Slipped Capital Femoral Epiphysis
Often atraumatic or associated with a minor injury, slipped capital femoral epiphysis (SCFE) - also known as slipped upper femoral epiphysis - is one of the most common adolescent hip disorders and represents a unique type of instability of the proximal femoral growth plate. Four separate clinical groups are seen:
Pre-slip: wide epiphyseal line without slippage.
Acute form: slippage occurs suddenly, normally spontaneously.
Acute-on-chronic: slippage occurs acutely where there is already existing chronic slip.
Chronic: steadily progressive slippage (the most common form).
The condition is also categorised as:
Stable (90% of cases): the patient is able to walk.
Unstable (10% of cases): the patient is unable to walk (even with crutches).
Diagnosis is often delayed - and this is associated with a worse prognosis. Although surgery remains the standard treatment, the management of SCFE remains controversial - a Cochrane review is currently assessing the outcome of surgical and non-operative treatments.
The incidence is 10/100,000 children per year.
Most commonly it occurs in boys of 10-17 years of age. Peak age is 13 years for boys and 11.5 years for girls.
It is the most common hip disorder in adolescents.
The left hip is more commonly affected than the right; it is bilateral in 20-40% of cases.
It is three times as common in boys.
Mechanical: local trauma, obesity.
Inflammatory conditions: neglected septic arthritis.
Hypothyroidism, hypopituitarism, growth hormone deficiency, pseudohypoparathyroidism, vitamin D deficiency.
Previous radiation of the pelvis, chemotherapy, renal osteodystrophy-induced bone dysplasia.
Discomfort in the hip, groin, medial thigh or knee (knee pain is referred from the hip joint) during walking; pain is accentuated by running, jumping, or pivoting activities.
Pre-slip: slight discomfort.
Severe pain such that the child is unable to walk or stand.
Alterations in gait, including a limp on the affected side, external rotation of the leg, and trunk shift.
Hip motion is limited, especially internal rotation and abduction, due to pain.
Acute-on-chronic: pain, limp and altered gait occurring for several months, suddenly becoming very painful.
Mild symptoms with the child able to walk with altered gait. In a significant number of cases knee pain is reported as the only symptom.
External rotation of the leg during walking. Range of motion of the hip shows reduced internal rotation with additional external rotation.
When flexed up, the hip tends to move in an externally rotated position.
Mild-to-moderate shortening of the affected leg.
Atrophy of the thigh muscle may be noted.
Other causes of hip pain - for example:
Acute transient synovitis
Anteroposterior and 'frog-leg' lateral X-rays show widening of epiphyseal line or displacement of the femoral head.
Earliest findings include globular swelling of the joint capsule, irregular widening of the epiphyseal line and decalcification of the epiphyseal border of the metaphysis.
Epiphysis normally extends slightly cephalad to the upper border of the femoral neck.
Small amounts of slippage can be detected by the epiphyseal edge becoming flush with the superior border of the neck.
Sometimes, however, the only evidence of epiphyseal injury is slight widening of the growth plate.
Associated injuries are common with slipped capital femoral epiphysis; patients should be evaluated for possible pelvic fractures.
Avoid moving or rotating the leg. The patient should not be allowed to walk.
Provide analgesia and immediate orthopaedic referral if the diagnosis is suspected.
The patient should be scheduled for surgery immediately.
Surgical closure of the epiphysis, usually by inserting screws percutaneously.
Corrective osteotomy is usually reserved for treatment of severe deformities after the patient has stopped growing.
Chondrolysis (degeneration of the articular cartilage), avascular necrosis of the epiphysis, and long-term effects of altered femoral head anatomy.
Chondrolysis is seen in 5-8% of slips, and is associated with specific risk factors: African-American race, female gender, screw penetration of articular cartilage, body cast immobilisation, femoral neck osteotomy, and severe slips.
Avascular necrosis of the epiphysis occurs in 10-25% of cases, and is associated with attempts to reduce a displaced epiphysis before treatment and with osteotomy of the femoral neck.
The prognosis depends on the initial degree of epiphyseal slippage and prompt recognition by the general practitioner.
The end result is good to excellent in 94-96% of cases if fragments are displaced by less than one third of the diameter of the femoral neck.
With increasing displacement, complications increase and up to 45% of patients have a fair-to-poor surgical result.
The Bone & Joint JournalVol. 104-B, No. 4 Children’s OrthopaedicsOpen AccessOpen Access license
The British Orthopaedic Surgery Surveillance study: slipped capital femoral epiphysis
the epidemiology and two-year outcomes from a prospective cohort in Great Britain
Daniel C. PerryBarbara ArchDuncan AppelbePriya FrancisJoanna CravenFergal P. MonsellPaula WilliamsonMarian Knight,
on behalf of the BOSS collaborators
Published Online:1 Apr 2022https://doi.org/10.1302/0301-620X.104B4.BJJ-2021-1709.R1
We have demonstrated that open reduction carries a high risk of AVN in SCFE, independent of stability at baseline, with no evidence that this risk is mitigated by the experience of the surgeon. However, the benefit of surgery on the physical function of the child may be sufficient to outweigh the risks, the answer to which is not available from this study.
Prophylactic surgery did prevent the development of SCFE but also had several major complications, including one patient who developed AVN and a subtrochanteric fracture, which must be balanced against the risk of SCFE in this group.
A sensible approach appears to be one that considers individual risk; however, the only baseline predictor contributing to future risk was age, with younger children having greater risk, especially younger than 12.5 years old.
Other factors, such as sex, BMI, clinical stability, or radiological severity, did not contribute to the risk.
Among stable hips for which open reduction was performed, (11.8%) developed AVN, whereas AVN occurred in (1.8%) stable hips that did not undergo open reduction.
AVN occurred in 20/90 hips (23.0%) presenting with ‘unstable’ SCFE.
The ORs of AVN were 4.4 for unstable versus stable hips, and 7.5 for hips undergoing open reduction versus not
Surgeon-reported experience in the technique of open reduction did not appear to mitigate the risk of AVN
Further reading & references
Slipped Capital Femoral Epiphysis; Wheeless' Textbook of Orthopaedics
Open reduction of slipped capital femoral epiphysis; NICE Interventional Procedure Guidance, January 2015
Peck D; Slipped capital femoral epiphysis: diagnosis and management. Am Fam Physician. 2010 Aug 1;82(3):258-62.
Weigall P, Vladusic S, Torode I; Slipped upper femoral epiphysis in children--delays to diagnosis. Aust Fam Physician. 2010 Mar;39(3):151-3.
Uglow MG, Clarke NM; The management of slipped capital femoral epiphysis. J Bone Joint Surg Br. 2004 Jul;86(5):631-5.
Sattar JM Alshryda, Kai Tsang, Jalal Al-Shryda, John Blenkinsopp, Akinwanda Adedapo, Richard Montgomery, James Mason; Interventions for treating slipped upper femoral epiphysis (SUFE), Published Online: 28 FEB 2013 DOI: 10.1002/14651858.CD010397
Lehmann CL, Arons RR, Loder RT, et al; The epidemiology of slipped capital femoral epiphysis: an update. J Pediatr Orthop. 2006 May-Jun;26(3):286-90.
Kenny P, Higgins T, Sedhom M, et al; Slipped upper femoral epiphysis. A retrospective, clinical and radiological study of fixation with a single screw. J Pediatr Orthop B. 2003 Mar;12(2):97-9.
Tokmakova KP, Stanton RP, Mason DE; Factors influencing the development of osteonecrosis in patients treated for slipped capital femoral epiphysis. J Bone Joint Surg Am. 2003 May;85-A(5):798-801.
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