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Page 1 of 3 Slipped Capital Femoral Epiphysis

Page 1 of 3

Page 1 of 3 Slipped Capital Femoral Epiphysis

Slipped Capital Femoral Epiphysis

Often atraumatic or associated with a minor injury, slipped capital femoral epiphysis (SCFE) - also known as slipped upper femoral epiphysis - is one of the most common adolescent hip disorders and represents a unique type of instability of the proximal femoral growth plate. Four separate clinical groups are seen:

Pre-slip: wide epiphyseal line without slippage.growth plate. Four separate clinical groups are seen: Acute form: slippage occurs suddenly, normally

Acute form: slippage occurs suddenly, normally spontaneously.are seen: Pre-slip: wide epiphyseal line without slippage. Acute-on-chronic: slippage occurs acutely where there is

Acute-on-chronic: slippage occurs acutely where there is already existing chronic slip.form: slippage occurs suddenly, normally spontaneously. Chronic: steadily progressive slippage (the most common

Chronic: steadily progressive slippage (the most common form).occurs acutely where there is already existing chronic slip. The condition is also categorised as: Stable

steadily progressive slippage (the most common form). The condition is also categorised as: Stable (90% of

The condition is also categorised as:

Stable (90% of cases): the patient is able to walk. [ 1 ] [1]

Unstable (10% of cases): the patient is unable to walk (even with crutches).Stable (90% of cases): the patient is able to walk. [ 1 ] Diagnosis is often

Diagnosis is often delayed - and this is associated with a worse prognosis. [2] Although surgery remains the standard treatment, the management of SCFE remains controversial - a Cochrane review is currently assessing the outcome of surgical and non-operative treatments. [3]

Epidemiology

The incidence is 10/100,000 children per year. [ 4 ] [4]

Most commonly it occurs in boys of 10-17 years of age. Peak age is 13 years for boys and 11.5 years for girls.The incidence is 10/100,000 children per year. [ 4 ] It is the most common hip

It is the most common hip disorder in adolescents.age. Peak age is 13 years for boys and 11.5 years for girls. The left hip

The left hip is more commonly affected than the right; it is bilateral in 20-40% of cases.girls. It is the most common hip disorder in adolescents. It is three times as common

It is three times as common in boys. [ 5 ] [5]

Risk factors

Mechanical: local trauma, obesity.It is three times as common in boys. [ 5 ] Risk factors Inflammatory conditions: neglected

Inflammatory conditions: neglected septic arthritis.[ 5 ] Risk factors Mechanical: local trauma, obesity. Hypothyroidism, hypopituitarism, growth hormone deficiency,

Hypothyroidism, hypopituitarism, growth hormone deficiency, pseudohypoparathyroidism, vitamin D deficiency.Inflammatory conditions: neglected septic arthritis. Previous radiation of the pelvis, chemotherapy, renal

Previous radiation of the pelvis, chemotherapy, renal osteodystrophy-induced bone dysplasia.arthritis. Hypothyroidism, hypopituitarism, growth hormone deficiency, pseudohypoparathyroidism, vitamin D deficiency.

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Presentation

Discomfort in the hip, groin, medial thigh or knee (knee pain is referred from the hip joint) during walking; pain is accentuated by running, jumping, or pivoting activities.Page 2 of 3 Presentation Pre-slip: slight discomfort. A c u t e : Severe pain

Pre-slip: slight discomfort.is accentuated by running, jumping, or pivoting activities. A c u t e : Severe pain

A c u t e : Acute:

Severe pain such that the child is unable to walk or stand.activities. Pre-slip: slight discomfort. A c u t e : Alterations in gait, including a limp

Alterations in gait, including a limp on the affected side, external rotation of the leg, and trunk shift.Severe pain such that the child is unable to walk or stand. Hip motion is limited,

Hip motion is limited, especially internal rotation and abduction, due to pain.side, external rotation of the leg, and trunk shift. Acute-on-chronic: pain, limp and altered gait occurring

Acute-on-chronic: pain, limp and altered gait occurring for several months, suddenly becoming very painful.especially internal rotation and abduction, due to pain. C h r o n i c :

C h r o n i c : Chronic:

Mild symptoms with the child able to walk with altered gait. In a significant number of cases knee pain is reported as the only symptom.suddenly becoming very painful. C h r o n i c : External rotation of the

External rotation of the leg during walking. Range of motion of the hip shows reduced internal rotation with additional external rotation.number of cases knee pain is reported as the only symptom. When flexed up, the hip

When flexed up, the hip tends to move in an externally rotated position.reduced internal rotation with additional external rotation. Mild-to-moderate shortening of the affected leg. Atrophy of

Mild-to-moderate shortening of the affected leg.up, the hip tends to move in an externally rotated position. Atrophy of the thigh muscle

Atrophy of the thigh muscle may be noted.position. Mild-to-moderate shortening of the affected leg. Differential diagnosis Other causes of hip pain - for

Differential diagnosis

Other causes of hip pain - for example:

Acute transient synovitis- for example: Acute hi p fracture Perthes' disease Osteom y elitis Septic arthritis Investigations

Investigations

Anteroposterior and 'frog-leg' lateral X-rays show widening of epiphyseal line or displacement of the femoral head.

Earliest findings include globular swelling of the joint capsule, irregular widening of the epiphyseal line and decalcification of the epiphyseal border of the metaphysis.of epiphyseal line or displacement of the femoral head. Epiphysis normally extends slightly cephalad to the

Epiphysis normally extends slightly cephalad to the upper border of the femoral neck.decalcification of the epiphyseal border of the metaphysis. Small amounts of slippage can be detected by

Small amounts of slippage can be detected by the epiphyseal edge becoming flush with the superior border of the neck.slightly cephalad to the upper border of the femoral neck. Sometimes, however, the only evidence of

Sometimes, however, the only evidence of epiphyseal injury is slight widening of the growth plate.edge becoming flush with the superior border of the neck. Associated diseases Associated injuries are common

Associated diseases

Associated injuries are common with slipped capital femoral epiphysis; patients should be evaluated for possible pelvic fractures.

Management

Avoid moving or rotating the leg. The patient should not be allowed to walk.be evaluated for possible pelvic fractures. Management Provide analgesia and immediate orthopaedic referral if the

Provide analgesia and immediate orthopaedic referral if the diagnosis is suspected.rotating the leg. The patient should not be allowed to walk. The patient should be scheduled

The patient should be scheduled for surgery immediately.orthopaedic referral if the diagnosis is suspected. Surgical closure of the epiphysis, usually by inserting

Surgical closure of the epiphysis, usually by inserting screws percutaneously. [ 6 ] [6]

Corrective osteotomy is usually reserved for treatment of severe deformities after the patient has stopped growing.scheduled for surgery immediately. Surgical closure of the epiphysis, usually by inserting screws percutaneously. [ 6

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Complications

Chondrolysis (degeneration of the articular cartilage), avascular necrosis of the epiphysis, and long- term effects of altered femoral head anatomy.Page 3 of 3 Complications Chondrolysis is seen in 5-8% of slips, and is associated with

Chondrolysis is seen in 5-8% of slips, and is associated with specific risk factors: African-American race, female gender, screw penetration of articular cartilage, body cast immobilisation, femoral neck osteotomy, and severe slips.and long- term effects of altered femoral head anatomy. Avascular necrosis of the epiphysis occurs in

Avascular necrosis of the epiphysis occurs in 10-25% of cases, and is associated with attempts toimmobilisation, femoral neck osteotomy, and severe slips. reduce a displaced epiphysis before treatment and with

reduce a displaced epiphysis before treatment and with osteotomy of the femoral neck.

[7]

Prognosis

The prognosis depends on the initial degree of epiphyseal slippage and prompt recognition by the general practitioner.and with osteotomy of the femoral neck. [7] Prognosis The end result is good to excellent

The end result is good to excellent in 94-96% of cases if fragments are displaced by less than one third of the diameter of the femoral neck.slippage and prompt recognition by the general practitioner. With increasing displacement, complications increase and up

With increasing displacement, complications increase and up to 45% of patients have a fair-to-poor surgical result.by less than one third of the diameter of the femoral neck. Further reading & references

Further reading & references

surgical result. Further reading & references Slipped Capital Femoral Epiphysis ; Wheeless' Textbook

Slipped Capital Femoral Epiphysis; Wheeless' Textbook of Orthopaedics

1. Peck D; Slipped capital femoral epiphysis: diagnosis and management.Am Fam Physician. 2010Aug 1;82(3):258-62.

2. Weigall P, Vladusic S, Torode I; Slipped upper femoral epiphysis in children--delays to diagnosis.Aust Fam Physician. 2010 Mar;39(3):151-3.

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

10.1002/14651858.CD010397

5. Lehmann CL,Arons RR, Loder RT, et al; The epidemiologyof slipped capital femoral epiphysis: an update. J Pediatr Orthop. 2006 May-Jun;26(3):286-90.

6. KennyP, Higgins T, Sedhom M, et al; Slipped upper femoral epiphysis.Aretrospective, clinical and radiological studyof fixation with a single screw. J Pediatr Orthop B. 2003 Mar;12(2):97-9.

7. Tokmakova KP, Stanton RP, Mason DE; Factors influencing the development of osteonecrosis in patients treated for slipped capital femoral epiphysis. J Bone Joint SurgAm. 2003 May;85-A(5):798-801.

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20/11/2013

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