History

Patients with slipped capital femoral epiphysis (SCFE) may present with the following symptoms:

Pain - The presenting feature is hip (groin) pain in most patients; as many as 46% of patients with chronic slips may present with thigh pain or knee pain (eg, referred pain, obturator nerve)
Limp
Inability to bear weight in acute slips
History of irradiation, renal failure, endocrinopathy (eg, 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, though some studies have reported the prevalence of bilaterality to be as high as 80%.^{[39, 40, 41]} Bilateral involvement may be evident at the time of initial presentation.^[20] Most patients who subsequently develop a contralateral slip do so within 18-24 months of initial symptoms, though slips may occur until physeal closure.^{[20, 25, 39, 42, 43, 44, 45]}

Management of the patient who presents with unilateral involvement is controversial. Significant morbidity can occur if the other side slips and displaces. Early recognition of a preslip on the contralateral side would help determine which patients are at greater risk. A scoring system has been developed to predict the risk of a contralateral slip.^[46]

Physical Examination

The following physical signs may be present:

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

Typically, knee examination and radiographic findings are normal in individuals with SCFE. All children with knee pain should have their hips evaluated.

Differential Diagnoses

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Media Gallery

Valgus slip (rare).
Frog-leg (Lauenstein) lateral view, showing a mild slip that can easily be missed on an anteroposterior view.
Klein line (line drawn along the superior border of the neck intersects less of the capital epiphysis than on the unaffected side).
Southwick head-shaft angle (angle between the metaphyseal surface of the physis and the shaft of the femur on a frog leg lateral view). Difference from the opposite side is used to grade the severity of the slip.
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 the extent of remodeling along the anterior neck (arrow).
Pin placement (anteroposterior view). A: The entry point must be at or above the level of the lesser trochanter to avoid the risk of subtrochanteric fracture. B: The pin (screw) should be in the center of the epiphysis. C: At least 2.5 threads engaging the epiphysis should be used for a secure hold.
Pin placement (lateral view). Arrow shows entry point in the anterolateral cortex.
Osteotomies in slipped capital femoral epiphysis (SCFE). A: Subcapital osteotomy. B: Base of the neck compensatory osteotomy. C: Intertrochanteric compensatory osteotomy. Note that the amount of correction increases from subcapital to intertrochanteric osteotomies.
Principle of the Dunn osteotomy. Reduction of the slip after shortening the neck to avoid stretch on the vessels and decrease the risk of avascular necrosis.

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Author

Mihir M Thacker, MBBS, MS(Orth), DNB(Orth), FCPS(Orth), D'Ortho Associate Professor of Orthopedic Surgery and Pediatrics, Jefferson Medical College of 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, Medical Council of India, Musculoskeletal Tumor Society, Pediatric Orthopaedic Society of North America, Limb Lengthening and Reconstruction Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

James J McCarthy, MD, FAAOS, FAAP Director, Division of Orthopedic Surgery, Cincinnati Children's Hospital; Professor, Department of Orthopedic Surgery, University of Cincinnati College of Medicine

James J McCarthy, MD, FAAOS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Orthopaedic Association, Pennsylvania Medical Society, Philadelphia County Medical Society, Pennsylvania Orthopaedic Society, Pediatric Orthopaedic Society of North America, Orthopaedics Overseas, Limb Lengthening and Reconstruction Society, Alpha Omega Alpha, American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Orthopediatrics, Phillips Healthcare, POSNA<br/>Serve(d) as a speaker or a member of a speakers bureau for: Synthes<br/>Received research grant from: University of Cincinnati<br/>Received royalty from Lippincott Williams and WIcins for editing textbook; Received none from POSNA for board membership; Received none from LLRS for board membership; Received consulting fee from Synthes for none.

Chief Editor

William L Jaffe, MD Clinical Professor of Orthopedic Surgery, New York University Grossman 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, New York Academy of Medicine

Disclosure: Received consulting fee from Stryker Orthopaedics for speaking and teaching.

Additional Contributors

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, Arthroscopy Association of North America, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, Missouri State Medical Association

Disclosure: Nothing to disclose.