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The adolescent with slipped capital femoral epiphysis
The Adolescent With Slipped Capital Femoral Epiphysis Rosalie Benchot, MSN, RNC
Slipped capital femoral epiphysis (SCFE)is an orthopedic disorder that occurs primarily in individuals in their early teen years. The disorder is one that requires immediate hospitalization for treatment purposes. This article discusses the symptoms of the disorder and the various treatments that are available for preventing future disability for the early adolescent. Because the adolescent has special needs and a long recovery period, nursing interventions must not only help in the resolution of the immediate orthopedic problems, but also be directed toward promotion of normal adolescent growth and development. Copyright 9 1996 by W.B. Saunders Company
LIPPED
CAPITAL femoral
epiphysis
S (SCFE), or adolescent coxa vara, is an orthopedic disorder in which there is displacement of the femoral head from the femoral neck in a downward and backward position. The displacement, a result of a widening of the upper femoral epiphyseal plate, causes limited mobility in the affected extremity. Although the annual incidence of 2.8 to 10.8/100,000 (Chung, 1986) does not make SCFE the most common orthopedic disorder, its occurrence during late childhood and early adolescence poses a threat to the individual's well-being, both physically and emotionally. Therefore, it becomes important that health care personnel assess for SCFE and determine its presence during the early stages so successful resolution of the disorder may occur, thus avoiding possible lifelong disability for developing adolescents. PATHOLOGICAL PROCESS
The epiphyses are the ends of the bones distinct from the shafts (metaphyses and diaphyses). The epiphysis of a bone is separated from the diaphysis by a line of cartilage known as the epiphyseal plate. In the child, this plate is composed of large chondrocytes (cartilage cells) and osteoblasts that form cartilage structures and bone. New bone added to the diaphysis from the epiphyseal plate during the child's growth period produces lengthening of the extremities (Carter, 1992). When skeletal maturity is reached, the epiphyseal plate becomes a narrow zone of ossified tissue that is the epiphyseal line (Figure 1). Journal of Pediatric Nursing, Vol 11, No 3 (June),1996
The slipping of the femoral head will occur at the proximal epiphyseal plate when it widens vertically. The femoral head will migrate to an abnormal position, but the thick, continuous periosteum covering the bones will keep the femoral head attached to the femur (Figure 2). Edematous and inflammed synovial membrane is present in the area of slipping. The slipping process is usually gradual and progressive, lasting at times for up to 3 years (Canale, 1992; Ferguson, 1981; MacEwen, Bunnell, & Ramsey, 1986). If the disorder is not treated, the inflammation decreases and healing occurs within 1 to 3 years after the slipping process ends (McCullough & Pellino, 1994; Morrissy & Selman, 1991). It is unknown why healing occurs, but the healing process produces a deformity that will need surgical treatment later in life. Callus builds up on the anterior area of the femoral neck, causing an abnormal hump of elevated periosteum. The accumulation of callus results in faulty bone articulation between the femoral head and the acetabulum and can produce a permanent limitation in the range of motion for the affected hip (Figure 3). RISK FACTORS AND ETIOLOGY
The cause of SCFE is unknown. The disorder most commonly occurs in children during their From Kent State University, School of Nursing, Kent, OH. Address reprint requests to Rosalie Benchot, MSN, RNC, School of Nursing, Kent State University, Kent, OH 44242. Copyright 9 1996 by W.B. Saunders Company 0882-5963/96/1103-000653.00/0 175
176
ROSALIE BENCHOT
EPIPHYSEALPLATEI
HEAD
GREATERTROCHANTER- -
DIAPHYSIS
I I
%
EPIPHYSEALPLATE
Figure 1. The femur.
pubertal growth spurt. The average age of occurence for boys is between 13 and 16 years. In girls, because of a normally earlier onset of puberty, SCFE occurs between 11 and 14 years of age (Canale, 1992; Ferguson, 1981; Weiner, 1993). SCFE occurs twice as often in boys as in girls (MacEwen et al., 1986). Bilateral hip involvement occurs in 25% to 40% of the affected adolescents. For this reason, diagnostic work-up of both hips is recommended, thus affording the less affected hip early treatment (Canale, 1992; Skinner, 1991). A highly significant risk factor for adolescents appears to be their body build (Chung, 1986; Kelsey, 1973; Puri et al., 1985; Weiner, 1993). Affected individuals are described as having adiposogenital syndrome in which obesity and hypogenitalism are features. Most adolescents diagnosed with SCFE are at or above the 90th percentile weight expected for their age. Skeletal maturation, which can be determined through hand radiographs, usually lags behind the normal growth for the specific chronological ages (Purl et al., 1985). Affected adolescents usually have a family history of obesity (Chung,
SLIPPED EPIPHYSIS
NORMAL HIP
Figure 2. Slipped epiphysis (left) and normal hip (right).
Figure 3. Abnormal hump with advanced slipped capital femoral epiphysis and how it may interfere with bone articulation.
1986). Also, there is speculation that SCFE may be transmitted genetically through an autosomal dominant trait (MacEwen et al., 1986). Although 88% of affected adolescents are described as being overweight, SCFE is known to occur in thin, tall individuals who have a history of rapid linear growth (Ferguson, 1981). Other risk factors may include treatment with chorionic gonadotropin, end-stage renal disease, and extensive radiation treatments that may arrest cartilage formation (MacEwen et al., 1986). The exact mechanism that initiates the weakening of the epiphyseal plate that results in slipping is unknown. Precipation of the process by acute trauma does happen, but the majority of adolescents have gradual slips. In either type of slipping, pain is the usual presenting symptom. Theories regarding possible causes are currently based on the physical features seen in the majority of affected individuals and an understanding of the pubertal endocrine changes that normally occur. During the normal pubertal growth spurt, anterior pituitary growth hormone increases the rate of proliferation of the chondrocytes. There is widening of the epiphyseal plates in all bones. Soon gonadal activity accelerates, and in turn initiates increased secretion of estrogen or testosterone. Higher levels of either estrogen or testosterone will help decrease the thickness of the epiphyseal plates and bring about eventual closure, signifying mature skeletal growth. Preadolescents who are larger in body size compared with their peers are believed to have a deficit of sex hormone in relation to growth hormone, making them more vulnerable to
SLIPPED EPIPHYS(S
epiphyseal displacement because the plate takes more time to close. Boys are considered to be more at risk for SCFE (twice as much as girls) because of a longer growth spurt and a slower increase in the level of protective androgens (Kelsey, 1973; Skinner, 1991). A decreased level of thyroid hormine is also cited as a risk factor that may contribute to delays of skeletal maturation and retarded closure of the growth plates (Morrissy & Selman, 1991; Puri et al., 1985; Skinner, 1991). Laboratory testing for levels of growth hormone, testosterone, estrogen, or thyroxine that can indicate an endocrine disorder may be interesting, but have not been helpful in establishing a diagnosis of SCFE. Laboratory testing may be only an additional expense for the adolescent and family because abnormal findings do not warrant a delay or change of any treatment interventions for SCFE (Chung, 1986). During the pubertal growth spurt, although all epiphyseal plates in the bones are affected, the femoral upper epiphyses are more prone to displacement because the force of weight bearing places more stress on the hip with forward body movement. Increased body weight, possibly combined with poor muscle tone (caused by lessened activity that might occur in obese adolescents), are considered to be the major contributory factors in SCFE. Also, during the adolescent growth period, the periosteum surrounding the epiphyses becomes thinner and becomes another area of weakness for slipping to occur (Skinner, 1991). Therefore, the classic patient with SCFE is described as being an early adolescent who is overweight, has hypogonadal body features, and has delayed skeletal maturity compared with actual chronological age. CLINICAL PICTURE Acute slips of the proximal femoral epiphysis can be a result of severe trauma from an automobile accident, a fall from a great height, or child battering. The ambulatory child will cease to walk, and any passive manipulation of the affected extremity will be very painful (Canale, 1992; Chung, 1986; Skinner, 1991). The majority of adolescents with SCFE have chronic slips. The symptoms appear gradually and become more prominent and persistent as the disease progresses. In the beginning, the adolescent will complain of pain in the groin,
177
thigh, and knee (Canale, 1992). Referred pain to the knee may be so severe that the possibility that the adolescent may have a hip disorder may be overlooked in the early stages. Eventually, the teen will walk with a limp because of the inflamed hip. The lower limb is usually held in an externally rotated position, and the characteristic walk is that of the individual leaning slightly forward over the affected hip as steps are taken. As the disorder progresses and if medical treatment is not obtained, leg length becomes asymmetrical, the affected limb becoming slightly shorter than the unaffected one (MacEwen, Bunnell, & Ramsey, 1986). Circumference of the thigh muscle on the affected leg becomes smaller than of the opposite thigh because of muscle atrophy (Chung, 1986). Hip motion, such as internal rotation, abduction, and flexion becomes limited and is painful. DIAGNOSIS The diagnosis of SCFE is confirmed by radiographs. The widening of the epiphyseal line and swelling of the joint capsule, as well as the displacement of the femoral head, are easly seen in the early stages of the disease (Canale, 1992; Chung, 1986). Adolescents having radiographs for SCFE must be in a frog-leg position where the knees are flexed and the legs abducted. Before the radiological test, the adolescent is told the purpose of the awkward position and is encouraged to wear pajama bottoms to avoid any undue embarrassment during the procedure. The gonads must also be protected while radiographs are taken. Generally, the adolescent's presenting symptoms, medical history, and radiographs are all that is needed to confirm the diagnosis of SCFE. However, a technetium bone scan, as an optional diagnostic measure, will show the widening of the epiphyseal plate. Because the bone scan is a procedure using small doses of the intravenous radionuclide (technetium 99m), informed consent is necessary and sedation may be needed. The adolescent can be told that although there is an initial intravenous injection, the procedure is not painful, but could be prolonged, about 2 or 3 hours, until the isotope appears in the bones and joints for an accurate visualization. An increased fluid intake after the procedure helps to secrete the isotope more quickly (Mourad, 1991). It is highly recom-
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mended that both hips be evaluated with either diagnostic procedure (Ferguson, 1981). TREATMENT Presently, the recommended treatment for SCFE is surgery that arrests slipping of the femoral head (Canale, 1992; Chung, 1986; Ferguson, 1981). Treatment begins the moment of diagnosis and does constitute emergent admission to the hospital where weight bearing on the affected leg is prohibited. Before surgery, the adolescent may be placed in Buck or Russell traction to correct internal rotation of the affected extremity and to stop accompanying muscle spasms. Bilateral traction may be used to maintain symmetrical alignment of both hips. Surgery is performed as soon as possible, usually within several days of hospitalization, and the type of surgical procedure performed is dependent on the degree of displacement of the femoral head. If displacement is less than 30~ (less than one third of the width of the femoral neck), it is classified as being a mild slip, and an internal fixation is recommended. This operation involves the placement of a fixation device, such a pin or a cannulate screw, through the inferior half of the femoral head and across the epiphyseal plate (Figure 4). Fears that premature fusion of the growth plate will cause a growth problem are unfounded and not an indication to delay surgical intervention. The growth plate of the femoral head is thought to contribute less than 30% of the total length of the femoral shaft, so growth of the femur will not be compromised (Gartland, 1979). Femoral head displacements of between 30~ and 50~ are classified as moderate slips. Moderate slips are treated with closed reduction with traction followed by internal fixations with pins. Severe slips are over 50~ and require surgical reconstruction of the femur on the affected side. Either the Southwick biplane osteotomy or a subtrochanteric osteotomy will be performed (Canale, 1992; Gartland, 1979, Ferguson, 1981). The purpose of these procedures is to reconstruct normal anatomical alignment of the proximal end of the femur. A wedge of bone is cut out, and the remaining bone fragments are positioned in place with metal pins, plates, and screws. The epiphyseal plate is untouched (Figures 5 and 6). Another surgical procedure that may be per-
J
Figure4.
Pinning in situ.
formed is a bone graft epiphysiodesis. With this procedure, the surgeon aseptically curettages the affected epiphyseal plate, and then applies small bone grafts obtained from the iliac crest across the plate. An epiphysiodesis will cause a permanent arrest of the growth plate, so the procedure may be reserved for an adolescent who has achieved maximal linear growth (Canale, 1992; MacEwen et al., 1986; Weiner, 1993). A cheilectomy is another surgical option. It involves the removal of the abnormal growth of bone that forms gradually on the femoral neck. The hump, after the initial acute phase of slipping and lack of immediate treatment, enlarges for several years. Cheilectomy is reconstructive surgery and is performed to help improve range of motion in the affected hip. Wedge of bone
Figure 5. Open reduction of slipped capital femoral epiphysis by osteotomy through the femoral neck with pinning.
SLIPPED EPIPHYSIS
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A
I I I I I I I I I I I I / /
!
I I I I
B Figure 6. Southwick osteotomy (subtrochanteric). (A) Premeasured wedge of bone removed; femur completely incised. (B) Correction with internal rotation.
The operation will most likely be performed when the adolescent reaches the late teen years. Regardless of which surgical procedure is performed, postoperatively, the adolescent must avoid total weight bearing on the operated hip for a defined length of time. Complete fusion of the epiphysis will vary anywhere from 2 to 8 months after surgical intervention. However, use of the cannulate screw does permit weight bearing within 2 and 6 weeks after insertion (Morrissy & Selman, 1991). The use of crutches aids mobility during the recovery phase. Surgical placement pins can be, and usually are, removed 2 years after the initial procedure (Canale, 1992). Complications after surgery are more likely to occur when slips are judged to be moderate or severe because more complicated and prolonged surgical intervention is necessary. Chon-
drolysis (cartilage necrosis) and avascular necrosis of the femoral head can develop anytime within 3 months after surgery. Clinical symptoms of these complications are pain and decreased range of motion in the affected hip (MacEwan et al., 1986; McCullough & Pellino, 1994; Weiner, 1993). Although surgical intervention is the usual mode of treatment for SCFE, a conservative measure, that of immobilizing the adolescent in a hip spica cast, has been reported to be an effective method of treatment (Betz, Steel, Emper, Huss, & Clancy, 1990; Ferguson, 1981). The casting is indicated for the adolescent with a chronic but mild or moderate slip, and the cast is applied after the teenager has been in traction for 10 to 30 days. Advantages of using the hip spica cast are possible preventing of a slipped epiphysis in the opposite hip and eliminating the necessity of surgical interventions. However, use of the hip spica cast for SCFE has some disadvantages. First, the teenager has a prolonged immobilized period, anywhere from 8 to 16 weeks. This length of time is recommended to suppress any additional slipping (Betz et al., 1990). Next, the cast may have to be removed and reapplied more than once for radiological purposes. Finally, the potential problems that prolonged immobilization presents must be considered. The adolescent will be at risk for skin breakdown, pulmonary problems, and ileus. The caregivers may have difficulty in turning and caring for an obese person in a large body cast. Additionally, the teenager is at risk for altered growth and development because of the potential for poor body image perception, being in a dependent role, and being separated from peers. The family also faces the decision of whether to care for the adolescent at home or to admit the adolescent to an appropriate rehabilitation center. Although hip spica casting for SCFE does require a relatively prolonged period of immobility, it still offers the affected individual another choice concerning a treatment measure. NURSING CARE
Care of the adolescent with SCFE offers many challenges, and the nurse must be familiar with both the principles of orthopedic nursing care and the theories of normal adolescent growth and development. Because the musculoskeletal disorder will greatly affect the lifestyle of both the adolescent and the family, both will
180 Table 1. Major Nursing Diagnoses and Nursing Interventions for the Adolescent With Slipped Capital Femoral Epiphysis Impaired physical mobility related to displacement of the femur at the epiphysis and/or corrective surgery. Postoperative care: Change position every 2 to 4 hours, avoid turning on the surgical site Provide overhead trapeze to aid in turning Facilitate or encourage physical therapy involvement as soon as possible Encourage arm strengthening exercises such as lifting 1 -pound weights strapped on the wrists Supervise isometric exercises (prescribed by physical therapist) with operated leg, range of motion exercises for all other extremities at 4-hour intervals Provide ambulatory aids such as crutches or walkers when appropriate, sturdy shoes such as high-top tennis shoes when up Limit time sitting in a straight, firm chair to 1 hour three times daily to decrease the pressure on the operative site Instruct the adolescent not to bear weight on the operated leg and supervise when ambulating with crutches or walkers Altered comfort: related to pain secondary to displacement of the femoral head, preoperative traction, and surgical incision Ask adolescent to describe duration, character, amount, and location of pain (use a pain rating scale for consistency) Observe adolescent for physiological changes indicating pain, such as increased pulse and respirations, sweating, or muscle tension Provide prescribed pain medications through patient-controlled analgesia pumps if available (assure that proper use of the machine is taught) Administer, if necessary, muscle relaxants for muscle spasms Understand an adolescent's reluctance to ask for pain medications because of fear of iniections, being considered a drug addict, or not being brave; anticipate need for pain relief and administer appropriate medication when necessary High risk for peripheral neurovascular dysfunction related to inflammation and venous stasis in lower extremeties secondary to preoperative traction and surgical opening of the hip joint. Preoperative care Explain the purpose and use of skin traction Check all traction components (ropes, pulleys, weights, sandbags) E~evate head of the bed only when necessary so there is adequate pull and countertraction~foet of bed may be elevated on shock blocks if necessary Assess for normal body alignment when adolescent is in traction Encourage active range-of-motion exercises for all unaffected extremities, isometric exercises on affected limb Provide ted hose, heel protectors as needed Postoperative care Evaluate the adolescent's statements about discomfort Do neurovascular and skin checks an both legs at least every 4 hours while awake and once during the night, Data from McCullough& Pellino (1994), Mourad (1991 ), Wang (1995), and Wright (1989).
ROSALIE BENCHOT
Table 1. (Cant'd) assessing legs for color, temperature, capillary refill, sensation, and swelling Note the rate and volume of the pulses distal to the operative site (femoral, popliteal, posterior tibial, dorsalis pedis) in both legs Evaluate extent of inflammation and edema in operative site Prevent compression of the sciatic nerve after surgery: when turning the adolescent, place a pillow between the legs (sign of sciatic nerve compression is a sharp pain that is felt down the length of the leg) Assess for complications of surgery (aseptic necrosis of femoral head): numbness, tingling, limitation of range of motion in affected leg High risk for infection related to surgical incision at the hip joint Preoperatively, do a meticulous skin preparation to decrease possibility of infection at the surgical site and potential contamination of the osteum Postoperatively, inspect the wound for redness and drainage, check color and amount of drainage if hemovac is present, check bed linen under patient for btood or drainage Inspect skin several times daily for redness and breakdown--use sheepskin, egg crate mattress, alternating air mattress as needed Cleanse perineal area after voids and stools Keep bed dry and wrinkle-free Assess for signs of infection---elevated body temperature, localized tenderness, painful movement High risk far impaired gas exchange related to effects of general anesthesia, surgical incision, and immobility Evaluate respiratory rate and skin color for deviations from normal Auscultate breath sounds Encourage to deep breathe and cough every 1 hour, or use incentive spirometry Encourage ambulation wilh ambulatory aids when permitted Monitor hematocrit and hemoglobin levels at intervals Knowledge deficit in both parent and child related to unfamiliarity with musculoskeletal disorder, hospitalization, diagnostic tests, treatment measures, and home care Explain the emergency nature of the hospitalization and need for bed rest Explain the nature of the radiographs or bone scan Do routine preoperative teaching Explain postoperative teaching Reinforce physician explanations concerning traction and surgical interventions Provide verbal and written instructions for family regarding prolonged healing process, no weight bearing, methods to assess neurovascular function of affected limb, adaptations in hygiene/bathing, return to school, postdischarge medical supervision, repeat radiographs to detect disorder in opposite hip, seek medical attention for any complications such as temperature elevations or continued pain in the operated hip Arrange for dietary consultation to emphasize need for a well-balanced diet with less high calorie/high sugar foods Explain methods of weight control, emphasize avoidance of crash diets
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SLIPPED EPIPHYSIS
Table 1. (Cont'd) Teach proper nutrition regarding both disorder and adolescent growth Explain altered pattern of elimination caused by immobility; give information on dietary fiber, fluid needs, and bowel medications High risk for self-esteem disturbance related to discomfort with immobility, dependent role, and lack of privacy Determine adolescent's perceptions about body and disorder Help adolescent verbalize concerns about own body Emphasize talents, capabilities, and achievement. If hospitalization is prolonged, encourage use of tutor to help with school assignments Explain recovery period and adaptations to maintain independence Involve adolescent in decisions about care Provide privacy during nursing care procedures and surgical evaluations High risk for altered growth and development related to separation from family and friends and from involvement in usual recreational activities Have a consistent relationship with the adolescent Encourage the adolescent to engage in age-appropriate diversional activities Discuss with family the need for frequent visits and telephone calls of family and friends Encourage development of peer friendships in the hospital Provide means to increase communication with personal friends Discuss any adjustments necessaryfor participation in future school activities
benefit greatly from being served by an interdisciplinary team. The services of other disciplines, such as physical therapy, education, child-life, social services, and dietary will be necessary to help promote, as much as possible, an uneventful recovery for the adolescent. The nurse can help coordinate these services and provide care that is teen-centered and directed toward prevention of the known complications that can result from the disorder. Major nursing diagnoses regarding physical care of the adolescent with SCFE are listed in Table 1, which also includes summarized nursing interventions. Frequently the adolescent's psychosocial needs are overlooked because of the demanding physical care that is required for those with SCFE. Adolescents are typically in the process of striving for and finally achieving independence from their parents. With SCFE, an unpredictable situation occurs when the emergency nature of the hospitalization combined with enforced bed rest produces much anxiety for the adolescent who may fear that his or her future independence may never be possible. The adolescent, unhappy about ambula-
tion restrictions and the lengthy hospital stay, may become critical, argumentative, or withdrawn. Another major psychological task of the adolescent period is development of a sense of personal identity (Wong, 1995). Adolescents engage in frequent self-reflection and become acutely aware of their personal appearance. They compare themselves with their peers, and if they perceive deviations in comparisons, they may develop a poor sense of self. Middle adolescence (ages 14 to 15) marks the beginning stage of heterosocial relationships in which there is normally more social interaction with the opposite sex (Schuster & Ashburn, 1992). The adolescent with SCFE, who is larger and heavier than the same-age peers and who has concerns over needing to use crutches for a prolonged period of time, may fear peer or opposite-gender rejection and have feelings of inferiority, inadequacy, or incompetence. These feelings may be expressed through mood swings, regressed behavior, withdrawl, or unusual demands placed on the nursing staff. The adolescent, recovering from surgery for SCFE, has a need for a well-balanced diet and supplemental iron and vitamins to promote bone and wound healing. Weight control is, in many instances, a major issue in the postoperative period, and teaching sound nutritional practices to the adolescent and the immediate family is an important nursing intervention. However, the adolescent may have difficulty changing eating habits. During hospitalization, even with decreased physical activity, the adolescent may want extra food or request special high-calorie, low-nutritive foods from a fastfood restaurant. Denial of these requests may be perceived as punishment, and power struggles between the nursing staff and the adolescent may result. Nurses can encourage adolescents to talk about their feelings, and emphasize the adolescents' attractive features and talents to motivate them for future weight loss. Throughout hospitalization, dietary consultation becomes very important, and before discharge, an exercise program can be prescribed that will be appropriate for individual mobility limitations that are present. CONCLUSION SCFE is a disorder that results in disruption of familiar routines for adolescents and their
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ROSALIE BENCHOT
families. Knowledge of the disease process, treatment measures, and adolescent growth and development will enhance nursing's ability not
only to provide high-quality individualized health care, but also to help the adolescent develop into a mature adult with a healthy self-concept.
REFERENCES Betz, R., Steel, H., Emper, W., Huss, G., & Clancy, M. (1990). Treatment of slipped capital femoral epiphysis. Journal of Bone and Joint Surgery, 72A, 587-600. Canale, S.T. (1992). Fractures and dislocations in children. In A. Crenshaw (Ed.), Campbell's operative orthopedics (pp. 1149-1181). St. Louis: Mosby. Carter, M. (1992). Anatomy and physiology of bones and joints. In S. Price & L. Wilson (Eds.), Pathophysiology; Clinical concepts of disease processes (pp. 935-940). St. Louis: Mosby. Chung, S. (1986). Diseases of the developing hip. Pediatric Clinics of North America, 53, 1457-1464. Ferguson, A. (1981). Orthopedic surgery in infancy and childhood. Baltimore: Williams & Wilkins. Gartland, J. (1979). Fundamentals of orthopedics. Philadelphia: W.B. Saunders. Kelsey, L. (1973). Epidemiology of slipped capital femoral epiphysis: A review of the literature. Pediatrics, 51, 1042-1050. MacEwen, G., Bunnell, W., & Ramsey, P. (1986). The hip. In W. Lovell & R. Winters (Eds.), Pediatric orthopaedics (pp. 703-780). Philadelphia: Lippincott. McCuUough, L., & Pellino, T. (1994). Congenital and developmental disorders. In A. Maher, S. Salmond, & T. Pellino, (Eds.), Orthopedic Nursing (pp. 617-700). Philadelphia: Saunders.
Morrissy, R., & Selman, S. (1991). Slipped capital femoral epiphysis. Orthopaedic Nursing, 10, 11-20. Mourad, L. (1991). Orthopedic disorders. St. Louis: Mosby. Puri, R., Smith, S., Malhotra, D., Williams, D., Owen, R., & Harris, F. (1985). Slipped upper femoral epiphysis and primary juvenile hypothyroidism. The Journal of Bone and Joint Surgery, 67, 14-20. Schuster, C., & Ashburn, S. (1992). Theprocess of human development: A holistic life span approach. Philadelphia: J.B. Lippincott. Skinner, S. (1991). Orthopedic problems in childhood. In A. Rudolph, J. Hoffman, C. Rudolph, & P. Sagan (Eds.), Rudolph's Pediatrics (pp. 1941-1942). Norwalk, CT: Appleton Lange. Weiner, D. (1993). Pediatric orthopaedics. New York: Churchill Livingston. Wong, D. (1995). Whaley & Wong's nursing care of infants and children. St. Louis: Mosby. Wong, D., & Whaley, L. (1990). Clinical manual of pediatric nursing. St. Louis: Mosby. Wright, S. (1989). Nursing strategies: Altered musculoskeletal function. In R. Foster, M. Hunsberger, & J. Anderson (Eds.), Family centered nursing care of children (pp. 17801843). Philadelphia: W.B. Saunders.
Slipped capital femoral epiphysis (SCFE)is an orthopedic disorder that occurs primarily in individuals in their early teen years. The disorder is one that requires immediate hospitalization for treatment purposes. This article discusses the symptoms of the disorder and the various treatments that are available for preventing future disability for the early adolescent. Because the adolescent has special needs and a long recovery period, nursing interventions must not only help in the resolution of the immediate orthopedic problems, but also be directed toward promotion of normal adolescent growth and development. Copyright 9 1996 by W.B. Saunders Company
LIPPED
CAPITAL femoral
epiphysis
S (SCFE), or adolescent coxa vara, is an orthopedic disorder in which there is displacement of the femoral head from the femoral neck in a downward and backward position. The displacement, a result of a widening of the upper femoral epiphyseal plate, causes limited mobility in the affected extremity. Although the annual incidence of 2.8 to 10.8/100,000 (Chung, 1986) does not make SCFE the most common orthopedic disorder, its occurrence during late childhood and early adolescence poses a threat to the individual's well-being, both physically and emotionally. Therefore, it becomes important that health care personnel assess for SCFE and determine its presence during the early stages so successful resolution of the disorder may occur, thus avoiding possible lifelong disability for developing adolescents. PATHOLOGICAL PROCESS
The epiphyses are the ends of the bones distinct from the shafts (metaphyses and diaphyses). The epiphysis of a bone is separated from the diaphysis by a line of cartilage known as the epiphyseal plate. In the child, this plate is composed of large chondrocytes (cartilage cells) and osteoblasts that form cartilage structures and bone. New bone added to the diaphysis from the epiphyseal plate during the child's growth period produces lengthening of the extremities (Carter, 1992). When skeletal maturity is reached, the epiphyseal plate becomes a narrow zone of ossified tissue that is the epiphyseal line (Figure 1). Journal of Pediatric Nursing, Vol 11, No 3 (June),1996
The slipping of the femoral head will occur at the proximal epiphyseal plate when it widens vertically. The femoral head will migrate to an abnormal position, but the thick, continuous periosteum covering the bones will keep the femoral head attached to the femur (Figure 2). Edematous and inflammed synovial membrane is present in the area of slipping. The slipping process is usually gradual and progressive, lasting at times for up to 3 years (Canale, 1992; Ferguson, 1981; MacEwen, Bunnell, & Ramsey, 1986). If the disorder is not treated, the inflammation decreases and healing occurs within 1 to 3 years after the slipping process ends (McCullough & Pellino, 1994; Morrissy & Selman, 1991). It is unknown why healing occurs, but the healing process produces a deformity that will need surgical treatment later in life. Callus builds up on the anterior area of the femoral neck, causing an abnormal hump of elevated periosteum. The accumulation of callus results in faulty bone articulation between the femoral head and the acetabulum and can produce a permanent limitation in the range of motion for the affected hip (Figure 3). RISK FACTORS AND ETIOLOGY
The cause of SCFE is unknown. The disorder most commonly occurs in children during their From Kent State University, School of Nursing, Kent, OH. Address reprint requests to Rosalie Benchot, MSN, RNC, School of Nursing, Kent State University, Kent, OH 44242. Copyright 9 1996 by W.B. Saunders Company 0882-5963/96/1103-000653.00/0 175
176
ROSALIE BENCHOT
EPIPHYSEALPLATEI
HEAD
GREATERTROCHANTER- -
DIAPHYSIS
I I
%
EPIPHYSEALPLATE
Figure 1. The femur.
pubertal growth spurt. The average age of occurence for boys is between 13 and 16 years. In girls, because of a normally earlier onset of puberty, SCFE occurs between 11 and 14 years of age (Canale, 1992; Ferguson, 1981; Weiner, 1993). SCFE occurs twice as often in boys as in girls (MacEwen et al., 1986). Bilateral hip involvement occurs in 25% to 40% of the affected adolescents. For this reason, diagnostic work-up of both hips is recommended, thus affording the less affected hip early treatment (Canale, 1992; Skinner, 1991). A highly significant risk factor for adolescents appears to be their body build (Chung, 1986; Kelsey, 1973; Puri et al., 1985; Weiner, 1993). Affected individuals are described as having adiposogenital syndrome in which obesity and hypogenitalism are features. Most adolescents diagnosed with SCFE are at or above the 90th percentile weight expected for their age. Skeletal maturation, which can be determined through hand radiographs, usually lags behind the normal growth for the specific chronological ages (Purl et al., 1985). Affected adolescents usually have a family history of obesity (Chung,
SLIPPED EPIPHYSIS
NORMAL HIP
Figure 2. Slipped epiphysis (left) and normal hip (right).
Figure 3. Abnormal hump with advanced slipped capital femoral epiphysis and how it may interfere with bone articulation.
1986). Also, there is speculation that SCFE may be transmitted genetically through an autosomal dominant trait (MacEwen et al., 1986). Although 88% of affected adolescents are described as being overweight, SCFE is known to occur in thin, tall individuals who have a history of rapid linear growth (Ferguson, 1981). Other risk factors may include treatment with chorionic gonadotropin, end-stage renal disease, and extensive radiation treatments that may arrest cartilage formation (MacEwen et al., 1986). The exact mechanism that initiates the weakening of the epiphyseal plate that results in slipping is unknown. Precipation of the process by acute trauma does happen, but the majority of adolescents have gradual slips. In either type of slipping, pain is the usual presenting symptom. Theories regarding possible causes are currently based on the physical features seen in the majority of affected individuals and an understanding of the pubertal endocrine changes that normally occur. During the normal pubertal growth spurt, anterior pituitary growth hormone increases the rate of proliferation of the chondrocytes. There is widening of the epiphyseal plates in all bones. Soon gonadal activity accelerates, and in turn initiates increased secretion of estrogen or testosterone. Higher levels of either estrogen or testosterone will help decrease the thickness of the epiphyseal plates and bring about eventual closure, signifying mature skeletal growth. Preadolescents who are larger in body size compared with their peers are believed to have a deficit of sex hormone in relation to growth hormone, making them more vulnerable to
SLIPPED EPIPHYS(S
epiphyseal displacement because the plate takes more time to close. Boys are considered to be more at risk for SCFE (twice as much as girls) because of a longer growth spurt and a slower increase in the level of protective androgens (Kelsey, 1973; Skinner, 1991). A decreased level of thyroid hormine is also cited as a risk factor that may contribute to delays of skeletal maturation and retarded closure of the growth plates (Morrissy & Selman, 1991; Puri et al., 1985; Skinner, 1991). Laboratory testing for levels of growth hormone, testosterone, estrogen, or thyroxine that can indicate an endocrine disorder may be interesting, but have not been helpful in establishing a diagnosis of SCFE. Laboratory testing may be only an additional expense for the adolescent and family because abnormal findings do not warrant a delay or change of any treatment interventions for SCFE (Chung, 1986). During the pubertal growth spurt, although all epiphyseal plates in the bones are affected, the femoral upper epiphyses are more prone to displacement because the force of weight bearing places more stress on the hip with forward body movement. Increased body weight, possibly combined with poor muscle tone (caused by lessened activity that might occur in obese adolescents), are considered to be the major contributory factors in SCFE. Also, during the adolescent growth period, the periosteum surrounding the epiphyses becomes thinner and becomes another area of weakness for slipping to occur (Skinner, 1991). Therefore, the classic patient with SCFE is described as being an early adolescent who is overweight, has hypogonadal body features, and has delayed skeletal maturity compared with actual chronological age. CLINICAL PICTURE Acute slips of the proximal femoral epiphysis can be a result of severe trauma from an automobile accident, a fall from a great height, or child battering. The ambulatory child will cease to walk, and any passive manipulation of the affected extremity will be very painful (Canale, 1992; Chung, 1986; Skinner, 1991). The majority of adolescents with SCFE have chronic slips. The symptoms appear gradually and become more prominent and persistent as the disease progresses. In the beginning, the adolescent will complain of pain in the groin,
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thigh, and knee (Canale, 1992). Referred pain to the knee may be so severe that the possibility that the adolescent may have a hip disorder may be overlooked in the early stages. Eventually, the teen will walk with a limp because of the inflamed hip. The lower limb is usually held in an externally rotated position, and the characteristic walk is that of the individual leaning slightly forward over the affected hip as steps are taken. As the disorder progresses and if medical treatment is not obtained, leg length becomes asymmetrical, the affected limb becoming slightly shorter than the unaffected one (MacEwen, Bunnell, & Ramsey, 1986). Circumference of the thigh muscle on the affected leg becomes smaller than of the opposite thigh because of muscle atrophy (Chung, 1986). Hip motion, such as internal rotation, abduction, and flexion becomes limited and is painful. DIAGNOSIS The diagnosis of SCFE is confirmed by radiographs. The widening of the epiphyseal line and swelling of the joint capsule, as well as the displacement of the femoral head, are easly seen in the early stages of the disease (Canale, 1992; Chung, 1986). Adolescents having radiographs for SCFE must be in a frog-leg position where the knees are flexed and the legs abducted. Before the radiological test, the adolescent is told the purpose of the awkward position and is encouraged to wear pajama bottoms to avoid any undue embarrassment during the procedure. The gonads must also be protected while radiographs are taken. Generally, the adolescent's presenting symptoms, medical history, and radiographs are all that is needed to confirm the diagnosis of SCFE. However, a technetium bone scan, as an optional diagnostic measure, will show the widening of the epiphyseal plate. Because the bone scan is a procedure using small doses of the intravenous radionuclide (technetium 99m), informed consent is necessary and sedation may be needed. The adolescent can be told that although there is an initial intravenous injection, the procedure is not painful, but could be prolonged, about 2 or 3 hours, until the isotope appears in the bones and joints for an accurate visualization. An increased fluid intake after the procedure helps to secrete the isotope more quickly (Mourad, 1991). It is highly recom-
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mended that both hips be evaluated with either diagnostic procedure (Ferguson, 1981). TREATMENT Presently, the recommended treatment for SCFE is surgery that arrests slipping of the femoral head (Canale, 1992; Chung, 1986; Ferguson, 1981). Treatment begins the moment of diagnosis and does constitute emergent admission to the hospital where weight bearing on the affected leg is prohibited. Before surgery, the adolescent may be placed in Buck or Russell traction to correct internal rotation of the affected extremity and to stop accompanying muscle spasms. Bilateral traction may be used to maintain symmetrical alignment of both hips. Surgery is performed as soon as possible, usually within several days of hospitalization, and the type of surgical procedure performed is dependent on the degree of displacement of the femoral head. If displacement is less than 30~ (less than one third of the width of the femoral neck), it is classified as being a mild slip, and an internal fixation is recommended. This operation involves the placement of a fixation device, such a pin or a cannulate screw, through the inferior half of the femoral head and across the epiphyseal plate (Figure 4). Fears that premature fusion of the growth plate will cause a growth problem are unfounded and not an indication to delay surgical intervention. The growth plate of the femoral head is thought to contribute less than 30% of the total length of the femoral shaft, so growth of the femur will not be compromised (Gartland, 1979). Femoral head displacements of between 30~ and 50~ are classified as moderate slips. Moderate slips are treated with closed reduction with traction followed by internal fixations with pins. Severe slips are over 50~ and require surgical reconstruction of the femur on the affected side. Either the Southwick biplane osteotomy or a subtrochanteric osteotomy will be performed (Canale, 1992; Gartland, 1979, Ferguson, 1981). The purpose of these procedures is to reconstruct normal anatomical alignment of the proximal end of the femur. A wedge of bone is cut out, and the remaining bone fragments are positioned in place with metal pins, plates, and screws. The epiphyseal plate is untouched (Figures 5 and 6). Another surgical procedure that may be per-
J
Figure4.
Pinning in situ.
formed is a bone graft epiphysiodesis. With this procedure, the surgeon aseptically curettages the affected epiphyseal plate, and then applies small bone grafts obtained from the iliac crest across the plate. An epiphysiodesis will cause a permanent arrest of the growth plate, so the procedure may be reserved for an adolescent who has achieved maximal linear growth (Canale, 1992; MacEwen et al., 1986; Weiner, 1993). A cheilectomy is another surgical option. It involves the removal of the abnormal growth of bone that forms gradually on the femoral neck. The hump, after the initial acute phase of slipping and lack of immediate treatment, enlarges for several years. Cheilectomy is reconstructive surgery and is performed to help improve range of motion in the affected hip. Wedge of bone
Figure 5. Open reduction of slipped capital femoral epiphysis by osteotomy through the femoral neck with pinning.
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A
I I I I I I I I I I I I / /
!
I I I I
B Figure 6. Southwick osteotomy (subtrochanteric). (A) Premeasured wedge of bone removed; femur completely incised. (B) Correction with internal rotation.
The operation will most likely be performed when the adolescent reaches the late teen years. Regardless of which surgical procedure is performed, postoperatively, the adolescent must avoid total weight bearing on the operated hip for a defined length of time. Complete fusion of the epiphysis will vary anywhere from 2 to 8 months after surgical intervention. However, use of the cannulate screw does permit weight bearing within 2 and 6 weeks after insertion (Morrissy & Selman, 1991). The use of crutches aids mobility during the recovery phase. Surgical placement pins can be, and usually are, removed 2 years after the initial procedure (Canale, 1992). Complications after surgery are more likely to occur when slips are judged to be moderate or severe because more complicated and prolonged surgical intervention is necessary. Chon-
drolysis (cartilage necrosis) and avascular necrosis of the femoral head can develop anytime within 3 months after surgery. Clinical symptoms of these complications are pain and decreased range of motion in the affected hip (MacEwan et al., 1986; McCullough & Pellino, 1994; Weiner, 1993). Although surgical intervention is the usual mode of treatment for SCFE, a conservative measure, that of immobilizing the adolescent in a hip spica cast, has been reported to be an effective method of treatment (Betz, Steel, Emper, Huss, & Clancy, 1990; Ferguson, 1981). The casting is indicated for the adolescent with a chronic but mild or moderate slip, and the cast is applied after the teenager has been in traction for 10 to 30 days. Advantages of using the hip spica cast are possible preventing of a slipped epiphysis in the opposite hip and eliminating the necessity of surgical interventions. However, use of the hip spica cast for SCFE has some disadvantages. First, the teenager has a prolonged immobilized period, anywhere from 8 to 16 weeks. This length of time is recommended to suppress any additional slipping (Betz et al., 1990). Next, the cast may have to be removed and reapplied more than once for radiological purposes. Finally, the potential problems that prolonged immobilization presents must be considered. The adolescent will be at risk for skin breakdown, pulmonary problems, and ileus. The caregivers may have difficulty in turning and caring for an obese person in a large body cast. Additionally, the teenager is at risk for altered growth and development because of the potential for poor body image perception, being in a dependent role, and being separated from peers. The family also faces the decision of whether to care for the adolescent at home or to admit the adolescent to an appropriate rehabilitation center. Although hip spica casting for SCFE does require a relatively prolonged period of immobility, it still offers the affected individual another choice concerning a treatment measure. NURSING CARE
Care of the adolescent with SCFE offers many challenges, and the nurse must be familiar with both the principles of orthopedic nursing care and the theories of normal adolescent growth and development. Because the musculoskeletal disorder will greatly affect the lifestyle of both the adolescent and the family, both will
180 Table 1. Major Nursing Diagnoses and Nursing Interventions for the Adolescent With Slipped Capital Femoral Epiphysis Impaired physical mobility related to displacement of the femur at the epiphysis and/or corrective surgery. Postoperative care: Change position every 2 to 4 hours, avoid turning on the surgical site Provide overhead trapeze to aid in turning Facilitate or encourage physical therapy involvement as soon as possible Encourage arm strengthening exercises such as lifting 1 -pound weights strapped on the wrists Supervise isometric exercises (prescribed by physical therapist) with operated leg, range of motion exercises for all other extremities at 4-hour intervals Provide ambulatory aids such as crutches or walkers when appropriate, sturdy shoes such as high-top tennis shoes when up Limit time sitting in a straight, firm chair to 1 hour three times daily to decrease the pressure on the operative site Instruct the adolescent not to bear weight on the operated leg and supervise when ambulating with crutches or walkers Altered comfort: related to pain secondary to displacement of the femoral head, preoperative traction, and surgical incision Ask adolescent to describe duration, character, amount, and location of pain (use a pain rating scale for consistency) Observe adolescent for physiological changes indicating pain, such as increased pulse and respirations, sweating, or muscle tension Provide prescribed pain medications through patient-controlled analgesia pumps if available (assure that proper use of the machine is taught) Administer, if necessary, muscle relaxants for muscle spasms Understand an adolescent's reluctance to ask for pain medications because of fear of iniections, being considered a drug addict, or not being brave; anticipate need for pain relief and administer appropriate medication when necessary High risk for peripheral neurovascular dysfunction related to inflammation and venous stasis in lower extremeties secondary to preoperative traction and surgical opening of the hip joint. Preoperative care Explain the purpose and use of skin traction Check all traction components (ropes, pulleys, weights, sandbags) E~evate head of the bed only when necessary so there is adequate pull and countertraction~foet of bed may be elevated on shock blocks if necessary Assess for normal body alignment when adolescent is in traction Encourage active range-of-motion exercises for all unaffected extremities, isometric exercises on affected limb Provide ted hose, heel protectors as needed Postoperative care Evaluate the adolescent's statements about discomfort Do neurovascular and skin checks an both legs at least every 4 hours while awake and once during the night, Data from McCullough& Pellino (1994), Mourad (1991 ), Wang (1995), and Wright (1989).
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Table 1. (Cant'd) assessing legs for color, temperature, capillary refill, sensation, and swelling Note the rate and volume of the pulses distal to the operative site (femoral, popliteal, posterior tibial, dorsalis pedis) in both legs Evaluate extent of inflammation and edema in operative site Prevent compression of the sciatic nerve after surgery: when turning the adolescent, place a pillow between the legs (sign of sciatic nerve compression is a sharp pain that is felt down the length of the leg) Assess for complications of surgery (aseptic necrosis of femoral head): numbness, tingling, limitation of range of motion in affected leg High risk for infection related to surgical incision at the hip joint Preoperatively, do a meticulous skin preparation to decrease possibility of infection at the surgical site and potential contamination of the osteum Postoperatively, inspect the wound for redness and drainage, check color and amount of drainage if hemovac is present, check bed linen under patient for btood or drainage Inspect skin several times daily for redness and breakdown--use sheepskin, egg crate mattress, alternating air mattress as needed Cleanse perineal area after voids and stools Keep bed dry and wrinkle-free Assess for signs of infection---elevated body temperature, localized tenderness, painful movement High risk far impaired gas exchange related to effects of general anesthesia, surgical incision, and immobility Evaluate respiratory rate and skin color for deviations from normal Auscultate breath sounds Encourage to deep breathe and cough every 1 hour, or use incentive spirometry Encourage ambulation wilh ambulatory aids when permitted Monitor hematocrit and hemoglobin levels at intervals Knowledge deficit in both parent and child related to unfamiliarity with musculoskeletal disorder, hospitalization, diagnostic tests, treatment measures, and home care Explain the emergency nature of the hospitalization and need for bed rest Explain the nature of the radiographs or bone scan Do routine preoperative teaching Explain postoperative teaching Reinforce physician explanations concerning traction and surgical interventions Provide verbal and written instructions for family regarding prolonged healing process, no weight bearing, methods to assess neurovascular function of affected limb, adaptations in hygiene/bathing, return to school, postdischarge medical supervision, repeat radiographs to detect disorder in opposite hip, seek medical attention for any complications such as temperature elevations or continued pain in the operated hip Arrange for dietary consultation to emphasize need for a well-balanced diet with less high calorie/high sugar foods Explain methods of weight control, emphasize avoidance of crash diets
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Table 1. (Cont'd) Teach proper nutrition regarding both disorder and adolescent growth Explain altered pattern of elimination caused by immobility; give information on dietary fiber, fluid needs, and bowel medications High risk for self-esteem disturbance related to discomfort with immobility, dependent role, and lack of privacy Determine adolescent's perceptions about body and disorder Help adolescent verbalize concerns about own body Emphasize talents, capabilities, and achievement. If hospitalization is prolonged, encourage use of tutor to help with school assignments Explain recovery period and adaptations to maintain independence Involve adolescent in decisions about care Provide privacy during nursing care procedures and surgical evaluations High risk for altered growth and development related to separation from family and friends and from involvement in usual recreational activities Have a consistent relationship with the adolescent Encourage the adolescent to engage in age-appropriate diversional activities Discuss with family the need for frequent visits and telephone calls of family and friends Encourage development of peer friendships in the hospital Provide means to increase communication with personal friends Discuss any adjustments necessaryfor participation in future school activities
benefit greatly from being served by an interdisciplinary team. The services of other disciplines, such as physical therapy, education, child-life, social services, and dietary will be necessary to help promote, as much as possible, an uneventful recovery for the adolescent. The nurse can help coordinate these services and provide care that is teen-centered and directed toward prevention of the known complications that can result from the disorder. Major nursing diagnoses regarding physical care of the adolescent with SCFE are listed in Table 1, which also includes summarized nursing interventions. Frequently the adolescent's psychosocial needs are overlooked because of the demanding physical care that is required for those with SCFE. Adolescents are typically in the process of striving for and finally achieving independence from their parents. With SCFE, an unpredictable situation occurs when the emergency nature of the hospitalization combined with enforced bed rest produces much anxiety for the adolescent who may fear that his or her future independence may never be possible. The adolescent, unhappy about ambula-
tion restrictions and the lengthy hospital stay, may become critical, argumentative, or withdrawn. Another major psychological task of the adolescent period is development of a sense of personal identity (Wong, 1995). Adolescents engage in frequent self-reflection and become acutely aware of their personal appearance. They compare themselves with their peers, and if they perceive deviations in comparisons, they may develop a poor sense of self. Middle adolescence (ages 14 to 15) marks the beginning stage of heterosocial relationships in which there is normally more social interaction with the opposite sex (Schuster & Ashburn, 1992). The adolescent with SCFE, who is larger and heavier than the same-age peers and who has concerns over needing to use crutches for a prolonged period of time, may fear peer or opposite-gender rejection and have feelings of inferiority, inadequacy, or incompetence. These feelings may be expressed through mood swings, regressed behavior, withdrawl, or unusual demands placed on the nursing staff. The adolescent, recovering from surgery for SCFE, has a need for a well-balanced diet and supplemental iron and vitamins to promote bone and wound healing. Weight control is, in many instances, a major issue in the postoperative period, and teaching sound nutritional practices to the adolescent and the immediate family is an important nursing intervention. However, the adolescent may have difficulty changing eating habits. During hospitalization, even with decreased physical activity, the adolescent may want extra food or request special high-calorie, low-nutritive foods from a fastfood restaurant. Denial of these requests may be perceived as punishment, and power struggles between the nursing staff and the adolescent may result. Nurses can encourage adolescents to talk about their feelings, and emphasize the adolescents' attractive features and talents to motivate them for future weight loss. Throughout hospitalization, dietary consultation becomes very important, and before discharge, an exercise program can be prescribed that will be appropriate for individual mobility limitations that are present. CONCLUSION SCFE is a disorder that results in disruption of familiar routines for adolescents and their
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families. Knowledge of the disease process, treatment measures, and adolescent growth and development will enhance nursing's ability not
only to provide high-quality individualized health care, but also to help the adolescent develop into a mature adult with a healthy self-concept.
REFERENCES Betz, R., Steel, H., Emper, W., Huss, G., & Clancy, M. (1990). Treatment of slipped capital femoral epiphysis. Journal of Bone and Joint Surgery, 72A, 587-600. Canale, S.T. (1992). Fractures and dislocations in children. In A. Crenshaw (Ed.), Campbell's operative orthopedics (pp. 1149-1181). St. Louis: Mosby. Carter, M. (1992). Anatomy and physiology of bones and joints. In S. Price & L. Wilson (Eds.), Pathophysiology; Clinical concepts of disease processes (pp. 935-940). St. Louis: Mosby. Chung, S. (1986). Diseases of the developing hip. Pediatric Clinics of North America, 53, 1457-1464. Ferguson, A. (1981). Orthopedic surgery in infancy and childhood. Baltimore: Williams & Wilkins. Gartland, J. (1979). Fundamentals of orthopedics. Philadelphia: W.B. Saunders. Kelsey, L. (1973). Epidemiology of slipped capital femoral epiphysis: A review of the literature. Pediatrics, 51, 1042-1050. MacEwen, G., Bunnell, W., & Ramsey, P. (1986). The hip. In W. Lovell & R. Winters (Eds.), Pediatric orthopaedics (pp. 703-780). Philadelphia: Lippincott. McCuUough, L., & Pellino, T. (1994). Congenital and developmental disorders. In A. Maher, S. Salmond, & T. Pellino, (Eds.), Orthopedic Nursing (pp. 617-700). Philadelphia: Saunders.
Morrissy, R., & Selman, S. (1991). Slipped capital femoral epiphysis. Orthopaedic Nursing, 10, 11-20. Mourad, L. (1991). Orthopedic disorders. St. Louis: Mosby. Puri, R., Smith, S., Malhotra, D., Williams, D., Owen, R., & Harris, F. (1985). Slipped upper femoral epiphysis and primary juvenile hypothyroidism. The Journal of Bone and Joint Surgery, 67, 14-20. Schuster, C., & Ashburn, S. (1992). Theprocess of human development: A holistic life span approach. Philadelphia: J.B. Lippincott. Skinner, S. (1991). Orthopedic problems in childhood. In A. Rudolph, J. Hoffman, C. Rudolph, & P. Sagan (Eds.), Rudolph's Pediatrics (pp. 1941-1942). Norwalk, CT: Appleton Lange. Weiner, D. (1993). Pediatric orthopaedics. New York: Churchill Livingston. Wong, D. (1995). Whaley & Wong's nursing care of infants and children. St. Louis: Mosby. Wong, D., & Whaley, L. (1990). Clinical manual of pediatric nursing. St. Louis: Mosby. Wright, S. (1989). Nursing strategies: Altered musculoskeletal function. In R. Foster, M. Hunsberger, & J. Anderson (Eds.), Family centered nursing care of children (pp. 17801843). Philadelphia: W.B. Saunders.