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Slipped Capital Femoral Epiphysis, Emergency Medicine


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)
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