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Slipped Capital Femoral Epiphysis

Slipped capital femoral epiphysis Epiphysis The head of a long bone that is separated from the shaft by the epiphyseal plate until bone growth stops. At that time, the plate disappears and the head and shaft are united. Bones: Structure and Types (SCFE) is an orthopedic disorder of early adolescence characterized by the pathologic “slipping” or displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms of the femoral head, or epiphysis Epiphysis The head of a long bone that is separated from the shaft by the epiphyseal plate until bone growth stops. At that time, the plate disappears and the head and shaft are united. Bones: Structure and Types, on the femoral neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess. Considered a type I Salter-Harris growth plate fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures, SCFE affects boys twice as often as girls. Thought to be due to a combination of biomechanical and endocrine factors, diagnosis is made with hip X-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays and treatment ranges from conservative to surgical. Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual's condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas depends on the severity of the slip or displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms.

Last updated: 22 Jan, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition

Slipped capital femoral epiphysis Epiphysis The head of a long bone that is separated from the shaft by the epiphyseal plate until bone growth stops. At that time, the plate disappears and the head and shaft are united. Bones: Structure and Types (SCFE) is a hip disorder common in adolescence that features the displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms of the capital epiphysis Epiphysis The head of a long bone that is separated from the shaft by the epiphyseal plate until bone growth stops. At that time, the plate disappears and the head and shaft are united. Bones: Structure and Types of the femoral head through the growth plate (physis) in relationship Relationship A connection, association, or involvement between 2 or more parties. Clinician–Patient Relationship to the femoral neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess.

Slipped capital femoral epiphysis

Slipped capital femoral epiphysis Epiphysis The head of a long bone that is separated from the shaft by the epiphyseal plate until bone growth stops. At that time, the plate disappears and the head and shaft are united. Bones: Structure and Types: displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms of the capital femoral epiphysis Epiphysis The head of a long bone that is separated from the shaft by the epiphyseal plate until bone growth stops. At that time, the plate disappears and the head and shaft are united. Bones: Structure and Types of the femoral head through the growth plate (physis) in relationship Relationship A connection, association, or involvement between 2 or more parties. Clinician–Patient Relationship to the femoral neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess

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Slipped capital femoral epiphysis Epiphysis The head of a long bone that is separated from the shaft by the epiphyseal plate until bone growth stops. At that time, the plate disappears and the head and shaft are united. Bones: Structure and Types (SCFE) is considered a Salter-Harris type 1 Type 1 Spinal Muscular Atrophy fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures, because SCFE is a transverse fracture Transverse Fracture Overview of Bone Fractures through the growth plate or physis.

Salter-harris classification

Salter-Harris classification of epiphyseal fractures
The epiphyseal plate Epiphyseal plate The area between the epiphysis and the diaphysis within which bone growth occurs. Cartilage: Histology is the growth center of long bones Long bones Length greater than width. Bones: Structure and Types. Fractures incurred during childhood that involve the epiphyseal plate Epiphyseal plate The area between the epiphysis and the diaphysis within which bone growth occurs. Cartilage: Histology are concerning because such fractures may damage the blood supply to the plate, affecting the bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types’s growth over time. Slipped capital femoral epiphysis Epiphysis The head of a long bone that is separated from the shaft by the epiphyseal plate until bone growth stops. At that time, the plate disappears and the head and shaft are united. Bones: Structure and Types is an example of a type 1 Type 1 Spinal Muscular Atrophy fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures of the femoral epiphysis Epiphysis The head of a long bone that is separated from the shaft by the epiphyseal plate until bone growth stops. At that time, the plate disappears and the head and shaft are united. Bones: Structure and Types with subsequent slipping of the fractured bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types.

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Classification

There are several classification systems for SCFE:

  • Temporal classification: time of presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor:
    • Acute: < 3 weeks
    • Chronic: > 3 weeks
  • Loder classification of stability: based on the ability to bear weight:
    • Stable: ambulation possible
    • Unstable: ambulation not possible
  • Southwick slip angle classification: femoral epiphyseal-diaphyseal angle difference:
    • Mild: < 30° 
    • Moderate: 30°–50°
    • Severe: > 50°
  • Gradation: based on the percentage of slippage:
    • Grade I: 0%–33%
    • Grade II: 34%–50%
    • Grade III: > 50%

Epidemiology

  • Incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency 1 in 1,000–10,000 children in the United States
  • Mean Mean Mean is the sum of all measurements in a data set divided by the number of measurements in that data set. Measures of Central Tendency and Dispersion age of presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor is 12–13 years.
  • Male : female ratio 2.5:1
  • More common in Pacific Islanders, Latinx, and Black adolescents 
  • Left hip more commonly affected in unilateral cases
  • Bilateral in 20%–40% of cases (up to 100% of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with endocrine disease) 
  • Associated with:
    • Obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity (the severity of disease worsens in parallel with obesity)
    • Hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto’s disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism
    • Hypogonadism Hypogonadism Hypogonadism is a condition characterized by reduced or no sex hormone production by the testes or ovaries. Hypogonadism can result from primary (hypergonadotropic) or secondary (hypogonadotropic) failure. Symptoms include infertility, increased risk of osteoporosis, erectile dysfunction, decreased libido, and regression (or absence) of secondary sexual characteristics. Hypogonadism
    • Panhypopituitarism 
    • Growth hormone disorders 
    • Several genetic disorders (e.g., Rubenstein-Taybi syndrome, Down’s syndrome)

Etiology

The causes of SCFE are multifactorial, a combination of endocrine and biomechanical factors. Excessive mechanical forces causing more shearing forces Shearing forces Vascular Resistance, Flow, and Mean Arterial Pressure to be applied to the femoral neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess result in the failure of a susceptible (weakened) physis.

  • Increased mechanical forces: 
    • Increased body weight 
    • Trauma 
  • Weakened physis:
    • Widening of the epiphysis Epiphysis The head of a long bone that is separated from the shaft by the epiphyseal plate until bone growth stops. At that time, the plate disappears and the head and shaft are united. Bones: Structure and Types and periosteal thinning during periods of rapid growth (e.g., pubertal growth) 
    • Chronic inflammation Chronic Inflammation Inflammation of the joint
    • Endocrine and metabolic disorders causing abnormal mineralization of cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology and instability of the perichondrial ring:
      • Hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto’s disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism
      • Renal osteodystrophy Osteodystrophy Cirrhosis
      • Growth hormone deficiency 
      • Panhypopituitarism
    • Radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma exposure Exposure ABCDE Assessment for treatment of bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types cancers

Pathophysiology

Repetitive shear forces applied to a weakened physis result in fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures and slipping. As slippage progresses, the metaphysis Metaphysis Bones: Structure and Types translates anteriorly and superiorly while rotating externally; the epiphysis Epiphysis The head of a long bone that is separated from the shaft by the epiphyseal plate until bone growth stops. At that time, the plate disappears and the head and shaft are united. Bones: Structure and Types remains in the acetabulum.

Clinical Presentation

Children who present with SCFE typically complain of groin Groin The external junctural region between the lower part of the abdomen and the thigh. Male Genitourinary Examination and anterior thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh: Anatomy pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, and demonstrate an altered gait Gait Manner or style of walking. Neurological Examination.  

  • History:
    • Chief complaint: hip pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways without a history of trauma: 
      • May complain primarily of pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways in the ipsilateral knee
      • Pain in the groin Groin The external junctural region between the lower part of the abdomen and the thigh. Male Genitourinary Examination, hip, knee, or thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh: Anatomy aggravated by physical exertion
    • Acute cases: severe and sudden pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways after injury or activity
    • Chronic cases: hip pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways for weeks or months
    • May report difficulty in daily activities (tying shoes)
  • Physical examination:
    • Limping while walking or running (inability to walk in severe cases)
    • External rotation External Rotation Examination of the Upper Limbs of the affected leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy and loss of range of motion Range of motion The distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises. Examination of the Upper Limbs (ROM)
    • Length discrepancy Length Discrepancy Blount’s Disease of lower limbs (the affected limb is shorter)
    • Gait becomes antalgic as slippage progresses.

Diagnosis

The diagnosis of SCFE is performed through a combination of history, physical examination, and plain film X-rays. 

  • Hip X-rays (anteroposterior (AP) and frog leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy lateral views of both hips):
    • Lateral X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests is the primary way to identify a subtle slip:
      • Epiphysiolysis: growth plate widening or lucency
    • Klein’s line: In AP view, a line drawn along the superior border of the femoral neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess will intersect less of the femoral head in a child with SCFE; asymmetry Asymmetry Examination of the Upper Limbs between sides is key.
  • Computed tomography (CT), magnetic resonance imaging (MRI), and bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types scans:
    • MRI may help diagnose a “preslip” condition.
    • If X-rays normal, but SCFE suspicion high, MRI can demonstrate widening of the growth plate with surrounding edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
  • Hormone levels according to clinical suspicion of endocrinopathies

Management and Complications

Management

The treatment involves immediate non–weight-bearing status and referral to orthopedic surgery:

  • Must be non–weight bearing to prevent further slippage
  • Operative stabilization is the primary treatment:
    • Percutaneous screw fixation through the femoral neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess, engaging the physis
    • Reduction of slipped epiphysis Epiphysis The head of a long bone that is separated from the shaft by the epiphyseal plate until bone growth stops. At that time, the plate disappears and the head and shaft are united. Bones: Structure and Types is not recommended because of increased risk of avascular necrosis Avascular Necrosis Hip Fractures.
    • Prophylactic pinning of the contralateral hip is controversial.
  • Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas:
    • Mild cases with less slippage have a better prognosis.
    • More severe cases are at risk of developing osteoarthritis Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis at a young age.

Complications

  • Osteonecrosis or avascular necrosis Avascular Necrosis Hip Fractures of the hip: loss of blood supply to the femoral head leading to necrosis of cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology and bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types
    • Most concerning complication leading to worst outcome 
    • Increased risk seen with acute, unstable slips 
    • 10%–15% of children with SCFE develop osteonecrosis.
  • Contralateral hip SCFE: increased risk in obese males with endocrine disorders
  • Chondrolysis: destruction of hip cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology: occurs with penetration Penetration X-rays of a stabilization pin into the joint during surgery
  • Residual deformity Deformity Examination of the Upper Limbs with limb length discrepancy
  • Femoroacetabular impingement (FAI): poor fit of the hip “ball in socket” causing grating and further injury with movement
  • Degenerative arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis with aging
  • Non-union after surgical pinning

Clinical Relevance

  • Avascular Avascular Corneal Abrasions, Erosion, and Ulcers necrosis of the hip: necrosis and deformation of the femoral head due to impaired blood supply to the head of the femur Head of the femur The hemispheric articular surface at the upper extremity of the thigh bone. Hip Joint: Anatomy. Development of avascular necrosis Avascular Necrosis Hip Fractures is a serious complication in SCFE or other conditions.
  • Osteoarthritis or degenerative joint disease: progressive degeneration of the joint characterized by a loss of cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology and growth of bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types spurs. Patients with SCFE, due to femoral head deformity Deformity Examination of the Upper Limbs, are at risk of developing degenerative changes Degenerative Changes Spinal Stenosis of the hip joint Hip joint The hip joint is a ball-and-socket joint formed by the head of the femur and the acetabulum of the pelvis. The hip joint is the most stable joint in the body and is supported by a very strong capsule and several ligaments, allowing the joint to sustain forces that can be multiple times the total body weight. Hip Joint: Anatomy and osteoarthritis Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis earlier in life.
  • Legg-Calvé-Perthes disease Legg-Calvé-Perthes Disease Legg-Calvé-Perthes disease (LCPD) is characterized by idiopathic avascular necrosis of the femoral head. The disease presents as a limp with an insidious onset and associated hip pain. Legg-Calvé-Perthes disease primarily affects school-age children and has a male predominance. Legg-Calvé-Perthes Disease ( LCPD LCPD Legg-Calvé-Perthes disease (LCPD) is characterized by idiopathic avascular necrosis of the femoral head. The disease presents as a limp with an insidious onset and associated hip pain. Legg-Calvé-Perthes disease primarily affects school-age children and has a male predominance. Legg-Calvé-Perthes Disease): idiopathic Idiopathic Dermatomyositis avascular necrosis Avascular Necrosis Hip Fractures of the femoral head. Exact mechanism is unknown and diagnosis is made by clinical findings and diagnostic imaging. Treatment can be conservative or surgical, depending on the severity and the patient’s age.

References

  1. McQuillen, K. K. (2018). Musculoskeletal disorders. In R. M. Walls MD, R. S. Hockberger MD & Gausche-Hill, Marianne, MD, FACEP, FAAP, FAEMS (Eds.), Rosen’s emergency medicine: Concepts and clinical practice (pp. 2201-2217.e2). https://www.clinicalkey.es/#!/content/3-s2.0-B9780323354790001756
  2. Moyer, J., Jacks, L., Hunter, J. D., & Chan, G. (2016). Slipped capital femoral epiphysis and associated hypothyroidism. A review of the literature with two classic case examples. Journal of pediatric endocrinology & metabolism.
  3. Wells D, King JD, Roe TF, & Kaufman FR. (1993). Review of slipped capital femoral epiphysis associated with endocrine disease. J Pediatr Orthop.
  4. Bowden, S. A., & Klingele, K. E. (2009). Chronic Bilateral Slipped Capital Femoral Epiphysis as an Unusual Presentation of Congenital Panhypopituitarism due to Pituitary Hypoplasia in a 17-Year-Old Female. International Journal of pediatric endocrinology, 2009, 609131. DOI:10.1155/2009/609131
  5. Mullins, M. M., Sood, M., Hashemi-Nejad, A., & Catterall, A. (2005). The management of avascular necrosis after slipped capital femoral epiphysis. The Journal of bone and joint surgery. British volume, 87(12), 1669–1674. DOI:10.1302/0301-620X.87B12.16665
  6. Helgesson, L., Johansson, P. K., Aurell, Y., Tiderius, C. J., Kärrholm, J., & Riad, J. (2018). Early osteoarthritis after slipped capital femoral epiphysis. Acta orthopaedica, 89(2), 222–228. DOI:10.1080/17453674.2017.1407055

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