Slipped Capital Femoral Epiphysis

SCFE

Slipped Capital Femoral Epiphysis

SCFE
George SM Dyer, Harvard Medical School Year-III
Gillian Lieberman, MD
George SM Dyer, Harvard Medical School Year-III
Gillian Lieberman, MD
George Dyer
Gillian Lieberman, MD
J anuary 2001
2
2
What is it?
What is it?

In a person with an open
femoral physis, mild
trauma shifts the femoral
head in relation to the
femoral neck

Femoral head

slips
posteriorly

and medially

In a person with an open
femoral physis, mild
trauma shifts the femoral
head in relation to the
femoral neck

Femoral head

slips
posteriorly

and medially
http://www.packardchildrenshospital.org/health/orthopaedics/scfe.htm
George Dyer
Gillian Lieberman, MD
3
3
Simplified Concept of SCFE
Simplified Concept of SCFE
George Dyer
Gillian Lieberman, MD
4
4
Simplified Concept of SCFE
Simplified Concept of SCFE
Open physis
Open Open physis physis
Slipped physis
Slipped Slipped physis physis
George Dyer
Gillian Lieberman, MD
5
5
Epidemiology
Epidemiology

Incidence 30/100,000

Age: 10 -

15 yrs

Boys > girls

Blacks > whites

More common in
overweight children

Incidence 30/100,000

Age: 10 -

15 yrs

Boys > girls

Blacks > whites

More common in
overweight children
George Dyer
Gillian Lieberman, MD
6
6
History and Differential Diagnosis
History and Differential Diagnosis

Ernst Mueller, 1889

Described it pathologically using
dissected specimens

There occurs in young
individuals aged 14-18, without
trauma to the hip, a limp, a
weariness, and gradual
shortening of the affected limb

Ernst Mueller, 1889

Described it pathologically using
dissected specimens

There occurs in young
individuals aged 14-18, without
trauma to the hip, a limp, a
weariness, and gradual
shortening of the affected limb

Distinguished by Mueller from
other hip disorders of the young

Congenital Hip Dysplasia

Legg-Calve-Perthes

disease

Can be related to renal
osteodystrophy, especially if
bilateral

Distinguished by Mueller from
other hip disorders of the young

Congenital Hip Dysplasia

Legg-Calve-Perthes

disease

Can be related to renal
osteodystrophy, especially if
bilateral
George Dyer
Gillian Lieberman, MD
7
7
Radiologic Studies
Radiologic Studies

Plain Film Projections

Posterior-Anterior

Frog-leg Lateral

CT

May resolve finer anatomy
(Guzzanti

V, Falciglia

F, 1991)

MR

Most sensitive for small changes
in soft tissues
(Umans

H, et al. 1998)

But diagnosis is still most often
made on plain film

Essential

to recognize

Plain Film Projections

Posterior-Anterior

Frog-leg Lateral

CT

May resolve finer anatomy
(Guzzanti

V, Falciglia

F, 1991)

MR

Most sensitive for small changes
in soft tissues
(Umans

H, et al. 1998)

But diagnosis is still most often
made on plain film

Essential

to recognize
George Dyer
Gillian Lieberman, MD
8
8
Radiographic Findings
Radiographic Findings

Its easy when the
findings are clear

Its easy when the
findings are clear
http://www.aafp.org/afp/980501ap/loder.html
George Dyer
Gillian Lieberman, MD
9
9
Radiographic Findings in SCFE
Radiographic Findings in SCFE

Kleins Criteria (1951)

Earliest: Widened and irregular growth plate, compared to contralateral

hip
Increased lucency

medially

Angulated contour of femoral head, then becomes rounded with adaptation

Periosteal

proliferation at inferior, posterior margins and further slippage
create crows beak

Klein's Line

Line drawn along superior border of femoral neck should cross at

least a
portion of the femoral epiphysis (Klein, 1951)

Most sensitive indicator of a mild slip on plain film
Classification
Grade I: displacement of epiphysis less than 30% of width of femoral neck
Grade II: slip between 30%-60%
Grade III: includes slips of greater than 60% the width of neck

Kleins Criteria (1951)

Earliest: Widened and irregular growth plate, compared to contralateral

hip
Increased lucency

medially

Angulated contour of femoral head, then becomes rounded with adaptation

Periosteal

proliferation at inferior, posterior margins and further slippage
create crows beak

Klein's Line

Line drawn along superior border of femoral neck should cross at

least a
portion of the femoral epiphysis (Klein, 1951)

Most sensitive indicator of a mild slip on plain film
Classification
Grade I: displacement of epiphysis less than 30% of width of femoral neck
Grade II: slip between 30%-60%
Grade III: includes slips of greater than 60% the width of neck
George Dyer
Gillian Lieberman, MD
10
10
Kleins Line
Kleins Line
Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston
Kleins line
demonstrates
slipped femoral
head on right,
normal on left

Kleins line
demonstrates
slipped femoral
head on right,
normal on left
George Dyer
Gillian Lieberman, MD
11
11
Importance of the Frog Leg:

Patient DG: Is There a Slip?

Importance of the Frog Leg:

Patient DG: Is There a Slip?
Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston
George Dyer
Gillian Lieberman, MD
12
12
Patient DG: Frog Leg
Patient DG: Frog Leg
Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston
Kleins line
demonstrates
slipped femoral
head bilaterally

Kleins line
demonstrates
slipped femoral
head bilaterally
George Dyer
Gillian Lieberman, MD
13
13
Comparison Patients
Comparison Patients

Now its time to practice finding SCFE in other patients

For each, identify whether there is a slip on the right side, the
left side, or both sides

Now its time to practice finding SCFE in other patients

For each, identify whether there is a slip on the right side, the
left side, or both sides
George Dyer
Gillian Lieberman, MD
14
14
Patient JB: 15 year old boy
Is the Slip on the Right, the Left,
Or Bilateral?

Patient JB: 15 year old boy
Is the Slip on the Right, the Left,
Or Bilateral?
Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston
George Dyer
Gillian Lieberman, MD
15
15
Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston
Kleins line
demonstrates
slipped femoral
head bilaterally

Kleins line
demonstrates
slipped femoral
head bilaterally
Patient JB: Frog leg view

Is the Slip on the Right, the Left,
Or Bilateral?

Patient JB: Frog leg view

Is the Slip on the Right, the Left,
Or Bilateral?
George Dyer
Gillian Lieberman, MD
16
16
Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston
Kleins line
demonstrates
slipped femoral
head on right

Kleins line
demonstrates
slipped femoral
head on right
Patient MC

Is the Slip on the Right, the Left,
Or Bilateral?

Patient MC

Is the Slip on the Right, the Left,
Or Bilateral?
George Dyer
Gillian Lieberman, MD
17
17
Patient KG: 11 year old girl

Is There a Slip?

Sometimes Kleins Line is Equivocal

Patient KG: 11 year old girl

Is There a Slip?

Sometimes Kleins Line is Equivocal
Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston
George Dyer
Gillian Lieberman, MD
18
18
Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston
Patient KG: Frog leg view

Is the Slip on the Right, the Left,
Or Bilateral?

Patient KG: Frog leg view

Is the Slip on the Right, the Left,
Or Bilateral?
George Dyer
Gillian Lieberman, MD
19
19
When Kleins Line Fails,
Try Capeners

Sign

When Kleins Line Fails,
Try Capeners

Sign

On PA, ischium

and
femoral head overlap to
yield crescent of double
density

SCFE reduces overlap area

Sometimes more sensitive
than Kleins line alone

On PA, ischium

and
femoral head overlap to
yield crescent of double
density

SCFE reduces overlap area

Sometimes more sensitive
than Kleins line alone
Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston
George Dyer
Gillian Lieberman, MD
20
20
Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston
Capeners

sign
suggests slipped
left

and normal
right

Capeners

sign
suggests slipped
left

and normal
right
Patient KG: Capeners

Sign

Is the Slip on the Right, the Left,
Or Bilateral?

Patient KG: Capeners

Sign

Is the Slip on the Right, the Left,
Or Bilateral?
George Dyer
Gillian Lieberman, MD
21
21
Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston
Capeners

sign
suggests slipped
right

and normal
left

Capeners

sign
suggests slipped
right

and normal
left
Patient MG: Is the Slip on the Right, the Left,
Or Bilateral?

Patient MG: Is the Slip on the Right, the Left,
Or Bilateral?
George Dyer
Gillian Lieberman, MD
22
22
Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston
Kleins line
demonstrates
slipped left

and
normal right

Kleins line
demonstrates
slipped left

and
normal right
Patient MO: Is the Slip on the Right, the Left,
Or Bilateral?

Patient MO: Is the Slip on the Right, the Left,
Or Bilateral?
George Dyer
Gillian Lieberman, MD
23
23
Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston
Kleins line
demonstrates
slipped left

and
normal right

Kleins line
demonstrates
slipped left

and
normal right
Patient MT: Is the Slip on the Right, the Left,
Or Bilateral?

Patient MT: Is the Slip on the Right, the Left,
Or Bilateral?
George Dyer
Gillian Lieberman, MD
24
24
Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston
Kleins line
demonstrates
slipped left

and
normal right

Kleins line Kleins line
demonstrates demonstrates
slipped left slipped left

and and
normal right normal right
Patient RW: Is the Slip on the Right, the Left,
Or Bilateral?

Patient RW: Is the Slip on the Right, the Left,
Or Bilateral?
George Dyer
Gillian Lieberman, MD
25
25
Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston
Kleins line
demonstrates
slipped right

and
normal left

Kleins line
demonstrates
slipped right

and
normal left
Patient SP: Is the Slip on the Right, the Left,
Or Bilateral?

Patient SP: Is the Slip on the Right, the Left,
Or Bilateral?
George Dyer
Gillian Lieberman, MD
26
26
Complications
Complications
Deformity
as bones grow
Deformity
as bones grow
Acute cartilage necrosis
(chondrolysis)
Acute cartilage necrosis
(chondrolysis)
Avascular

Necrosis
(AVN)
Avascular

Necrosis
(AVN)
Time

If undetected, SCFE has disabling sequelae

If undetected, SCFE has disabling sequelae
George Dyer
Gillian Lieberman, MD
27
27
Tenuous Blood Supply of Femoral Head
Tenuous Blood Supply of Femoral Head

Arterial supply to the head of the femur is from the medial
and lateral circumflex arteries, distally, and from the foveal

artery in the ligamentum

teres, proximally

All three are threatened by SCFE

Shift of the femoral head in relation to the femoral neck can shear
the circumflex arteries

The displacement of the femoral head within the acetabulum

often
shears or damages the ligamentum

teres

The result is avascular

necrosis of the femoral head

Arterial supply to the head of the femur is from the medial
and lateral circumflex arteries, distally, and from the foveal

artery in the ligamentum

teres, proximally

All three are threatened by SCFE

Shift of the femoral head in relation to the femoral neck can shear
the circumflex arteries

The displacement of the femoral head within the acetabulum

often
shears or damages the ligamentum

teres

The result is avascular

necrosis of the femoral head
George Dyer
Gillian Lieberman, MD
28
28
Progression of AVN
in a Sickle-Cell Patient

Progression of AVN
in a Sickle-Cell Patient
http://gait.aidi.udel.edu/res695/homepage/pd_ortho/educate/clincase/clcsimge/sickle1.jpg
Age Age
Age Age
Age Age
Progressive Progressive

This patient does not have SCFE, but the
pathologic changes of AVN would look
similar to those pictured here

This patient does not have SCFE, but the
pathologic changes of AVN would look
similar to those pictured here
George Dyer
Gillian Lieberman, MD
29
29
Treatment by Femoral Head Fixation
Treatment by Femoral Head Fixation
Femoral head
pinned for
reduction and
stability
Femoral head
pinned for
reduction and
stability
http://www.aafp.org/afp/980501ap/loder.html

If detected early, standard-of-care treatment for SCFE is
fixation of the femoral head

If detected early, standard-of-care treatment for SCFE is
fixation of the femoral head
George Dyer
Gillian Lieberman, MD
30
30
Early Detection Leads to Better Outcomes
Early Detection Leads to Better Outcomes
Excel l ent % Good % Fai r % Poor %
Earl y Treatment 72 14 4 10
Del ayed < 3 mo 67 20 7 6
Del ayed 3-6 mo 64 12 12 12
Del ayed >6 mo 36 9 49 9
Del ayed >9 mo 28 18 18 36
(Cowell, 1966)
(Cowell, 1966)

It is crucial to detect even subtle indication of SCFE because early
detection leads to much better long-term outcome

It is crucial to detect even subtle indication of SCFE because early
detection leads to much better long-term outcome
George Dyer
Gillian Lieberman, MD
31
31
Summary
Summary

Devastating if missed, essential

to
recognize

Diagnosis is still most often made
on plain film

When SCFE is in question, get a
frog leg

Look for Kleins line and
Capeners

sign

Devastating if missed, essential

to
recognize

Diagnosis is still most often made
on plain film

When SCFE is in question, get a
frog leg

Look for Kleins line and
Capeners

sign
George Dyer
Gillian Lieberman, MD
32
32
References
References

Mueller E. Ueber

die Verbiegung

des Schenkelhalses

im

Wachstumsalter, Eine

neus

Krankheitsbild. Beitraege

zur

Klinische

Chirurgie

1889; 4: 137. Transby

Bick EM, Clin

Orthopedics 1966; 48: 7-10

Klein A, Joplin RJ, Reidy

JA, Havelin

J. Roentgenographic

features of slipped capital
femoral epiphysis. Am J Roentgenography

1951; 66: 361-364

Umans

H, Liebling

MS, Moy L, Haramati

N, Macy NJ, Pritzker

HA. Slipped capital
femoral epiphysis: a physeal

lesion diagnosed by MRI, with radiographic and CT
correlation. Skeletal Radiol

1998 Mar;27(3):139-44

Guzzanti

V, Falciglia

F. Slipped capital femoral epiphysis: comparison of a
roentgenographic

method andcomputed

tomography in determining slip severity. J
Pediatr

Orthop

1991 Jan-Feb;11(1):6-12

Stanitski

CL, Litts

CS, Stanitski

DF J Pediatr

Orthop

Tibial

torsion in chronic, stable
slipped capital femoral epiphyses: evaluation by CT scan. 1997 Sep-Oct;17(5):657-8

Cowell

H. Significance of early diagnosis and treatment of slipped capital femoral
epiphysis. Clin

Orthopedics 1966; 48: 89-94

Slipped capital femoral epiphysis. Wheeless

on-line textbook of orthopedics.
http://www.medmedia.com/05/314.htm

Mueller E. Ueber

die Verbiegung

des Schenkelhalses

im

Wachstumsalter, Eine

neus

Krankheitsbild. Beitraege

zur

Klinische

Chirurgie

1889; 4: 137. Transby

Bick EM, Clin

Orthopedics 1966; 48: 7-10

Klein A, Joplin RJ, Reidy

JA, Havelin

J. Roentgenographic

features of slipped capital
femoral epiphysis. Am J Roentgenography

1951; 66: 361-364

Umans

H, Liebling

MS, Moy L, Haramati

N, Macy NJ, Pritzker

HA. Slipped capital
femoral epiphysis: a physeal

lesion diagnosed by MRI, with radiographic and CT
correlation. Skeletal Radiol

1998 Mar;27(3):139-44

Guzzanti

V, Falciglia

F. Slipped capital femoral epiphysis: comparison of a
roentgenographic

method andcomputed

tomography in determining slip severity. J
Pediatr

Orthop

1991 Jan-Feb;11(1):6-12

Stanitski

CL, Litts

CS, Stanitski

DF J Pediatr

Orthop

Tibial

torsion in chronic, stable
slipped capital femoral epiphyses: evaluation by CT scan. 1997 Sep-Oct;17(5):657-8

Cowell

H. Significance of early diagnosis and treatment of slipped capital femoral
epiphysis. Clin

Orthopedics 1966; 48: 89-94

Slipped capital femoral epiphysis. Wheeless

on-line textbook of orthopedics.
http://www.medmedia.com/05/314.htm
George Dyer
Gillian Lieberman, MD
33
33
Acknowledgements
Acknowledgements

Thanks to Ms. Beverlee

Turner for her invaluable technical
assistance in preparing this presentation for publication on
the internet

Special thanks to Dr. Carlo Buonomo, Childrens Hospital
Boston, for his expert instruction on reading pelvic plain
film, and for generously allowing access to his teaching
collection

Larry Barbaras and Ben Crandall our webmasters

Thanks to Ms. Beverlee

Turner for her invaluable technical
assistance in preparing this presentation for publication on
the internet

Special thanks to Dr. Carlo Buonomo, Childrens Hospital
Boston, for his expert instruction on reading pelvic plain
film, and for generously allowing access to his teaching
collection

Larry Barbaras and Ben Crandall our webmasters
George Dyer
Gillian Lieberman, MD