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Evaluation and management of slipped capital femoral epiphysis (SCFE)

Authors
Andrew J Kienstra, MD
Charles G Macias, MD, MPH
Section Editors
William Phillips, MD
Jonathan I Singer, MD
Deputy Editor
James F Wiley, II, MD, MPH

INTRODUCTION

This topic will cover the evaluation and management of SCFE. Other causes of hip pain, knee pain, and limp in children and their diagnosis are discussed in greater detail separately:

(See "Approach to the child with a limp" and "Overview of the causes of limp in children".)

(See "Approach to chronic knee pain or injury in children or skeletally immature adolescents".)

(See "Overview of hip pain in childhood".)

DEFINITION

SCFE, also called slipped upper femoral epiphysis (SUFE) and physiolysis of the hip, is characterized by a displacement of the capital femoral epiphysis from the femoral neck through the physeal plate. It is one of the most common hip disorders of adolescence. Hip pain is a common presenting feature. However, approximately 15 percent of patients present with isolated thigh or knee pain. Thus, physicians must have a high degree of suspicion to prevent delay in diagnosis, which can worsen prognosis [1].

                            

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Literature review current through: Nov 2016. | This topic last updated: Wed Mar 02 00:00:00 GMT+00:00 2016.
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References
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  1. Kocher MS, Bishop JA, Weed B, et al. Delay in diagnosis of slipped capital femoral epiphysis. Pediatrics 2004; 113:e322.
  2. Kelsey JL, Keggi KJ, Southwick WO. The incidence and distrubition of slipped capital femoral epiphysis in Connecticut and Southwestern United States. J Bone Joint Surg Am 1970; 52:1203.
  3. Jerre R, Karlsson J, Henrikson B. The incidence of physiolysis of the hip: a population-based study of 175 patients. Acta Orthop Scand 1996; 67:53.
  4. Loder RT. The demographics of slipped capital femoral epiphysis. An international multicenter study. Clin Orthop Relat Res 1996; :8.
  5. Loder RT, Aronson DD, Greenfield ML. The epidemiology of bilateral slipped capital femoral epiphysis. A study of children in Michigan. J Bone Joint Surg Am 1993; 75:1141.
  6. Hägglund G, Hansson LI, Ordeberg G, Sandström S. Bilaterality in slipped upper femoral epiphysis. J Bone Joint Surg Br 1988; 70:179.
  7. Wells D, King JD, Roe TF, Kaufman FR. Review of slipped capital femoral epiphysis associated with endocrine disease. J Pediatr Orthop 1993; 13:610.
  8. Benson EC, Miller M, Bosch P, Szalay EA. A new look at the incidence of slipped capital femoral epiphysis in new Mexico. J Pediatr Orthop 2008; 28:529.
  9. Murray AW, Wilson NI. Changing incidence of slipped capital femoral epiphysis: a relationship with obesity? J Bone Joint Surg Br 2008; 90:92.
  10. Loder RT, Hensinger RN. Slipped capital femoral epiphysis associated with renal failure osteodystrophy. J Pediatr Orthop 1997; 17:205.
  11. Loder RT, Hensinger RN, Alburger PD, et al. Slipped capital femoral epiphysis associated with radiation therapy. J Pediatr Orthop 1998; 18:630.
  12. Burrow SR, Alman B, Wright JG. Short stature as a screening test for endocrinopathy in slipped capital femoral epiphysis. J Bone Joint Surg Br 2001; 83:263.
  13. Rappaport EB, Fife D. Slipped capital femoral epiphysis in growth hormone-deficient patients. Am J Dis Child 1985; 139:396.
  14. Blethen SL, Rundle AC. Slipped capital femoral epiphysis in children treated with growth hormone. A summary of the National Cooperative Growth Study experience. Horm Res 1996; 46:113.
  15. Shaw ED, Beals RK. The hip joint in Down's syndrome. A study of its structure and associated disease. Clin Orthop Relat Res 1992; :101.
  16. Bonioli E, Bellini C, Sénès FM, et al. Slipped capital femoral epiphysis associated with Rubinstein-Taybi syndrome. Clin Genet 1993; 44:79.
  17. Loder RT, Greenfield ML. Clinical characteristics of children with atypical and idiopathic slipped capital femoral epiphysis: description of the age-weight test and implications for further diagnostic investigation. J Pediatr Orthop 2001; 21:481.
  18. Loder RT, Starnes T, Dikos G. Atypical and typical (idiopathic) slipped capital femoral epiphysis. Reconfirmation of the age-weight test and description of the height and age-height tests. J Bone Joint Surg Am 2006; 88:1574.
  19. Della-Giustina K, Della-Giustina DA. Emergency department evaluation and treatment of pediatric orthopedic injuries. Emerg Med Clin North Am 1999; 17:895.
  20. Tachdijan MO. Slipped capital femoral epiphysis. In: Clinical Pediatric Orthopedics: The Art of Diagnosis and Principles of Management, Appleton and Lange, Stamford 1997. p.223.
  21. Koop S, Quanbeck D. Three common causes of childhood hip pain. Pediatr Clin North Am 1996; 43:1053.
  22. Weiner D. Pathogenesis of slipped capital femoral epiphysis: current concepts. J Pediatr Orthop B 1996; 5:67.
  23. Feydy A, Carlier RY, Mompoint D, et al. Bilateral slipped capital femoral epiphysis occuring in an adult with acromegalic gigantism. Skeletal Radiol 1997; 26:188.
  24. Morrissy RT. Slipped capital femoral epiphysis. In: Pediatric Orthopaedics, Morrisy RT. (Ed), Lippincott, Philadelphia 1990. Vol 2, p.885.
  25. Tachdijan MO. Slipped capital femoral epiphysis. In: Pediatric Orthopedics, WB Saunders, Philadelphia 1990. Vol 2, p.1016.
  26. Moreira JF, Neves MC, Lopes G, Gomes AR. Slipped capital femoral epiphysis. A report of 4 cases occurring in one family. Int Orthop 1998; 22:193.
  27. Hägglund G, Hansson LI. Slipped capital femoral epiphysis in three generations. Acta Orthop Scand 1986; 57:240.
  28. Hägglund G, Hansson LI, Sandström S. Familial slipped capital femoral epiphysis. Acta Orthop Scand 1986; 57:510.
  29. Ochsner PE, Razavi R, Schinzel A. [Slipped capital femoral epiphyses in ten members of one family: probably autosomal dominant transmission with variable penetrance (author's transl)]. Z Orthop Ihre Grenzgeb 1977; 115:840.
  30. Jingushi S, Hara T, Sugioka Y. Deficiency of a parathyroid hormone fragment containing the midportion and 1,25-dihydroxyvitamin D in serum of patients with slipped capital femoral epiphysis. J Pediatr Orthop 1997; 17:216.
  31. Kempers MJ, Noordam C, Rouwé CW, Otten BJ. Can GnRH-agonist treatment cause slipped capital femoral epiphysis? J Pediatr Endocrinol Metab 2001; 14:729.
  32. Mostoufi-Moab S, Isaacoff EJ, Spiegel D, et al. Childhood cancer survivors exposed to total body irradiation are at significant risk for slipped capital femoral epiphysis during recombinant growth hormone therapy. Pediatr Blood Cancer 2013; 60:1766.
  33. Kay RM. Slipped capital femoral epiphysis. In: Lovell and Winter's Pediatric Orthopaedics, 6th, Morrissey RT, Weinstein SL. (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.1085.
  34. Kallio PE, Paterson DC, Foster BK, Lequesne GW. Classification in slipped capital femoral epiphysis. Sonographic assessment of stability and remodeling. Clin Orthop Relat Res 1993; :196.
  35. Boyer DW, Mickelson MR, Ponseti IV. Slipped capital femoral epiphysis. Long-term follow-up study of one hundred and twenty-one patients. J Bone Joint Surg Am 1981; 63:85.
  36. FAHEY JJ, O'BRIEN ET. ACUTE SLIPPED CAPITAL FEMORAL EPIPHYSIS: REVIEW OF THE LITERATURE AND REPORT OF TEN CASES. J Bone Joint Surg Am 1965; 47:1105.
  37. Renshaw TS. Pediatric Orthopedics, WB Saunders, Philadelphia 1986.
  38. Matava MJ, Patton CM, Luhmann S, et al. Knee pain as the initial symptom of slipped capital femoral epiphysis: an analysis of initial presentation and treatment. J Pediatr Orthop 1999; 19:455.
  39. Ledwith CA, Fleisher GR. Slipped capital femoral epiphysis without hip pain leads to missed diagnosis. Pediatrics 1992; 89:660.
  40. Reynolds RA. Diagnosis and treatment of slipped capital femoral epiphysis. Curr Opin Pediatr 1999; 11:80.
  41. Loder RT, O'Donnell PW, Didelot WP, Kayes KJ. Valgus slipped capital femoral epiphysis. J Pediatr Orthop 2006; 26:594.
  42. Loder RT, Richards BS, Shapiro PS, et al. Acute slipped capital femoral epiphysis: the importance of physeal stability. J Bone Joint Surg Am 1993; 75:1134.
  43. McPartland TG, Sankar WN, Kim YJ, Millis MB. Patients with unstable slipped capital femoral epiphysis have antecedent symptoms. Clin Orthop Relat Res 2013; 471:2132.
  44. Southwick WO. Osteotomy through the lesser trochanter for slipped capital femoral epiphysis. J Bone Joint Surg Am 1967; 49:807.
  45. Causey AL, Smith ER, Donaldson JJ, et al. Missed slipped capital femoral epiphysis: illustrative cases and a review. J Emerg Med 1995; 13:175.
  46. Uglow MG, Clarke NM. The management of slipped capital femoral epiphysis. J Bone Joint Surg Br 2004; 86:631.
  47. Søballe K, Juhl M, Høgh JP. [Delayed diagnosis of epiphysiolysis capitis femoris]. Ugeskr Laeger 1990; 152:604.
  48. BURROWS HJ. Slipped upper femoral epiphysis; characteristic of a hundred cases. J Bone Joint Surg Br 1957; 39-B:641.
  49. Cowell HR. The significance of early diagnosis and treatment of slipping of the capital femoral epiphysis. Clin Orthop Relat Res 1966; 48:89.
  50. Hubbard AM. Imaging of pediatric hip disorders. Radiol Clin North Am 2001; 39:721.
  51. Bloomberg TJ, Nuttall J, Stoker DJ. Radiology in early slipped femoral capital epiphysis. Clin Radiol 1978; 29:657.
  52. Steel HH. The metaphyseal blanch sign of slipped capital femoral epiphysis. J Bone Joint Surg Am 1986; 68:920.
  53. KLEIN A, JOPLIN RJ, REIDY JA, HANELIN J. Roentgenographic features of slipped capital femoral epiphysis. Am J Roentgenol Radium Ther 1951; 66:361.
  54. Pinkowsky GJ, Hennrikus WL. Klein line on the anteroposterior radiograph is not a sensitive diagnostic radiologic test for slipped capital femoral epiphysis. J Pediatr 2013; 162:804.
  55. Green DW, Mogekwu N, Scher DM, et al. A modification of Klein's Line to improve sensitivity of the anterior-posterior radiograph in slipped capital femoral epiphysis. J Pediatr Orthop 2009; 29:449.
  56. Cohen MS, Gelberman RH, Griffin PP, et al. Slipped capital femoral epiphysis: assessment of epiphyseal displacement and angulation. J Pediatr Orthop 1986; 6:259.
  57. Guzzanti V, Falciglia F. Slipped capital femoral epiphysis: comparison of a roentgenographic method and computed tomography in determining slip severity. J Pediatr Orthop 1991; 11:6.
  58. Lalaji A, Umans H, Schneider R, et al. MRI features of confirmed "pre-slip" capital femoral epiphysis: a report of two cases. Skeletal Radiol 2002; 31:362.
  59. Umans H, Liebling MS, Moy L, et al. Slipped capital femoral epiphysis: a physeal lesion diagnosed by MRI, with radiographic and CT correlation. Skeletal Radiol 1998; 27:139.
  60. Kallio PE, Lequesne GW, Paterson DC, et al. Ultrasonography in slipped capital femoral epiphysis. Diagnosis and assessment of severity. J Bone Joint Surg Br 1991; 73:884.
  61. Magnano GM, Lucigrai G, De Filippi C, et al. Diagnostic imaging of the early slipped capital femoral epiphysis. Radiol Med 1998; 95:16.
  62. Castriota-Scanderbeg A, Orsi E. Slipped capital femoral epiphysis: ultrasonographic findings. Skeletal Radiol 1993; 22:191.
  63. Kallio PE, Mah ET, Foster BK, et al. Slipped capital femoral epiphysis. Incidence and clinical assessment of physeal instability. J Bone Joint Surg Br 1995; 77:752.
  64. Parsch K, Weller S, Parsch D. Open reduction and smooth Kirschner wire fixation for unstable slipped capital femoral epiphysis. J Pediatr Orthop 2009; 29:1.
  65. Mann DC, Weddington J, Richton S. Hormonal studies in patients with slipped capital femoral epiphysis without evidence of endocrinopathy. J Pediatr Orthop 1988; 8:543.
  66. Busch MT, Morrissy RT. Slipped capital femoral epiphysis. Orthop Clin North Am 1987; 18:637.
  67. Carney BT, Weinstein SL, Noble J. Long-term follow-up of slipped capital femoral epiphysis. J Bone Joint Surg Am 1991; 73:667.
  68. Segal LS, Jacobson JA, Saunders MM. Biomechanical analysis of in situ single versus double screw fixation in a nonreduced slipped capital femoral epiphysis model. J Pediatr Orthop 2006; 26:479.
  69. Kishan S, Upasani V, Mahar A, et al. Biomechanical stability of single-screw versus two-screw fixation of an unstable slipped capital femoral epiphysis model: effect of screw position in the femoral neck. J Pediatr Orthop 2006; 26:601.
  70. Schultz WR, Weinstein JN, Weinstein SL, Smith BG. Prophylactic pinning of the contralateral hip in slipped capital femoral epiphysis : evaluation of long-term outcome for the contralateral hip with use of decision analysis. J Bone Joint Surg Am 2002; 84-A:1305.
  71. MacLean JG, Reddy SK. The contralateral slip. An avoidable complication and indication for prophylactic pinning in slipped upper femoral epiphysis. J Bone Joint Surg Br 2006; 88:1497.
  72. Clement ND, Vats A, Duckworth AD, et al. Slipped capital femoral epiphysis: is it worth the risk and cost not to offer prophylactic fixation of the contralateral hip? Bone Joint J 2015; 97-B:1428.
  73. Loder RT, Wittenberg B, DeSilva G. Slipped capital femoral epiphysis associated with endocrine disorders. J Pediatr Orthop 1995; 15:349.
  74. Nasreddine AY, Heyworth BE, Zurakowski D, Kocher MS. A reduction in body mass index lowers risk for bilateral slipped capital femoral epiphysis. Clin Orthop Relat Res 2013; 471:2137.
  75. Riad J, Bajelidze G, Gabos PG. Bilateral slipped capital femoral epiphysis: predictive factors for contralateral slip. J Pediatr Orthop 2007; 27:411.
  76. Popejoy D, Emara K, Birch J. Prediction of contralateral slipped capital femoral epiphysis using the modified Oxford bone age score. J Pediatr Orthop 2012; 32:290.
  77. Kocher MS, Sarwark JF, Council of Musculoskeletal Specialty Societies of the American Academy of Orthopaedic Surgeons. What's new in pediatric orthopaedics. J Bone Joint Surg Am 2004; 86-A:1337.
  78. Castro FP Jr, Bennett JT, Doulens K. Epidemiological perspective on prophylactic pinning in patients with unilateral slipped capital femoral epiphysis. J Pediatr Orthop 2000; 20:745.
  79. Loder RT. Controversies in slipped capital femoral epiphysis. Orthop Clin North Am 2006; 37:211.
  80. Kocher MS, Bishop JA, Hresko MT, et al. Prophylactic pinning of the contralateral hip after unilateral slipped capital femoral epiphysis. J Bone Joint Surg Am 2004; 86-A:2658.
  81. Baghdadi YM, Larson AN, Sierra RJ, et al. The fate of hips that are not prophylactically pinned after unilateral slipped capital femoral epiphysis. Clin Orthop Relat Res 2013; 471:2124.
  82. Loder RT. Slipped capital femoral epiphysis in children. Curr Opin Pediatr 1995; 7:95.
  83. Crawford AH. Role of osteotomy in the treatment of slipped capital femoral epiphysis. J Pediatr Orthop B 1996; 5:102.
  84. Leunig M, Slongo T, Ganz R. Subcapital realignment in slipped capital femoral epiphysis: surgical hip dislocation and trimming of the stable trochanter to protect the perfusion of the epiphysis. Instr Course Lect 2008; 57:499.
  85. Spencer S, Millis MB, Kim YJ. Early results of treatment of hip impingement syndrome in slipped capital femoral epiphysis and pistol grip deformity of the femoral head-neck junction using the surgical dislocation technique. J Pediatr Orthop 2006; 26:281.
  86. Lubicky JP. Chondrolysis and avascular necrosis: complications of slipped capital femoral epiphysis. J Pediatr Orthop B 1996; 5:162.
  87. Hoaglund FT, Steinbach LS. Primary osteoarthritis of the hip: etiology and epidemiology. J Am Acad Orthop Surg 2001; 9:320.
  88. Goodman DA, Feighan JE, Smith AD, et al. Subclinical slipped capital femoral epiphysis. Relationship to osteoarthrosis of the hip. J Bone Joint Surg Am 1997; 79:1489.
  89. Leunig M, Casillas MM, Hamlet M, et al. Slipped capital femoral epiphysis: early mechanical damage to the acetabular cartilage by a prominent femoral metaphysis. Acta Orthop Scand 2000; 71:370.
  90. Ganz R, Parvizi J, Beck M, et al. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res 2003; :112.
  91. Hosalkar HS, Pandya NK, Bomar JD, Wenger DR. Hip impingement in slipped capital femoral epiphysis: a changing perspective. J Child Orthop 2012; 6:161.
  92. Krahn TH, Canale ST, Beaty JH, et al. Long-term follow-up of patients with avascular necrosis after treatment of slipped capital femoral epiphysis. J Pediatr Orthop 1993; 13:154.
  93. Rattey T, Piehl F, Wright JG. Acute slipped capital femoral epiphysis. Review of outcomes and rates of avascular necrosis. J Bone Joint Surg Am 1996; 78:398.
  94. Maeda S, Kita A, Funayama K, Kokubun S. Vascular supply to slipped capital femoral epiphysis. J Pediatr Orthop 2001; 21:664.
  95. Kennedy JG, Hresko MT, Kasser JR, et al. Osteonecrosis of the femoral head associated with slipped capital femoral epiphysis. J Pediatr Orthop 2001; 21:189.
  96. Ballard J, Cosgrove AP. Anterior physeal separation. A sign indicating a high risk for avascular necrosis after slipped capital femoral epiphysis. J Bone Joint Surg Br 2002; 84:1176.
  97. Ingram AJ, Clarke MS, Clarke CS Jr, Marshall WR. Chondrolysis complicating slipped capital femoral epiphysis. Clin Orthop Relat Res 1982; :99.
  98. Mandell GA, Keret D, Harcke HT, Bowen JR. Chondrolysis: detection by bone scintigraphy. J Pediatr Orthop 1992; 12:80.
  99. Murgier J, Reina N, Cavaignac E, et al. The frequency of sequelae of slipped upper femoral epiphysis in cam-type femoroacetabular impingement. Bone Joint J 2014; 96-B:724.
  100. Dodds MK, McCormack D, Mulhall KJ. Femoroacetabular impingement after slipped capital femoral epiphysis: does slip severity predict clinical symptoms? J Pediatr Orthop 2009; 29:535.
  101. Fraitzl CR, Käfer W, Nelitz M, Reichel H. Radiological evidence of femoroacetabular impingement in mild slipped capital femoral epiphysis: a mean follow-up of 14.4 years after pinning in situ. J Bone Joint Surg Br 2007; 89:1592.
  102. Azegami S, Kosuge D, Ramachandran M. Surgical treatment of femoroacetabular impingement in patients with slipped capital femoral epiphysis: A review of current surgical techniques. Bone Joint J 2013; 95-B:445.
  103. Saisu T, Kamegaya M, Segawa Y, et al. Postoperative improvement of femoroacetabular impingement after intertrochanteric flexion osteotomy for SCFE. Clin Orthop Relat Res 2013; 471:2183.
  104. Tibor LM, Sink EL. Risks and benefits of the modified Dunn approach for treatment of moderate or severe slipped capital femoral epiphysis. J Pediatr Orthop 2013; 33 Suppl 1:S99.
  105. Carney BT, Weinstein SL. Natural history of untreated chronic slipped capital femoral epiphysis. Clin Orthop Relat Res 1996; :43.
  106. Harris WH. Etiology of osteoarthritis of the hip. Clin Orthop Relat Res 1986; :20.
  107. Larson AN, Sierra RJ, Yu EM, et al. Outcomes of slipped capital femoral epiphysis treated with in situ pinning. J Pediatr Orthop 2012; 32:125.