Slipped capital femoral epiphysis. The mechanical function of the periosteum: new aspects and theory including bilaterality.

Acta radiologica. Supplement Pub Date : 2004-08-01
L Billing, H G Bogren, B Henrikson, J Wallin
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Abstract

This particular ailment has many designations in the literature but none is quite adequate. Here we use the terminology slipped capital femoral epiphysis (SCFE). The anatomy of the proximal femur in all mammals reflects their growth and function. The main forces acting on the head are perpendicular to the growth plate. The thick tear-proof perichondrium-periosteum on the femoral neck is like a stocking attached to the epiphysis and the trochanter region. Growth in length causes a strong tensile stress in the periosteum, pressing the epiphysis against the metaphysis and thus stabilizing the vulnerable growth plate-the periosteum theory. Several factors may diminish the stability of the growth plate. SCFE begins with fissures, which coalesce to a fracture in the growth plate, invisible on a radiograph. As the slip progresses, an increasing angulation between the epiphysis and the remainder of the femur occurs. Weight and muscular forces displace the epiphysis posteriorly in a flexed hip. A rift in the ventral half of the periosteal stocking occurs at the border to the perichondrium and, after that, a longitudinal rift in the periosteum at the anterior midline of the femoral neck. This rift becomes broader as the epiphysis slips posteriorly, withdrawing the ruptured periosteum. Displacement of the epiphysis is due to a rotational slip and tilt, made possible by a compression fracture in the posterior part of the metaphysis. Parts of the periosteum function as reins steering the slip direction and counteracting the displacement. SCFE may be regarded as a pseudoarthrosis in the growing cartilage of the plate. The periosteum theory extended to a pseudoarthrosis theory has been supported by findings at surgery and on true lateral radiographs of usual and unusual cases of SCFE presented in this opus. On a true lateral view, the displacement can be measured as the slipping angle (SA) based on anatomical and geometrical considerations. SA values from 95 normal hips and from 22 contralateral asymptomatic hips from SCFE patients are presented in a histogram and bar graph. Statistically, SCFE is always bilateral, but in about 1/3 of the asymptomatic, contralateral hips, the physis ossifies and closes with SA below 13 degrees, and surgery is not necessary. It is most important that the position of the femur on the X-ray table is exactly defined in two dimensions: 1) the angle between the femoral shaft and the tabletop (angle of elevation), 2) the degree of rotation of the femur around its axis. A precisely defined positioning of the femur is a prerequisite for an exact reproducible measurement of the SA on a true lateral view and is also valuable for the evaluation of radiographic "signs". An aid, the Youth Hip Triangle (YHT), has been designed to facilitate positioning of the femur and measurement of SA. YHT is recommended for routine use in every X-ray facility. The method is quick, cost effective and makes it possible to diagnose SCFE in the contralateral hip before clinical signs or symptoms have occurred.

股骨头骨骺滑动。骨膜的力学功能:新的方面和理论,包括双侧性。
这种特殊的疾病在文献中有许多名称,但没有一个是相当充分的。这里我们使用术语“股骨头骨骺滑动”(SCFE)。所有哺乳动物股骨近端解剖结构反映了它们的生长和功能。作用于头部的主要力垂直于生长板。股骨颈上厚的防泪硬骨膜就像长统袜一样连接着骨骺和粗隆区。骨膜长度的增长在骨膜中产生强大的拉伸应力,将骨骺压向干骺端,从而稳定脆弱的生长板——骨膜理论。有几个因素可能会降低生长板的稳定性。SCFE始于裂缝,这些裂缝在生长板中合并成骨折,在x光片上看不见。随着滑移的进展,骨骺和股骨其余部分之间的成角增加。髋关节屈曲时,重量和肌肉力量使骨骺向后移位。骨膜长袜的腹侧部分在软骨膜边界处出现裂口,之后,在股骨颈前中线的骨膜上出现纵向裂口。当骨骺向后滑动时,裂口变宽,使破裂的骨膜收回。骨骺移位是由于旋转滑移和倾斜造成的,这可能是干骺端后部的压缩性骨折造成的。部分骨膜的功能如同缰绳,控制滑移方向并抵消移位。SCFE可视为板内生长软骨中的假关节。骨膜理论扩展到假关节理论已经得到手术和真实侧位x线片的支持,正常和不寻常的SCFE病例在本著作中提出。在真正的横向视图,位移可以测量为滑移角(SA)基于解剖和几何考虑。SCFE患者的95个正常髋关节和22个对侧无症状髋关节的SA值以直方图和条形图的形式呈现。据统计,SCFE总是发生在双侧,但在约1/3无症状的对侧髋关节中,骨化和关闭时SA低于13度,无需手术。最重要的是,股骨在x光台上的位置在两个维度上精确定义:1)股骨轴与桌面之间的角度(仰角),2)股骨绕其轴旋转的程度。股骨的精确定位是在真正的侧位视图上精确测量SA的先决条件,对于评估x线“征象”也很有价值。一种辅助装置,青年髋三角(YHT),被设计用于股骨定位和SA测量。建议在每个x光设备中常规使用YHT。该方法快速,经济有效,并且可以在出现临床体征或症状之前诊断对侧髋关节的SCFE。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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