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Slipped Capital Femoral Epiphysis: Differential Diagnoses & Workup

Author: Kevin D Walter, MD, FAAP, Assistant Professor, Department of Pediatric Orthopaedics and Department of Pediatrics, Medical College of Wisconsin; Member of Children's Specialty Group of Children's Hospital of Wisconsin; Program Director, Children's Hospital of Wisconsin Pediatric and Adolescent Primary Care Sports Medicine
Coauthor(s): David Y Lin, MD, Fellow, Department of Orthopedic Surgery, Section of Pediatrics, University of Tennessee Campbell Clinic; Evan Schwartz, MD, Director of Orthopedic Surgery, New York Medical College; Assistant Professor, St John's Queens Hospital, Department of Surgery, Albert Einstein School of Medicine
Contributor Information and Disclosures

Updated: Dec 17, 2009

Differential Diagnoses

Femoral Head Avascular Necrosis
Femoral Neck Fracture
Femoral Neck Stress Fracture
Femur Injuries and Fractures
Groin Injury
Osteitis Pubis

Other Problems to Be Considered

Chronic developmental hip dysplasia
Femoral hernia
Legg-Calvé-Perthes disease
Neoplastic processes
Septic joint
Synovitis

Also consider concomitant endocrinopathies.

Workup

Laboratory Studies

  • Routine hormonal screening of children with slipped capital femoral epiphysis (SCFE) is not indicated. 
  • Endocrinopathies and medical disorders (hypothyroidism, low growth hormone level, pituitary tumors, craniopharyngioma, Down syndrome, renal osteodystrophy, and adiposogenital syndrome) should be appropriately worked up in patients with an atypical presentation or other findings on history and physical examination that are consistent with endocrinologic disorders. Atypical presentation is considered for children who present with SCFE who are younger than age 10 years or older than 16 years, as well as children who present with SCFE and short stature. It is also worth considering endocrinology laboratory work for a patient that is not obese but who falls within the 10 to 16 year age range.

Imaging Studies

  • Obtain anteroposterior and frog-lateral radiographs of the pelvis or bilateral hips.
    • Determine the amount of head displacement off the femoral neck as a percentage to classify the degree of slippage.
      • Type I slippage is less than 33% displacement.
      • Type II slippage is between 33% and 50% displacement.
      • Type III slippage is greater than 50% displacement.
    • Note any bony changes of the femoral neck and head because they may demonstrate chronic adaptive changes during alterations in hip biomechanics as the femoral head displaces.
    • AP radiograph: The Klein line is drawn straight up the superior aspect of the femoral neck. This should intersect the epiphysis. If not, then it is likely an SCFE (see the image below).
      A Klein line is a line drawn along the superior b...

      A Klein line is a line drawn along the superior border of the femoral neck that would normally pass through a portion of the femoral head. If not, slipped capital femoral epiphysis is diagnosed.

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      A Klein line is a line drawn along the superior b...

      A Klein line is a line drawn along the superior border of the femoral neck that would normally pass through a portion of the femoral head. If not, slipped capital femoral epiphysis is diagnosed.

    • Frog leg radiograph: A straight line through the center of the femoral neck proximally should be at the center of the epiphysis. If not, and the line is anterior in the epiphysis, it is likely an SCFE.
    • Assess radiographs for signs of underlying medical disorders (rickets, renal osteodystrophy, etc).
  • Bone scanning, magnetic resonance imaging (MRI),22 and computed tomography (CT) scanning are not routinely performed, but these imaging modalities may be helpful to confirm the diagnosis of SCFE or more accurately measure the degree of displacement and epiphyseal perfusion.
    • A report by Tins et al suggests that pretreatment MRI in established cases of SCFE has a role with prognostic implications for the treatment approach and outcome of this condition.23 The investigators noted that synovitis, periphyseal edema, and joint effusion are regular features of SCFE; however, "the clinical history and findings are unreliable for the classification of SCFE," and "radiographs underestimate the severity of SCFE." On the other hand, Tins et al stated that "MRI can potentially identify unstable, reducible slips. If the mode of surgical treatment depends on the particular nature of the SCFE then MRI contributes to surgical decision-making."23

More on Slipped Capital Femoral Epiphysis

Overview: Slipped Capital Femoral Epiphysis
Differential Diagnoses & Workup: Slipped Capital Femoral Epiphysis
Treatment & Medication: Slipped Capital Femoral Epiphysis
Follow-up: Slipped Capital Femoral Epiphysis
Multimedia: Slipped Capital Femoral Epiphysis
References
Further Reading
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References

  1. Kehl DK. Slipped capital femoral epiphysis. In: Lovell WW, Winter RB, Morrissy RT, Weinstein SL, eds. Lovell & Winter's Pediatric Orthopaedics. 4th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 1996.

  2. Katz DA. Slipped capital femoral epiphysis: the importance of early diagnosis. Pediatr Ann. Feb 2006;35(2):102-11. [Medline].

  3. Loder RT. Controversies in slipped capital femoral epiphysis. Orthop Clin North Am. Apr 2006;37(2):211-21, vii. [Medline].

  4. Frick SL. Evaluation of the child who has hip pain. Orthop Clin North Am. Apr 2006;37(2):133-40, v. [Medline].

  5. Peterson MD, Weiner DS, Green NE, Terry CL. Acute slipped capital femoral epiphysis: the value and safety of urgent manipulative reduction. J Pediatr Orthop. Sep-Oct 1997;17(5):648-54. [Medline].

  6. Loder RT, Richards BS, Shapiro PS, Reznick LR, Aronson DD. Acute slipped capital femoral epiphysis: the importance of physeal stability. J Bone Joint Surg Am. Aug 1993;75(8):1134-40. [Medline]. [Full Text].

  7. Klein A, Joplin RJ, Reidy JA, Hanelin J. Roentgenographic features of slipped capital femoral epiphysis. Am J Roentgenol Radium Ther Nucl Med. Sep 1951;66(3):361-74. [Medline].

  8. Uglow MG, Clarke NM. The management of slipped capital femoral epiphysis. J Bone Joint Surg Br. Jul 2004;86(5):631-5. [Medline].

  9. Crawford AH. Slipped capital femoral epiphysis. J Bone Joint Surg Am. Oct 1988;70(9):1422-7. [Medline]. [Full Text].

  10. Stanitski CL. Acute slipped capital femoral epiphysis: treatment alternatives. J Am Acad Orthop Surg. Mar 1994;2(2):96-106. [Medline].

  11. Lehmann CL, Arons RR, Loder RT, Vitale MG. The epidemiology of slipped capital femoral epiphysis: an update. J Pediatr Orthop. May-Jun 2006;26(3):286-90. [Medline].

  12. Kelsey JL, Keggi KJ, Southwick WO. The incidence and distribution of slipped capital femoral epiphysis in Connecticut and Southwestern United States. J Bone Joint Surg Am. Sep 1970;52(6):1203-16. [Medline]. [Full Text].

  13. Azzopardi T, Sharma S, Bennet GC. Slipped capital femoral epiphysis in children aged less than 10 years. J Pediatr Orthop B. Jan 2010;19(1):13-8. [Medline].

  14. Riad J, Bajelidze G, Gabos PG. Bilateral slipped capital femoral epiphysis: predictive factors for contralateral slip. J Pediatr Orthop. Jun 2007;27(4):411-4. [Medline].

  15. Hagglund G, Hansson LI, Ordeberg G, Sandstrom S. Bilaterality in slipped upper femoral epiphysis. J Bone Joint Surg Br. Mar 1988;70(2):179-81. [Medline]. [Full Text].

  16. Benson EC, Miller M, Bosch P, Szalay EA. A new look at the incidence of slipped capital femoral epiphysis in new Mexico. J Pediatr Orthop. Jul-Aug 2008;28(5):529-33. [Medline].

  17. Zupanc O, Krizancic M, Daniel M, et al. Shear stress in epiphyseal growth plate is a risk factor for slipped capital femoral epiphysis. J Pediatr Orthop. Jun 2008;28(4):444-51. [Medline].

  18. Brenkel IJ, Dias JJ, Davies TG, Iqbal SJ, Gregg PJ. Hormone status in patients with slipped capital femoral epiphysis. J Bone Joint Surg Br. Jan 1989;71(1):33-8. [Medline]. [Full Text].

  19. Pritchett JW, Perdue KD. Mechanical factors in slipped capital femoral epiphysis. J Pediatr Orthop. Jul-Aug 1988;8(4):385-8. [Medline].

  20. Wells D, King JD, Roe TF, Kaufman FR. Review of slipped capital femoral epiphysis associated with endocrine disease. J Pediatr Orthop. Sep-Oct 1993;13(5):610-4. [Medline].

  21. Zubrow AB, Lane JM, Parks JS. Slipped capital femoral epiphysis occurring during treatment for hypothyroidism. J Bone Joint Surg Am. Mar 1978;60(2):256-8. [Medline]. [Full Text].

  22. Dwek JR. The hip: MR imaging of uniquely pediatric disorders. Magn Reson Imaging Clin N Am. Aug 2009;17(3):509-20, vi. [Medline].

  23. Tins B, Cassar-Pullicino V, McCall I. The role of pre-treatment MRI in established cases of slipped capital femoral epiphysis. Eur J Radiol. Apr 23 2008;epub ahead of print. [Medline].

  24. Aronson DD, Carlson WE. Slipped capital femoral epiphysis. A prospective study of fixation with a single screw. J Bone Joint Surg Am. Jul 1992;74(6):810-9. [Medline]. [Full Text].

  25. Ward WT, Stefko J, Wood KB, Stanitski CL. Fixation with a single screw for slipped capital femoral epiphysis. J Bone Joint Surg Am. Jul 1992;74(6):799-809. [Medline]. [Full Text].

  26. Kocher MS, Bishop JA, Hresko MT, et al. Prophylactic pinning of the contralateral hip after unilateral slipped capital femoral epiphysis. J Bone Joint Surg Am. Dec 2004;86-A(12):2658-65. [Medline]. [Full Text].

  27. Weiner DS, Weiner S, Melby A, Hoyt WA Jr. A 30-year experience with bone graft epiphysiodesis in the treatment of slipped capital femoral epiphysis. J Pediatr Orthop. Mar 1984;4(2):145-52. [Medline].

  28. Betz RR, Steel HH, Emper WD, Huss GK, Clancy M. Treatment of slipped capital femoral epiphysis. Spica-cast immobilization. J Bone Joint Surg Am. Apr 1990;72(4):587-600. [Medline]. [Full Text].

  29. Witbreuk MM, Bolkenbaas M, Mullender MG, Sierevelt IN, Besselaar PP. The results of downgrading moderate and severe slipped capital femoral epiphysis by an early Imhauser femur osteotomy. J Child Orthop. Sep 26 2009;epub ahead of print. [Medline]. [Full Text].

  30. Lawane M, Belouadah M, Lefort G. Severe slipped capital femoral epiphysis: The Dunn's operation. Orthop Traumatol Surg Res. Nov 18 2009;epub ahead of print. [Medline].

  31. Castaneda P, Macias C, Rocha A, Harfush A, Cassis N. Functional outcome of stable grade III slipped capital femoral epiphysis treated with in situ pinning. J Pediatr Orthop. Jul-Aug 2009;29(5):454-8. [Medline].

  32. Krahn TH, Canale ST, Beaty JH, Warner WC, LourenCo P. Long-term follow-up of patients with avascular necrosis after treatment of slipped capital femoral epiphysis. J Pediatr Orthop. Mar-Apr 1993;13(2):154-8. [Medline].

  33. Larson AN, Yu EM, Melton LJ 3rd, Peterson HA, Stans AA. Incidence of slipped capital femoral epiphysis: a population-based study. J Pediatr Orthop B. Jan 2010;19(1):9-12. [Medline].

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Further Reading

Related eMedicine Topics

Clinical Trials

Clinical Guidelines

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Keywords

slipped capital femoral epiphysis, hip pain, pain in hip, hip joint pain, SCFE, slipped epiphysis, femoral pain, hip disorder, slipped hip, adolescent hip disorder, femoral head displacement, Salter-Harris physeal fracture, Salter-Harris fracture, femoral head avascular necrosis

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Contributor Information and Disclosures

Author

Kevin D Walter, MD, FAAP, Assistant Professor, Department of Pediatric Orthopaedics and Department of Pediatrics, Medical College of Wisconsin; Member of Children's Specialty Group of Children's Hospital of Wisconsin; Program Director, Children's Hospital of Wisconsin Pediatric and Adolescent Primary Care Sports Medicine
Kevin D Walter, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics and American Medical Society for Sports Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

David Y Lin, MD, Fellow, Department of Orthopedic Surgery, Section of Pediatrics, University of Tennessee Campbell Clinic
David Y Lin, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

Evan Schwartz, MD, Director of Orthopedic Surgery, New York Medical College; Assistant Professor, St John's Queens Hospital, Department of Surgery, Albert Einstein School of Medicine
Evan Schwartz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.

Medical Editor

Anthony J Saglimbeni, MD, Staff Physician, Family Practice Residency, President, South Bay Sports and Preventive Medicine Associates; Private Practice; Team Internist, San Francisco Giants; Team Internist, West Valley College; Team Physician, Bellarmine College Prep; Team Physician, Presentation High School
Disclosure: Nothing to disclose.

Pharmacy Editor

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

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, and Phi Beta Kappa
Disclosure: Nothing to disclose.

 
 
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