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Slipped Capital Femoral Epiphysis, Emergency Medicine

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Slipped Capital Femoral Epiphysis, Emergency Medicine

Basics

Description

If septic hip is suspected, aspiration and fluid analysis may be needed to exclude. ‚

Patient should be immobilized for transport, as with suspected hip fracture or dislocation. ‚

Pain management as indicated; avoid oral medications if operative intervention is planned ‚

None (no role for observation or attempts at closed reduction due to risk of complications, including osteonecrosis and/or chondrolysis) ‚

Should be arranged by orthopedic specialist ‚

  • Femoral epiphysis translates (slips) posteriorly and inferiorly relative to the femoral head/neck
  • Classification systems:Degree of femoral head "slip " ¯ as a percentage of femoral neck diameter:(Mild, grade 1) <33.3%(Moderate, grade 2) 33.3 " “50%(Severe, grade 3) >50%Temporal:Acute: <3 wk of symptomsChronic: >3 wk of symptomsAcute on chronic: >3 wk of symptoms, now with acute painStability:Stable: Bears weight w/or w/o crutchesUnstable: Unable to bear weight
  • Epidemiology:Peak age: 12 " “14 yr (boys), 11 " “12 yr (girls)Male > female (1.6:1)Bilateral slips: 20% at presentation; additional 20 " “40% progress to bilateralAtypical SCFE: Endocrinopathy associated:Patient may be <10 yr age, >16 yr age, or weight <50th percentileHigh risk of bilateral SCFE (up to 100%)
  • Degree of femoral head "slip " ¯ as a percentage of femoral neck diameter:(Mild, grade 1) <33.3%(Moderate, grade 2) 33.3 " “50%(Severe, grade 3) >50%
  • Temporal:Acute: <3 wk of symptomsChronic: >3 wk of symptomsAcute on chronic: >3 wk of symptoms, now with acute pain
  • Stability:Stable: Bears weight w/or w/o crutchesUnstable: Unable to bear weight
  • (Mild, grade 1) <33.3%
  • (Moderate, grade 2) 33.3 " “50%
  • (Severe, grade 3) >50%
  • Acute: <3 wk of symptoms
  • Chronic: >3 wk of symptoms
  • Acute on chronic: >3 wk of symptoms, now with acute pain
  • Stable: Bears weight w/or w/o crutches
  • Unstable: Unable to bear weight
  • Peak age: 12 " “14 yr (boys), 11 " “12 yr (girls)
  • Male > female (1.6:1)
  • Bilateral slips: 20% at presentation; additional 20 " “40% progress to bilateral
  • Atypical SCFE: Endocrinopathy associated:Patient may be <10 yr age, >16 yr age, or weight <50th percentileHigh risk of bilateral SCFE (up to 100%)
  • Patient may be <10 yr age, >16 yr age, or weight <50th percentile
  • High risk of bilateral SCFE (up to 100%)

Etiology

  • Proximal physis position changes in adolescence from horizontal to oblique; hence hip forces shift from "compression " ¯ to "shear " ¯
  • Shear force > strength of femoral physis
  • Weakest point of physis = zone of hypertrophy
  • Risk factors:Obesity: May contribute to shear forcesDown syndromeEndocrinopathy such as hypothyroidism, growth hormone deficiency, renal osteodystrophy (2 ‚ ° hyperparathyroidism): May contribute to growth plate weakening
  • Obesity: May contribute to shear forces
  • Down syndrome
  • Endocrinopathy such as hypothyroidism, growth hormone deficiency, renal osteodystrophy (2 ‚ ° hyperparathyroidism): May contribute to growth plate weakening

Diagnosis

Signs and Symptoms

  • Determine chronicity of symptoms and whether or not the patient can bear weight
  • Pain in the knee, thigh, groin, or hip (referred pain from the obturator nerve):Vague and dull for weeks in chronic SCFESevere and sudden onset in acute SCFE, often in the setting of trauma
  • Vague and dull for weeks in chronic SCFE
  • Severe and sudden onset in acute SCFE, often in the setting of trauma
  • If stable, presents with limp or exertional limp
  • If unstable (patient cannot ambulate), avoid further ambulation attempts
  • Commonly presents with leg externally rotated
  • Restricted internal rotation, abduction, and flexion (cannot touch thigh to abdomen)
  • Anterior hip joint tenderness
  • Test: Apply gentle passive hip flexion ¢ † ’ if hip externally rotates + abducts ¢ † ’ highly suggestive of SCFE
  • Gait:Antalgic (patient takes short steps on affected side to minimize weight-bearing during "stance " ¯ phase of gait)Trendelenburg (shift of torso over affected hip; sign of moderate/severe slip)Waddling (sign of bilateral SCFE)
  • Antalgic (patient takes short steps on affected side to minimize weight-bearing during "stance " ¯ phase of gait)
  • Trendelenburg (shift of torso over affected hip; sign of moderate/severe slip)
  • Waddling (sign of bilateral SCFE)

Essential Workup

  • Plain radiographs:Further imaging with aid from consultant
  • Orthopedic consultation
  • Further imaging with aid from consultant

Diagnosis Tests & Interpretation

  • If no diagnostic radiographic abnormality, the practitioner may consider the following to help risk stratify possible alternative diagnoses:CBC with differential, sedimentation rate, C-reactive protein
  • If endocrinopathy suspected, consider thyroid function testing
  • CBC with differential, sedimentation rate, C-reactive protein
  • Both hips should be imaged for comparison
  • Some clinicians prefer cross-table lateral view in acute SCFE instead of frog-leg view (theoretical risk of worsening displacement)
  • Anteroposterior radiograph:Widened or irregular physisBirds beak appearance of the epiphysis "slipping " ¯ off of the femoral headKlein line: Parallel line drawn from superior border of the femoral neck; line intersects the epiphysis in normal patient
  • Lateral radiograph (frog-leg or cross-table)
  • Widened or irregular physis
  • Birds beak appearance of the epiphysis "slipping " ¯ off of the femoral head
  • Klein line: Parallel line drawn from superior border of the femoral neck; line intersects the epiphysis in normal patient

Differential Diagnosis

  • Legg " “Calve " “Perthes:Typically seen in 4 " “9-yr-old age range
  • Septic arthritis of hip
  • Osteomyelitis
  • Toxic synovitis
  • Femur or pelvic fractures
  • Inguinal or femoral hernia
  • Typically seen in 4 " “9-yr-old age range

Treatment

Pre-Hospital

Initial Stabilization/Therapy

  • Immobilize hip; keep nonweight bearing
  • Do not attempt reduction.

Ed Treatment/Procedures

  • SCFE is an urgent orthopedic condition; delay in diagnosis may lead to chronic irreversible hip joint disability.
  • Consult orthopedics immediately for definitive immobilization or operative intervention.

Medication

Follow-Up

Disposition

  • Acute, acute on chronic and bilateral SCFE requires orthopedic admission for urgent operative fixation (usually insitu single cannulated screw fixation)
  • Chronic SCFE may be managed with delayed operative fixation

Followup Recommendations

Pearls and Pitfalls

  • Klein line can be a helpful tool in picking up the abnormality on plain radiograph
  • Remember to examine the hip when a child presents with knee or thigh pain

Additional Reading

  • Aronsson ‚ DD, Loder ‚ RT, Breur ‚ GJ, et al. Slipped capital femoral epiphysis: Current concepts. J Am Acad Orthop Surg. 2006;14(12):666 " “679.
  • Gholve ‚ PA, Cameron ‚ DB, Millis ‚ MB. Slipped capital femoral epiphysis update. Curr Opin Pediatr. 2009;21(1):39 " “45.
  • Kay ‚ RM. Slipped capital femoral epiphysis. In: Morrisey ‚ RT, Weinstein ‚ SL, eds. Lovell & Winters Pediatric Orthopaedics. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:1085 " “1124.
  • Lehmann ‚ CL, Arons ‚ RR, Loder ‚ RT, et al. The epidemiology of slipped capital femoral epiphysis: An update. J Pediatr Orthop. 2006;26(3):286 " “290.
  • Loder ‚ RT. Controversies in slipped capital femoral epiphysis. Orthopedic Clin North Am. 2006;37(2):211 " “221.
  • Loder ‚ RT, Dietz ‚ FR. What is the best evidence for the treatment of slipped capital femoral epiphysis? J Pediatr Orthop. 2012;32(suppl 2):S158 " “S165.

Codes

ICD9

  • 732.2 Nontraumatic slipped upper femoral epiphysis
  • 732.9 Unspecified osteochondropathy

ICD10

  • M93.003 Unspecified slipped upper femoral epiphysis (nontraumatic), unspecified hip
  • M93.013 Acute slipped upper femoral epiphysis (nontraumatic), unspecified hip
  • M93.023 Chronic slipped upper femoral epiphysis (nontraumatic), unspecified hip
  • M93.033 Acute on chronic slipped upper femoral epiphysis (nontraumatic), unspecified hip
  • M93.001 Unspecified slipped upper femoral epiphysis (nontraumatic), right hip
  • M93.002 Unspecified slipped upper femoral epiphysis (nontraumatic), left hip
  • M93.00 Unspecified slipped upper femoral epiphysis (nontraumatic)
  • M93.011 Acute slipped upper femoral epiphysis (nontraumatic), right hip
  • M93.012 Acute slipped upper femoral epiphysis (nontraumatic), left hip
  • M93.01 Acute slipped upper femoral epiphysis (nontraumatic)
  • M93.021 Chronic slipped upper femoral epiphysis (nontraumatic), right hip
  • M93.022 Chronic slipped upper femoral epiphysis (nontraumatic), left hip
  • M93.02 Chronic slipped upper femoral epiphysis (nontraumatic)
  • M93.031 Acute on chronic slipped upper femoral epiphysis (nontraumatic), right hip
  • M93.032 Acute on chronic slipped upper femoral epiphysis (nontraumatic), left hip
  • M93.03 Acute on chronic slipped upper femoral epiphysis (nontraumatic)
  • M93.0 Slipped upper femoral epiphysis (nontraumatic)
  • S79.019A Sltr-haris Type I physeal fx upper end of unsp femur, init

SNOMED

  • 26460006 Slipped upper femoral epiphysis (disorder)
  • 203374004 Non-traumatic acute slipped upper femoral epiphysis (disorder)
  • 203376002 Non-traumatic chronic slipped upper femoral epiphysis (disorder)
  • 203375003 Non-traumatic acute-on-chronic slipped upper femoral epiphysis (disorder)