Basics
Description
Slipped capital femoral epiphysis (SCFE) is displacement of the epiphysis of the head of the femur.
Epidemiology
- Males > females (3:2)
- Left hip twice as often as right, 25% bilateral
- Associated with obesity, increased height, genital underdevelopment, pituitary tumors, growth hormone therapy
Incidence
- 1 " 5 per 100,000
- Age of onset: boys, 14 " 16 years; girls, 11 " 13 years (essentially, premenarche)
Risk Factors
Genetics
5% of children affected have a parent with SCFE.
Pathophysiology
- Unclear: abnormal stress on normal physeal plate versus a process that weakens the plate
- The femoral head slips posteriorly and inferiorly, exposing the anterior and superior aspects of the metaphysis of the femoral neck.
Commonly Associated Conditions
- Obesity
- Endocrine dysfunction
- Primary hypothyroidism
- Pituitary dysfunction
- Hypogonadism
- Cryptorchidism
- Chemotherapy
- Pelvic radiotherapy
- Renal rickets
Diagnosis
History
Pain in hip or knee
- Occasional history of trauma; however, usually not sufficient to explain the findings
- 3 patterns
- Chronic: most common, onset of symptoms >3 weeks, lack of full internal rotation of hip
- Acute: sudden onset with inability to walk or severe pain and difficulty walking
- Acute-on-chronic: sudden exacerbation of symptoms that have been present for a while
Alert
Hip pain may be absent; there may be no pain, or only thigh or knee pain due to referred pain.
Physical Exam
- Limp if unilateral or waddling gait if bilateral
- Positive Trendelenburg sign
- Tenderness and occasional palpable thickening over hip
- Thigh atrophy
- Lack of full internal rotation of hip and decreased motion in all planes secondary to mechanical limitation due to the slip
- Maneuver: When the hip is flexed, the thigh is forced into external rotation.
Diagnostic Tests & Interpretation
Imaging
- Anteroposterior and lateral view (frog leg or Lowenstein)
- Measure degree of displacement.
- Minimal: alteration in plane of epiphysis relative to femoral neck; significant if angle <82 degrees
- Mild: displacement <1 cm
- Moderate: displacement >1 cm, <2/3 diameter of femoral neck
- Epiphyseal plate widened and irregular
- Decreased height of physis
- "Blanch sign " : dense area in femoral neck
- A "Klein line " drawn along the superior femoral neck on the anteroposterior view should transect the epiphysis but not on the slipped side.
- Hormonal evaluation if suspected
Pathologic Findings
Histologic findings include widening of the epiphyseal plate, large clefts, and necrotic debris in the cartilage and synovitis.
Differential Diagnosis
- Septic arthritis of the hip
- Ischemic necrosis (Legg-Calve-Perthes)
- Tuberculosis of the hip; however, pain is associated with movement in all directions, and there should be other evidence of disease.
- Renal rickets
- Achondroplasia
- Shwachman syndrome: metaphyseal chondrodysplasia with pancreatic insufficiency
Treatment
Additional Treatment
General Measures
- Designed to prevent complications and further slipping; urgent orthopedic consultation mandatory
- Conservative: bed rest with traction; probably does not reduce slipping; temporizing until surgery can be scheduled
- Manipulative reduction: risk of damage to epiphyseal vessels or breakdown of callus, probably only to be considered if within 24 hours of acute slip
- Epiphyseal fixation: risk of damage to articular surface or growth plate
- Intertrochanteric osteotomy
- Salvage: hip fusion
Ongoing Care
Follow-up Recommendations
Patient Monitoring
Chondrolysis and avascular necrosis are uncommon side effects of slipped capital femoral epiphysis.
Complications
- Ischemic necrosis of epiphysis
- Usually due to manipulative reduction of the slippage
- More common in males
- Radiographs reveal increased density, irregularity, and ultimately collapse of epiphysis.
- Chondrolysis (acute cartilage necrosis)
- Seen in 1 " 40%
- More common in females and blacks
- Etiology unclear
- Radiographs reveal narrowed joint space, sclerosis of acetabular rim, and osteoporosis of femoral head.
Prognosis
- Most patients with SCFE can return to activities 3 " 6 months postoperatively.
- Compared to chronic SCFE, acute SCFE has higher likelihood of poor outcome.
- Satisfactory outcomes associated with in situ fixation of chronic SCFE
Additional Reading
- Larson AN, Sierra RJ, Yu EM, et al. Outcomes of slipped capital femoral epiphysis treated with in situ pinning. J Pediatr Orthop. 2012;32(2):125 " 130. [View Abstract]
- 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. [View Abstract]
- Loder RT. Controversies in slipped capital femoral epiphysis. Orthop Clin North Am. 2006;37(2):211 " 221, vii. [View Abstract]
- Peck D. Slipped capital femoral epiphysis: diagnosis and management. Am Fam Physician. 2010;82(3):258 " 262. [View Abstract]
- Tosounidis T, Stengel D, Kontakis G, et al. Prognostic significance of stability in slipped upper femoral epiphysis: a systematic review and meta-analysis. J Pediatr. 2010;157(4):674 " 680, 680.e1. [View Abstract]
- Wensaas A, Svenningsen S, Terjesen T. Long-term outcome of slipped capital femoral epiphysis: a 38-year follow-up of 66 patients. J Child Orthop. 2011;5(2):75 " 82. [View Abstract]
Codes
ICD09
- 732.2 Nontraumatic slipped upper femoral epiphysis
ICD10
- M93.003 Unspecified 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
- M93.013 Acute slipped upper femoral epiphysis (nontraumatic), unspecified hip
- M93.002 Unspecified slipped upper femoral epiphysis (nontraumatic), left hip
- M93.032 Acute on chronic slipped upper femoral epiphysis (nontraumatic), left hip
- M93.021 Chronic slipped upper femoral epiphysis (nontraumatic), right hip
- M93.031 Acute on chronic slipped upper femoral epiphysis (nontraumatic), right hip
- M93.022 Chronic slipped upper femoral epiphysis (nontraumatic), left hip
- M93.001 Unspecified slipped upper femoral epiphysis (nontraumatic), right hip
- M93.011 Acute slipped upper femoral epiphysis (nontraumatic), right hip
- M93.012 Acute slipped upper femoral epiphysis (nontraumatic), left hip
SNOMED
- 26460006 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)
- 203374004 Non-traumatic acute slipped upper femoral epiphysis (disorder)