George Dyer Gillian Lieberman, MD

January 2001

Slipped Capital Femoral Epiphysis SCFE

George SM Dyer, Harvard Medical School Year-III Gillian Lieberman, MD

George Dyer Gillian Lieberman, MD

What is it?
In In a a person person with with an an open open

femoral femoral physis, physis, mild mild trauma trauma shifts shifts the the femoral femoral head head in in relation relation to to the the femoral femoral neck neck Femoral Femoral head head slips slips posteriorly posteriorly and and medially medially

http://www.packardchildrenshospital.org/health/orthopaedics/scfe.htm

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George Dyer Gillian Lieberman, MD

Simplified Concept of SCFE

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George Dyer Gillian Lieberman, MD

Simplified Concept of SCFE

Open physis Slipped Slipped physis physis

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George Dyer Gillian Lieberman, MD

Epidemiology

Incidence 30/100,000 Age: 10 - 15 yrs Boys > girls Blacks > whites More common in overweight children

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George Dyer Gillian Lieberman, MD

History and Differential Diagnosis

Ernst Mueller, 1889
Described Described it it pathologically pathologically using using
dissected dissected specimens specimens There There occurs occurs in in young young individuals individuals aged aged 14-18, 14-18, without without trauma trauma to to the the hip, hip, a a limp, limp, a a weariness, weariness, and and gradual gradual shortening shortening of of the the affected affected limb 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

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George Dyer Gillian Lieberman, MD

Radiologic Studies
Plain Plain Film Film Projections Projections

Posterior-Anterior Posterior-Anterior Frog-leg Frog-leg Lateral Lateral

CT
May May resolve resolve finer finer anatomy anatomy
((Guzzanti Guzzanti V, V, Falciglia Falciglia F, F, 1991) 1991)

MR
in in soft soft tissues tissues ((Umans Umans H, H, et et al. al. 1998) 1998) But But diagnosis diagnosis is is still still most most often often made made on on plain plain film film Essential Essential to recognize recognize

Most Most sensitive sensitive for for small small changes changes

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George Dyer Gillian Lieberman, MD

Radiographic Findings

Its easy when the

findings are clear

http://www.aafp.org/afp/980501ap/loder.html

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George Dyer Gillian Lieberman, MD

Radiographic Findings in SCFE

Kleins Kleins Criteria Criteria (1951) (1951) Earliest: Widened Widened and and irregular irregular growth growth plate, plate, compared compared to to contralateral contralateral hip hip Earliest:

Increased Increased lucency lucency medially medially Angulated Angulated contour contour of of femoral femoral head, head, then then becomes becomes rounded rounded with with adaptation adaptation Periosteal Periosteal proliferation proliferation at at inferior, inferior, posterior posterior margins margins and and further further slippage slippage create crows beak create crows beak

portion portion of of the the femoral femoral epiphysis epiphysis (Klein, (Klein, 1951) 1951) Most Most sensitive sensitive indicator indicator of of a a mild mild slip slip on on plain plain film film Classification Classification Grade Grade I: I: displacement displacement of of epiphysis epiphysis less less than than 30% 30% of of width width of of femoral femoral neck neck Grade Grade II: II: slip slip between between 30%-60% 30%-60% Grade Grade III: III: includes includes slips slips of of greater greater than than 60% 60% the the width width of of neck neck
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Klein's Klein's Line Line Line Line drawn drawn along along superior superior border border of of femoral femoral neck neck should should cross cross at at least least a a

George Dyer Gillian Lieberman, MD

Kleins Line

Kleins Kleins line line demonstrates demonstrates slipped slipped femoral femoral head head on on right right,, normal normal on on left left
Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston

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George Dyer Gillian Lieberman, MD

Importance of the Frog Leg: Patient DG: Is There a Slip?

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Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston

George Dyer Gillian Lieberman, MD

Patient DG: Frog Leg

Kleins Kleins line line demonstrates demonstrates slipped slipped femoral femoral head head bilaterally bilaterally

Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston

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George Dyer Gillian Lieberman, MD

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

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George Dyer Gillian Lieberman, MD

Patient JB: 15 year old boy Is the Slip on the Right, the Left, Or Bilateral?

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Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston

George Dyer Gillian Lieberman, MD

Patient JB: Frog leg view Is the Slip on the Right, the Left, Or Bilateral?

Kleins Kleins line line demonstrates demonstrates slipped slipped femoral femoral head head bilaterally bilaterally

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Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston

George Dyer Gillian Lieberman, MD

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

Kleins Kleins line line demonstrates demonstrates slipped slipped femoral femoral head head on on right right

Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston

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George Dyer Gillian Lieberman, MD

Patient KG: 11 year old girl Is There a Slip? Sometimes Kleins Line is Equivocal

Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston

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George Dyer Gillian Lieberman, MD

Patient KG: Frog leg view Is the Slip on the Right, the Left, Or Bilateral?

Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston

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George Dyer Gillian Lieberman, MD

When Kleins Line Fails, Try Capeners Sign

On On PA, PA, ischium ischium and and
femoral femoral head head overlap overlap to to yield yield crescent crescent of of double double density density SCFE SCFE reduces reduces overlap overlap area area Sometimes Sometimes more more sensitive sensitive than than Kleins Kleins line line alone alone

Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston

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George Dyer Gillian Lieberman, MD

Patient KG: Capeners Sign Is the Slip on the Right, the Left, Or Bilateral?

Capeners Capeners sign sign suggests slipped suggests slipped left left and and normal normal right right

Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston

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George Dyer Gillian Lieberman, MD

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

Capeners Capeners sign sign suggests slipped suggests slipped right right and and normal normal left left

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Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston

George Dyer Gillian Lieberman, MD

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

Kleins Kleins line line demonstrates demonstrates slipped slipped left left and and normal normal right right
Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston

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George Dyer Gillian Lieberman, MD

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

Kleins Kleins line line demonstrates demonstrates slipped slipped left left and and normal normal right right

Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston

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George Dyer Gillian Lieberman, MD

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

Kleins Kleins line line demonstrates demonstrates slipped slipped left left and and normal normal right right
Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston

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George Dyer Gillian Lieberman, MD

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

Kleins Kleins line line demonstrates demonstrates slipped slipped right right and and normal normal left left

Courtesy of Dr. Carlo Buonomo, Childrens Hospital, Boston

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George Dyer Gillian Lieberman, MD

Complications
If undetected, SCFE has disabling sequelae
Acute Acute cartilage cartilage necrosis necrosis (chondrolysis) (chondrolysis) Avascular Avascular Necrosis Necrosis (AVN) (AVN) Deformity Deformity as as bones bones grow grow

Time

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George Dyer Gillian Lieberman, MD

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

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George Dyer Gillian Lieberman, MD

Progression of AVN in a Sickle-Cell Patient

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

Progressive Age Age

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Age

http://gait.aidi.udel.edu/res695/homepage/pd_ortho/educate/clincase/clcsimge/sickle1.jpg

George Dyer Gillian Lieberman, MD

Treatment by Femoral Head Fixation

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

http://www.aafp.org/afp/980501ap/loder.html

Femoral Femoral head head pinned pinned for for 29 29 reduction reduction and and stability stability

George Dyer Gillian Lieberman, MD

Early Detection Leads to Better Outcomes

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

Early Treatment Delayed < 3 mo Delayed 3-6 mo Delayed >6 mo Delayed >9 mo

Excellent % 72 67 64 36 28

Good % 14 20 12 9 18

Fair % 4 7 12 49 18

Poor % 10 6 12 9 36

(Cowell, (Cowell, 1966) 1966)

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George Dyer Gillian Lieberman, MD

Summary

Devastating Devastating if if missed, missed, essential essential to to

recognize recognize Diagnosis Diagnosis is is still still most most often often made made on on plain plain film film

When SCFE is in question, get a

frog leg Look for Kleins line and Capeners sign

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George Dyer Gillian Lieberman, MD

References

Mueller Mueller E. E. Ueber Ueber die die Verbiegung Verbiegung des des Schenkelhalses Schenkelhalses im im Wachstumsalter, Wachstumsalter, Eine Eine neus neus Krankheitsbild. Beitraege zur Klinische Chirurgie 1889; 4: 137. Transby Bick EM, Krankheitsbild. Beitraege zur Klinische Chirurgie 1889; 4: 137. Transby Bick EM, Clin Clin Orthopedics 1966; 48: 7-10 Orthopedics 1966; 48: 7-10 Klein Klein A, A, Joplin Joplin RJ, RJ, Reidy Reidy JA, JA, Havelin Havelin J. J. Roentgenographic Roentgenographic features features of of slipped slipped capital capital femoral femoral epiphysis. epiphysis. Am Am JJ Roentgenography Roentgenography 1951; 1951; 66: 66: 361-364 361-364 Umans Umans H, H, Liebling Liebling MS, MS, Moy Moy L, L, Haramati Haramati N, N, Macy Macy NJ, NJ, Pritzker Pritzker HA. HA. Slipped Slipped capital capital femoral femoral epiphysis: epiphysis: a a physeal physeal lesion lesion diagnosed diagnosed by by MRI, MRI, with with radiographic radiographic and and CT CT correlation. correlation. Skeletal Skeletal Radiol Radiol 1998 1998 Mar;27(3):139-44 Mar;27(3):139-44 Guzzanti Guzzanti V, V, Falciglia Falciglia F. F. Slipped Slipped capital capital femoral femoral epiphysis: epiphysis: comparison comparison of of a a roentgenographic method andcomputed tomography in determining slip severity. roentgenographic method andcomputed tomography in determining slip severity. JJ Pediatr Pediatr Orthop Orthop 1991 1991 Jan-Feb;11(1):6-12 Jan-Feb;11(1):6-12 Stanitski Stanitski CL, CL, Litts Litts CS, CS, Stanitski Stanitski DF DF JJ Pediatr Pediatr Orthop Orthop Tibial Tibial torsion torsion in in chronic, chronic, stable stable slipped slipped capital capital femoral femoral epiphyses: epiphyses: evaluation evaluation by by CT CT scan. scan. 1997 1997 Sep-Oct;17(5):657-8 Sep-Oct;17(5):657-8 Cowell Cowell H. H. Significance Significance of of early early diagnosis diagnosis and and treatment treatment of of slipped slipped capital capital femoral femoral epiphysis. epiphysis. Clin Clin Orthopedics Orthopedics 1966; 1966; 48: 48: 89-94 89-94 Slipped Slipped capital capital femoral femoral epiphysis. epiphysis. Wheeless Wheeless on-line on-line textbook textbook of of orthopedics. orthopedics. http://www.medmedia.com/05/314.htm http://www.medmedia.com/05/314.htm 32 32

George Dyer Gillian Lieberman, MD

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

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