Slipped Capital Femoral Epiphysis

Digital illustration of Slipped Capital Femoral EpiphysisSlipped Capital Femoral Epiphysis (SCFE) is a hip condition that affects growing pre-teens and teens. In this condition, the ball at the femoral head slips off the neck of the femur in a backward direction. To keep your child’s condition from progressing, seek a diagnosis and treatment as soon as possible. Because without treatment, your child’s condition can progress to a more severe diagnosis. The cause of this is not yet clearly understood and the condition may occur because of other hip disorders:

Patients with SCFE sometimes have symptoms that include pain, stiffness, and instability of the affected hip joint. Usually, the condition develops over time. Slipped Capital Femoral Epiphysis appears more common in boys than girls.

Without early detection and prompt treatment, Slipped Capital Femoral Epiphysis can cause pain and lead to serious complications such as arthritis. The treatment for Slipped Capital Femoral Epiphysis is surgery. In addition, the aim of the surgery is to stop the head of the femur from slipping. For the best outcomes, doctors should treat the condition as early as possible.

Anatomy

The hip joint consists of one ball and a socket in a joint. The ball is formed by the femoral head while the socket is formed by the acetabulum, a part of the pelvis bone.

The femur grows at the ends of the bone around the growth plates called the physis. In addition, the growth plates are found between the shaft of the bone also called the metaphysics and the end of the bone also called the epiphysis. The femoral head is formed from the epiphysis at the upper part of the femur.

Description

Slipped Capital Femoral Epiphysis is the most common hip joint disorder in teens and preteens. In this condition, as described above, the head of the femur slips downwards and backward from the neck of the bone at the growth plate.

Slipped Capital Femoral Epiphysis occurs during the periods of rapid growth that children witness after the onset of puberty. This sudden growth occurs between the ages of 12 and 16 in boys and between the ages of 10 and 14 in girls.

Slipped Capital Femoral Epiphysis can also occur after a minor fall or an incidence of trauma to the hip.

It is common for the condition to develop gradually over several weeks or months even without the child or caregivers being able to identify any previous injury. The description of Slipped Capital Femoral Epiphysis is often based on the child’s ability to bear weight on the affected hip. Different types of Slipped Capital Femoral Epiphysis have different treatment modalities.

The types of SCFE are:

  1. Stable SCFE: This type of SCFE is often referred to as a stable slip. Thus, the child is able to walk (bear weight) on the affected hip either with a walking aid (such as crutches) or without. Most cases of SCFE fall under this category. A bilateral slip is diagnosed when the patient walks with a waddle-type gait.
  2. Unstable SCFE: This is a more severe form of the condition. In this form of SCFE, the child cannot walk or bear weight even with walking aids such as crutches. Unstable SCFE requires prompt treatment. Patients with unstable SCFE are more likely to develop complications of the disease.

SCFE is usually a unilateral (one-sided) condition. However, up to 40 percent of patients develop SCFE on the other hip as well. This is common in children younger than ten years of age and usually develops within a year and a half.

Causes

The cause (or causes) of Slipped Capital Femoral Epiphysis is unknown.

However, certain risk factors have been associated with the condition. Those risk factors include:

      • Genetics: Children with a family history of SCFE have a higher likelihood of developing the condition. Usually during early teens while a child is in a growth sprint.
      • Excess weight or obesity: Most children that develop the condition are overweight.
      • Presence of metabolic or endocrine disorders: The presence of endocrine or metabolic disorders such as hyperthyroidism is strongly associated with the condition. This is usually seen in children that are older or younger than the usual age range of 10-16 years.
      • The condition is more common in boys (12 to 15 years of age) than girls (10-13 years of age during growth spurts.

Symptoms

The symptoms of SCFE depend on the stage, type, and severity of the condition. There are two types: acute and chronic slip.  Diagnosis occurs by symptoms and confirmed by x-ray images. Some of the typical symptoms a child will present are:

Pain – Each child may have different levels and types of pain. Children with stable SCFE often have pain that comes and goes.  The pain can occur in the groin, hip, and/or thigh for several weeks or months. Knee pain and stiffness may be present as well. After brief periods of activity, the child might suddenly begin to walk or run with a limp.

Limping – In order to limit the pain or due to a discrepancy in the length of their legs, children with SCFE will often limp. Limping occurs after brief periods of activity.

Inability to walk – This symptom is associated with Unstable SCFE. The inability of a child to walk or bear weight on the affected hip is a sign of unstable SCFE which is a more severe form of the disease that requires urgent treatment.

Outward turning of the leg/Difference in leg length – Due to the downward and backward slipping of the head of the femur, the leg can appear to turn outwards. The same action causes the leg on the affected side to appear shorter than the other.

Doctor’s Consultation

It is important to consult a pediatric orthopedic physician for this condition. Pediatric Orthopedic physicians are trained and specialists in children’s hip conditions and child bone growth. They are the experts in growing bones. We strongly recommend that you take your child to see our Experts – Dr. Kishan and Dr. Wiesman.

During your appointment with either Dr. Shyam Kishan or Dr. Kathryn Wiesman, board-certified pediatric orthopedic surgeons, they will want to know all about your child’s symptoms. Your doctor will want to complete a physical examination and ask about your child’s age, general health, and medical history. Parents will want to tell the doctor about a family history of similar symptoms or a history of injury.

Your doctor will perform a general examination of your child and examine the affected hip. Your physician will want to know about the following:

      • any pain especially with extremes of motion
      • any stiffness or limited motion
      • Your child will walk so that the doctor can evaluate and detect any awkward gait or limping.
      • any involuntary muscle spasms or guarding

After the examination, your doctor may order some additional testing to complete a diagnosis and treatment plan.

X-rays

Doctor examining an x-ray for SCFE.X-ray of the pelvis, hip and thigh will help your doctor properly diagnose your child’s condition. There are many hip disorders that your child’s symptoms and pain may attribute to; so your doctor will want to confirm the diagnosis. The types of x-rays normally ordered are both AP of Pelvis and Frog Leg Lateral View of the Hip, because a Chronic Slip may be subtle and missed on the AP Pelvis alone. Sometimes a Frog Leg Lateral is more sensitive for detecting the condition, often showing the displacement posterior and medial to the femoral neck.

In cases of SCFE, your child’s x-ray images will show the head of the femur slipping off the neck of the bone. When viewing the X-rays, a virtual line (Klein’s line) can be drawn to help with diagnosis. Placement of the line starts on the child’s hip parallel to the upper edge of the femoral neck. If your child has SCFE, the line will intersect with the outermost part of the femoral head’s end. If further clarification is needed for a proper diagnosis your doctor may order Ultrasound, CT, MRI, and/or a bone scan.

Treatment

The goal of treatment in SCFE is simple: prevent the displaced femoral head from slipping any further and relieve your child’s pain and symptoms. This is done through surgery. Surgery is usually prompt and performed within 24 to 48 hours. The surgical procedure of choice will depend on the severity of your child’s diagnosed condition. There are three main types of surgery that the doctor may consider for the child and these are:

In situ fixation. This is a procedure used for patients with stable SCFE. A metal screw is inserted across the growth plate to keep the position of the femoral head intact and prevent it from slipping further. Over time the growth plate closes. Once it is closed, no further slippage occurs.

Open reduction. In patients with more severe unstable SCFE, the doctor may need to carry out a more extensive surgery known as open reduction. Here the doctor has to manipulate the femoral head back to its normal position then hold it in place with some metal screws until the growth plate closes.

In situ fixation of the opposite side. If a child is at high risk for developing SCFE in the opposite hip, the doctor may insert a screw into that hip as well to prevent SCFE. This possibility will be discussed with you before surgery. Normally, 25% develop SCFE on the contralateral hip within 2 years and 60% develop ultimately develop bilateral SCFE.

Complications

The most common complications of SCFE are Avascular Necrosis (AVN) and Idiopathic Chondrolysis of the Hip (ICH).

Avascular Necrosis

In severe cases of SCFE, the blood supply to the femoral head becomes reduced. This can lead to a gradual collapse of the bone. The collapse of the bone also causes a collapse of the articular cartilage. Without the cartilage, there is bony friction leading to intense pain and inflammation in the joints (arthritis).

Patients with Unstable SCFE are more likely to develop AVN. If AVN has occurred, then the patient may need further surgery to reconstruct the hip joint.

Idiopathic Chondrolysis of the Hip (ICH) is a rare condition, occurring mostly in black female adolescence. Chondrolysis is a condition where the articular cartilage rapidly degenerates. This degeneration and disappearance of the articular cartilage cause pain, deformity, and permanent loss of motion. Chondrolysis is rare and is not yet fully understood. Some studies have suggested that it is due to inflammation of the hip joint following untreated SCFE. Doctors manage Chondrolysis with anti-inflammatory medication and physical therapy.

Recovery

Walking/Weight-bearing 

Your child will use crutches for many weeks after surgery. Also, parents will receive specific instructions about how and when the child should resume walking or bearing weight. Parents should ensure their children follow these instructions closely to avoid further injury and slow healing.

Physical Therapy 

After your child can put weight on his or her hip, then the child must commence physical therapy. The goals of physical therapy are to strengthen the hip and leg muscles. While also improving the range of movement through guided exercises. Your therapist will also show you some exercises you can your child can do at home.

Sports and other physical activities 

After surgery, your child will not engage in sports and physical activities for a while. Finally, your doctor will provide guidance on what activities your child can engage in. He or she will tell you when your child can resume their normal activities. Furthermore, parents should pay attention to this advice to avoid complications and allow the bones to fully heal.

Follow-Up Care 

Your child will visit the doctor for follow-up care normally every 3 to 4 months after they have been discharged from the hospital. During visits, your doctor will examine your child and order x-rays to monitor the progress of healing.

To ensure your child makes a full recovery, a multidisciplinary team of experts such as the dietician, pediatrician, and/or endocrinologist may provide care for your child.