eMedicine Specialties > Sports Medicine > Lower Limb
Slipped Capital Femoral Epiphysis: Treatment & Medication
Updated: Aug 25, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Medical Issues/Complications
Treatment of slipped capital femoral epiphysis (SCFE) is emergent; therefore, early and accurate diagnosis is paramount. There is no role for observation or attempts at closed reduction.
Classification schemes are as follows:
- Determine whether the SCFE is acute (<3 weeks), chronic (3+ weeks), or acute on chronic (3+ weeks of symptoms with acute exacerbation or change).
- Determine whether the SCFE stable (able to bear weight) or unstable (non-weight bearing). This determination has become more important than acute versus chronic due to the fact that unstable patients have been found to have a high complication rate.
- Determine the radiographic classification. This is determined by the percentage of displacement of the hip in relation to the neck. Type I is less than 33% displacement, type II is 33-50% displacement, and type III is greater than 50% displacement.
Prophylactic treatment of the asymptomatic hip remains controversial. In Europe, the majority of patients receive prophylactic fixation of the contralateral hip. Each case should be approached individually, and the benefits and risks should be weighed when contemplating surgery on the unaffected hip.
In a review of the literature, prophylactic treatment may be considered in patients younger than 10 years or patients affected by various endocrinopathies because these individuals have higher relative risks for bilateral involvement. Prophylactic treatment should also be considered in a patient or family that is unreliable. In a typical patient who presents with unilateral SCFE, the parents should be warned of possible sequential bilateral involvement. The need for close follow-up and early operative intervention if the other hip becomes symptomatic must be understood by the family.
Delays in diagnosis or treatment can be very detrimental to the patient's outcome. The slip may progress, and increased severity of SCFE leads to early degenerative arthritis. With a diagnostic or treatment delay, stable slips may become unstable, which leads to higher rates of AVN.
Surgical Intervention
At this time, immediate internal fixation in-situ using a single cannulated screw is the treatment of choice of SCFE. Fixation allows early stabilization of the slippage, enhancement of physeal closure, prevention of further slippage, and amelioration of symptoms with minimal morbidity.21,22 Unstable or grade III slips may require gentle repositioning to improve alignment. Revision of the screw fixation may be needed if the child "outgrows" the screw, placing the child at risk for a repeat slip.
Prophylactic fixation of the unaffected hip in unilateral SCFE remains controversial.3,23 Each case should be approached individually. However, stronger consideration for the prophylactic fixation should be given to patients with endocrinologic or metabolic comorbidities, or patients who fall outside of the usual age range (10-16 y).
There is evidence that if surgical intervention occurs within 24 hours of SCFE onset, there is significantly less complications (7% AVN). However, if surgical intervention occurs between 24 and 48 hours, the AVN rate dramatically increases (87.5%). This risk decreases to 32% if the procedure is done after 48 hours. True cause and effect among onset, diagnosis, and intervention cannot be truly ascertained, thus, urgency with surgical intervention is still the unquestioned rule.
Osteotomy of the proximal femur is not indicated as the primary procedure for SCFE. However, it may be needed as a secondary procedure for repositioning of the femoral head to improve functional range of motion, or as a primary procedure for patients with severe morphologic displacement.
Bone-graft epiphysiodesis in combination with internal fixation or casting is advocated by some surgeons, but the procedure is associated with a high learning curve, a high prevalence of AVN and chondrolysis, poor initial fixation, prolonged operative time, increased intraoperative blood loss, and loss of epiphyseal position.24
Historically, spica casts were used25 ; however, because of the high morbidity (eg, AVN, chondrolysis) and difficulty in applying and maintaining these casts, especially in patients who are obese, spica casts have fallen out of favor.
Consultations
Orthopedic surgery consultation should be immediate in cases of SCFE.
Endocrinology consultation may be indicated for patients presenting earlier than age 10 years of or later than age 16 years. Also, if there are any concerns for endocrinopathy found on history or physical examination, consultation may be necessary to help evaluate for a potential disorder.
Medication
No medical therapy is available for the treatment of slipped capital femoral epiphysis (SCFE) except symptomatic pain relief. Medications may include acetaminophen, nonsteroidal anti-inflammatory drugs, or narcotics, depending on the physician's preference.
Related eMedicine topics:
Toxicity, Acetaminophen
Toxicity, Narcotics
Toxicity, Nonsteroidal Anti-inflammatory Agents
Related Medscape topics:
Resource Center Adverse Drug Events Reporting
Resource Center Opioids: A Guide to State Opioid Prescribing Policies
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
Analgesics/Antipyretics
Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who have sustained trauma or who have sustained injuries.
Acetaminophen (Tylenol, Feverall, Tempra)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Adult
650 mg PO q4h prn
Pediatric
10-15 mg/kg PO q4h prn
Rifampin can reduce the analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity.
Documented hypersensitivity; known G6PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity is possible in chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative doses that exceed the recommended maximum dose.
Hydrocodone and acetaminophen (Vicodin, Lorcet, Lortab)
Drug combination for moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/d
Coadministration with phenothiazines may decrease the analgesic effects; the toxicity increases with CNS depressants or TCAs
Documented hypersensitivity; HACE or elevated ICP
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
The tables contain metabisulfite, which may cause hypersensitivity; caution in patients who are dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction
Acetaminophen with codeine (Tylenol With Codeine [# 2, # 3, # 4])
Indicated for mild to moderate pain. Opioid and analgesic.
Acetaminophen and codeine content of Tylenol products is as follows:
Tylenol #2: 300 mg acetaminophen/15 mg codeine
Tylenol #3: 300 mg acetaminophen/30 mg codeine
Tylenol #4: 300 mg acetaminophen/60 mg codeine
Adult
1-2 tab Tylenol #2 or #3 PO q4h prn
1 tab Tylenol #4 PO q4h prn
Pediatric
Tylenol with codeine elix (120 mg acetaminophen and 12 mg codeine)/5 mL
<3 years: Not established
3-6 years: 5 mL PO 3-4 times/d prn
7-12 years: 10 mL PO 3-4 times/d prn
>12 years: Administer as in adults
Toxicity increases with CNS depressants or TCAs
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Head injury; increased ICP; acute abdomen; impaired renal, hepatic, thyroid, or adrenocortical function; prostatic hypertrophy or urethral stricture; asthma (tabs); drug abuse; elderly; debilitated; labor and delivery; nursing mothers
May cause dizziness, sedation, nausea, vomiting, constipation, urinary retention, rash, respiratory depression, hepatotoxicity (overdose)
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities, which make these ideal agents for treating ankle injuries. The mechanism of action of NSAIDs is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation and various cell membrane functions.
Ibuprofen (Motrin, Advil)
DOC for mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-600 mg PO q8h prn
Pediatric
10 mg/kg PO q6-8h prn
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy.
Ketoprofen (Orudis, Actron, Oruvail)
Indicated for mild to moderate pain and inflammation.
Small initial doses are indicated in small and elderly patients and in those with renal or liver disease.
Doses >75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe the patient for the response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Naprelan, Anaprox, Naprosyn)
Indicated for mild to moderate pain; inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug.
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 |
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References
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Further Reading
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
