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 bilaterally in about a fourth of the cases.

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 hypothesized that as weight increases, shearing forces across the physis are also increased, causing it to weaken. 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. However, this is not a prevalent finding.

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
• 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). 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. 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.

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 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. Radiographs in both the Anterior/Posterior view and the "frog" postion (or Lauenstein-projection) of each hip is required.

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).

Outcome Measures

• Diagnostic Imaging
  • Radiographs:
    • Anterior/posterior view
    • Lauenstein-projection
    • Wilson classification system
  • Bonescan (MRI, CT):
    • Epifysiolyse
  • MRI:
    • Epiphyseal avascular necrosis
• Functional outcome measures
  • Functional Gait Assessment
  • International Hip Outcome Tool (iHOT)
  • Lower Extremity Functional Scale (LEFS)

Examination

With passive movement, there will typically be a restriction with internal rotation, and a remarkably large hip external rotation.

Medical Management

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. 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, chondrolysis and infection.

Physical Therapy Management

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.

After surgery, the patient must protected the limb against 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 forward the patient to an orthopedic surgeon. SCFE is a risk factor in the early development of osteoarthritis.

Recent Related Research (from Pubmed)

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