Slipped capital femoral epiphysis

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Slipped capital femoral epiphysis
Other namesSlipped upper femoral epiphysis, coxa vara adolescentium, SCFE, SUFE
Epilys.jpg
X-ray showing a slipped capital femoral epiphysis, before and after surgical fixation.
Specialty Orthopedic surgery   OOjs UI icon edit-ltr-progressive.svg
Symptoms Groin pain, referred knee and thigh pain, waddling gait, restricted range of motion of leg
Usual onset Adolescence
Risk factors Obesity, hypothyroidism

Slipped capital femoral epiphysis (SCFE or skiffy, slipped upper femoral epiphysis, SUFE or souffy, coxa vara adolescentium) is a medical term referring to a fracture through the growth plate (physis), which results in slippage of the overlying end of the femur (metaphysis).

Contents

Normally, the head of the femur, called the capital, should sit squarely on the femoral neck. Abnormal movement along the growth plate results in the slip. The term slipped capital femoral epiphysis is actually a misnomer, because the epiphysis (end part of a bone) remains in its normal anatomical position in the acetabulum (hip socket) due to the ligamentum teres femoris. It is actually the metaphysis (neck part of a bone) which slips in an anterior direction with external rotation.

SCFE is the most common hip disorder in adolescence. SCFEs usually cause groin pain on the affected side, but sometimes cause knee or thigh pain. One in five cases involves both hips, resulting in pain on both sides of the body. SCFEs occurs slightly more commonly in adolescent males, especially young black males, although it also affects females. Whilst it can occur in any child, the major risk factor is childhood obesity. [1] Symptoms include the gradual, progressive onset of thigh or knee pain with a painful limp. Hip motion will be limited, particularly internal rotation. Running, and other strenuous activity on legs, will also cause the hips to abnormally move due to the condition and can potentially worsen the pain. Stretching is very limited.

Signs and symptoms

Usually, a SCFE causes groin pain, but it may cause pain in only the thigh or knee, because the pain may be referred along the distribution of the obturator nerve. [2] The pain may occur on both sides of the body (bilaterally), as up to 40 percent of cases involve slippage on both sides. [3] In cases of bilateral SCFEs, they typically occur within one year of each other. [4] About 20 percent of all cases include a SCFE on both sides at the time of presentation. [5]

Signs of a SCFE include a waddling gait, decreased range of motion. Often the range of motion in the hip is restricted in internal rotation, abduction, and flexion. [2] A person with a SCFE may prefer to hold their hip in flexion and external rotation.[ citation needed ]

Complications

Failure to treat a SCFE may lead to: death of bone tissue in the femoral head (avascular necrosis), degenerative hip disease (hip osteoarthritis), [6] gait abnormalities and chronic pain. SCFE is associated with a greater risk of arthritis of the hip joint later in life. [6] 17–47 percent of acute cases of SCFE lead to the death of bone tissue (osteonecrosis) effects. [2]

Cause

In general, SCFE is caused by increased force applied across the epiphysis, or a decrease in the resistance within the physis to shearing. [4] Obesity is the by far the most significant risk factor. A study in Scotland looked at the weight of 600,000 infants, and followed them up to see who got SCFE. [1] This study identified that obese children had an almost twenty times greater risk than thin children, with a 'dose-response'- so the greater the weight of the child, the greater the risk of SCFE. In 65 percent of cases of SCFE, the person is over the 95th percentile for weight. [2] Endocrine diseases may also contribute (though are far less of a risk than obesity), such as hypothyroidism, hypopituitarism, and renal osteodystrophy. [2] [7]

Sometimes no single cause accounts for SCFE, and several factors play a role in the development of a SCFE i.e. both mechanical and endocrine (hormone-related) factors. Skeletal changes may also make someone at risk of SCFE, including femoral or acetabular retroversion, [4] those these may simply be chronic skeletal manifestations of childhood obesity.

Pathophysiology

SCFE is a Salter-Harris type 1 fracture (fracture through the physis or growth plate) through the proximal femoral physis, which can be distinguished from other Salter-Harris type 1 fractures by identifying prior epiphysiolysis, an intact (in chronic SCFE) or partially torn (in acute SCFE) periosteum, and the displacement being slower. Stress around the hip causes a shear force to be applied at the growth plate, with metaphysis anteriorly translating and externally rotating, while epiphysis remains within acetabulum. [8]

An intrinsic weakness in the physis with a high axial load is the hypothesized mechanism. Obesity is the most important predisposing factor in the development of SCFE (working by increasing axial load). The physis being more vertical and weak, perichondrial ring being thin and unlocking of interlocking mamillary processes - in adolescence - contributes to high incidence. The condition is also more common in boys. [9]

The fracture occurs at the hypertrophic zone of the physeal cartilage. Stress on the hip causes the epiphysis to move posteriorly and medially, relative to the metaphysis. Although it is not the epiphysis that displaced, 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 (as in an attempted reduction, especially a forceful one) frequently results in osteonecrosis and the acute loss of articular cartilage (chondrolysis) because of the tenuous nature of the blood supply.[ citation needed ]

Diagnosis

The diagnosis is a combination of clinical suspicion plus radiological investigation. Children with a SCFE experience a decrease in their range of motion, and are often unable to complete hip flexion or fully rotate the hip inward. [10] 20–50% of SCFE are missed or misdiagnosed on their first presentation to a medical facility.[ citation needed ] SCFEs may be initially overlooked, because the first symptom is knee pain, referred from the hip. The knee is investigated and found to be normal. [7]

SCFE FROG B&W.jpg

The diagnosis requires x-rays of the pelvis, with anteriorposterior (AP) and frog-leg lateral views. [11] The appearance of the head of the femur in relation to the shaft likens that of a "melting ice cream cone", visible with Klein's line. The severity of the disease can be measured using the Southwick angle.[ citation needed ]

Classification

Treatment

The disease can be treated with external in-situ pinning or open reduction and pinning. Consultation with an orthopaedic surgeon is necessary to repair this problem. Pinning the unaffected side prophylactically is not recommended for most patients, but may be appropriate if a second SCFE is very likely. [11]

Once SCFE is suspected, the patient should be non-weight bearing and remain on strict bed rest. In severe cases, after enough rest the patient may require physical therapy to regain strength and movement back to the leg. A SCFE is an orthopaedic emergency, as further slippage may result in occlusion of the blood supply and avascular necrosis (risk of 25 percent). Almost all cases require surgery, which usually involves the placement of one or two pins into the femoral head to prevent further slippage. [12] The recommended screw placement is in the center of the epiphysis and perpendicular to the physis. [13] Chances of a slippage occurring in the other hip are 20 percent within 18 months of diagnosis of the first slippage and consequently the opposite unaffected femur may also require pinning.[ citation needed ]

The risk of reducing this fracture includes the disruption of the blood supply to the bone. 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.[ citation needed ]

Epidemiology

SCFE affects approximately 1–10 per 100,000 children. [4] The incidence varies by geographic location, season of the year, and ethnicity. [4] In eastern Japan, the incidence is 0.2 per 100,000 and in the northeastern U.S. it is about 10 per 100,000. [2] Africans and Polynesians have higher rates of SCFE. [2]

SCFEs are most common in adolescents 11–15 years of age, [6] and affects boys more frequently than girls (male 2:1 female). [2] [4] It is strongly linked to obesity, and weight loss may decrease the risk. [14] Other risk factors include: family history, endocrine disorders, radiation / chemotherapy, and mild trauma.

The left hip is more often affected than the right. [2] Over half of cases may have involvement on both sides (bilateral). [2]

See also

Related Research Articles

<span class="mw-page-title-main">Legg–Calvé–Perthes disease</span> Osteochondrosis that results in death and fracture located in hip joint

Legg–Calvé–Perthes disease (LCPD) is a childhood hip disorder initiated by a disruption of blood flow to the head of the femur. Due to the lack of blood flow, the bone dies and stops growing. Over time, healing occurs by new blood vessels infiltrating the dead bone and removing the necrotic bone which leads to a loss of bone mass and a weakening of the femoral head.

<span class="mw-page-title-main">Coxa vara</span> Deformity of the hip

Coxa vara is a deformity of the hip, whereby the angle between the head and the shaft of the femur is reduced to less than 120 degrees. This results in the leg being shortened and the development of a limp. It may be congenital and is commonly caused by injury, such as a fracture. It can also occur when the bone tissue in the neck of the femur is softer than normal, causing it to bend under the weight of the body. This may either be congenital or the result of a bone disorder. The most common cause of coxa vara is either congenital or developmental. Other common causes include metabolic bone diseases, post-Perthes deformity, osteomyelitis, and post traumatic. Shepherd's Crook deformity is a severe form of coxa vara where the proximal femur is severely deformed with a reduction in the neck shaft angle beyond 90 degrees. It is most commonly a sequela of osteogenesis imperfecta, Paget's disease, osteomyelitis, tumour and tumour-like conditions.

<span class="mw-page-title-main">Hip replacement</span> Surgery replacing hip joint with prosthetic implant

Hip replacement is a surgical procedure in which the hip joint is replaced by a prosthetic implant, that is, a hip prosthesis. Hip replacement surgery can be performed as a total replacement or a hemi/semi(half) replacement. Such joint replacement orthopaedic surgery is generally conducted to relieve arthritis pain or in some hip fractures. A total hip replacement consists of replacing both the acetabulum and the femoral head while hemiarthroplasty generally only replaces the femoral head. Hip replacement is one of the most common orthopaedic operations, though patient satisfaction varies widely. Approximately 58% of total hip replacements are estimated to last 25 years. The average cost of a total hip replacement in 2012 was $40,364 in the United States, and about $7,700 to $12,000 in most European countries.

<span class="mw-page-title-main">Limp</span> Type of asymmetric abnormality of the gait

A limp is a type of asymmetric abnormality of the gait. Limping may be caused by pain, weakness, neuromuscular imbalance, or a skeletal deformity. The most common underlying cause of a painful limp is physical trauma; however, in the absence of trauma, other serious causes, such as septic arthritis or slipped capital femoral epiphysis, may be present. The diagnostic approach involves ruling out potentially serious causes via the use of X-rays, blood tests, and sometimes joint aspiration. Initial treatment involves pain management. A limp is the presenting problem in about 4% of children who visit hospital emergency departments.

<span class="mw-page-title-main">Avascular necrosis</span> Death of bone tissue due to interruption of the blood supply

Avascular necrosis (AVN), also called osteonecrosis or bone infarction, is death of bone tissue due to interruption of the blood supply. Early on, there may be no symptoms. Gradually joint pain may develop, which may limit the person's ability to move. Complications may include collapse of the bone or nearby joint surface.

<span class="mw-page-title-main">Hip fracture</span> Broken bone in hip joint region

A hip fracture is a break that occurs in the upper part of the femur, at the femoral neck or (rarely) the femoral head. Symptoms may include pain around the hip, particularly with movement, and shortening of the leg. Usually the person cannot walk.

<span class="mw-page-title-main">Hip</span> Anatomical region between the torso and the legs, holding the buttocks and genital region

In vertebrate anatomy, hip refers to either an anatomical region or a joint.

<span class="mw-page-title-main">Knee replacement</span> Surgical procedure

Knee replacement, also known as knee arthroplasty, is a surgical procedure to replace the weight-bearing surfaces of the knee joint to relieve pain and disability, most commonly offered when joint pain is not diminished by conservative sources. It may also be performed for other knee diseases, such as rheumatoid arthritis. In patients with severe deformity from advanced rheumatoid arthritis, trauma, or long-standing osteoarthritis, the surgery may be more complicated and carry higher risk. Osteoporosis does not typically cause knee pain, deformity, or inflammation, and is not a reason to perform knee replacement.

<span class="mw-page-title-main">Femoral head ostectomy</span> Surgical removal of the head and neck of the femur

A femoral head ostectomy is a surgical operation to remove the head and neck from the femur. It is performed to alleviate pain, and is a salvage procedure, reserved for condition where pain can not be alleviated in any other way. It is common in veterinary surgery. Other names are excision arthroplasty of the femoral head and neck, Girdlestone's operation, Girdlestone procedure, and femoral head and neck ostectomy.

A Southwick angle is a radiographic angle used to measure the severity of a slipped capital femoral epiphysis (SCFE) on a radiograph. It was named after Wayne O. Southwick, a famous surgeon.

<span class="mw-page-title-main">Transient synovitis</span> Medical condition

Transient synovitis of hip is a self-limiting condition in which there is an inflammation of the inner lining of the capsule of the hip joint. The term irritable hip refers to the syndrome of acute hip pain, joint stiffness, limp or non-weightbearing, indicative of an underlying condition such as transient synovitis or orthopedic infections. In everyday clinical practice however, irritable hip is commonly used as a synonym for transient synovitis. It should not be confused with sciatica, a condition describing hip and lower back pain much more common to adults than transient synovitis but with similar signs and symptoms.

<span class="mw-page-title-main">Salter–Harris fracture</span> Medical condition

A Salter–Harris fracture is a fracture that involves the epiphyseal plate of a bone, specifically the zone of provisional calcification. It is thus a form of child bone fracture. It is a common injury found in children, occurring in 15% of childhood long bone fractures. This type of fracture and its classification system is named for Robert B. Salter and William H. Harris who created and published this classification system in the Journal of Bone and Joint Surgery in 1963.

<span class="mw-page-title-main">Hip dysplasia</span> Joint abnormality

Hip dysplasia is an abnormality of the hip joint where the socket portion does not fully cover the ball portion, resulting in an increased risk for joint dislocation. Hip dysplasia may occur at birth or develop in early life. Regardless, it does not typically produce symptoms in babies less than a year old. Occasionally one leg may be shorter than the other. The left hip is more often affected than the right. Complications without treatment can include arthritis, limping, and low back pain. Females are affected more often than males. Risk factors for hip dysplasia include female sex, family history, certain swaddling practices, and breech presentation whether an infant is delivered vaginally or by cesarean section. If one identical twin is affected, there is a 40% risk the other will also be affected. Screening all babies for the condition by physical examination is recommended. Ultrasonography may also be useful.

<span class="mw-page-title-main">Pigeon toe</span> Medical condition affecting the feet

Pigeon toe, also known as in-toeing, is a condition which causes the toes to point inward when walking. It is most common in infants and children under two years of age and, when not the result of simple muscle weakness, normally arises from underlying conditions, such as a twisted shin bone or an excessive anteversion resulting in the twisting of the thigh bone when the front part of a person's foot is turned in.

<span class="mw-page-title-main">Femoral fracture</span> Broken femur, at shaft or distally

A femoral fracture is a bone fracture that involves the femur. They are typically sustained in high-impact trauma, such as car crashes, due to the large amount of force needed to break the bone. Fractures of the diaphysis, or middle of the femur, are managed differently from those at the head, neck, and trochanter; those are conventionally called hip fractures. Thus, mentions of femoral fracture in medicine usually refer implicitly to femoral fractures at the shaft or distally.

<span class="mw-page-title-main">Orthopaedic Studio</span>

Orthopaedic Studio is an application designed to help orthopaedic specialists perform several common quantitative hip examinations that are based on standard x-ray images.

<span class="mw-page-title-main">Chandler's disease</span> Medical condition

Chandler's disease, also known as idiopathic avascular osteonecrosis of the femoral head, is a rare condition in which the bone cells in the head of the femur (FH) die due to lack of blood. This disease is caused when blood flow is reduced to the part of a bone near a joint. It is specifically unique because the femoral head is for some reason the only affected part of the body and rarely travels down to the main part of the femur. In 1948, F. A. Chandler did a multi-case review and first released his interpretations as Coronary Disease of the Hip. This term is now considered incorrect as it improperly describes the actual disease.

<span class="mw-page-title-main">Klein's line</span> Medical condition

Klein's line or the line of Klein is a virtual line that can be drawn on an X-ray of an adolescent's hip parallel to the anatomically upper edge of the femoral neck. It was the first tool to aid in the early diagnosis of a slipped capital femoral epiphysis (SCFE), which if treated late or left untreated leads to crippling arthritis, leg length discrepancy and lost range of motion. It is named after the American orthopedic surgeon Armin Klein at Harvard University, who published its description and usefulness in 1952. Subsequent modification of its use has increased the sensitivity and reliability of the tool.

<span class="mw-page-title-main">Hip pain</span>

Pain in the hip is the experience of pain in the muscles or joints in the hip/ pelvic region, a condition commonly arising from any of a number of factors. Sometimes it is closely associated with lower back pain.

The Drehmann sign describes a clinical test of examining orthopedic patients and is widely used in the functional check of the hip joint. It was first described by Gustav Drehmann.

References

  1. 1 2 Perry, Daniel C.; Metcalfe, David; Lane, Steven; Turner, Steven (2018). "Childhood Obesity and Slipped Capital Femoral Epiphysis". Pediatrics. 142 (5): e20181067. doi: 10.1542/peds.2018-1067 . hdl: 2164/13140 . PMID   30348751.
  2. 1 2 3 4 5 6 7 8 9 10 Kliegman, Robert M. (2011). Nelson textbook of pediatrics (19th ed.). Philadelphia: Saunders. p. 2363. ISBN   9781437707557.
  3. ↑ Loder, RT (1 May 1998). "Slipped capital femoral epiphysis". American Family Physician. 57 (9): 2135–42, 2148–50. PMID   9606305 . Retrieved 30 November 2012.
  4. 1 2 3 4 5 6 Novais, Eduardo N.; Millis, Michael B. (December 2012). "Slipped Capital Femoral Epiphysis: Prevalence, Pathogenesis, and Natural History". Clinical Orthopaedics and Related Research. 470 (12): 3432–3438. doi:10.1007/s11999-012-2452-y. PMC   3492592 . PMID   23054509.
  5. ↑ Slipped Capital Femoral Epiphysis at eMedicine
  6. 1 2 3 Kaneshiro, Neil. "Slipped capital femoral epiphysis". U.S. National Library of Medicine. PubMed Health. Retrieved 1 December 2012.
  7. 1 2 Perry, Daniel C.; Metcalfe, David; Costa, Matthew L.; Van Staa, Tjeerd (2017). "A nationwide cohort study of slipped capital femoral epiphysis". Archives of Disease in Childhood. 102 (12): 1132–1136. doi:10.1136/archdischild-2016-312328. PMC   5754864 . PMID   28663349.
  8. ↑ Johns, Mabrouk, Tavarez (2022). Slipped Capital Femoral Epiphysis. StatPearls Publishing LLC.{{cite book}}: CS1 maint: multiple names: authors list (link)
  9. ↑ Johns, Mabrouk, Tavarez (2022). Slipped Capital Femoral Epiphysis. StatPearls Publishing LLC.{{cite book}}: CS1 maint: multiple names: authors list (link)
  10. ↑ Pediatric Orthopaedic Society of North America. "Slipped Capital Femoral Epiphysis". American Academy of Orthopaedic Surgeons. Retrieved 1 December 2012.
  11. 1 2 3 Peck, David (Aug 1, 2010). "Slipped capital femoral epiphysis: diagnosis and management". American Family Physician. 82 (3): 258–62. PMID   20672790 . Retrieved 1 December 2012.
  12. ↑ Kuzyk, Paul R.; Kim, YJ; Millis, MB (Nov 2011). "Surgical management of healed slipped capital femoral epiphysis". The Journal of the American Academy of Orthopaedic Surgeons. 19 (11): 667–77. doi:10.5435/00124635-201111000-00003. PMID   22052643. S2CID   38580394 . Retrieved 1 December 2012.
  13. ↑ Merz, Michael K.; Amirouche, Farid; Solitro, Giovanni F.; Silverstein, Jeffrey A.; Surma, Tyler; Gourineni, Prasad V. (2014). "Biomechanical Comparison of Perpendicular Versus Oblique in Situ Screw Fixation of Slipped Capital Femoral Epiphysis". Journal of Pediatric Orthopaedics. 35 (8): 816–20. doi:10.1097/BPO.0000000000000379. PMID   25526584. S2CID   11578375.
  14. ↑ "Slipped Capital Femoral Epiphysis". U.S. National Library of Medicine. National Institute of Health. Retrieved 1 December 2012.
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