slipped_capital_femoral_epiphysis_flashcards

Question 1

What is Slipped Capital Femoral Epiphysis (SCFE) also known as?

Answer 1

Slipped upper femoral epiphysis

Question 2

What is the typical age group for SCFE?

Answer 2

Typically age group is 10-15 years

Question 3

Which children are more commonly affected by SCFE?

Answer 3

More common in obese children and boys

Question 4

Describe the displacement of the femoral head epiphysis in SCFE.

Answer 4

Displacement of the femoral head epiphysis postero-inferiorly

Question 5

How may SCFE present in children?

Answer 5

May present acutely following trauma or more commonly with chronic, persistent symptoms

Question 6

What are the common symptoms of SCFE?

Answer 6

Hip, groin, medial thigh or knee pain; loss of internal rotation of the leg in flexion

Question 7

What percentage of SCFE cases are bilateral?

Answer 7

Bilateral slip in 20% of cases

Question 8

Which imaging views are diagnostic for SCFE?

Answer 8

AP and lateral (typically frog-leg) views

Question 9

What is the typical management for SCFE?

Answer 9

Internal fixation: typically a single cannulated screw placed in the centre of the epiphysis

Question 10

Name some complications of SCFE.

Answer 10

Osteoarthritis, avascular necrosis of the femoral head, chondrolysis, leg length discrepancy

Question 11

What is the initial management for a patient with suspected SUFE?

Answer 11

Ensure the patient remains non-weight-bearing, provide analgesia, and make an immediate orthopaedic referral.

Question 12

What is the definitive treatment for SUFE?

Answer 12

Surgical repair

Question 13

What surgical technique is commonly used to treat SUFE?

Answer 13

In situ screw fixation across the growth plate.

Question 14

What is Trethowan’s sign on an X-ray indicative of SUFE?

Answer 14

The line of Klein does not intersect the superior femoral epiphysis or there is asymmetry between the lines of Klein on either side.

Question 15

What is the purpose of in situ screw fixation in SUFE?

Answer 15

To stabilize the femoral head and prevent further slipping.

Question 16

summarise slipped capital femoral epiphysis

Answer 16

Slipped capital femoral epiphysis

Slipped capital femoral epiphysis is rare hip condition seen in children, classically seen in obese boys. It is also is known as slipped upper femoral epiphysis.

Basics
typically age group is 10-15 years
More common in obese children and boys
Displacement of the femoral head epiphysis postero-inferiorly
May present acutely following trauma or more commonly with chronic, persistent symptoms

Features
hip, groin, medial thigh or knee pain
loss of internal rotation of the leg in flexion
bilateral slip in 20% of cases

Investigation
AP and lateral (typically frog-leg) views are diagnostic

Management
internal fixation: typically a single cannulated screw placed in the centre of the epiphysis

Complications
osteoarthritis
avascular necrosis of the femoral head
chondrolysis
leg length discrepancy

Question 17

summarise management of SUFE

Answer 17

Slipped Capital Femoral Epiphysis (SUFE)
 Ensure patient remains non-weight-bearing, analgesia, immediate orthopaedic referral
 Surgical repair
 In situ screw fixation across the growth plate Viva Tips
 What are the X-ray findings?
o Trethowan’s sign: line of Klein does not intersect superior femoral
epiphyses/asymmetry between line of Klein’s on either side

Question 18

A 15-year-old boy presents to the GP with a 5-week history of gradual onset left groin pain and a limp. The right leg is not affected and he is otherwise well, with no past medical or family history. On examination, there is a loss of internal rotation of the left leg. There is no swelling or warmth felt over the joints. His notes document normal vital signs, height in the 50th percentile and weight in the 95th percentile.

Which of the following is the most likely diagnosis?

Developmental dysplasia of the hip
Perthes’ disease
Septic arthritis
Slipped capital femoral epiphysis
Transient synovitis

Answer 18

Slipped capital femoral epiphysis

Obesity is a risk factor for slipped capital femoral epiphysis

The correct option is slipped capital femoral epiphysis (classically seen in obese boys aged 10-15). It results from a weakness in the proximal femoral growth plate, which can be due to obesity, endocrine disorders or rapid growth. On examination, a loss of internal rotation of the affected leg is usually seen.

Perthes’ disease can also present with groin pain, though it typically presents in 4 to 8-year-olds (Perthes’ in Primary school, SUFE in Secondary school). Other risk factors include being male and having a lower socioeconomic status.

In septic arthritis, the child would more likely be systemically unwell, with a hot and swollen joint. This is likely to occur acutely. However, the vital signs have been documented as normal in this case making it an unlikely diagnosis.

Developmental dysplasia of the hip is usually identified much earlier, during the first year of life, in routine examinations of the hip (Barlow/Ortolani tests, limited hip abduction).

Transient synovitis is a diagnosis of exclusion. It usually presents in 2-12-year-olds and there may be a history of recent upper respiratory tract infection.

Question 19

A 13-year-old boy is brought to the emergency department with his parents with acute-onset right-sided groin pain and an inability to weight bear after a fall.

His heart rate is 95 bpm, his blood pressure is 120/74 mmHg, his BMI is 32 kg/m² and he is afebrile. On examination, he has an antalgic gait and decreased range of motion. The neurovascular status of both legs is intact.

Given the likely diagnosis, what is also most likely to be seen on examination?

Reduced external rotation of the leg in extension
Reduced external rotation of the leg in flexion
Reduced internal rotation of the leg in extension
Reduced internal rotation of the leg in flexion
Reduced leg abduction while leg is extended

Answer 19

Reduced internal rotation of the leg in flexion

There is often the loss of internal rotation of the leg in flexion in slipped capital femoral epiphysis

Reduced internal rotation of the leg in flexion is correct in this case. The most likely diagnosis is slipped capital femoral epiphysis (SCFE) due to the acute-onset right-sided groin pain and inability to weight bear following potential trauma in a boy with obesity aged between 10-15 years. SCFE is technically a misnomer, as the epiphysis remains in place and it is the metaphysis which slips anteriorly and externally rotates. Attempting to internally rotate the leg while the hip is flexed will attempt to overcome this external rotation which is limited in SCFE, therefore making this option correct.

Reduced external rotation of the leg in extension is incorrect in this case. In SCFE, the metaphysis of the femur slips anteriorly and externally rotates. Therefore, on examination, the external rotation would already be present, and attempting to do this further would demonstrate very little limitation. Many patients with SCFE prefer to hold their leg in external rotation as this hurts less.

Reduced external rotation of the leg in flexion is incorrect in this case. Similarly to the above, external rotation of the leg is not limited, as SCFE leads to external rotation of the femoral metaphysis. As well as this, many patients with SCFE prefer to hold the leg in external rotation as this causes less pain.

Reduced internal rotation of the leg in extension is incorrect in this case. Although SCFE causes reduced internal rotation of the leg, the most effective way to asses this would be to flex the hip, as this facilitates internal rotation of the hip, which would be reduced in SCFE. Internal and external rotation of the hip cannot be effectively tested without holding the hip in flexion.

Reduced leg abduction while leg is extended is incorrect in this case. Although restricted abduction of the leg may be seen in SCFE, reduced internal rotation of the leg while the hip is flexed is more strongly associated with SCFE, as SCFE causes displacement of the femoral metaphysis anteriorly and externally rotates it, therefore internal rotation would be more obviously limited.

Question 20

A 12-year-old boy is seen in the paediatric clinic with his mother. She tells you that her son has been limping over the last week with complaints of pain in his left hip and groin. There is no history of trauma to note. His past medical history includes eczema and he completed a course of antibiotics for tonsillitis 3 weeks ago.

On examination, there is palpable tenderness in the left groin, hip and knee. There is a loss of internal rotation of left hip flexion due to extreme pain. He is in the 95th percentile of weight for his age.

What is the most likely diagnosis?

Juvenile idiopathic arthritis
Legg-Calve-Perthe’s disease
Septic arthritis
Slipped upper femoral epiphysis
Transient synovitis

Answer 20

Slipped upper femoral epiphysis

Obese boy with groin/thigh/knee pain → ?slipped capital femoral epiphysis

Slipped upper femoral epiphysis (SUFE) is correct. This is a rare hip condition seen in children (10-15 years), particularly obese boys. The condition causes displacement of the femoral head epiphysis posteroinferiorly causing hip, groin, and medial thigh +/- knee pain. Loss of internal rotation of the leg whilst in flexion may also be seen.

Juvenile idiopathic arthritis (JIA) is incorrect. JIA is characterised by joint inflammation persisting for at least six weeks in children under the age of 16 years. All other causes of joint inflammation must be excluded to make the diagnosis. The relatively short history of hip pain in this patient’s presentation, combined with being overweight is more indicative of SUFE.

Legg-Calve-Perthe’s disease is incorrect. This is characterised by necrosis of the femoral head that is most often seen in young boys aged between 4-8 years. Symptoms include a painless limp and a restricted range of movement. The presence of painful hip movements in an overweight 12-year-old makes SUFE more likely.

Septic arthritis is incorrect. This is always an important differential diagnosis to consider. However, septic arthritis would be much more likely if the patient presented with a fever in association with symptoms of systemic upset.

Transient synovitis is incorrect. This is a self-limiting condition secondary to inflammation of the synovium, commonly due to a recent viral illness. Transient synovitis is most common between 3-8 years of age and symptoms include groin or hip pain with a limp and refusal to weight bear. Although there is a history of a previous infection, the timeframe since the infection and the age of the patient makes transient synovitis unlikely.