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Musculoskeletal System ORGAN SYSTEMS

Slipped capital femoral epiphysis (SCFE)

Posterior & inferior slippage of proximal femoral epiphysis on metaphysis through the epiphyseal plate (growth plate) of femoral neck in an immature hip.

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
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X-ray showing a slipped capital femoral epiphysis, before and after surgical fixation. | Dr. Jochen Lengerke – Praxis Dr. Jochen Lengerke, Public Domain, https://commons.wikimedia.org/w/index.php?curid=6637014
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Anatomy of the developing hip. | Peck D. Slipped capital femoral epiphysis: diagnosis and management. Am Fam Physician. 2010;82(3):259.

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°
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Obligatory external rotation of the hip (Drehmann sign). While supine, the patient is asked to flex the involved hip. Flexion with external rotation occurs when slipped capital femoral epiphysis is present. | Peck D. Slipped capital femoral epiphysis: diagnosis and management. Am Fam Physician. 2010;82(3):259.

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)
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Radiologic signs of slipped capital femoral epiphysis. | Peck D. Slipped capital femoral epiphysis: diagnosis and management. Am Fam Physician. 2010;82(3):260.
Anteroposterior radiography of left-sided slipped capital femoral epiphysis. Radiologic signs include: (A) Steel sign—on anteroposterior radiography, double density is found at the metaphysis (caused by the posterior lip of the epiphysis being superimposed on the metaphysis); (B) widening of the growth plate (physis) compared with the uninvolved side; (C) decreased epiphyseal height compared with the uninvolved side; (D) Klein’s line—on anteroposterior radiography, a line drawn along the superior edge of the femoral neck should normally cross the epiphysis; the epiphysis will fall below this line in slipped capital femoral epiphysis; and (E) lesser trochanter prominence, which is caused by external rotation of the femur. | Peck D. Slipped capital femoral epiphysis: diagnosis and management. Am Fam Physician. 2010;82(3):260.
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Southwick method for determining slipped capital femoral epiphysis (SCFE) severity using a frog-leg lateral radiograph. The first line (a) is drawn from the anterior to the posterior epiphyseal edges. Next, a line (b) is drawn perpendicular to the first line. A third line (c) is drawn down the middle of the femoral diaphysis. The angle formed by lines b and c is the lateral epiphyseal-shaft angle (LESA). The actual slip angle is the difference between the LESA of the SCFE hip and that of the uninvolved hip. | Peck, D. (2010). Slipped capital femoral epiphysis: diagnosis and management. American Family Physician, 82(3), 258–262.
Frog-leg lateral radiography of mild stable slipped capital femoral epiphysis.| Peck D. Slipped capital femoral epiphysis: diagnosis and management. Am Fam Physician. 2010;82(3):260.

Differential diagnosis:

Condition*Age (years)Clinical featuresIncidenceDiagnosis
Apophyseal avulsion fracture of the anterosuperior and anteroinferior iliac spine12 to 25Pain after sudden forceful movementCommonHistory of trauma; radiography
Apophysitis of the anterosuperior and anteroinferior iliac spine12 to 25Activity-related hip painCommonHistory of overuse; radiography to rule out fractures
Transient synovitis< 10Limping or hip painCommonRadiography, laboratory testing, ultrasonography
FractureAll agesPain after traumatic eventLess commonHistory of trauma; radiography
Slipped capital femoral epiphysis8 to 15Hip, groin, thigh, or knee pain; limpingLess commonBilateral hip radiography
Legg-Calvé-Perthes disease4 to 9Vague hip pain, decreased internal rotation of hipUncommonHip radiography or magnetic resonance imaging
Septic arthritisAll agesFever, limping, hip painUncommonRadiography; laboratory testing; joint aspiration
Adductor muscle strain (groin pull)12 to 20Groin pain after activityVery uncommonRadiography to rule out fracture; physical examination
Peck D. Slipped capital femoral epiphysis: diagnosis and management. Am Fam Physician. 2010;82(3):259.


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
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A 27-year-old-female 16 years post in situ pinning for stable SCFE. She had four years of pain with sitting. Flexion possible to 90˚. Internal rotation in flexion only to neutral. On imaging, slip angle is only about 25˚. Slip deformity classified as mild, but there is a large metaphyseal prominence. (a and b) AP and Lauenstein lateral radiographs at presentation. (c) Severe anterior acetabular damage found at time of surgical dislocation and neck osteoplasty. (d) Large metaphyseal prominence | Millis, M. B. (2017). SCFE: clinical aspects, diagnosis, and classification. Journal of Children’s Orthopaedics, 11(2), 93–98. https://doi.org/10.1302/1863-2548-11-170025

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
A 12-year-old female with six months of right knee pain and limp. Normal right knee radiographs and normal knee MRI. Physiotherapy for knee did not help knee pain. There were three weeks of groin pain. Crutches were prescribed. She was able to walk with crutches. First hip radiographs show severe bilateral SCFE. On examination she can lift both legs off table, but the right hip is painful. (a and b) Anteroposterior and Lauenstein lateral radiographs at presentation. (c and d) At modified Dunn osteotomy surgery, right femoral head was very unstable, despite abundant posterior callus, and preoperative ability to ambulate with crutches. (e, f and g) one year post-operatively right Dunn osteotomy, left ISP. Groin pain only in left hip. (h and i) five years post right Dunn osteotomy, three years post left hip anterior arthrotomy and neck osteoplasty. Asymptomatic in both hips. | Millis M. B. (2017). SCFE: clinical aspects, diagnosis, and classification. Journal of children’s orthopaedics, 11(2), 93–98. https://doi.org/10.1302/1863-2548-11-170025

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