Slipped capital femoral epiphysis
Encyclopedia
Slipped capital femoral epiphysis (SCFE, also known as "Slipped upper femoral epiphysis") is a medical term referring to a fracture through the physis (the growth plate), which results in slippage of the overlying epiphysis.
The capital (head of the femur
) should sit squarely on the femoral neck. Abnormal movement along the growth plate results in the slip.
Often this condition will present in obese adolescent males, especially young black males, and sometimes females, with an insidious onset of thigh or knee pain with a painful limp. Hip motion will be limited, particularly internal rotation.
SCFE (sometimes pronounced "skiffy") is a common cause of hip and knee pain in children aged 10–17. It is the most common hip disorder in adolescence. It is the displacement of the upper femoral epiphysis
. Slippage occurs through the growth plate (epiphysis between the head and neck of the bone). The femoral epiphysis remains in the acetabulum (hip socket), while the metaphysis (end of the femur) move in an anterior direction with external rotation.
the knee starts to get sore about 2-4 months before the actual hip goes. the pain in the knee can come and go.
. The Centers for Disease Control offers a body mass index
(BMI) calculator to help determine a person's risk for obesity. http://www.cdc.gov/nccdphp/dnpa/bmi/index.htm
The disorder can sometimes be associated with endocrinopathies such as thyroid
problems.
This disease warrants x-rays of the pelvis (AP and frog lateral). The appearance of the head of the femur in relation to the shaft likens that of a "melting ice cream cone". The severity of the disease can be measured using the Southwick angle
.
Consultation with an orthopaedic surgeon is necessary to repair this problem. Untreated cases can result in serious growth abnormalities and permanent disability.
The disease can be treated with external in-situ pinning or open reduction and pinning. The risk of reducing this fracture is disruption of the blood supply. Some also advocate pinning the unaffected side prophylactically.
and remain on strict bed rest
. It should be regarded as an orthopaedic emergency as further slippage may result in occlusion of the blood supply and avascular necrosis (risk 25%). Almost all treatment requires surgery. Surgery involves the placement of one or two pins into the femoral head to prevent further slippage. The chances of a slippage occurring in the other hip are 20% within 18 months of diagnosis of the first slippage and consequently the opposite unaffected femur may also require pinning.
It has been shown in the past that attempts to correct the slippage by moving the head back into its correct position can cause the bone to die. Therefore the head of the femur is usually pinned 'as is'. A small incision is made in the outer side of the upper thigh and metal pins are placed through the femoral neck and into the head of the femur. A dressing covers the wound.
The fracture occurs at the hypertrophic zone of the physeal cartilage. Stress on the hip causes the epiphysis to move posteriorly and medially. By convention, position and alignment in SCFE is described by referring to the relationship of the proximal fragment (capital femoral epiphysis) to the normal distal fragment (femoral neck). Because the physis has yet to close, the blood supply to the epiphysis still should be derived from the femoral neck; however, this late in childhood, the supply is tenuous and frequently lost after the fracture occurs. Manipulation of the fracture frequently results in osteonecrosis and chondrolysis because of the tenuous nature of the blood supply.4,5,6
SCFE affects approximately 1-3 per 100,000 people. It should be suspected in adolescents and more frequently occurs in boys (male 2:1 female). It is strongly linked to obesity. Other risk factors include: Family history, Endocrine disorders, Radiation / chemotherapy, African heritage or Mild trauma. Author: Brent Adler, MD, Chief of Musculoskeletal Imaging, Department of Radiology, Children's Hospital
The capital (head of the femur
Femur
The femur , or thigh bone, is the most proximal bone of the leg in tetrapod vertebrates capable of walking or jumping, such as most land mammals, birds, many reptiles such as lizards, and amphibians such as frogs. In vertebrates with four legs such as dogs and horses, the femur is found only in...
) should sit squarely on the femoral neck. Abnormal movement along the growth plate results in the slip.
Often this condition will present in obese adolescent males, especially young black males, and sometimes females, with an insidious onset of thigh or knee pain with a painful limp. Hip motion will be limited, particularly internal rotation.
SCFE (sometimes pronounced "skiffy") is a common cause of hip and knee pain in children aged 10–17. It is the most common hip disorder in adolescence. It is the displacement of the upper femoral epiphysis
Epiphysis
The epiphysis is the rounded end of a long bone, at its joint with adjacent bone. Between the epiphysis and diaphysis lies the metaphysis, including the epiphyseal plate...
. Slippage occurs through the growth plate (epiphysis between the head and neck of the bone). The femoral epiphysis remains in the acetabulum (hip socket), while the metaphysis (end of the femur) move in an anterior direction with external rotation.
Signs and symptoms
Symptoms are waddling gait, loss of motion in the hip joint, externally rotated foot, pain in the knee / groin / hip and shortening of the hip. In up to 20% of cases slippage is bilateral.the knee starts to get sore about 2-4 months before the actual hip goes. the pain in the knee can come and go.
Cause
SCFE is often associated with obesityObesity
Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...
. The Centers for Disease Control offers a body mass index
Body mass index
The body mass index , or Quetelet index, is a heuristic proxy for human body fat based on an individual's weight and height. BMI does not actually measure the percentage of body fat. It was invented between 1830 and 1850 by the Belgian polymath Adolphe Quetelet during the course of developing...
(BMI) calculator to help determine a person's risk for obesity. http://www.cdc.gov/nccdphp/dnpa/bmi/index.htm
The disorder can sometimes be associated with endocrinopathies such as thyroid
Thyroid
The thyroid gland or simply, the thyroid , in vertebrate anatomy, is one of the largest endocrine glands. The thyroid gland is found in the neck, below the thyroid cartilage...
problems.
Diagnosis
The diagnosis is a combination of clinical suspicion plus radiological investigation. 20-50% of SCFE are missed or misdiagnosed on their first presentation to a medical facility. This is because the common symptom is knee pain. This is referred pain from the hip. The knee is investigated and found to be normal.This disease warrants x-rays of the pelvis (AP and frog lateral). The appearance of the head of the femur in relation to the shaft likens that of a "melting ice cream cone". The severity of the disease can be measured using the Southwick angle
Southwick angle
A Southwick angle is a radiographic angle used to measure the severity of a slipped capital femoral epiphysis on a radiograph. It was named after Wayne O. Southwick, a famous surgeon.The angle is measured on a frog lateral view of the bilateral hips...
.
Consultation with an orthopaedic surgeon is necessary to repair this problem. Untreated cases can result in serious growth abnormalities and permanent disability.
The disease can be treated with external in-situ pinning or open reduction and pinning. The risk of reducing this fracture is disruption of the blood supply. Some also advocate pinning the unaffected side prophylactically.
Treatment
Once SCFE is suspected, the patient should be non weight bearingWeight bearing
In orthopedics, weight-bearing is the amount of weight a patient puts on the leg on which surgery has been performed. In general, it is described as a percentage of the body weight, because each leg of a healthy person carries the full body weight when walking, in an alternating fashion.After...
and remain on strict bed rest
Bed rest
Bed rest is a medical treatment involving a period of consistent recumbence in bed. It is used as a treatment for an illness or medical condition, especially when prescribed or chosen rather than resulting from severe prostration or imminent death...
. It should be regarded as an orthopaedic emergency as further slippage may result in occlusion of the blood supply and avascular necrosis (risk 25%). Almost all treatment requires surgery. Surgery involves the placement of one or two pins into the femoral head to prevent further slippage. The chances of a slippage occurring in the other hip are 20% within 18 months of diagnosis of the first slippage and consequently the opposite unaffected femur may also require pinning.
It has been shown in the past that attempts to correct the slippage by moving the head back into its correct position can cause the bone to die. Therefore the head of the femur is usually pinned 'as is'. A small incision is made in the outer side of the upper thigh and metal pins are placed through the femoral neck and into the head of the femur. A dressing covers the wound.
Complications
Failure to treat the condition may lead to: avascular necrosis (death of the femoral head), degenerative hip disease, gait abnormalities and chronic pain.Epidemiology
SCFE is a Salter-Harris type 1 Fracture through the proximal femoral physis. Stress around the hip causes a shear force to be applied at the growth plate. Certainly, trauma has a role in the manifestation of the fracture, but an intrinsic weakness in the physeal cartilage also is present. The almost exclusive incidence of SCFE during the adolescent growth spurt indicates a hormonal role. Obesity is another key predisposing factor in the development of SCFE.3The fracture occurs at the hypertrophic zone of the physeal cartilage. Stress on the hip causes the epiphysis to move posteriorly and medially. By convention, position and alignment in SCFE is described by referring to the relationship of the proximal fragment (capital femoral epiphysis) to the normal distal fragment (femoral neck). Because the physis has yet to close, the blood supply to the epiphysis still should be derived from the femoral neck; however, this late in childhood, the supply is tenuous and frequently lost after the fracture occurs. Manipulation of the fracture frequently results in osteonecrosis and chondrolysis because of the tenuous nature of the blood supply.4,5,6
SCFE affects approximately 1-3 per 100,000 people. It should be suspected in adolescents and more frequently occurs in boys (male 2:1 female). It is strongly linked to obesity. Other risk factors include: Family history, Endocrine disorders, Radiation / chemotherapy, African heritage or Mild trauma. Author: Brent Adler, MD, Chief of Musculoskeletal Imaging, Department of Radiology, Children's Hospital
See also
- Legg–Calvé–Perthes syndrome - another cause of avascular necrosis of the femoral head, seen in younger children than SCFE.