eMedicine Specialties > Orthopedic Surgery > Hip

Slipped Capital Femoral Epiphysis

Author: Mihir M Thacker, MBBS, MS(Orth), DNB(Orth), FCPS(Orth), D'Ortho, Assistant Professor of Orthopedic Surgery and Pediatrics, Thomas Jefferson University; Consulting Staff, Department of Pediatric Orthopedic Surgery, Alfred I duPont Hospital for Children; Orthopedic Oncologist, Helen F Graham Cancer Center and Christiana Care Health Services
Coauthor(s): Michael S Clarke, MD, Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine
Contributor Information and Disclosures

Updated: Jul 7, 2009

Introduction

Slipped capital femoral epiphysis (SCFE) was first described by Ernst Muller, who called it Schenkelhalsverbiegungen im Jungesalter, meaning "bending of the femoral neck in adolescence." The term slipped capital femoral epiphysis is a misnomer because the epiphysis is held in the acetabulum by the ligamentum teres; thus, the metaphysis actually moves proximally and anteriorly while the epiphysis remains in the acetabulum.

Valgus slip (rare).

Valgus slip (rare).

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Valgus slip (rare).

Valgus slip (rare).



Bilateral slipped capital femoral epiphysis. One ...

Bilateral slipped capital femoral epiphysis. One side shows evidence of remodeling of the neck and an anterior bone bump that restricts flexion. The other side demonstrates an acute slip as seen by the absence of any evidence of remodeling.

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Bilateral slipped capital femoral epiphysis. One ...

Bilateral slipped capital femoral epiphysis. One side shows evidence of remodeling of the neck and an anterior bone bump that restricts flexion. The other side demonstrates an acute slip as seen by the absence of any evidence of remodeling.



Chronic slipped capital femoral epiphysis showing...

Chronic slipped capital femoral epiphysis showing the extent of remodeling along the anterior neck (arrow).

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Chronic slipped capital femoral epiphysis showing...

Chronic slipped capital femoral epiphysis showing the extent of remodeling along the anterior neck (arrow).


In most patients, SCFE appears radiographically as a varus relationship between the head and the neck. Occasionally, the slip appears to be in a valgus position, with the epiphysis displaced superiorly in relation to the neck.1,2,3,4,5 In the vast majority of cases, the etiology is unknown, although atypical slips may be associated with a known endocrine disorder, with renal failure osteodystrophy, or with previous radiation therapy.6,7,8,9,10

Recent studies
Castaneda et al studied 105 patients with a slip greater than 60 º who were treated with in situ pinning with a single cannulated screw to determine functional outcome. There were excellent results in 52 patients, good results in 28, fair results in 16, and bad results in 9 (resulting from inadequate pin placement). Better results were found to have occurred in patients younger than 12 years.11

Green et al in a study of the diagnosis of SCFE using the Klein line AP radiograph or the frog-leg lateral radiograph found that the classic Klein line failed to identify 60% of slips. A modification of the Klein line by the authors increased sensitivity to 79%.12

Parsch et al treated 64 consecutive cases of unstable SCFE (20 mild slips; 24 moderate; and 20 severe) with capsulotomy, evacuation of intra-articular effusion or hematoma, gentle reduction, and fixation with unthreaded Kirschner wires (K-wires). Reduction was successful in 61 cases, without development of avascular necrosis (AVN). Three patients did develop AVN (2 with moderate slips; 1 with a severe slip).13  

History of the Procedure

See Surgical therapy.

Problem

Slipped capital femoral epiphysis (SCFE) is not life threatening. However, untreated and complicated slipped capital femoral epiphysis can lead to deformity and early osteoarthrosis of the hip and, thus, can cause considerable morbidity. Factors that increase morbidity include avascular necrosis (AVN) of the hip and chondrolysis. Both of these may result in damage severe enough to warrant a salvage procedure, in the form of an arthrodesis or a total hip arthroplasty. Prompt diagnosis is critical to prevent further deformity and AVN. The diagnosis is often subtle, and symptoms, such as groin or knee pain, can be misleading.

Frequency

Prevalence of slipped capital femoral epiphysis (SCFE) varies widely even within the continental United States. Prevalence has been reported to be 2.13 cases per 100,000 population in the southwestern United States and 10.08 cases per 100,000 population in the northeastern United States.14   Prevalence is lowest in the mountain and Great Plains states. Prevalence is reported to be quite low in Asia, with just 0.2 cases per 100,000 children affected in eastern Japan.15

A race predilection exists for slipped capital femoral epiphysis. The relative racial frequency of SCFE is as follows16 :

  • Whites - 1.0
  • Pacific islanders - 4.5
  • Blacks - 2.2
  • American Indians and Hispanic individuals - 1.05
  • Indonesian-Malay peoples (eg, Chinese, Japanese, Thai, Vietnamese) - 0.5
  • Indo-Mediterranean peoples (those of Near East, North African, or Indian subcontinent ancestry) - 0.1

Males are affected more commonly than females. The male-to-female ratio is 2-5:1.

The mean age at diagnosis is 13.5 years in boys (age range 13-15 y) and 12 years in girls (age range 11-13 y).16 This corresponds to the period of maximum skeletal growth. Juvenile SCFE (in children <10 y) should raise the suspicion of an underlying cause, such as an endocrinopathy. Radiation-associated slips tend to occur in young children.

Etiology

Causative factors of slipped capital femoral epiphysis (SCFE) include the following:

  • Habitus
    • Obesity - At least 50% of patients are above the 95th percentile for weight17
    • Excessive tallness, thinness
  • Endocrinopathy - If height is <10th percentile, likelihood of an underlying endocrinopathy is high18,19
  • Radiation therapy, especially for childhood leukemias or lymphomas
    • Tend to occur in young children
    • Affected children are also light, so tend to have mild slips
  • Renal failure
    • High incidence of simultaneous bilateral presentations (approximately 87%)
    • Highest incidence of severe slips in these patients
    • Two distinct subgroups of patients, as follows:
      • Those whose disease is controlled early (less hyperparathyroidism) tend to have mild slips
      • Those with poorly controlled disease (significant hyperparathyroidism) tend to have severe slips


 


Pathophysiology

Slipped capital femoral epiphysis (SCFE) is caused by increased stresses across a weakened physis, with a combination of both biomechanical and biochemical factors contributing to the development of the slip. Factors affecting stability of the physis include the following:

  • Perichondrium - Thick in children, but progressively thins with age.
  • Perichondrial ring - Fibrous ring that spans the physeal plate and extends from the metaphysis to the epiphysis; this also thins with age.
  • Transphyseal collagen - Weakens because of progressive mineralization; cross-linkage of collagen affected in osteolathyrism, leading to slippage in these patients.
  • Mammillary projections - Assume increasing importance as the perichondrial ring thins.
  • Contour of the growth plate - Normally convex toward the physis with undulations at the periphery, which contribute to its resistance to linear shear and torque forces.
  • Growth plate thickness - Mainly affected by biochemical and endocrine factors.
  • Mechanical factors - Increased stress across the physis.20  Also includes the following:
    • Relative femoral retroversion, which also increases the stress across the physis.21,22,23,24
    • Obesity - Increases the forces across the physis; associated with femoral retroversion, which also increases the stress across the physis.14,16 (The average femoral version of patients who are not obese was found to be 10.6°, compared with 0.40° in patients who are obese.21 )
    • Increased physeal slope - Increase in inclination of the physis at the time of rapid skeletal growth around puberty.25 (Patients with SCFE have been shown to have a higher physeal inclination even on the opposite side.)
    • Deeper acetabula - Higher mean center-edge angle of Wiberg in children with SCFE compared with control subjects; lead to increased coverage of the femoral heads and increased stress across the physis.26
  • Biochemical factors - SCFE most common in the peripubertal age group; possible contribution of hormones on the physes to the likelihood of developing a slip.27
    • Growth hormone - Causes widening of the physes and consequent weakening.
    • Sex hormones - Increased physeal width and decreased physeal strength from testosterone,  probably accounting for increased frequency in boys; narrowing of the physis and increased physis strength from estrogen, possibly explaining why slips seldom occur in postpubertal females.28,29
    • Thyroid hormone - Effect not very clear, although slips can occur in patients with hypothyroidism and those receiving thyroid hormone replacements for hypothyroidism.

Even though most children with SCFE do not have an overt endocrinopathy, they may very well have some subtle endocrine disorder.30,31,32,33,34 A delay in bone age with respect to chronologic age in some of these children lends further credence to this theory.28,29

Valgus slip (rare).

Valgus slip (rare).

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Valgus slip (rare).

Valgus slip (rare).


Shear stresses across a physis made vulnerable by the biomechanical and biochemical factors outlined above leads to the slip. The displacement is determined by the direction of the deforming force. Posteroinferior displacement of the head (anterosuperior migration of the neck) is the most common pattern, although rarely, the head may displace posterosuperiorly, giving rise to an apparent valgus slip (see Image 1).1,2

Presentation

Slipped capital femoral epiphysis (SCFE) must be considered in the differential diagnosis in children presenting with knee pain. Typically, knee examination and radiographic findings are normal in individuals with SCFE. All children with knee pain should have their hips evaluated.

Patients may present with the following symptoms:

  • Pain - The presenting feature is hip (groin) pain in most patients. Up to 46% of patients with chronic slips may present with thigh pain or knee pain (referred pain, obturator nerve).
  • Limp
  • Inability to bear weight in acute slips
  • History of irradiation, renal failure, endocrinopathy (hypothyroidism and treatment thereof, acromegaly, short stature [growth hormone supplementation])

Either side may be affected. The left hip is involved in 60% of unilateral cases. In most studies, 18-50% of cases are bilateral, although other studies have reported a prevalence of bilaterality of as high as 80%.35,36,37 Bilateral involvement may be evident at the time of initial presentation.16 Most patients who subsequently develop a contralateral slip do so within 18-24 months of initial symptoms, although slips may occur until physeal closure.16,29,35,38,39,40,41

The following physical signs may be present:

  • Externally rotated attitude of the affected lower limb
  • Restriction of flexion, abduction, and internal rotation of the affected hip in varus slips, and restriction of flexion, adduction, and internal rotation in valgus slips
  • Obligatory external rotation on flexion (this is a diagnostic clue)
  • Wasting of the thigh in chronic slips
  • True supratrochanteric shortening (Bryant triangle, Nélaton line)
  • Trendelenburg sign and gait possible; antalgic gait in acute or acute-on-chronic slips

Differential diagnosis

  • Knee injury
  • "Groin pull"
  • Trauma - Hemarthrosis or fracture may manifest similarly to an acute slip
  • Infections - Septic arthritis and acute osteomyelitis must be excluded in acute cases
  • Legg-Calvé-Perthes disease - This disease usually affects children aged 4-9 years
  • Juvenile rheumatoid arthritis - This condition may manifest with hip involvement and minimal systemic manifestations
  • Transient synovitis
  • Benign or malignant tumors

Indications

See Surgical therapy for indications for various procedures.

Relevant Anatomy

See Surgical therapy.

Contraindications

The treatment of slipped capital femoral epiphysis (SCFE) is stabilization. Although surgery should be performed promptly, it is elective; therefore, severe medical conditions that would significantly increase surgical risk should be addressed.

More on Slipped Capital Femoral Epiphysis

Overview: Slipped Capital Femoral Epiphysis
Workup: Slipped Capital Femoral Epiphysis
Treatment: Slipped Capital Femoral Epiphysis
Follow-up: Slipped Capital Femoral Epiphysis
Multimedia: Slipped Capital Femoral Epiphysis
References
Further Reading
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References

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Keywords

slipped capital femoral epiphysis, SCFE, adolescent coxa vara, slipped upper femoral epiphysis, knee pain, hip pain, knee injury, hip injury, obesity, hypothyroidism, osteotomy, total hip arthroplasty

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Contributor Information and Disclosures

Author

Mihir M Thacker, MBBS, MS(Orth), DNB(Orth), FCPS(Orth), D'Ortho, Assistant Professor of Orthopedic Surgery and Pediatrics, Thomas Jefferson University; Consulting Staff, Department of Pediatric Orthopedic Surgery, Alfred I duPont Hospital for Children; Orthopedic Oncologist, Helen F Graham Cancer Center and Christiana Care Health Services
Mihir M Thacker, MBBS, MS(Orth), DNB(Orth), FCPS(Orth), D'Ortho is a member of the following medical societies: Children's Oncology Group, Limb Lengthening and Reconstruction Society ASAMI-North America, Medical Council of India, and Musculoskeletal Tumor Society
Disclosure: Nothing to disclose.

Coauthor(s)

Michael S Clarke, MD, Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine
Michael S Clarke, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Arthroscopy Association of North America, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, and Missouri State Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Steven I Rabin, MD, Clinical Associate Professor, Loyola University Medical Center; Chair, Department of Orthopedic Surgery, Dreyer Medical Clinic
Steven I Rabin, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Fracture Association, AO Foundation, and Orthopaedic Trauma Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

James J McCarthy, MD, FAAOS, FAAP, Associate Professor, Consulting Orthopedic Surgeon, Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health;
James J McCarthy, MD, FAAOS, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Orthopaedic Association, Limb Lengthening and Reconstruction Society ASAMI-North America, Orthopaedics Overseas, Pediatric Orthopaedic Society of North America, Pennsylvania Medical Society, Pennsylvania Orthopaedic Society, and Philadelphia County Medical Society
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

William L Jaffe, MD, Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Vice Chairman, Department of Orthopedic Surgery, New York University Hospital for Joint Diseases
William L Jaffe, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, Eastern Orthopaedic Association, and New York Academy of Medicine
Disclosure: Stryker Orthopaedics Consulting fee Speaking and teaching

 
 
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