Review Article Open Access
Valgus Slipped Capital Femoral Epiphysis (SCFE) Managed by Plaster Cast Immobilization Treatment: Seven Case Reports and Review of The Literature
Pedro Carlos de M. S. Pinheiro* & Vanessa dos Santos Madeira Côrtes Salvio
Department of Orthopedic Surgery, Jesus Children’s Hospital, Rio de Janeiro, RJ, Brazil
*Corresponding author: Dr. Pedro Carlos M. Sarmento Pinheiro, Department of Orthopedic Surgery, Jesus Children’s Hospital, Rio de Janeiro, RJ, Brazil,Tel: 55.21.2255-4685 Email: @
Received: December 17,2018; Accepted: January 08, 2019; Published: January 31, 2019
Citation: Pinheiro PMS, Santos VD, Madeira CS (2019) Valgus Slipped Capital Femoral Epiphysis (SCFE) Managed by Plaster Cast Immobilization Treatment: Seven Case Reports and Review of The Literature J Exerc Sports Orthop 6(1): 1-13.177 http://dx.doi.org/10.15226/2374-6904/6/1/00178
Abstract
Background: This report provides detailed information with illustrative examples of more than seven patients (eight hips) with one specific rare condition valgus of SCFE. The purpose of this study was to describe and comment on the complete analysis of seven cases of valgus SCFE.

Patients and Methods: The research was performed based on the study of the following variables: clinical patient history, symptomatology and physical findings. Admission for anteroposterior (AP) view and Lauenstein [1] frog-leg position for lateral radiograph view of both hips (validated instrument) was performed. A retrospective review maintained data base of patients diagnosed with valgus SCFE was conducted. Patients with radiographically valgus SCFE were identified, confirmed and in the analysis, included. Medical records for clinical features, treatment, and outcomes, were reviewed.

Results: Seven patients from the database were indentified: the patient average age at diagnosis was ten years and six months old, within follow up time of thirty six months. All valgus SCFE patients with localized disease with conservative treatment using cast immobilization were managed. Two hips showed evidences of chondrolysis; however just one patient presented juvenile rheumatoid arthritis (JRA) disease diagnosed.

Conclusions: The hip joint in our series treated by plaster cast immobilization method to control the progressive valgus displacement of the epiphysis was effective and capable of being justified, and functional. Chondrolysis and its link as a complication were described. This research is justified by the importance and attention that the entity deserves.

Keywords: SCFE; Coxa Valga; Plaster Cast Immobilization
Literature Review
Slipped Capital Femoral Epiphysis (SCFE)
SCFE is a painful hip disorder which most commonly occurs in prepubescence and early adolescence, period that boys and girls may present the proximal capital femoral epiphysis from the metaphysis of the growth plate breaks away.[2,3] The etiology of SCFE is multifactorial.
Valgus Slipped Capital Femoral Epiphysis
Valgus SCFE is a very rare entity, defined as a lateral and superior displacement of the proximal capital femoral epiphysis relative to the metaphysis.[3]
History of Slipped Capital Femoral Epiphysis
The first description of a separation of the proximal capital femoral epiphysis has been credited to Ambroise Paré (1572)[ 4]. He admitted the feasibility of confounding the separation of the capital femoral epiphysis with luxation in a hip dislocated.
XXI. De La Fracture Du Col Du Fémur
Quelquefois, il se fait une fracture près de la jointure de la hanche, au col du fémur: J’ai vu ce cas chez une dame qui m’avait appelé pour la panser. Voyant que sa jambe était plus courte que l’autre, avec une éminence faite par le trochanter extérieurement, au-dessus de la jointure de l´ischion, j’estimai d’abord que c’était la tête de l’os et qu’il y avait luxation et non fracture. Je tirai alors et poussai l’os, ce me semblait-il en sa boîte, étant donné que les deux jambes étaient égales de longueur et d’aspect et je la pansai ensuite comme s’il s’agissait d’une luxation. Deux jours après, je revins voir la malade qui se plaignait alors d’une extrême douleur. Je trouvai sa jambe courte et son pied tourné en dedans. Je défis toutes les bandes et vis la même éminence qu’auparavant. Je m’efforçai à nouveau de réduire l’os en sa boîte. Cependant, je m’aperçus qu’il crépitait et sus alors qu’il y avait fracture et non luxation. De même, l’épiphyse de la tête de cet os se sépare quelquefois et le chirurgien est trompé, estimant qu’il y a luxation et non disjonction. Donc, je réduisis l’os, appliquai des attelles sur les compresses et fis une ligature à deux têtes, la croissant pardessus la jointure et autour du corps en croix de Saint- André. Le reste de la cure se fit comme nous l’avons déjà indiqué plus haut.

Ambroise Paré [4], Sabatier, M. Mémoire Sur la Fracture du Col du Fémur The first investigation description about the word spica in old French was published.[5].

“On fait le fpica avec une bande longue de quatre ou cinq aunes roulée à um chef le globe paffe plufieurs fois fous la cuiffe malade pour le faire revenir fur le grand trochanter, & leconduire enfuite autour du corps Celui dont plus nombre des Auteurs recommande l’ufage eft le fpica...

Walther Müller introduced, in March 2, 1926, from the Surgical University Clinic of Marburg, descriptions, illustrations, interpretations, comments, and observations of the Coxa valga forms (lateral and upward displacement of the epiphysis against the femoral neck).[6] There is no explanation for the formation of the Coxa valga adolescentium. The displacement of the femoral head on the metaphysis in the literature is little discussed. This process of lateral displacement of the epiphysis on the femoral neck, in fact, represents the key to the explanation of most forms of the Coxa valga. The genesis was not yet clarified at all. Müller report epiphyseal Coxa valga in patients with coexisting acetabular dysplasia. In several parameters the articles from world literature, the authors did not report the subject matter from the demographic data of valgus SCFE.

The authors, in 2017, presented seven more patients with valgus SCFE (eight hips). A female patient had the right hip treated by spica cast immobilization. The other female patient (left hip) had bilateral long casts (with cross bar-struts) employed. A male patient (both hips) and a female patient (left hip) had the hips treated by short casts in abduction with antirotational bars. A male patient (left hip) and two female patients (both left hips) had the hips with bilateral short casts in abduction and internal rotation of about 30’ with cross bar-struts applied.

Detailed information from the literature investigated, baseline demographic characteristics of included 69 patients with 89 valgus SCFEs on (Table 1) are reported.
Table 1: Relevant Demographic Data on 89 Valgus SCFEs in 69 Patients of 27 articles from the Orthopedic Literature

Year

Author

Patient

Sex

Age at Diagnosis (Yrs.)

Race

Hip R/L

Weight (kg)

Stability

IR

ER

ABD

FLEX

Type

Grade

Treatment

Complications

1926

Müller6

--

--

--

--

--

--

--

--

--

--

--

--

--

--

--

1930

Scheuermann7

One

F

14

--

R

--

--

--

--

--

--

--

--

Confinement to bed for 2 months

--

1946

Finch and Roberts8

F

14

N-W

R+L

--

--

-- / 10o

15o / --

-- / --

-- / --

Ch / Ch

-- / --

Bilateral long-leg casts in IR / abduction of   300 Adhesive traction for 8 weeks +  right hip spica for six weeks

Avascular necrosis

1949

Howorth9

Two

F

13

N-W

R+L

--

-- / --

-- / --

-- / --

--

Ch  /  --

-- / --

--

1950

Jerre10

Three

--

--

--

3

--

--

--

--

--

--

--

--

--

--

1957

Meyer et al11

Four

--

--

--

7

--

--

--

--

--

--

--

3 slight

Different  forms of treatment

5 arthrosis deformans

1965

Fahey and O´Brien12

4 marked

 

1965

Wilson et al13

Two

F

13

W

L

--

--

--

--

--

--

Ch

--

Manipulation and well-leg traction

Some limitation of IR

1970

Schott and Vianna14

--

--

--

--

--

--

--

--

--

--

--

Non weight bearing on crutches

Some limitation of IR

1972

Krishan and Shelton15

One

F

11.8

W

R

--

--

--

--

--

--

AcCh

--

Gentle traction + fixation  with 2 threaded pins

Sclerotic changes+ regression

1972

Mihran O. Tachdjian16

Two

F

12

--

L

--

--

--

--

--

--

--

--

--

--

1978

Skinner and Berkheimer17

--

--

--

--

--

--

--

--

--

--

--

--

--

--

1979

Rothermel 18

One

F

12

--

L

--

--

--

--

--

--

Ac

--

in situ  three left  Steinmann’ pins

Chondrolysis+ hip joint restored

1984

Carlioz et al19

One

F

11

N-W

R+L

--

--

300  / 300

450 / 450

--/--

700 / 900

Ch /Ch

--/--

in situ three Knowles’ pins of the right hip

--/--

1989

Scher et al20

in situ three Knowles’ pins of the left hip

--/--

1996

Segal et al21

F

--

--

R+L

--

--

--

--

--

--

RI /LII

in situ two Knowles’ pins of the left hip. Two threaded pins  +  spica cast  + crutches  + varization osteotomy

--/--

2003

Rajan et al22

Two

M

13

N-W

R

--

--

--

--

--

--

--

--

Two threaded pins out of the neck + pins removed

2004

Docquier et al23

One

M

12

N-W

R

--

--

--

--

--

60o

Ch

--

in situ three Knowles’pins of the right hip

--

2005

Yngve et al24

One

M

15

W

R

--

--

--

--

--

10o

Ch

--

in situ four Knowles’pins of the right hip

--

2006

Loder et al3

Two

F

14

--

L

--

--

--

--

--

--

Ch

--

in situ left screw fixation

--

2007

Shea et al25

F

13

--

R

--

--

--

--

--

Ch

--

in situ right screw fixation

--

2010

Mata and Ovejero26

One

F

14

--

R+L

56

--

--

--

--

1000 / 900

AcCh

--

Imhauser-Weber osteotomies

L femoral head segmental  a vascular necrosis

2010

Shank et al27

AcCh

2011

Renganathan et al28

F

9.9

W

R

36

1 Stable

--

--

--

--

Ac

III

in situ right cingulated screw fixation

--

2011

Venkatadass et al29

Two

F

10.11

N-W

R

91

1 Stable

0

300

300

400

Ch

III

in situ  right cannulated screw fixation

--

2013

Koczewski30

2017

Kotoura et al31

One

F

10

--

R

--

1 Stable

reduced

--

reduced

reduced

Ch

--

An adductor tenotomy + varus osteotomy+ Richards’ screw and hip spica

--

F indicates, female; M, male; R,right; L,left; W,white; NW, non-white; weight; IR, internal rotation; ER, external rotation; ABD, abduction; FL, flexion; AC, acute; Ch, chronic; AcCh, acute on chronic, Y, year; m.age,mean age.
Materials and Methods
As usual, trough Brazil Platform institutional review board, the Research Project of study entitled: Valgus slipped capital femoral epiphysis have been managed by plaster cast immobilization treatment: seven case reports and review of the literature has been analyzed validated and approved. The study with PCEA (Presentation Certificate of Ethical Appreciation) number 73819017.0.0000.5279 on November 28, 2017, was registered. The typology (type of study) of the design in this sample, a retrospective cohort study of an individualizing, observational (nonrandomized) longitudinal characteristics has been employed. The independent variable (a form of treatment) was cast treatment. In this research the dependent variable was chondrolysis. A total of 131 patients in 166 hip joint affected of SCFEs from 1999 until 2012 at the authors’ own department, were treated. The first 84 patients (106 hips) with SCFE, by one of the authors, have already been published [32]. It was found in the total series 7 patients (eight hips) with one specific condition – valgus SCFE, using plaster cast immobilization as the method of treatment chosen.

To qualify this study, valgus hip SCFE and painful condition in the hip had been the characteristic deformity. Radiographs (type of imaging) remains the gold standards used as validated instruments (important tools) to improve medical care in daily clinical practice and by modifying treatment protocols were the basis of the results. The outcome instruments, focused on biological and physiological factors in orthopedic research were considered. The valgus SCFE patient’s sex, race, weight, hip treated, age at diagnosis, time in a cast and the type of cast were recorded. The methods used were based on symptomatology, and categorized as acute (symptoms for < 3 weeks), chronic (symptoms for ≥ 3 weeks), and acute-on-chronic (chronic symptoms, complaints initially and the subsequent exacerbation of acute symptoms); according to Fahey and O’Brien criteria were evaluated. Slip degrees were documented by the standard method of thirds and classified as mild (<33%), moderate (33% to 50%), or severe (>50%), according to Wilson, Jacobs, Schecter, MacEwen and Ramsey, who use the three grades (<30%) (30%-50%), (>50%) of slip percentage [12,13,33]. The hips were evaluated systematically roentgenographically as well as functionally, according to Heyman and Herdon’s criteria, and were also categorized as satisfactory and unsatisfactory by means of Aadalen, Weiner, Hoyt, Herdon and Herdon’s criteria [34,35]. Methods to analyze the joint cartilage and detect chondrolysis were utilized based on Ingram, Clarke, Clark and Marshall’s criteria [36]. Chondrolysis leads to deformity, pain, and limp, limitation of motion in the hip and narrowing of the joint space affected according to radiographies criterion if the joint space measured 3mm or less, then chondrolysis was present. The type of SCFE as stable or unstable was classified [37]. A stable SCFE is defined when the patient is able to ambulate, with or without crutches. An unstable SCFE is classified when the patient, with or without crutches cannot ambulate. The lack of intersection between a line draw parallel to the superior edge of the femoral neck (Klein’s Line) and the epiphysis confirms a slip [38]. In valgus SCFE, the Klien line will always be normal [3]. For an opportune diagnosis The Klein’s line, therefore, the Lauenstein frog-leg position for the lateral radiograph view of both hips are absolutely necessary [1]. Weight category was based on 2000 CDC Growth Charts for the United States: Methods and Development [39]. The method of treatment of the valgus SCFE, in this project the immobilization in a spica cast and bilateral long/ short leg casts in abduction internal rotation with antirotational bars has been applied. The protocol period for immobilizing the patient’s hip for twelve weeks, was established.
Statistic Methodology
The descriptive analysis in the form of tables and the observed data were expressed by frequency (n) and percentage (%) for categorical data (qualitative) and for the medium and interval Interquartile range (1° quartile - 3° quartile) for numeric data, was presented.

The inferential analysis for comparison between the two SCFE (classic and valgus) subgroups by the Fisher accurate test in the categorical data and by the Mann-Whitney U test (non parametric) in the numeric data was composed. The association among the characteristics of the hips affected by chondrolysis complication by the qui-square (χ2) test or by the Fisher accurate test was analyzed.
The non parametric method, because the variables did not present normal distribution (Gaussian distribution), due to the rejection of the normality hypothesis according to the Shapiro- Wilk test was used. The determination criterion of the significance was at 5% level was adopted. The statistical analysis by the statistical software SAS® System, version 6.04 (SAS Institute, Inc., Cary, North Carolina) was processed.
Results
Between 1999 and 2012, 131 patients (166 hips) were treated by conservative method, from the author’s own department. Among this group, 7 patients (8 hips) were defined as having a valgus SCFE characteristic deformity with painful hip.

Summary of clinical and characteristics parameters of valgus SCFE (author’s own series) in table 2 is described. Proximal Femoral angular measurements in patients with valgus SCFE in table 3 is observed.
Table 2: Data on 7 patients (8 hips) of Valgus SCFE (author’s own series)

Case

Age at Diagnosis (Yrs)

Sex*

Race#

Hip Treated¥

Weight kg

Classification Fahey and  O’Brien33

Grade Of Slip Wilson. Jacobs.

Stability Loder et al39

Time  in Cast (Days)

Type of cast

Complications

Functional evaluation criteria of Heyman/ Herdon36  and Aadalen37

Follow up analysis (months)

1

11.7

F

N-W

R

49

Acute

Mild

Stable

116

1 ½ Hip Spica

JRA Chondrolyis

Unsatisfactory

77

2

11.8

F

W

L

28

Acute

Mild

Unstable

93

Bilateral Long Casts

__________

Satisfactory

21

3

11.4

M

W

R

65

Chronic

Mild

Stable

91

Bilateral Short Casts

__________

Satisfactory

58

L

Chronic

Mild

Stable

Satisfactory

 

4

9.1

F

N-W

R

60

Acute

Mild

Stable

94

Bilateral Short Casts

__________

Satisfactory

28

5

11.4

M

N-W

L

50

Chronic

Mild

Stable

90

Bilateral Short Casts

__________

Satisfactory

26

6

10.3

F

N-W

L

36

Chronic

Mild

Stable

93

Bilateral Short Casts

Chondrolyis

Unsatisfactory

29

7

10.7

F

N-W

L

50

Chronic

Mild

Stable

90

Bilateral Short Casts

_________

Satisfactory

15

F indicates female; M, male; R, right; L, left; JRA, Juvenile rheumatoid arthritis
Table 3: Range of motion before cast/at latest follow-up (degrees) of Valgus SCFE (author`s own series)

Case

Flexion

Abduction

Adduction

Internal Rotation

External Rotation

Comments

Before

Latest

Before

Latest

Before

Latest

Before

Latest

Before

Latest

__________

1

(R) 30°

20°

10°

10°

20°

Juvenile rhematoid arthritis

Right hip(chondrolysis)

2

(L) 90°

90°

60°

45°

30°

30°

20°

15°

90°

80°

Idiopathic Valgus SCFE

3

(R) 75°

120°

45°

45°

20°

30°

10°

20°

60°

60°

Bilateral  Idiopathic

(L) 80°

120°

45°

45°

20°

30°

15°

20°

60°

60°

Valgus SCFE

4

(R) 90°

90°

35°

60°

30°

30°

15°

15°

80°

60°

Endocrine Dysfunction

5

(L) 90°

90°

45°

40°

20°

20°

15°

15°

45°

45°

Idiopathic Valgus SCFE

6

(L) 60°

30°

40°

10°

20°

15°

30°

Left hip-Chondrolysis

7

(L)100°

90°

45°

45°

20°

20°

20°

20°

60°

45°

Idiopathic Valgus SCFE

R indicates right; L, left; JRA, Juvenile rheumatoid arthritis
First Work Objective
The present variables association between the classic and valgus SCFE were characterized in patients sample.(Table 4)
Second work objective
The patient’s hip joint of the sample and the chondrolysis as complications, were characterize and reported. The classic/valgus SCFEs hip joint characteristics and complication (chondrolysis) were observed.(Table 5)
Table 4: Clinical characteristics of the patient’s sample with classic and valgus SCFE and descriptive level (p value) of the statistical test (author’sown institution)

Variable

category

Total

SCFE

Classic

Valgus

p value

(n = 131)

(n = 124)

(n = 7)

Clínical  Characteristics

Age (years)

median (Q1 - Q3)

 

12  (11 - 13)

12  (11 - 13)

11  (10 - 11)

0,049

Age-group - n (%)

< 12 years

68

51.9

61

49,2

7

100

0,009

≥ 12 years

63

48.1

63

50,8

0

0

Sex- n (%)

male

71

54.2

69

55,6

2

28,6

0,16

female

60

45.8

55

44,4

5

71,4

Race - n (%)

white

64

48.9

62

50,0

2

28,6

0,24

non-white

67

51.1

62

50,0

5

71,4

Wheight (kg)

median (Q1 - Q3)

 

62  (49 - 72)

62  (50 - 74)

49  (36 - 60)

0,019

Obese - n (%)

yes

86

65.6

84

67,7

2

2,9

0,046

no

45

34.4

40

32,3

5

97,1

Patient side envolvement- n (%)

right

42

32.1

40

32,3

2

28,6

left

54

41.2

51

41,1

3

42,9

0,99

bilateral

35

26.7

33

26,6

2

28,6

Treatment and follow-up

Cast type- n (%)

spica

58

44.3

57

46,0

1

14,3

short cast

72

55.0

66

53,2

6

85,7

0,18

crutches

1

0.8

1

0,8

0

0,0

Time in cast (weeks)

median (Q1 - Q3)

13  (12 - 13)

13  (12 - 13)

13  (12 - 14)

0,35

Follow up (months)

 

median (Q1 - Q3)

34  (13 - 57)

35  (13 - 57)

25  (12 - 70)

0.92

The categorical data by frequency (n), percentage (%), compared by the Fisher’s accurate test; and the numeric data by the median (1° quartile - 3° quartile)were compared by the Mann-Whitney U test
Comments:
The subgroup with valgus SCFE have presented: age in years (p=0,049), age group ≥ 12 years (p=0,009), weight (p=0,019) and obesity (p=0,0046) significantly smaller than the subgroup with classic SCFE. The other clinical characteristics of the patients, between the two SFCE subgroups did not present significant differences at 5% level. Also the treatment characteristics and follow-up did not present significant differences at 5% level, between the two SCFE subgroups.
Obs: The interquartile interval (IIQ) have 50% of the observations between the limits which corresponds to 10 quartile (Q1) and 30 (Q3). This interval as a measure dispersion which follows the median (as the standard deviation follows the medium) it was obtained.
Table 5: The above table shows characteristic and complications of the hip joint patient’s with classic and valgus SCFE of the 166 hip joint affected

Variable

category

Total  (n = 166)

SCFE

p value

Classic  (n = 157)

Valgus   (n = 8)

Hip Joint Characteristics

Hip Side - n (%)

right

77

46,4

74

46,8

3

37,5

0,44

left

89

53,6

84

53,2

5

62,5

Symptomatology - n (%)

acute

26

15,7

23

14,6

3

37,5

0,17

cronic

131

78,9

126

79,7

5

62,5

acute-on cronic

9

5,4

9

5,7

0

0,0

Stability - n (%)

stable

151

91,0

143

90,5

8

100,0

0,46

unstable

15

9,0

15

9,5

0

0,0

Slip degrees - n (%)

mild

119

71,7

111

70,2

8

100,0

0,74

moderate

28

16,9

28

17,8

0

0,0

severe

19

11,4

19

12,0

0

0,0

Complication - n (%)

right chondrolysis

8

4,8

7

4,4

1

12,5

0,19

left chondrolysis

9

5,4

8

5,1

1

12,5

no complication

149

89,8

143

90,5

6

75,0

The categorical data by the frequency (n), percentage (%) were compared by the Fisher’s accurate test
Comments
The characteristics and complications (chondrolysis) of the affected hip joint between the two SCFE classic and valgus subgroups did not present significant difference, at 5% level. Chondrolysis classic/valgus subgroups, great proportion between female (76.9%) and non-white race (84.6%) in comparison with patients without chondrolysis (42.4%) and (47.5%) respectively was verified.

Results of the patients with valgus slipped capital femoral epiphysis (SCFE) by plaster cast immobilization treatment were performed. (Cases 1, 2, 3, 4, 5, 6, 7)

Distribution of the seven cases with valgus SCFE. Radiographs and pictures of the patients during follow-up treatment, Cases 1,2,3,4,5,6,7 was demonstrated.(Figures 1-7)
Figure 1: Anteroposterior and frog-leg lateral radiographs of a girl aged 11-year-7 month-old, with a painful valgus right SCFE (a). More detailed view on anteroposterior of the right hip joint at 18-year-old, was demonstrated narrowing and irregularity with demineralization of the surrounding bone and obliteration of the joint space (chondrolysis) (b). Patient lying down with and irreversible clinical range of motion, flexion contraction, loss of strength and stiffness of the right hip joint was presented (c). Patient in orthostatic position showing right limb-length discrepancy (d). A crouching impossibility (Get-up and Go-test) movement of the right hip joint is demonstrated (e). A radiograph of the pelvis showing the right hip after total hip surgery in another center was performed (f). Obs.: Patient had poly-articular rheumatoid (Still’s) disease during treatment of the valgus SCFE diagnosed.
Figure 2: Anteroposterior and frog-leg lateral radiographs of a girl aged 9-year-10-month-old, with an open physic and a painful mild valgus right SCFE is showed. The femoral capital epiphysis is eccentric (a). Anteroposterior and frog-leg lateral radiographs at 10-year-4-month-old was taken.The physic orientation is more horizontal (b). Last radiographs taken at 12-year-2-month-old, in anteroposterior and frog-leg lateral views; the epiphyseal line had closed (c). Patient in orthostatic / lying down abduction and crouch anteroposterior positions is presented (d).
Figure 3: Anteroposterior and frog-leg lateral radiographs of a boy aged 11-year-4month-old, with bilateral horizontal epiphyseal plate and painful mild bilateral valgus SCFE (a). More detailed view on the anteroposterior radiograph showing slipping an open bilateral physic of both proximal valgus capital femoral epiphyses showing a laterally displaced capital epiphyses of the head of the femur (b). Radiographs taken at 16-year-2-monthold,in anteroposterior and frog-leg lateral radiographs, observing both proximal epiphyseal lines closed (c). Patient in orthostatic abduction and anteroposterior / lateral crouch position (d).
Figure 4: Anteroposterior and frog-leg lateral radiographs of a girl who hesitated to stand up, aged 11-years-8 month, with an open physic of valgus left SCFE (a). A more detailed view showing valgus slipping of the left hip (b). A double long leg (toe-to-groin) casts with antirational bars (cross bar-struts) as a rule of treatment which maintain the extremities in abduction and internal rotation of about 300 degrees have been applied (c). Radiographs taken at 13-year-old- 5 month-old, in anteroposterior and frog-leg lateral radiographs, the epiphyseal line had physical fusion (d). Patient in orthostatic and lying down abduction positions; in ventral decubitus with some limitation of the internal rotation of the left hip joint and excellent anteroposterior and lateral crouching positions at the end of the treatment (e).
Figure 5: Anteroposterior and frog-leg lateral radiographs of a boy aged 11-year-4-month-old, with a painful and open physis on a mild left valgus SCFE (a). The orientation of the growth plate is more horizontal in anteroposterior views. Radiograph control in anteroposterior and frog-pelvis aged 12year-6-month-old (b). Last radiograph aged 13-years-6 month, in anteroposterior and frog-leg lateral radiographs, showing left proximal capitalfemoral epiphyseal line complete closured (c).
Figure 6: Anteroposterior and frog-leg lateral radiographs of a girl aged 10-years-3-month-old, with a painful and open physic of the left valgus SCFE,physic more horizontally can be observed (a). Radiographs at the age of 11-year-8-month-old (b) and a 12year-8-month-old views taken narrowing of the left hip joint space (chondrolysis of the left hip/necrosis of the joint cartilage – Waldenströn50 disease) , was demonstrated (c).
Figure 7: Anteroposterior and frog-leg lateral radiographs of a girl with an open physic aged 10-year-7month-old, showing a painful varus right and valgus of left SCFE with the left hip physic appear more horizontally (a). Radiographs taken at 10-year-10 month–old (b) and 11-year-10 month-old, showing both left physic in anteroposterior and frog-pelvis almost completely closed(c).
Case Comments
Chondrolysis as complication were detected in two cases (1 and 6) in 8 analyzed hip joint. Chondrolysis is defined as pain, muscle spasms, stiffness, mobility limitation, narrowing of the hip joints as well as radiographic measurements. The results of chondrolysis incidence in relation to sex, race, side, symptomatology, concerning to slip degrees were documented. One patient with juvenile rheumatoid arthritis (Case 1) and the other patient with endocrine dysfunction (Case 2) as atypical valgus SCFEs were observed. The other five patients with absence of diseases as idiopathic valgus SCFE were documented. The type of cast, only in one patient (Case 1) hip spica was used, and in the other six patients have been employed (Cases 3 until 7), long/short leg cast with anti-rotational bars with lower limbs in abduction and internal rotation about 300 . Avascular necrosis in none of the hips with cast treatment was detected. On radiograph taken in patients with valgus SCFE, the Klein’s line in all hips, an increase of intersection between a line draw parallel to the superior edge of the femoral neck was observed [39]. The case 1 of our valgus SCFE list, the right hip (non-white female patient), showed periarticular osteoporosis, joint space narrowing and coxa valga deformity compatible with chondrolysis. Another chondrolysis complication result treated with bilateral short cast in non-white female patient (Case 6) was reported.
Valgus SCFE Treatment Literature
Concerning treatment of SCFE Sir Reginald Watson-Jones, said: the treatment of displacements of the upper femoral epiphysis is not a very happy chapter in the history of orthopedic surgery [40]. The treatment of the SCFE has been the matter of much contestation and debate. The principal treatment’s objective of SCFE is to identify the condition, avoiding progressive displacement and accomplish the most adequate management. The first essential to treatment is early diagnosis [13]. To obtain a good prognosis of the treatment is necessary: an early clinical patient history, a good physical finding and good radiographs in anteroposterior and frog-leg lateral (Lauenstein 1) position. The purpose of treatment is to avoid sequential displacement with the safest and the most effective technique proposing to arrest the growth plate. The author’s literature treatment of valgus SCFE is above reported. Scheuermann 7 patient confinement to bed was prescribed. Finch and Roberts bilateral long-leg casts in internal rotation with cross bar strut and in another patient, traction plus spica cast for six weeks was used [8]. Meyer et al manipulation and well-leg traction was employed. Shelton three Knowles’ pins were used [11,15]. Mihran O. Tachdjian pins in situ and varization osteotomies with spica cast were reported [16]. Skinner and Berkheimer three Knowles pins were used [17]. Rothermel four Knowles’ pins were applied [18]. Carlioz et al started to use screw fixation, as the classical percutaneous technique [19]. Scher et al had bilateral modified Imahauser- Weber osteotomies carried out [20]. Segal et al in situ screw fixation was employed [21]. Rajan et al an adductor tenotomy following varus osteotomy plus Richards’ screw and spica cast for 6 weeks was utilized. Docquier et al, Yngue et al, Loder et al, Shea et al, Mata and Ovejero fixation with screws were used[22-26,3]. Shank et al screws and two surgical osteotomies were employed [27]. Renganathan et al had patients treated by traction. Venkatadass et al Koczewski, Kotoura et al screw fixation were used. In recent years, the treatment of valgus SCFE, using screw pin fixation has been usually surgical [3, 19, 21-31]. In some cases of severe displacement, authors have found difficulties of placing in situ screws, due to potential danger to the neurovascular structures in patients with more valgus slip and they recommend a limited open anteromedial approach for fixation of valgus SCFE [3,21,24-27,29,31].

The routine methodology in current report on conservative principle with the use of spica cast immobilization in accordance with Betz et al protocol and bilateral short/long leg casts in abduction, slight internal rotation (30o) with antirotational bars based on Kite; Wright, et al and King works was used[41- 44]. Cast immobilization for 12 weeks, in accordance with the casting protocol was carried out. No weight-bearing during the “casting period” was permitted. One case of Waldenström’s disease associated with poly-articular rheumatoid with the use of spica cast immobilization was observed. Moule and Golding the appearance of hip changes in a patient with polyarticular rheumatoid disease (Still´s disease) associated with coxa valga have been described [45,46]. The manifestation and prevalence of chondrolysis as complication in female and nonwhite patients are some of the unclarified points in the literature [32]. Wright et al and King presented 52 cases with the use of bilateral short-leg cast immobilization as a form of treatment for SCFE without chondrolysis [43,44]. Regarding the frequency of development of chondrolysis in non-white patients with the diagnosis of SCFE, we think that cast immobilization, at least, is not the major factor in the development of this complication [47]. Pinheiro [32] used cast treatment for SCFE (106 hip joints) and had 11.3% of chondrolysis as complication [32]. Betz et al 41 with spica-cast immobilization in 37 hips had five hips (13.5%) with chondrolysis. Ingram et al the incidence of chondrolysis varies from 2% to 55%. It may occur after any type of treatment, whether conservative or operative [48,49]. In summary, the cause of chondrolysis after SCFE still remains obscure and their genesis either not yet clarified at all [49].

Note: Skinner and Berkheimer [17] in his article observed a patient with a right valgus slip with contralateral varus, probably the first case in the orthopedic literature [17]. Venkatadass et al also have shown varus of the right (1 year ago) and valgus of the left the hip treated with two 6.5mm partially threaded cancellous screws in both hips (second case) [29]. Kotoura et al presented the third case with right valgus SCFE and left typical varus SCFE [31]. In our sample we had a patient (Case 7) with a varus of the right and valgus SCFE of the left hip. Presumably the fourth varus + valgus patient in the literature published.
Discussion
SCFE is a painful adolescent hip disorder in which the capital femoral epiphysis is dislocated around the metaphysis of the proximal femur [2,3]. In the majority of SCFE cases, the capital femoral epiphysis posterior and medial in relation to the femoral neck is displaced. When the displacement is lateral (rare condition) we use the term valgus SCFE [3]. The first article to describe the lateral displacement of the epiphysis against the femoral neck to Müller has been credited [6]. The lateral displacement of the femoral head in the literature is less discussed and only 27 articles as valgus SCFE have been published. About 69 patients with 89 valgus SCFE in the pertinent review of the literature from 1926 until 2017 have been collected. The epidemiology, occurrence and demographics of valgus SCFE patients by the following authors are described. Loder et al, 4 patients (4.7%) with 7 valgus SCFEs (3.8%) from 105 children with 141 idiopathic SCFEs until 2006, have been published[3]. Howorth in his series of 243 cases of SCFE has reported three hips with valgus deformity[9]. Jerre in his series of 153 re-examined patients (183 hip joints) has found four patients (2.6%) seven hip joints (3.8%), with valgus SCFE [10]. Wilson et al in their series of 240 patients (300 hips) two patients (0.83%) with valgus SCFE and two hips (0.66%) were collected [13]. Carlioz et al in his series of 80 patients two (2.5%) were valgus SCFE. Shank et al has observed 12 valgus SCFEs (16 hips) among 258 patients (4.7%). Koczewski a total of 115 patients 11(9.6%) were valgus SCFE [19,27,30]. In this work, 7 patients (5.3%), 8 hips (4.8%) with valgus SCFEs among 131 patients (166 hip joints) with SCFE were observed.

The clinical characteristic scope of valgus SCFE has permitted new relations and discoveries and for this reason each main topic will be separately discussed.
Age
Concerning the average age of patients at diagnosis presentation (years) of the literature with valgus SCFE was 12 years [7,8,11-31]. In this work the author’s average of 11 years was similar to the literature. The medium age at diagnosis of patients with valgus SCFE was 2.3 years lower than the classic SCFE Loder et al, and Shank et al [3,27].
Gender
Loder and Skopelja mentioned: in a review of 4343 children with classic varus SCFE, 64.3% were boys and 35.7% girls. The reviews of the valgus SCFE literature, investigations in a relationship about sex, 40 (66.6%) were female and 20 (33.3%) males [50,7,8,11-31]. Loder et al 50%, Yngue et al 57%, Shank et al 58.3%. Koczewski, 55% also the same predominance in girls was found. In this sample, 5 females (71.4%) and 2 males (28.6%) were similar to the valgus female SCFEs literature (76%) [3,24,27,30]. The possible explanation of the higher female predominance in valgus SCFE may be increasing femoral anteversion in females [51]. Anteverted femoral neck with a horizontal physis predisposes to a valgus SCFE [22].
Racial
Articles on the racial frequency of valgus SCFE literature, describe 21 (65.0%) non-white and 11 (34.4%) white patients [3,7,8,11-31]. In this series 2 (28.6%) white and 5 (71.4%) nonwhite children, valgus SCFE were in accordance with valgus SCFE literature.
Body Weight
Obesity is a predisposing factor of SCFE [50]. Previous studies confirm a very high percentage (72%) of these patients to be substantially overweight (maturation factors [52]). The article abstracted from valgus SCFE literature some comments about body weight was found: Loder et al [3] noted the average weight was (69.1±17.2kg); Segal in the first case the weight 36kg (above the 75th percentile for her age) and the second weighed 91kg (above the 95th percentile for age); Docquier et al reported patient weight was 26kg(P3 = 34kg); Yngue et al collected 4 obese patients who have presented the 95th percentile weight for obesity; Shea et al in both case body weights bellowed the 45th percentile for age, neither of these patients were obese; Shank et al noted (67.7±20.2kg) [21,23-25,27]. In the present work among 7 valgus SCFE, 2 children (2.9%) were considered obese (48.2±17.5kg) and 5 (97.1%) non obese. The results were based on the graphics for obesity [39]. In this report, obesity was not a risk factor for development of the disease.
Side of Involvement
The authors that have mentioned side of involvement from valgus SCFE literature were: 41.5% right, 28.3% left and 30.2% bilateral involvements [3,7,11-31]. In the present series the prevalence of the left side was 62.5%, right 37.5% and 1 bilateral 12.5% had side of involvement identified. This report confirmed that previous studies are in accordance with the literature.
Symptom Duration
Concerning symptomatology of valgus SCFE literature, a chronic category was the prevalence data [3,8,11,12,14, 15,17- 26,28-31]. In this sample chronic presentation category (62,5%) was widely found, in accordance with the valgus SCFE literature.
Stability
Concerning the concept of stability the average of the valgus SCFE literature, 10% were instable and 90% stables [3, 21,-23, 26-31]. According to stability type, Loder et al had 7 stable valgus SCFEs, Segal et al had 2 stable hips, Rajan et al 1, Docquier et al 1, Yngve et al 7, Mata and Ovejero 1, Shank et al 10 stables and 1 unstable[3,21-24,26]. Renganathan et al 1 stable, Venkatadass et al 1 stable and 1 unstable, Koczewski 10 stables and 1 unstable, Kotoura et al 1 unstable valgus SCFE [28-31]. In this article all stable valgus patients SCFEs were observed.
Slip Severity
The slip severity of the valgus SCFE, Loder et al3 (7 hips / grade I), Jerre (3 slight and 4 marked), Tachdjian (1 hip grade I and 1 grade II), Segal et al (1 hip / grade III), Rajan et al (1 hip / grade III), Shea and Kotoura et al (1 hip / grade II) from author’s literature were reported [3,10,16,21,22,25,31]. Among this study all 8 (100%) slip severity were grade I.
Conclusions
Evaluation in modern medicine must be based on evidences of the results and on the functional radiographic measurements. This article has shown an optional method, using cast treatment for patients with a very rare entity known as valgus SCFE. The authors have presented a disease with radiographic aspects of the unusual entity. The plaster cast immobilization as a form of conservative treatment has been employed. Differences between groups of continuous data statically were analyzed. The dependent variables (Chondrolysis) as complication by the authors in our owns series of valgus and classic SCFE were cited. We want to call attention to the orthopedic surgeons and rheumatologists for patients with valgus SCFE with associated of JRA and the possibility of having chondrolysis as a complication[50].

In conclusion, we judged that cast treatment for SCFE’s (classic/valgus) was productive, functional, competent and it can be used for services with the difficulties of using a safe surgical procedure with appropriate fluoroscopy (X- ray machine) and cannulated screws for slipping fixation as a method of treatment.
Acknowledgement
The authors wish to thank Randall T. Loder, Angela Marquini, Henry Achcar Junior, João Pedro Valladão Pinheiro, Paulo Vinicius Valladão Pinheiro, Rosangela Aparecida G. Martins Luciana Dias Pereira and Carlos Brown Scavarda for their review, advice, encouragement, and help in preparing the manuscript.
Ethical Approval
The procedures in this study involving human participants was in accordance with the ethical standards of the Institutional Jesus Children Hospital Rio de Janeiro, Brazil, and with the 1964 declaration of Helsinki (DoH) and its later amendments/ clarifications have been performed. This study with CAAE (Presentation Certificate for Ethical Appreciation) number 73819017.0.0000.5279 of November 28, 2017 was registered.
Consent
Written informed consent from parents/guardians for publication of this report and accompanying images was obtained. Written consent on the patient’s chart registration number # 814330 # 25127 # 47008 # 81788 # 106805 # 80826 # 49174, Departments of Orthopedic, and Radiologic Services of Jesus Children’s Hospital, Rio de Janeiro, Brazil is available.
Disclosure
None of the authors received payments or services, either directly or indirectly, i.e., via his or her institution of any aspect of this work. None of the authors, or their intuition(s), have had any financial relationship, prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this article. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work.
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