Slipped capital femoral epiphysis

Background

• Abbreviation: SCFE
• Most common cause of hip disability in adolescents
• Head of femur displaces from epiphysis
• Common complications: avascular necrosis of femoral head (increased risk with high grade slip), arthritis

Risk Factors

• Obesity
• Black race
• Male sex (male:female 3:1)
• Times of high growth velocity (male growth spurt, around 13 years; female growth spurt, around 11 years)
• Left hip more common
• Endocrine disorders
  • Hypothyroid common
  • High clinical concern for SCFE in children less than <10 yrs of age

Clinical Features

• Mild to severe pain hip pain
  • Often present with referred knee pain
• Abnormal gait
  • Limp
  • Weakness
  • Thigh atrophy
• Externally rotated hip
  • Loss of internal rotation
  • Loss of abduction
  • Loss of flexion
• May present as acute (unstable), chronic (stable), or acute on chronic (following trauma)

Differential Diagnosis

Pediatric limp

Hip Related

• Acute rheumatic fever
• Developmental dysplasia of hip
• Femur fracture
• Juvenile idiopathic arthritis
• Legg-Calve-Perthes disease
• Septic arthritis of the hip (peds)
  • Lyme disease arthritis
• Slipped capital femoral epiphysis
• Transient (toxic) synovitis
• Osteosarcoma

Other Causes of Limping

• Developmental dysplasia
• Fracture
  • Toddler's fracture
  • Tillaux fracture, adolescent
• Neoplasm:
  • Leukemia
  • Ewings
  • Osteogenic sarcoma
  • Metastatic neuroblastoma
• Osteomyelitis
• Myositis
• Other:
  • Appendicitis
  • Meningitis
  • Epidural abscess (spinal)

Evaluation

X-ray showing a slipped capital femoral epiphysis, before and after surgical fixation.

• Plain radiographs of the hip (bilateral AP and frog-leg views)
  • Widened physis (early finding)
  • Displacement of femoral neck to head (late finding, so called 'ice cream cone' sign)
  • May show necrosis of the femoral head in late cases complicated by avascular necrosis
  • Note that up to 40% of patients will have bilateral involvement
• Klein's line

A normal and abnormal epiphyseal line as described by Klein et al. in an 11 year 6 month old boy with a left SCFE. Proximal prolongation of the superior neck line transects the epiphysis in the normal hip (right) but either lies flush with or does not transect the epiphysis in SCFE (left hip).

• • Line from superior cortex of femoral neck parallel to greater trochanter
  • Normally should cross through 1/3 of femoral head
    • If does not cross the femoral head, highly suspicious for SCFE
• May require MRI in ambiguous cases

Management

• Orthopedic surgery consultation in ED
• Strict non-weight bearing
• Pain control
• Internal fixation
  • Performed immediately for unstable SCFE
  • May be delayed by a few days for stable SCFE

Disposition

• Admit

See Also

• Pediatric hip pain
• Hip pain
• Limp (peds)