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Slipped Capital Femoral Epiphysis

Aka: Slipped Capital Femoral Epiphysis, SCFE
  1. See Also
    1. Pediatric Limp
  2. Definitions
    1. Slipped Capital Femoral Epiphysis (SCFE)
      1. Posterior and inferior slippage of proximal femoral epiphysis on the femoral neck metaphysis, at the Hip Joint
  3. Epidemiology
    1. Age of onset (8-15 years old)
    2. Peak age of onset occurs during maximal pubertal growth spurt
      1. Males: age 14 to 16 years (mean 13.5 years)
      2. Females: age 11 to 13 years (mean 12 years)
    3. Most common adolescent hip disorder
      1. Prevalence: 10.8 per 100,000
  4. Classification
    1. Stability
      1. Unstable SCFE (10% of cases) is defined as unable to ambulate without Crutches
    2. Chronicity
      1. Chronic SCFE is defined as being present for more than 3 weeks
  5. Risk Factors
    1. Standard risks
      1. Black, pacific islander, or hispanic children affected more often than white children
      2. Overweight or obese (63% of cases)
    2. Younger onset or atypical cases (e.g. underweight, Short Stature)
      1. Arthritis
      2. Endocrinopathy
        1. Hypothyroidism
        2. Growth Hormone supplementation
        3. Hypogonadism
        4. Panhypopituitarism
      3. Renal Failure
      4. Radiation Therapy
      5. Chemotherapy
  6. Pathophysiology
    1. Posterior and inferior slippage of proximal femoral epiphysis on the femoral neck metaphysis, at the Hip Joint
    2. Occurs before the Epiphyseal Plate closes
  7. Precautions
    1. SCFE is frequently misdiagnosed as benign diagnosis
      1. Example: Adductor Strain (uncommon in this age group)
    2. Best prognosis with early diagnosis (have a high index of suspicion in a preadolescent or adolescent with Hip Pain)
  8. Symptoms
    1. Limp
    2. Poorly localized hip and Leg Pain
    3. Hip Pain with indolent course
      1. Unilateral in up to 90% of cases
    4. Pain may be referrred to knee
      1. May present primarily as knee or distal thigh pain in 15-25% of cases
  9. Signs
    1. Antalgic Gait
    2. Compare exam to opposite side (except in bilateral SCFE)
    3. Hip held in abduction and external rotation
    4. Obligatory external rotation (Drehmann Sign)
      1. Patient externally rotates hip when the hip is actively flexed to 90 degrees
    5. Markedly limited internal rotation (most predictive finding)
  10. Imaging
    1. Hip XRay AP with Frog-Leg Lateral View (Compare sides)
      1. Widened Epiphyseal Plate (Growth Plate) compared with uninvolved side
      2. Decreased epiphyseal height compared with uninvolved side
      3. Displacement of femoral head (Wlison method of grading)
        1. Hip epiphysis displaced <33% of metaphysis width (mild)
        2. Hip epiphysis displaced 33-50% of metaphysis width (moderate)
        3. Hip epiphysis displaced >50% of metaphysis width (severe)
      4. Draw line down the femoral neck on AP View (Klein's Line)
        1. Line does not transect lateral 25% of femoral head and neck in SCFE
        2. Frog-leg view is important, as AP Hip will miss SCFE in up to 60% of cases
      5. Steel Sign
        1. Double density (double line) at the hip metaphysis
      6. Lesser trochanter prominent
        1. Due to external rotation of hip
    2. MRI Hip
      1. Consider in high suspicion cases where XRay is non-diagnostic
      2. May be indicated in early slippage
  11. Management
    1. Orthopedic Urgency!
    2. Non-weight bearing status (Crutches or wheel chair)
    3. Do not attempt to forcefully relocate SCFE
      1. Risk of avascular necrosis
    4. Hospitalization and operative fixation
      1. Stable SCFE
        1. In situ fixation with single screw (preferred method)
      2. Unstable SCFE
        1. High risk for longterm Disability from Hip Osteonecrosis, Femoroacetabular Impingement
        2. Repair timing and reduction method vary based on patient and surgeon preference
        3. Severe chronic Slipped Capital Femoral Epiphyses may require osteotomies to realign and stabilize
    5. Postoperative Rehabilitation
      1. Multi-phased return to activity managed by physical therapy
      2. Phase 1: Reduce inflammation, protect repair, Crutches, gait analysis
      3. Phase 2: Crutches discontinued if normal pain free gait and painless Straight Leg Raise abduction
      4. Phase 3/4: Improve strengthening, range of motion and aerobic fitness
      5. Phase 5: Preparing for return to sport and other activity
    6. Older methods
      1. Spica hip Casting for 6 to 8 weeks
        1. Was used to reduce risk of Femoral Neck Fracture and protect epiphyses
  12. Prevention
    1. Prophylactic pinning of unaffected hip
      1. Not typically recommended
      2. May be indicated in high risk for future SCFE (e.g. young patient, Obesity, endocrine cause)
  13. Complications
    1. Avascular Necrosis of the Femoral Head (20-50% of unstable SCFE patients)
      1. Premature degenerative hip Arthritis (and need for hip reconstruction)
    2. Premature closure of the femoral head Growth Plate
    3. Chrondrolysis (articular cartilage acute loss)
      1. May result from pin penetration of femoral head during single screw placement
      2. Previously Incidence was as high as 7% following pinningm but now decreased to 1%
        1. Reduced risk attributed to improved pinning techniques
    4. Femoroacetabular Impingement
      1. Results from proximal femur anatomic changes with severe slip and malpositioning
      2. May be prevented with subtrochanteric osteotomy
  14. Prognosis
    1. Stable SCFE
      1. In situ fixation has a good longterm outcome, with advancing of athletic activity after epiphysis closes
    2. Unstable SCFE
      1. High risk for Hip Osteonecrosis (20-50% risk) and Femoroacetabular Impingement
  15. References
    1. Jhun and Raam in Herbert (2016) EM:Rap 16(2):15-6
    2. Peck (2017) Am Fam Physician 95(12): 779-84 [PubMed]

Slipped Capital Femoral Epiphyses (C0149887)

Definition (MSH) A developmental deformity in which the metaphysis of the FEMUR moves proximally and anteriorly away from FEMUR HEAD (epiphysis) at the upper GROWTH PLATE. It is most common in male adolescents and is associated with a greater risk of early OSTEOARTHRITIS of the hip.
Concepts Disease or Syndrome (T047)
MSH D060048
Dutch epifysiolyse heupkop
French Epiphysiolyse fémorale supérieure, Coxa vara de l'adolescent, Épiphysiolyse de la tête fémorale, Glissement de l'épiphyse fémorale supérieure, Glissement épiphysaire fémoral supérieur, Épiphysiolyse fémorale supérieure, Épiphysiolyse de l'adolescent
German verrutschte Femurkopfepiphyse, Adoleszente Coxa Vara, Jugendliche Hüftkopflösung, Jugendliche Hueftkopfloesung, Epiphyseolysis capitis femoris, Coxa Vara beim Adoleszenten
Italian Frattura cronica dell'epifisi della testa del femore, Slittamento dell'epifisi femorale
Portuguese Epifisiólise da cabeça do fémur, Escorregamento das Epífises Proximais do Fêmur, Escorregamento Epifisário Proximal do Fêmur, Escorregamento da Epífise Proximal do Fêmur
Spanish Epífisis femoral superior dislocada, Epífisis Desprendida de Cabeza Femoral
Japanese 大腿骨頭すべり症, ダイタイコットウスベリショウ, ダイタイコツトウスベリショウ
English Slipped capital femoral epiphyses, EPIPHYSIOLYSIS CAPITIS FEMORIS, SLIPPED FEMORAL CAPITAL EPIPHYSES, Proximal femoral epiphysiolysis, slipped femoral capital epiphysis, capital epiphysis femoral slipped, Adolescent Coxa Vara, Slipped Capital Femoral Epiphyses, Coxa Varas, Adolescent, Coxa Vara, Adolescent, Adolescent Coxa Varas, Slipped Capital Femoral Epiphysis, Slipped Capital Femoral Epiphyses [Disease/Finding], Slipped Femoral Capital Epiphyses, Epiphysiolysis Capitis Femoris, Slipped femoral capital epiphysis
Czech Sklouzlá horní femorální epifýza, epifyseolysis capitis femoris, sklouznutí hlavice stehenní kosti, coxa vara dospívajících, kyčelní kloub - posun epifýzy hlavice, skluz hlavice kosti stehenní dospívajících, coxa vara adolescentium, CVA, sklouznutí epifýzy femuru
Hungarian Félrecsúszott comb epiphysisfej
Russian PODROSTKOV SHEIKI BEDRA VARUSNAIA DEFORMATSIIA, PODROSTKOVAIA KOKSA VARA, СМЕЩЕНИЕ ЭПИФИЗА ГОЛОВКИ БЕДРЕННОЙ КОСТИ, ПОДРОСТКОВ ШЕЙКИ БЕДРА ВАРУСНАЯ ДЕФОРМАЦИЯ, ЭПИФИЗИОЛИЗ ГОЛОВКИ БЕДРЕННОЙ КОСТИ, ПОДРОСТКОВАЯ КОКСА ВАРА, SMESHCHENIE EPIFIZA GOLOVKI BEDRENNOI KOSTI, EPIFIZIOLIZ GOLOVKI BEDRENNOI KOSTI
Polish Złuszczenie głowy kości udowej młodzieńcze, Młodzieńcze złuszczenie głowy kości udowej
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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