Slipped Capital Femoral Epiphysis (SCFE)

Displacement of the proximal femoral epiphysis

Incidence rate:

 Uncommon 1-3 : 100.000

 In children undergoing pubertal growth spurt
 Boys > Girls
 Left hip > Right hip, 25-40% chance the other side also slips

Etiology

 The slip occurs through the hypertrophic zone of the cartilaginous growth plate
 Many of the patients are either fat and sexually immature or excessively tall and thin
 Trauma plays a part, in 30% of cases with an ‘acute’ slip, the other 70% slow, progressive displacement
sometimes culminating in ‘acute-on-chronic’ slip

Pathology

 Femoral shaft rolls into external rotation and femoral neck displaced forwards while the epiphysis remains
seated in the acetabulum.
 The epiphysis slips posteriorly on the femoral neck. If the slip is severe, the anterior retinacular vessels are
torn and may result in avascular necrosis.

Clinical features:

 Slipping usually occurs as a series of minor episodes

 Patient is usually a child around puberty, overweight or very tall and thin
 Pain, sometimes in the groin, but often only in thigh or knee
 Limping occurs early
 Leg is turning out (External rotation)

Physical examination:

 Leg is externally rotated and is 1-2 cm short

 Limitation in flexion, abduction, and medial rotation
 Classic sign – increasing external rotation as hip is flexed
Radiographical examination:

 X-Ray
o In AP view
 Trethowan’s sign – A line drawn along the superior surface of the femoral neck
 Normal if it intersect the epiphysis | (+)ve if epiphysis is below the line
o In lateral view
 Draw a line through the base of the epiphysis and up the middle of femoral neck
 Normal if it’s 90° | Posterior displacement if < 87°
 USG – May detect hip effusion in acute slip, or metaphyseal remodeling in chronic slip
 MRI – Detect and stage avascular necrosis (AVN)
 CT-scan – Useful in preoperative planning of realignment procedures

Grading

Based on timing of onset:

 Pre-slip
o Groin or knee pain, particularly on exertion
o Examination is often normal
o X-ray may show widening or irregularity of the physis
 Acute slip
o Symptoms present for < 3 weeks
o Painful hip movements with external rotation deformity, shortening and marked limitation of
rotation
 Chronic slip
o Pain in groin, thigh, or knee lasting > 3 weeks
o Episodes of deterioration and remission
o Loss of internal rotation, abduction, and flexion of the hip and limb shortening
 Acute-on-chronic slip
o Long prodromal history and acute, severe exacerbation

Based on percentage slip (Loder – 1993):

 Mild - Displacement < 1⁄3 of the width of the femoral neck

 Moderate - Displacement between 1⁄3 and ½
 Severe - Displacement > ½ femoral neck width

Based on epiphyseal-femoral shaft angle (Jerre and Billing – 1994)

 Mild – Angle < 30°

 Moderate – Angle 31°-50°
 Severe – Angle > 50°
Treatment

Aim of treatment:

 Preserve the epiphyseal blood supply

 Stabilise the physis
 Correct any residual deformity

Treat based on degree of slips

 Minor slips
o Needs no correction
 Moderate slips
o If position is acceptable, observe. If after a year or two, there is noticeable deformity  Corrective
osteotomy
 Severe slips
o Closed reduction by manipulation is dangerous and shouldn’t be attempted
o Open reduction by Dunn’s method

Complications

 Slipping at the opposite hip

 Avascular necrosis
 Articular chondrolysis
 Coxa vara