Slipped Capital Femoral Epiphysis

Original Editor - Juliana Doyle, Roel De Groef as part of the Vrije Universiteit Brussel's Evidence-based Practice project

Top Contributors - Wanda van Niekerk, Roel De Groef, Nicolas D'Hondt, Admin, Juliana Doyle, Kim Jackson, Anouk Toye, Daphne Jackson, Vidya Acharya and Lucinda hampton

Definition/Description

Slipped Capital Femoral Ephysis (SCFE) occurs in the adolescent population when the proximal femoral epiphysis slips posteriorly on the femoral neck at the physis In actuality, the metaphysis of the femoral neck is displaced superiorly and anteriorly of the capital femoral epiphysis. Epiphysiolysis occurs in about a fourth of the cases bilaterally.

Clinically Relevant Anatomy

The growth plate is located between the caput femoris and collum femoris of the thighbone. The bone fibers have pressure- and pull trabeculae, their shape and course is determined by the angle of the femoral neck.

Epidemiology / Etiology

There are several factors that can contribute to developing a SCFE. Antropometric risk factors can be a long, small person but the most widely recognized factor is obesity. It is hypothesiszed that as weight increases shearing forces across the physis are also increased causing it to weakenOther mechanical contributors to this condition are retroversion of the femur,and increased physeal obliquity. Changes is hormone levels (spikes in testosterone) during growth spurts can having a weakening effect on the physis. There is some association with endocrine disorders, such as Hypothyroidism, Hypopituitarism, hupogonadisme and metabolic disorders resulting from the English disease or treatment of chemotherapy or radiation. These situations lead to weakening of the growth plate. However this is not a prevalent finding. There are several classification systems to determine the severity of a SCFE. One delineates the disorder into acute, acute-on-chronic, and chronic. Acute signifies the SCFE occurred with trauma and results in immediate pain and decreased hip ROM (abduction and internal rotation). Acute-on chronic describes a patient having symptoms for months and then has an increased slip due to trauma. Chronic is identified as the most common presentation, and the child has had symptoms for several months The preferred classification system is stable/unstable which is based on the weight-bearing ability of the child. A classification of stable is given to those who can bear weight with/without an assistive device on the affected leg. Those who cannot are deemed unstable.

Characteristics / Clinical Presentation

Typical presentation is a child between the ages of 10 - 20 years. There are some differences found between the literature about the exact age. This has to do with the maturity of the growth plate (epiphysial line). Very common is the prevalence in the period of rapid growth, shortly after the puberty. This disorder is more prevalent in male than females (2:1 ratio). The child usually presents with some combination of hip,knee, thigh, and groin pain. The leg is typically externally rotated and an antalgic gait is noted. The majority of patients will be able to bear weight and will present with a limp. When testing hip range of motion , internal rotation, flexion and abduction are limited. External rotation and adduction are often increased and all directions are painful. Typically, the involved hip will fall into external rotation when the hip is passively flexed beyond 90 degrees.

Differential Diagnosis

Other conditions to rule out:

• Femoral fractures
• Avascular necrosis of the femoral head
• Legg-Calve-Perthes Disease
• Osteomyelitis
• Septic Arthritis
• Groin pull

Diagnostic Procedures

For a correct and reliable medical diagnosis, medical imaging is necessary for example the of radiographs. With radiographs even a slight displacement of the epiphysis is recognizable. With antero-posterior films, you can examine SCFE. Also lateral radiographs are essential to see when the epiphysis is tilted over towards the back of the femoral neck. Radiographs in both the Anterior/Posterior view and the "frog" postion (or Lauenstein-projection) of each hip is required. The Wilson classification system utlizes the radiographs to classify a mild slip (less than 1/3 displacement), moderate slip (between 1/3 - 1/2 displacement), and severe slip (greater than 1/2 displacment).

Outcome Measures

• Radiographs:
  • Anterior/posterior view
  • Lauenstein-projection
  • Wilson classification system
• Bonescan (MRI, CT):
  • Epifysiolyse
• MRI:
  • Epiphyseal avascular necrosis

Examination

The passive movement research shows that there is a restricted internal rotation, and a remarkably large hip external rotation.

Medical Management

Surgical management of this condition is warranted due to the secondary complications of AVN or chondrolysis. A delay in diagnosis results in a less favorable prognosis. This can lead to long term effects such as OA and cam type impingement due to changes in the femoral neck. Surgical stabilization is performed by placing a screw/screws through the epiphysis to minimize displacement and maintain motion. This operation can have some complications such as avascular bone necrosis, Chondrolyse and infection.

Physical Therapy Management

Patients who had SCFE have a higher level of risk to develop Osteoarthritis. This is something the physiotherapist should know. So he can give hints or tips to his patient about preventive treatment of osteoarthritis. Conservative treatment is not recommended because it can take many years before the growth plate is closed, and risk of further landslide is not inconceivable. After the surgery the patient must protected weight-bearing with crutches for six weeks.

Key Research

Loder RT, Richards BS, Shapiro PS, Reznick LR. Acute slipped capital femoral epiphysis: the importance of physeal stability. J bone joint surg 1993;75A:1134-1140.

van den Berg ME, Keessen W, van der Hoeven H. Epiphysiolysis van de heupkop. Ned Tijdschr Geneeskd 1992;136:1339-43.

Resources

www.rijnlandorthopedie.nl/content.asp

Clinical Bottom Line

As a physiotherapist you should know the symptoms of SCFE, so you can forwarded the patiënt to a orthopedic surgeon. It’s also important to note that SCFE is a risk factor in the early development of osteoarthritis.

Recent Related Research (from Pubmed)

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