Slipped Capital Femoral Epiphysis (SCFE) is the most common hip disorder affecting adolescents. It is a disorder of the immature hip in which anatomic disruption occurs through the proximal femoral physis.
It is characterized by a posterior displacement of the epiphysis through the hypertrophic zone with the metaphysis taking on an anterior and superior position.
The injury is a Salter-Harris type 1 physeal fracture and happens when a shearing force in excess of the strength of the growth is applied to the femoral head. The SCFE deformity exposes the anterior metaphysis and edge of neck to the anterolateral rim and labrum and therefor causing impingement.
As a result, there is damage to the anterior acetabular cartilage, the labrum and the rim. This damage usually occurs very early.
The extent of articular damage is variable and is influenced by the duration of the slip, the severity of the deformity as well as the activity level of the patient.
SCFE is associated with a highly variable degree of posterior translation of the epiphysis and simultaneous anterior displacement of the metaphysis. In SCFE, there is a spectrum of each of the following elements: temporal acuity, physical stability of the slipping physis, degree of displacement between the proximal femoral neck and the epiphysis and the amount of deformity that the protruding anterior metaphyseal prominence presents to the anterior acetabular rim with hip flexion.
Fortunately, SCFE can be treated and the complications averted or minimized if diagnosed early. In most of the cases surgery is necessary to stabilize the hip and prevent the situation from getting worse.
Clinically Relevant Anatomy
The hip joint, a ball and socket synovial joint at the juncture of the leg (femur) and pelvis (os coxa), is one of the most flexible joints in the human body.In addition to being flexible, the hip joint must be able to support half of the body’s weight along with any other forces acting upon the body.
The hip joint must be able to accommodate these extreme forces repeatedly during intense physical activities. In the femur of a growing child, the femoral growth plates are placed between the epiphysis and metaphysis.
As we grow, the growth plate builds bone on top of the end of the metaphysis, which assures bone lengthening.
The strength of the cartilage epiphyseal plate itself is inferior to those of its surrounding bone parts.
Subsequently, increased force on the hip at a time when the femoral head is not fully ready to support these forces makes the femoral head fail at the weakest point - through the epiphyseal plate.
Furthermore, the capital femoral epiphysis is one of the only epiphyses in the body that is inside its joint capsule.
The blood vessels that supplies the epiphysis run along the side of the femoral neck and are in real danger of being torn or pinched off if something happens to the growth plate. When this happens, it can result in a loss of the blood supply to the epiphysis which leads to an avascular necrosis and chondolysis.
Epidemiology / Etiology
The prevalence of SCFE is 10.8 cases per 100 000 children.[8][9]SCFE presents bilaterally in 18 to 50 percent of patients.The prevalence is more common in boys than girls and varies widely among ethnic groups (higher prevalence rate in blacks, Hispanics, Polynesians, and Native Americans ), geographic locations (higher rates in the north and western parts of the United States), and different seasons (late summer and fall).
Eventhough the pathogenesis is most likely multi-factorial, mechanical factors
There are several factors that can contribute to developing a SCFE:
- Obesity
- Femoral retroversion (>10°)
- Increased physis height
- More vertical slope of the physis
- Renal failure osteodystrophy
- Previous radiation therapy
- Endocrine disorders such as
- Hypothyroidism
- Growth hormone deficiency
- Growth hormone excess
- Panhypopituitarism
- Craniopharyngioma
- Hypogonadism
- Hyperparathyroidism
- Multiple endocrine neoplasia
- Turner's syndrome
- Elevation of Leptin levels
Characteristics / Clinical Presentation
Typical presentation is a child between the ages of 10 - 20 years. There are some differences found between the literature about the exact age. This has to do with the maturity of the growth plate (epiphysial line).There is an increased prevalence during the period of rapid growth, shortly after puberty. The disorder is more prevalent in male than females (2:1 ratio).
The child usually presents with some combination of hip, knee, thigh, and groin pain. The leg is typically externally rotated and an antalgic gait is noted. The majority of patients will be able to bear weight and will present with a limp. When testing hip range of motion, internal rotation, flexion, and abduction are limited.
External rotation and adduction are often increased and movement in all directions are painful. Typically, the involved hip will fall into external rotation when the hip is passively flexed beyond 90 degrees.
Differential Diagnosi
- Femoral fractures
- Avascular necrosis of the femoral head
- Legg-Calve-Perthes Disease
- Osteomyelitis
- Septic Arthritis
- Groin Strain
- Apophyseal avulsion fracture of the anterosuperior and anteroinferior iliac spine
- Apophysitis of the anterosuperior and anteroinferior iliac spine
- Transient synovitis
Diagnostic Procedures
ImagingPlain radiograph (AP and true lateral view)
X-ray image of SCFE before and after surgical fixation
Frog lateral review is often requested,but care must be taken as this may displace an unstable slip further. It is also less accurate in assessment of severity because of the variations in positioning of the limbs[10]
Radiological signs that are used to confirm the diagnosis and assess the severity of the slip include:
Widening of the growth plate (this is an early sign).
Trethowan's sign (Klein's line) - On an AP view, a line drawn on the superior border of the femoral neck will intersect less of the femoral head or not at all in a patient with SFCE. This is as a result of the posterior displacement of the femoral epiphysis.
There is a decrease in epiphyseal height , as the femoral head is slipped posteriorly behind the neck.
Resultant remodelling changes are present in the femur neck such as a sclerotic, smooth superior part of the neck and callus formation on the inferior border. (This is not always present in an acute slip).
There is an increased distance between the tear drop and the femoral neck metaphysis.
Capener's sign - In a patient with SFCE, the whole metaphysis is lateral to the posterior acetabular margin on an AP view of the pelvis. Normally the posterior acetabular margin will cut across the medial corner of the upper femoral metaphysis[10]
Steel's blanch sign - a crescent shape dense area in the metaphysis as a result of superimposition of the neck and the head.
CT scan
provides a 3D image helpful in pre-surgical planningVery useful in severe slips in need of corrective surgery
Callus presence can easily be identified by CT scan and this may indicate a chronic slip rather than an acute slip.
Helpful to investigate the positioning of wires and screws to prevent joint penetration.
Ultrasound
May support the diagnosis of an unstable slipLimited value in clinical practice
MRI
Valuable in diagnosing SFCE in the pre-slip stageOnly way to detect early signs of avascular necrosis
Blood tests
Blood tests are necessary to identify or rule out any underlying endocrine problems when the age-weight test is positive. It is also essential as part of the preoperative work up.Classification of SCFE
Classification of the patient and hip affected with SCFE is essential to advance treatment, and the selection thereof, as well as to improve the outcome. Key factors to consider at initial diagnosis are:Physeal stability
Previous clinical classifications has often placed untreated SCFE hips into categories such as Acute, Acute-on-Chronic and Chronic. These classifications have limited correlation with the pathomechanics seen in SCFE.The degree of physeal stability in SFCE can range from a complete disruption of the physis to total stability in the healed slip.
Degree of Deformity
The degrees of deformity are:
- Pre-slip (widening of the physis, no displacement)
- Mild slip (up to 1/3 displacement, or 30° of femoral head tilt)
- Moderate slip (1/3 to 1/2 displacement or 30° to 60° slip angle)
- Severe slip (> 1/2 displacement or > 60° of slip angle)
Medical Management
Once the diagnosis of SCFE is made, the patient should be placed on non–weight-bearing crutches or in a wheelchair and quickly referred to an orthopedic surgeon familiar with the treatment of SCFE. The initial goals of treatment are to prevent slip progression and avoid complications.Prophylactic treatment of the contralateral hip in patients with SCFE is controversial, but it is not recommended in most patients.
Stable SCFE
The standard treatment of stable SCFE is in situ fixation with a single screw. Case series and animal model studies have shown this to be a simple technique with low rates of recurrence and complications.Unstable SCFE
Unstable SCFE is a much more severe injury than stable SCFE. The rate of osteonecrosis is as high as 20 to 50 percent in patients with the unstable form. Treatment goals are similar to those of stable SCFE with in situ fixation, but there is controversy as to the specifics of treatment, including timing of surgery, value of reduction, and whether traction should be used.Physical Therapy Management
Once the patient is diagnosed with SCFE, the patient should seize to bear weight on this leg. The first goal of treatment is to prevent the further slipping and avoid complications.Conservative treatment can include Spica Casting, easy range of motion exercises and hydrotherapeutic exercises. This method consists of a period of immobilization that is much longer than when undergoing surgical treatment.
When pinning-in-situ surgery is performed the first goal is to is decrease the pain. Modalities such as ice, ultrasound and electrical current may be used. Continuous passive motion of the hip to maintain range of motion is recommended after surgery.
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