Contents
Introduction
Posterior & inferior slippage of proximal femoral epiphysis on metaphysis through the epiphyseal plate (growth plate) of femoral neck in an immature hip.
- M/C hip disorder in adolescents
- Affects approximately 1–10 per 100,000 children
Classification
Based on stability:
- Stable SCFE (90% cases): Ambulatory with/without crutches
- Unstable SCFE: Non-ambulatory even with crutches
Based on duration:
- Acute SCFE: Symptoms < 3 weeks
- Chronic SCFE: Symptoms ≥ 3 weeks
- Acute-on-chronic: Acute exacerbation of chronic symptoms
Aetiology
Obesity, growth spurts:
63% cases weight ≥ 90th percentile
Endocrine disorders:
Less common; considered in atypical presentations including 8 year age or > 15 year age, underweight, or short stature
- Hypothyroidism
- Growth hormone supplementation
- Hypogonadism
- Panhypopituitarism
Clinical features
Bilateral in 18-50% patients.
- Limping & pain that is poorly localized to the hip, groin, thigh, or knee (M/C symptom)
- Knee/distal thigh pain (15% cases)
- History of trauma to the area (rare)
88% of patients with unstable SCFE had antecedent symptoms before presentation:
- Delayed diagnosis of SCFE may result in a poorer prognosis, it is imperative that
- Thus physicians strongly consider SCFE when a child presents with vague hip or knee pai
Complications
- Avascular osteonecrosis (20-50 % in unstable SCFE) → Early degenerative osteoarthritis
- Serious complication associated with severe displacement and fixation with more than one screw
- Chondrolysis (acute loss of articular cartilage, causing joint stiffness and pain)
- Complication of surgical treatment of SCFE (1-2% cases), but can occur with use of hip spica cast and in untreated advanced SCFE
Diagnosis
Clinical diagnosis:
Compare range of motion with the uninvolved hip (unless B/L SCFE).
- Antalgic gait or may be unable to bear weight with a severe slip
- Limited internal rotation of the hip (M/telling sign)
- Drehmann sign: Obligatory external rotation noted in involved hip when passively flexed to 90°
Radiographs:
- Steel sign (AP view): Double density found at metaphysis (posterior lip of epiphysis superimposed on metaphysis)
- Widening of growth plate (physis) compared with the uninvolved side
- Decreased epiphyseal height compared with the uninvolved side
- Klein’s line (AP view): Line drawn along superior edge of femoral neck normally crosses the epiphysis; epiphysis falls below this line in SCFE
- Lesser trochanter prominence (d/t external rotation of the femur)
Differential diagnosis:
| Condition* | Age (years) | Clinical features | Incidence | Diagnosis |
|---|---|---|---|---|
| Apophyseal avulsion fracture of the anterosuperior and anteroinferior iliac spine | 12 to 25 | Pain after sudden forceful movement | Common | History of trauma; radiography |
| Apophysitis of the anterosuperior and anteroinferior iliac spine | 12 to 25 | Activity-related hip pain | Common | History of overuse; radiography to rule out fractures |
| Transient synovitis | < 10 | Limping or hip pain | Common | Radiography, laboratory testing, ultrasonography |
| Fracture | All ages | Pain after traumatic event | Less common | History of trauma; radiography |
| Slipped capital femoral epiphysis | 8 to 15 | Hip, groin, thigh, or knee pain; limping | Less common | Bilateral hip radiography |
| Legg-Calvé-Perthes disease | 4 to 9 | Vague hip pain, decreased internal rotation of hip | Uncommon | Hip radiography or magnetic resonance imaging |
| Septic arthritis | All ages | Fever, limping, hip pain | Uncommon | Radiography; laboratory testing; joint aspiration |
| Adductor muscle strain (groin pull) | 12 to 20 | Groin pain after activity | Very uncommon | Radiography to rule out fracture; physical examination |
Management
Patient should be placed on non–weight-bearing crutches or in a wheelchair. The initial goals of treatment are to prevent slip progression and avoid complications. Forceful relocation of the injury should not be attempted; such maneuvers can result in avascular necrosis caused by restricted blood supply to the femoral head.29
Stable SCFE
- In-situ fixation with a single screw
- After closure of the growth plate, progression of athletic activities may be allowed, including running and, eventually, participating in contact sports
Unstable SCFE:
Treatment goals are similar to those of stable SCFE with in situ fixation
- Modified Dunn procedure: Surgical hip dislocation that helps restore the alignment of the proximal femur to decrease the rate of femoroace-tabular impingement
