Basics
Description
- 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 symptoms
- Chronic: >3 wk of symptoms
- Acute on chronic: >3 wk of symptoms, now with acute pain
- Stability:
- Stable: Bears weight w/or w/o crutches
- Unstable: 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 bilateral
- Atypical SCFE: Endocrinopathy associated:
- 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 forces
- Down syndrome
- Endocrinopathy such as hypothyroidism, growth hormone deficiency, renal osteodystrophy (2 ‚ ° hyperparathyroidism): May contribute to growth plate weakening
Diagnosis
Signs and Symptoms
History
- 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 SCFE
- Severe and sudden onset in acute SCFE, often in the setting of trauma
Physical Exam
- 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)
Essential Workup
- Plain radiographs:
- Further imaging with aid from consultant
- Orthopedic consultation
Diagnosis Tests & Interpretation
Lab
- 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
Imaging
- 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 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
- Lateral radiograph (frog-leg or cross-table)
Diagnostic Procedures/Surgery
If septic hip is suspected, aspiration and fluid analysis may be needed to exclude. ‚
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
Treatment
Pre-Hospital
Patient should be immobilized for transport, as with suspected hip fracture or dislocation. ‚
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
Pain management as indicated; avoid oral medications if operative intervention is planned ‚
Follow-Up
Disposition
Admission Criteria
- 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
Discharge Criteria
None (no role for observation or attempts at closed reduction due to risk of complications, including osteonecrosis and/or chondrolysis) ‚
Followup Recommendations
Should be arranged by orthopedic specialist ‚
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)