What are the diagnosis and treatment options for Slipped Capital Femoral Epiphysis (SCFE)?

Diagnosis and Treatment of Slipped Capital Femoral Epiphysis (SCFE)

The definitive treatment for slipped capital femoral epiphysis (SCFE) is urgent surgical stabilization, with in situ single screw fixation being the gold standard for stable SCFE and urgent gentle reduction with decompression and internal fixation for unstable SCFE to prevent further slippage and complications. 1

Diagnosis

Clinical Presentation

• Typical age: 8-15 years old (peak incidence during adolescent growth spurt) 2
• Risk factors:
  • Obesity (most common) 3, 2
  • Endocrine disorders: hypothyroidism, growth hormone supplementation, hypogonadism, panhypopituitarism 2
  • Growth spurts 2

Symptoms and Signs

• Limping
• Pain patterns:
  • Hip or groin pain (primary location)
  • Referred pain to thigh or knee (may be the only complaint)
  • Pain worsens with activity
• Physical examination:
  • Obligatory external rotation of affected hip when flexed
  • Limited internal rotation and abduction
  • Positive Trendelenburg sign
  • Leg length discrepancy (affected side shorter)

Diagnostic Imaging

• Radiographs are the primary diagnostic tool:
  • Anteroposterior (AP) view
  • Lateral view: frog-leg position for stable SCFE; cross-table lateral for unstable SCFE 2
  • Key finding: displacement of femoral epiphysis posteriorly and inferiorly relative to femoral neck
• Classification based on severity (Southwick angle):
  • Mild: <30°
  • Moderate: 30-50°
  • Severe: >50° 4, 5
• Classification based on stability:
  • Stable: patient can bear weight on affected limb
  • Unstable: patient cannot bear weight even with crutches 2

Treatment Algorithm

Stable SCFE

1. Immediate weight-bearing restriction
2. Surgical intervention: In situ single screw fixation (preferred over multiple pins) 1, 4
   • For mild slips (<30°): In situ fixation alone is sufficient 4
   • For moderate slips (30-50°): Consider individual factors (age, functional limitation) to determine if in situ fixation alone is sufficient or if additional osteotomy is needed 4

Unstable SCFE

1. Immediate non-weight bearing
2. Urgent surgical intervention: Gentle reduction with decompression and internal fixation 1
   • Timing is critical - should be performed as soon as possible to reduce risk of avascular necrosis

Prophylactic Fixation

• Consider prophylactic fixation of the contralateral hip in high-risk patients:
  • Young age at presentation
  • Presence of endocrine disorders
  • Obesity

Complications and Monitoring

Major Complications

• Avascular necrosis (most serious complication, more common in unstable SCFE)
• Chondrolysis
• Femoroacetabular impingement
• Early osteoarthritis 5, 6

Monitoring

• Regular radiographic follow-up:
  • 6 weeks, 3 months, 6 months, and 1 year post-surgery
  • Monitor for:
    • Implant position
    • Fracture healing
    • Signs of complications 7

Outcomes and Prognosis

• Long-term outcomes are generally good with appropriate treatment:
  • Studies show 75% of patients are pain-free at 10-year follow-up 4
  • 92% achieve good or very good results according to hip scoring systems 4
  • Risk of osteoarthritis increases with:
    • Severity of initial slip
    • Delay in diagnosis and treatment
    • Development of complications

Important Considerations

• SCFE is one of the most commonly missed diagnoses in children 2
• Any adolescent presenting with hip, groin, thigh, or knee pain should be evaluated for SCFE
• Slips >35° appear to have higher risk of developing hip impingement and should prompt consideration of additional surgical procedures beyond in situ fixation 5
• Growth hormone therapy must be discontinued if SCFE is diagnosed in a patient receiving it 3

Early diagnosis and prompt surgical stabilization are essential to prevent progression of the slip and minimize the risk of long-term complications that can significantly impact morbidity, mortality, and quality of life.