Slipped Capital Femoral Epiphysis

Question 1

Define Slipped Capital Femoral Epiphysis

Answer 1

Weakness in the proximal femoral growth plate allows displacement of the capital femoral epiphysis

The metaphysis that displaces anteriorly and superiorly and the femoral head epiphysis postero-inferiorly, leading to the slipped state

Question 2

What are the types of Slipped Capital Femoral Epiphysis

Answer 2

Acute: prodromal symptoms lasting <3 weeks prior to an acute fracture-like event
Chronic: symptoms lasting >3 weeks
Acute-on-chronic: symptoms lasting >3 weeks with a sudden onset of increased pain and irritation.

Stable: can bear weight with or without support. This classification accounts for nearly 90% of all SCFE cases
Unstable: unable to bear weight with or without support.

Question 3

What are the risk factors for Slipped Capital Femoral Epiphysis

Answer 3

Obesity
Adolescence
Puberty onset
Endocrine disorders e.g. hypothyroidism, panhypopituitarism, renal osteodystrophy, growth hormone deficiency

Question 4

What are the symptoms of Slipped Capital Femoral Epiphysis

Answer 4

Bilateral hip pain (60% bilat, may refer to groin or knee)
Restricted range of motion
Recent trauma

Question 5

What are the differentials for Slipped Capital Femoral Epiphysis

Answer 5

Hip fracture
Avascular necrosis
Perthes’ disease
Hip dysplasia
Osteomyelitis
Septic arthritis
Stress fracture
Groin pull/pain

Question 6

What are the signs of Slipped Capital Femoral Epiphysis on examination

Answer 6

MSK:
Gait with affected leg externally rotated
Restricted range of motion
Trendelenburg’s gait - the child leans the trunk towards the unaffected side (child stands on the affected leg with the knee flexed and the hip extended)

Question 7

What investigations should be done for Slipped Capital Femoral Epiphysis

Answer 7

Bloods: U&Es, TFTs, GH

Other
- Frog-leg lateral x-rays: abnormal Klein line (does not intersect the femoral head)
- Bilateral antero-posterior x-rays: abnormal Klein line (does not intersect the femoral head)

Klein line = line drawn from superior aspect of the femoral neck

Question 8

What is the management for stable Slipped Capital Femoral Epiphysis

Answer 8

First line: In-situ fixation of the epiphysis with a single screw
(weight bearing permitted in first 2 weeks, crutches used for few weeks)
+ monitor weight, encourage weight loss
± prophylactic fixation of contralateral hip
Second line: Modified Dunn procedure (open reduction and internal fixation)
Third line: one graft epiphysiodesis (removes a portion of residual physis with drill and curettage through a rectangular window on the anterior aspect of the neck)

Question 9

What is the management for unstable Slipped Capital Femoral Epiphysis

Answer 9

Acute surgery:
(1) Percutaneous decompression of the hip joint (2) incidental repositioning of the slip (3) fixation with 2 screws
Modified Dunn procedure: open reduction and internal fixation (decreases risk of avascular necrosis)
± prophylactic fixation of the contralateral hip

Question 10

What are the complications of Slipped Capital Femoral Epiphysis

Answer 10

Chondrolysis (acute dissolution of articular cartilage)
Late deformity (disabling external rotation deformity persists in a few patients causing gait disturbance and femoro-acetabular impingement)
SCFE in the contralateral hip
Osteonecrosis

Question 11

What is the prognosis for Slipped Capital Femoral Epiphysis

Answer 11

Related to initial severity of the slip, success of surgery, avoidance of serious complications, underlying disorders, and whether it is bilateral or not
A study of stable SCFE cases treated with surgical dislocation of the hip noted that 87% of cases had some degree of labral damage and 85% of cases had some degree of cartilage damage