Slipped Capital Femoral Epiphysis

Ovid: 5-Minute Sports Medicine Consult, The

Slipped Capital Femoral Epiphysis
Tara Merrit
W. Franklin Sease Jr.
  • A disorder of unknown cause in which the proximal femoral epiphysis (head of the femur) begins to “fall off” the femoral neck.
  • The slippage occurs at the epiphyseal plate, which begins to weaken as it matures.
  • There are 4 presentation patterns for SCFE:
    • Preslip
    • Acute
    • Acute-on-chronic
    • chronic
  • SCFEs are classified based on the intensity and duration of symptoms present as well as the radiographic findings.
  • The disorder affects 0.2–10/100,000 children.
  • Predominant age: The mean age at which it occurs is 12 yrs in girls and 13.5 yrs in boys. Age decreases with increasing obesity.
  • The disorder is bilateral in 18–63% of affected children.
  • The disorder frequently occurs in 2 distinct body types: (1) slender, tall, rapidly growing boys and (2) large, obese boys ± undeveloped sexual characteristics. The 2nd body type is more prevalent than the 1st.
  • Pacific Islanders have the highest incidence, followed by African Americans, Hispanics, Native Americans, Americans, and children of Indonesian/Malay descent.
Risk Factors
  • Occurs during the rapid growth spurt
  • Endocrine disorders that weaken the physis are associated with slipped epiphyses and are particularly prevalent in preadolescent children.
  • Radiation therapy and renal failure are also associated with slipped capital femoral epiphysis (SCFE).
  • Obesity
Biomechanical and biochemical factors play a role in SCFE.
  • Biomechanical factors include obesity, femoral retroversion, and increased physeal obliquity.
  • Biochemical factors include increased growth hormone during puberty, which increases the height of the zone of hypertrophy, and increased testosterone, which decreases physeal strength.
Commonly Associated Conditions
  • GH deficiency
  • Hyperthyroidism
  • Hypothyroidism
  • Multiple endocrine neoplasia
  • Panhypopit
  • Renal failure
  • Radiation therapy
  • Determined by history, physical examination, and anteroposterior (AP) and frog lateral view radiographs.
  • It is important to always examine both sides owing to possibility of bilateral disease.
Physical Exam
  • The most common presenting complaint is hip pain and a limp (antalgic gait). Trendelenburg test is positive when the patient stands on the affected leg and a downward pelvic tilt occurs due to hip weakness on the affected side.
  • The pain typically is located in the groin area and very commonly presents as referred medial knee pain ± thigh pain.
  • Pain is usually gradual in onset, and symptoms occur even when minimal displacement is present. Pain also may occur acutely with a dramatic onset of injury and sudden severe hip or knee pain and inability to bear weight.
  • The physical exam reveals tenderness over the hip joint capsule, and an external rotation deformity of the lower extremity may be present.
  • There is restricted hip motion, especially internal rotation, abduction, and forward flexion.
  • The hip tends to rotate externally and abduct as it is flexed (Whitman sign).
  • In chronic cases, the affected leg may be 1–3 cm shorter than the normal leg, and the thigh muscles may be atrophied.
Diagnostic Tests & Interpretation
  • CT is occasionally useful for grading chronic slips.
  • MRI is useful for detecting preslips that may be symptomatic but have normal radiographs.
  • AP and frog-leg lateral views confirm the diagnosis. The affected side always should be compared with the unaffected leg. Up to 10% of SCFE patients have normal radiographs initially.
  • The capital epiphysis is seen to displace posteriorly and downward, whereas the femoral neck displaces upward and anteriorly. In some patients, displacement is not obvious, but the physeal plate is widened (preslipping stage).
  • Classification is based on the severity of the slip. Type 1 slips involve <33% of the width of the femoral epiphysis. Type 2 involves a 33–50% slip, and a type 3 involves >50% of the width of the femoral epiphysis.
Differential Diagnosis
  • Femoral cutaneous nerve entrapment (more common in muscular girls)
  • Proximal femur fracture
  • Avascular necrosis
  • Juvenile rheumatoid arthritis
  • Chondrolysis
  • Psoas abscess
  • Legg-Calve-Perthes disease (in younger age range)
  • Septic joint
  • Toxic synovitis
  • Intra-abdominal tumor


Ongoing Care
Follow-Up Recommendations
Orthopedic referral should be made immediately on diagnosis.
  • Prognosis is usually good, except in patients with acute traumatic separation.
  • Slight shortening of the leg of <1.25 cm may result, along with a mild external rotation deformity.
  • The internal fixation devices are removed after the physeal plate closes in 1–2 yrs.
Additional Reading
Aronsson DD, Loder RT, Breur GJ, et al. Slipped capital femoral epiphysis: current concepts. J Am Acad Orthop Surg. 2006;14:666–679.
Mercier L. Practical orthopedics. St. Louis: Mosby-Year Book, 1995.
Paletta GA, Andrish JT. Injuries about the hip and pelvis in the young athlete. Clin Sports Med. 1995;14:591–628.
Snider RK, Greene WB, Johnson TR, et al. Essentials of musculoskeletal care. Rosemont, IL: American Academy of Orthopedic Surgeons, 1998.
Stanitski CL, DeLee JC, Drez D Jr. Pediatric and adolescent sports medicine. Philadelphia: WB Saunders, 1994.
732.2 Nontraumatic slipped upper femoral epiphysis

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