Introduction

Slipped Capital Femoral Epiphysis (SCFE), also sometimes called Slipped Upper Femoral Epiphysis (SUFE) is a disease of childhood, typically seen in late childhood and early adolescence.

In the condition, the head of the femur ‘slips’ out of alignment due to shearing forces across the physics (growth plate).

SCFE is associated with obesity, and often presents as hip and / or knee pain. It is usually unilateral but can be bilateral. The affected leg may be shortened and external rotated.

It can be diagnosed with a frog leg lateral view x-ray of the hip and always requires surgical intervention. Left untreated, there is often further slippage and permanent disability.

 

Epidemiology

  • Weight often >90th percentile (at least 50% of cases)
    • Obesity more likely to cause earlier age of onset, more severe disease and bilateral disease
  • Between 0.2 and 10 per 100,000
  • Slightly more common in boys (60% of cases)
    • Boys mean age – 13.5
    • Girls mean age – 12
  • Left hip is more commonly affected
  • Bilateral in 20-50% of cases
  • Sometimes associated with endocrine disorders – check for hypothyroidism

Pathology

  • Capital femoral physis is displaced from the metaphysis
  • Due to mechanical forces on a susceptical physis
  • Exact aetiology is unknown
  • Capital femoral physis is displaced from the metaphysis
  • Slipped Capital Femoral Epiphysis (SCFE / SUFE)

    X-ray demonstrating Slipped Capital Femoral Epiphysis (SCFE / SUFE)

Presentation

  • Pain in the groin, thigh or knee. Often vague
    • Knee pain is often the only presenting complaint
  • Antalgica gait
  • Externally rotated hip / “out toeing”
  • Affected leg may be shortened
  • Can be acute, chronic, or acute on chronic
  • Child may or pay not be able to weight bear
    • 85% of cases are chronic (>3 weeks gradual onset of symptoms)
  • Drehmann sign – there is passive flexion of the hip during obligatory external rotation – this is highly suggestive of SCFE
  • Thigh atrophy may be present

Differentials

  • Transient Synovitis
    • Usually younger children
    • Always acute
    • Resolves within a few days
    • Investigations normal
  • Septic Arthritis
    • Child often unwell
    • Signs of sepsis
    • Bloods suggestive of infection (raised WCC and CRP)
  • Perthes Disease
    • Usually younger children (age 4-8)

Investigation

  • X-ray – AP and frog leg lateral views of the hip
  • Always x-ray both sides!
  • Usually diagnostic
  • MRI performed rarely – where there is high clinical suspicion but negative x-rays it can identify pre-slip pathology such as growth plate widening and oedema of the metaphysis
  • Bloods – normal

 

Management

  • Surgical management is always required – refer urgently for orthopaedic assessment
  • If SCFE is suspected, then the child should be kept non-weight bearing until the diagnosis is made
  • Surgical techniques – usually screws to prevent any further slipping

Complications

  • Osteonecrosis – even with surgical treatment – 50% risk without treatment, about 5% risk with treatment
  • Chondrolysis
  • Osteoarthritis – earlier risk of OA
  • Impingement – femoral acetabular impingement due to severe deformity of the femoral neck. Further surgery may be required
  • Chronic pain (5-10%)

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