         blood  supply                 to the            femoral          head.   For
the      same      reason     a plaster                         boot    with               a cross                 bar          to maintain                  medial              rotation         in bed is
undesirable.                    The          placing         of the             pins     must            ensure           that         there       is no danger                   of redisplacement
and      the         leg     should            be allowed                to roll         out.
         If reduction                  is unsuccessful                    the     surgeon                must         resist  the temptation                         to” have another     go.”
If the         degree           of      slip       is mild,          tension             on        the       leg       is relaxed    and the                        hip is pinned    with the




                                                                                                      FIG.       19




                                                                                                      FIG.       20
                              Case      3.     Figures        19   and      20-Thirteen                  years        later.     Good          restoration          of     contour.
                                                                                   Trivial            symptoms             only.



displacement                    uncorrected;                  if the            degree          of       slip      remains              unacceptable                     the      surgeon           proceeds
forthwith              to the          further           operation              of his choice.
      Only             in mild cases                  may manipulation                             produce               only partial  correction                           of position              and       this
is accepted              gratefully.                 In the moderate                         and      severe             cases the writer     finds                       that reduction                   either
occurs         completely                 or not           at all.        In two           instances                  radiographs               revealed            over-reduction                    in both
antero-posterior                       and       lateral      projections;                   immediate                   release        of tension             corrected               this     potentially
dangerous                  situation           (Figs.        13 to 20) and                      no disaster                ensued.

VOL.     51     B,    NO.      2,    MAY       1969
258                                                                                                    T.      J.      FAIRBANK


          Weight-bearing                      was             avoided                    for        at least            three           months,              although               some         patients         no doubt
discarded   their crutches     much                                             earlier, except   for hospital                                     visits.            The pin or pins were                           removed
when fusion      of the epiphysial                                              plate neared    completion,                                      usually              about  a year later.


                                                                                                              RESULTS
          With        two       exceptions                    lost          to follow-up                       after       removal               of the pins,                these         sixteen          patients       have
been       followed             for     an average                              of seven             years             within           the     range           of three            to seventeen                years.


                                                                          444


                            1
                            1/                            .




                                                          FIG.              21                                                                               FIG.      22




                                                       Fio. 23                                                                                                 FIG.     24
                            Case 4-Acute               slip in a patient of 10, with continuation                                                       of growth            at the epiphysial
                            plate. Figure            21-Before       reduction. Figure 22-After                                                         reduction.             Figures   23 and
                            24-Nine           years later.                            Growth         has continued                  and the head of the nail is no longer
                                                  close              to         the     articular           surface.            There         were      no     symptoms.



          In     no    case           did     ischaemic                               necrosis          of the             femoral                   head        occur.             In     one       case        temporary
minimal              changes           occurred                  around                    the       point             of the       Smith-Petersen                          nail,        apparently             from       local
trauma.
          In eleven             patients            the         hip              was        completely                    symptomless;                        in the         remainder                symptoms             were
trivial        and     in only              one     sufficient                          to restrict                 activities            in any             way.
     Objectively     in only                          six cases was the range       of movement                                                                 strictly        full; the rest                 lacked        5 to
15 degrees     of movement                              in one or more  directions,     usually                                                              abduction            and medial                   rotation.

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                            MANIPULATIVE                  REDUCTION           IN SLIPPED         UPPER    FEMORAL        EPIPHYSIS                   259




                                         FIG.        25                                                         FIG.    26




                                          FIG.       27                                                         FIG.    28




                                          FIG.       29                                                          FIG.    30
          Case 5-Patient               aged 15. Late result                after   mild degree     of slip.   Symptoms        for five weeks,   no
          injury.   Figures   25 and 26-Before                          reduction.   Figures    27 and 28-Two       weeks after reduction.
          Improvement       in position is shown                       only in the lateral view. Figures      29 and 30-Ten      years later.
               Shortening         of    the   neck        and   some      prominence     of the greater trochanter.      No symptoms.




VOL.   51 B,   NO.    2,    MAY        1969
260                                                   T. J. FAIRBANK




                            FIG.     31                                                 FIG.     32




                            FIG.     33                                                 FIG.     34




                         FIG.       35                                                        FIG.        36
      Case 6-Moderate           degree of slip in a patient of 12. Four     weeks’ symptoms,            no injury.       Figures
      31 and 32-Before            reduction.   Figures    33 and 34-Three       months   after        reduction.         Figures
                   35 and 36-Two           years later.   Note the widening     of the femoral             head.



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                               MANIPULATIVE              REDUCTION               IN   SLIPPED            UPPER      FEMORAL          EPIPHYSIS   261




                      A




                                                                             ,        I
                                          FIG.      41                                                                       FIG.   42
          Case       7-Persistent             widening       of the joint space in a patient    aged 13 at the time of diagnosis.
          Three      months’     symptoms.               Figures    37 and 38-Before    reduction.    Figures     39 and 40-After
          reduction.         One   pin has          penetrated      too  far. Figures 41 and 42-Three        years later. Persistent
                                                  widening      of   the   joint          space,   but     no    symptoms.




VOL.   51 B,   NO.        2,    MAY   1969
262                                                                                       T. J. FAIRBANK

           In two           patients             the      leg was         25       centimetres               short,       and       one        of them               required              a slight             heel
raise       ; in the            remainder                  shortening              was       insignificant,               only           reaching               1 2 centimetres                        in       two
instances.
Radiographic                    results-In                   only      one    patient       with an acute  minor     slip almost       perfectly     reduced
did       growth            continue             (Figs.         21 to      24).
           In most,             late      radiographs                  revealed       some shortening     of the femoral       neck, and often a little
widening              of the           femoral      head             in a lateral       direction  with a suggestion      of flattening,        even though
serial        films         had        shown            no      suggestion             of ischaemic                   changes            and       the     films          taken            immediately
after        reduction             showed               symmetrical                femoral    heads    (Figs.     25 to 30 and                                  3 1 to 36). In one there
was        a curious              persistent              widening               of the joint    space     (Figs.    37 to 42).                                  Except    in acute cases,
however               perfect           the       original            reduction,             there       usually           remains              for       the         discerning                 eye        some
trace   of abnormality.                                There          may be a little                  new        bone       formation                   behind              the        neck,       and          the
greater   trochanter                       may         appear          unduly large.


                                                                                          CONCLUSIONS
           This       series,           albeit         consecutive               and      unselected,              is very          small          ; conclusions                    must           therefore
be tentative.        The                   results           do however              suggest    that             the dangers                of late           manipulative                       reduction
properly      performed                       may            have been             exaggerated.                   Attempted                 without            undue       force                  it proved
a harmless                procedure,                   often        successful           even        in cases          of long           duration.                 When             it succeeds,                 the
results           in slips        of     unacceptable                   degree         are       at least       as good             as     those         following                 the     more           major
surgical   procedures,                   which       can thus be avoided.           Even   when     the displacement           is minor                                                                           its
correction    should                on theoretical        grounds     at least decrease      the prospects     of later osteoarthritis.
The only absolute                   contra-indication          is a fused epiphysial     plate.    The degree     of slip and above                                                                               all
the       duration            of symptoms          should    not preclude     an attempt       at manipulative      reduction.

I am most grateful                      to my colleagues,   Mr R. W. Butler                            and      Mr A. H. G. Murley,                       who         have         generously           handed
over their patients                    to me for treatment.


                                                                                             REFERENCES

BIANCO,        A. J. (1965): Treatment                          of Mild        Slipping         of the Capital           Femoral           Epiphysis.                Journal        ofBone           and Joint
          Surgery, 47-A, 387.
DURBIN,            F. C. (1960):              Treatment              of Slipped          Upper        Femoral          Epiphysis.              Journal        of      Bone         and     Joint       Surgery,
     42-B, 289.
FAHEY,    J. J., and O’BRIEN,                          E. T. (1965):           Acute       Slipped      Capital         Femoral            Epiphysis.              Journal         of     Bone      and      Joint
      Surgery,   47-A, 1105.
HALL,        J. E. (1957):             The Results             ofTreatment             of Slipped        Femoral          Epiphysis.            Journal         ofBone             and Joint           Surgery,
          39-B,      659.
JACOBS,           B. W. (1968):                Slipped         Capital         Femoral          Epiphysis.             American            Academy              of     Orthopaedic                  Surgeons.
          instructional           Course         Lecture        (unpublished).
JERRE,  T. (1950):  A Study in Slipped   Upper Femoral     Epiphysis.      Acta Orthopaedica      Scandinavica,     Supplementum
     No. 6.
NEWMAN,      P. H. (1960): The Surgical Treatment      of Slipping      of the Upper    Femoral     Epiphysis.     Journal   of Bone
     and Joint Surgery, 42-B, 280.
VAUGHAN-JACKSON,        0. J. (1956): Reducibility of Slipped      Femoral     Capital Epiphyses.      Proceedings     of the Royal
     Society of Medicine,     49, 812.




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