Diagnostic Considerations

Slipped capital femoral epiphysis (SCFE) must be considered in the differential diagnosis for 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.

Conditions to be considered in the differential diagnosis include the following:

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

Workup

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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.