Slipped capital femoral epiphysis
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Slipped capital femoral epiphysis (SCFE) is a medical term referring to a fracture through the epiphyseal growth plate.
The capital (head of the femur) should sit squarely on the femoral neck. Abnormal movement along the growth plate results in the slip. The femoral head is displaced posteriorly and inferiorly in relation to neck of femur. Despite its rarity, it needs to be addressed immediately for the fear of avascular necrosis.
Often this condition will present in obese prepubescent males, especially young black males, and sometimes females with an insidious onset of thigh or knee pain with a painful limp. Hip motion will be limited, particularly internal rotation. The Centers for Disease Control offers a body mass index (BMI) calculator to help you determine your risk for obesity. [2]
The disorder can sometimes be associated with endocrinopathies such as thyroid problems.
Classification
- Stable- patient can ambulate.
- Unstable- patient cannot ambulate even with crutches. There is high chance of AVN
- Acute
- Chronic
Diagnosis
History and Symptoms
SCFE most commonly affects the left hip compared to the right. The patient presents with a knee pain and painful limp. The duration of symptoms for more than 3 weeks is considered to be chronic. It is also associated with some endocrine disorders like hypothyroidism, panhypopituitarism, renal osteodystrophy and growth hormone abnormalities.
Physical Examination
In any case of knee pain, the clinician should not forget that the pain may be referred from the hip. The gait may be antalgic. The sign to note in this condition is affected hip held externally rotated. To differentiate between stable versus unstable types, determine ability to bear weight on the affected side.
In hip examination, the two sides must always be compared. With patient lying down and knee flexed at 90 degrees, test for rotation at hip joint. On passive hip flexion now, the leg would rotate externally and abduct, if SCFE is present.
Radiography
This disease warrants x-rays of the pelvis (AP and frog lateral). The appearance of the head of the femur in relation to the shaft likens that of a "melting ice cream cone". The severity of the disease can be measured using the Southwick angle.
On imaging, Salter-Harris type 1 fracture of the proximal femoral physis with posterior-medial displacement of the proximal femoral epiphysis is seen.
Patient #1: Radiographs demonstrate left slipped capital femoral epiphysis
Patient #2: Radiographs demonstrate right slipped capital femoral epiphysis
Consultation with an orthopaedic surgeon is necessary to repair this problem. Untreated cases can result in serious growth abnormalities and permanent disability.
Many of these are treated with in-situ pinning. Others such as Dr. Ganz advocate open reduction and pinning. The risk of reducing this fracture is disruption of the blood supply. Some also advocate pinning the unaffected side prophylactically.
References
Loder, R. Slipped Capital Femoral Epiphysis. American Family Physician 1998 57: 2135.