ORTHO Slipped Capital Femoral Epiphysis

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A 14-year-old athletic male with a medium build presents with 3 weeks of atraumatic
left hip and thigh pain. For that last 12 hours, he has been unable to bear weight, even
with crutches. He denies right hip pain. He has obligatory external rotation of the left
hip upon flexion. Radiographs are seen in figures A, B. What is the best next step?
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Slipped Capital Femoral Epiphysis

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irs
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Overview
• Condition of the proximal

femoral physis that leads
to slippage of the
metaphysis relative to the
epiphysis
• Most commonly seen in
adolescent obese males
• Treatment is usually
percutaneous pin fixation
Epidemiology
• Most common disorder affecting adolescent
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hips
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• 10 per 100,000(USA)
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• More common in
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– obese children
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– males
– African Americans,Pacific islanders, Latinos
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Epidemiology
• During period of rapid growth (10-16 years)
• 13 for boys
• 12 for girls
• Associated with puberty
• Left hip is more common
• Bilateral in (~25%)
Risk factors
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• Obesity-single greatest risk factor

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• Acetabular retroversion and femoral

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retroversion
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Associated conditions
• Hypothyroidism -most common etiology of

nonidiopathic SCFE
• Renal osteodystrophy
• Growth hormone deficiency
• Panhypopituitarism
• Indications for endocrine workup
– child is < 10 years old
– weight is < 50th percentile
• Down syndrome
Pathophysiology
• Adolescence-perichondrial ring thins and
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weakens
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• Physis is still vertical in this age group

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• Mechanical forces acting on a susceptible

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physis
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• Slippage occurs though the hypertrophic zone

of the physis
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Pathoanatomy
• Angulation-metaphysis translates anterior and
externally rotates
• Epiphysis remains in the acetabulum
• Periosteum remains intact (chronic SCFE)
• In acute SCFE, periosteum can be partially torn
Loder Classification
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• Based on ability to bear weight

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• Stable-Able to bear weight with or without

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irs
crutches
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– Minimal risk of osteonecrosis (<10%)

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• Unstable-Unable to ambulate (not even with

crutches)
– High risk of osteonecrosis (25-35%)
• Provides prognostic information
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Southwick Slip Angle Classification

• Based on femoral
epipyseal-diaphyseal
angle difference
• Mild < 30°
• Moderate 30-50°
• Severe > 50°
• Based on the degree of
difference between the
affected and
unaffected hip
Grading System -- based on

percentage of slippage
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• Grade I 0-33% of slippage

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• Grade II 34-50% of slippage

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• Grade III >50% of slippage

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Symptoms
• Groin and thigh pain -most common presentation
• knee pain
– can lead to missed diagnosis
• Limp
– antalgic gait
– externally rotated foot progression angle
• Patients prefer to sit in a chair with affected leg
crossed over the other
• Duration
– symptoms for weeks to months before diagnosis is made
• Acute on chronic-severe pain,unable to bear weight
Physical exam
• Abnormal gait
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– antalgic, waddling, externally rotated gait or

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Trendelenburg gait
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an
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• Decreased hip motion

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– Loss of hip IR, abduction, and flexion

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– Obligatory external rotation during passive flexion

of hip (Drehmann sign)
• Weakness
– thigh atrophy
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Radiographs
• AP & frog-leg lateral of right and left hip
• lateral radiograph is best way to identify a
subtle slip
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Radiographs
• Klein's line
• Line drawn along
superior border femoral
neck
• Will intersect less of the
femoral head or not at
all in SCFE
Radiographs
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• Epiphysiolysis (growth plate widening or

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lucency)
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• Blurring of proximal femoral metaphysis

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(metaphyseal blanch sign of Steel)

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– seen on AP due to overlapping of the metaphysis

and posteriorly displaced epiphysis
• MRI
– may help diagnose a preslip condition
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Treatment-Stable slip
• Operative-percutaneous in situ fixation
• indications
– both stable and unstable slips
– one vs. two cannulated screws is controversial
• benefit of 2 screws needs to be considered in
the face of greater screw related
complications
• contralateral hip prophylactic fixation-
controversial
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Treatment
• Open epiphyseal reduction and fixation
– controversial
– unstable and severe slips
• technique
– capital realignment via the modified Dunn
procedure
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Complications
• Osteonecrosis of femoral head

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– increased risk with unstable slips (~24-47%), most

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common predictor
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• operative complication (4-6%)

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– hardware placement in posteriosuperior femoral neck

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has the greatest risk of disrupting the vascular supply

• Chondrolysis (0-2%)
• Residual proximal femoral deformity & limb
length discrepancy
• Degenerative arthritis
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www.FirstRanker.com www.FirstRanker.

Slipped Capital Femoral Epiphysis

• Condition of the proximal

• Obesity-single greatest risk factor

• Acetabular retroversion and femoral

• Hypothyroidism -most common etiology of

• Physis is still vertical in this age group

• Mechanical forces acting on a susceptible

• Slippage occurs though the hypertrophic zone

• Based on ability to bear weight

• Stable-Able to bear weight with or without

– Minimal risk of osteonecrosis (<10%)

• Unstable-Unable to ambulate (not even with

Southwick Slip Angle Classification

Grading System -- based on

• Grade I 0-33% of slippage

• Grade II 34-50% of slippage

• Grade III >50% of slippage

– antalgic, waddling, externally rotated gait or

• Decreased hip motion

– Loss of hip IR, abduction, and flexion

– Obligatory external rotation during passive flexion

• Epiphysiolysis (growth plate widening or

• Blurring of proximal femoral metaphysis

(metaphyseal blanch sign of Steel)

– seen on AP due to overlapping of the metaphysis

• Osteonecrosis of femoral head

– increased risk with unstable slips (~24-47%), most

• operative complication (4-6%)

– hardware placement in posteriosuperior femoral neck

has the greatest risk of disrupting the vascular supply

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