Slipped Capital Femoral Epiphysis: Difference between revisions
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== Definition/Description<br> == | == Definition/Description<br> == | ||
Slipped Capital Femoral Ephysis (SCFE) occurs in the adolescent population when the proximal femoral epiphysis slips posteriorly on the femoral neck at the physis<ref name="Verhaar">Verhaar JAN, Linden AJ van der. Orthopedie. Houten: Bohn Stafleu Van Loghum, 2001.</ref> In actuality, the metaphysis of the femoral neck is displaced superiorly and anteriorly of the capital femoral epiphysis<ref name="Gholve">Gholve P, Cameron D, Millis M. Slipped capital femoral epiphysis update. Curr Opin Pediatr 2009;21:39-45.</ref>. Epiphysiolysis occurs in about a fourth of the cases | Slipped Capital Femoral Ephysis (SCFE) occurs in the adolescent population when the proximal femoral epiphysis slips posteriorly on the femoral neck at the physis<ref name="Verhaar">Verhaar JAN, Linden AJ van der. Orthopedie. Houten: Bohn Stafleu Van Loghum, 2001.</ref>. In actuality, the metaphysis of the femoral neck is displaced superiorly and anteriorly of the capital femoral epiphysis<ref name="Gholve">Gholve P, Cameron D, Millis M. Slipped capital femoral epiphysis update. Curr Opin Pediatr 2009;21:39-45.</ref>. Epiphysiolysis occurs bilaterally in about a fourth of the cases<ref name="Staheli">Staheli LT. Fundamentals of pediatric orthopedics, 3rd ed. Philadelphia: Lippincott Williams and Wilkins, 2003:88-89.</ref>. | ||
== Clinically Relevant Anatomy == | == Clinically Relevant Anatomy == | ||
The growth plate is located between the caput femoris and collum femoris of the thighbone. The bone fibers have pressure | 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 == | == Epidemiology / Etiology == | ||
There are several factors that can contribute to developing a SCFE | 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<ref name="Koos van Nugteren">Koos van Nugteren. De kwetsbaarheid van het jeugdige skelet. Bohn Stafleu Van Loghum, 2005:44-48.</ref>. It is hypothesized that as weight increases, shearing forces across the physis are also increased, causing it to weaken<ref name="Gholve" />. Other mechanical contributors to this condition are retroversion of the femur and increased physeal obliquity. | |||
*'''Changes in 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<ref name="Koos van Nugteren" />. However, this is not a prevalent finding<ref name="Gholve" /><ref name="Campbell">Campbell S, Vander Linden D, Palisano R. Physical therapy for children. St. Louis, MO:Elsevier Inc, 2006.</ref>. | |||
There are several classification systems to determine the severity of a SCFE: | |||
*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<ref name="Campbell" /> | |||
*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'''.<ref name="Gholve" /> | |||
== Characteristics / Clinical Presentation == | == 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). | 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). There is an increased prevalence during the period of rapid growth, shortly after puberty. The 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<ref name="Gholve" /><ref name="Campbell" />. When testing hip range of motion, internal rotation, flexion, and abduction are limited. External rotation and adduction are often increased and movement in all directions are painful. Typically, the involved hip will fall into external rotation when the hip is passively flexed beyond 90 degrees<ref name="Gholve" /><ref name="Campbell" />. | |||
== Differential Diagnosis == | == Differential Diagnosis == | ||
| Line 33: | Line 49: | ||
== Diagnostic Procedures == | == Diagnostic Procedures == | ||
For a correct and reliable medical diagnosis, medical imaging is necessary for example | For a correct and reliable medical diagnosis, medical imaging is necessary, for example [[X-Rays|radiographs]]. With radiographs, even a slight displacement of the epiphysis is recognizable. With antero-posterior films, you can examine for SCFE. Lateral radiographs are essential to see when the epiphysis is tilted over towards the back of the femoral neck<ref name="Adams">Adams JC, Hamblen, DL. Outline of orthopaedics. 12th ed, 1995:317-321.</ref>. Radiographs in both the Anterior/Posterior view and the "frog" postion (or Lauenstein-projection) of each hip is required<ref name="Gholve" /><ref name="Campbell" />. | ||
The Wilson classification system utilizes 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)<ref name="Gholve" />. | |||
== Outcome Measures == | == Outcome Measures == | ||
*[[Medical Imaging|Radiographs]]<ref name="Gholve" /><ref name="Campbell" /><ref name="Koos van Nugteren" />: | *Diagnostic Imaging | ||
**Anterior/posterior view | **[[Medical Imaging|Radiographs]]<ref name="Gholve" /><ref name="Campbell" /><ref name="Koos van Nugteren" />: | ||
**Lauenstein-projection | ***Anterior/posterior view | ||
**Wilson classification system | ***Lauenstein-projection | ||
*[[Medical Imaging|Bonescan (MRI, CT)]]<ref name="Koos van Nugteren" />: | ***Wilson classification system | ||
**Epifysiolyse | **[[Medical Imaging|Bonescan (MRI, CT)]]<ref name="Koos van Nugteren" />: | ||
*[[Medical Imaging|MRI]]<ref name="Koos van Nugteren" />: | ***Epifysiolyse | ||
**Epiphyseal avascular necrosis | **[[Medical Imaging|MRI]]<ref name="Koos van Nugteren" />: | ||
***Epiphyseal avascular necrosis | |||
*Functional outcome measures | |||
**[[Functional Gait Assessment]] | |||
**[[International Hip Outcome Tool (iHOT)]] | |||
**[[Lower Extremity Functional Scale (LEFS)]] | |||
== Examination == | == Examination == | ||
With passive movement, there will typically be a restriction with internal rotation, and a remarkably large hip external rotation<ref name="Koos van Nugteren" />. | |||
{{#ev:youtube|bIUrbbiD8Qg|300}} | |||
== Medical Management == | == Medical Management == | ||
Surgical management of this condition is warranted due to the secondary complications of | Surgical management of this condition is warranted due to the secondary complications of [[Avascular Necrosis]] or chondrolysis. A delay in diagnosis results in a less favorable prognosis. This can lead to long term effects such as [[Osteoarthritis]] and [[Hip Labral Disorders|cam type impingement]] due to changes in the femoral neck<ref name="Gholve" />. Surgical stabilization is performed by placing a screw/screws through the epiphysis to minimize displacement and maintain motion<ref name="Gholve" /><ref name="Campbell" />. This operation can have some complications such as [[Avascular Necrosis|avascular bone necrosis]], chondrolysis and infection. | ||
== Physical Therapy Management == | == Physical Therapy Management == | ||
Patients who had SCFE have a higher level of risk | Patients who had SCFE have a higher level of risk of developing [[Osteoarthritis]]. Conservative treatment is not recommended because it can take many years before the growth plate is closed, and risk of further displacement is not inconceivable<ref name="van den Berg">van den Berg ME, Keessen W, van der Hoeven H. Epiphysiolysis van de heupkop. Ned Tijdschr Geneeskd 1992;136:1339-43.</ref>. | ||
After surgery, the patient must protected the limb against weight-bearing with crutches for six weeks<ref name="Loder">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.</ref>. | |||
== Key Research == | == Key Research == | ||
| Line 64: | Line 91: | ||
van den Berg ME, Keessen W, van der Hoeven H. Epiphysiolysis van de heupkop. Ned Tijdschr Geneeskd 1992;136:1339-43. | van den Berg ME, Keessen W, van der Hoeven H. Epiphysiolysis van de heupkop. Ned Tijdschr Geneeskd 1992;136:1339-43. | ||
== Resources | == Resources == | ||
[http://www.rijnlandorthopedie.nl/content.asp?id=144 www.rijnlandorthopedie.nl/content.asp] | [http://www.rijnlandorthopedie.nl/content.asp?id=144 www.rijnlandorthopedie.nl/content.asp] | ||
== Clinical Bottom Line == | == Clinical Bottom Line == | ||
As a physiotherapist you should know the symptoms of SCFE, so you can | As a physiotherapist you should know the symptoms of SCFE, so you can forward the patient to an orthopedic surgeon. SCFE is a risk factor in the early development of osteoarthritis. | ||
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) == | == Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) == | ||
Revision as of 06:05, 1 April 2014
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
[edit | edit source]
Slipped Capital Femoral Ephysis (SCFE) occurs in the adolescent population when the proximal femoral epiphysis slips posteriorly on the femoral neck at the physis[1]. In actuality, the metaphysis of the femoral neck is displaced superiorly and anteriorly of the capital femoral epiphysis[2]. Epiphysiolysis occurs bilaterally in about a fourth of the cases[3].
Clinically Relevant Anatomy[edit | edit source]
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[edit | edit source]
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[4]. It is hypothesized that as weight increases, shearing forces across the physis are also increased, causing it to weaken[2]. Other mechanical contributors to this condition are retroversion of the femur and increased physeal obliquity.
- Changes in 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[4]. However, this is not a prevalent finding[2][5].
There are several classification systems to determine the severity of a SCFE:
- 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[5]
- 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.[2]
Characteristics / Clinical Presentation[edit | edit source]
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). There is an increased prevalence during the period of rapid growth, shortly after puberty. The 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[2][5]. When testing hip range of motion, internal rotation, flexion, and abduction are limited. External rotation and adduction are often increased and movement in all directions are painful. Typically, the involved hip will fall into external rotation when the hip is passively flexed beyond 90 degrees[2][5].
Differential Diagnosis[edit | edit source]
Other conditions to rule out[2]:
- Femoral fractures
- Avascular necrosis of the femoral head
- Legg-Calve-Perthes Disease
- Osteomyelitis
- Septic Arthritis
- Groin pull
Diagnostic Procedures[edit | edit source]
For a correct and reliable medical diagnosis, medical imaging is necessary, for example radiographs. With radiographs, even a slight displacement of the epiphysis is recognizable. With antero-posterior films, you can examine for SCFE. Lateral radiographs are essential to see when the epiphysis is tilted over towards the back of the femoral neck[6]. Radiographs in both the Anterior/Posterior view and the "frog" postion (or Lauenstein-projection) of each hip is required[2][5].
The Wilson classification system utilizes 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)[2].
Outcome Measures[edit | edit source]
- Diagnostic Imaging
- Radiographs[2][5][4]:
- Anterior/posterior view
- Lauenstein-projection
- Wilson classification system
- Bonescan (MRI, CT)[4]:
- Epifysiolyse
- MRI[4]:
- Epiphyseal avascular necrosis
- Radiographs[2][5][4]:
- Functional outcome measures
Examination[edit | edit source]
With passive movement, there will typically be a restriction with internal rotation, and a remarkably large hip external rotation[4].
Medical Management[edit | edit source]
Surgical management of this condition is warranted due to the secondary complications of Avascular Necrosis or chondrolysis. A delay in diagnosis results in a less favorable prognosis. This can lead to long term effects such as Osteoarthritis and cam type impingement due to changes in the femoral neck[2]. Surgical stabilization is performed by placing a screw/screws through the epiphysis to minimize displacement and maintain motion[2][5]. This operation can have some complications such as avascular bone necrosis, chondrolysis and infection.
Physical Therapy Management[edit | edit source]
Patients who had SCFE have a higher level of risk of developing Osteoarthritis. Conservative treatment is not recommended because it can take many years before the growth plate is closed, and risk of further displacement is not inconceivable[7].
After surgery, the patient must protected the limb against weight-bearing with crutches for six weeks[8].
Key Research[edit | edit source]
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[edit | edit source]
www.rijnlandorthopedie.nl/content.asp
Clinical Bottom Line[edit | edit source]
As a physiotherapist you should know the symptoms of SCFE, so you can forward the patient to an orthopedic surgeon. SCFE is a risk factor in the early development of osteoarthritis.
Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
- ↑ Verhaar JAN, Linden AJ van der. Orthopedie. Houten: Bohn Stafleu Van Loghum, 2001.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 Gholve P, Cameron D, Millis M. Slipped capital femoral epiphysis update. Curr Opin Pediatr 2009;21:39-45.
- ↑ Staheli LT. Fundamentals of pediatric orthopedics, 3rd ed. Philadelphia: Lippincott Williams and Wilkins, 2003:88-89.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 Koos van Nugteren. De kwetsbaarheid van het jeugdige skelet. Bohn Stafleu Van Loghum, 2005:44-48.
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 Campbell S, Vander Linden D, Palisano R. Physical therapy for children. St. Louis, MO:Elsevier Inc, 2006.
- ↑ Adams JC, Hamblen, DL. Outline of orthopaedics. 12th ed, 1995:317-321.
- ↑ van den Berg ME, Keessen W, van der Hoeven H. Epiphysiolysis van de heupkop. Ned Tijdschr Geneeskd 1992;136:1339-43.
- ↑ 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.
