What is the recommended treatment for a 14-year-old obese boy with acute right hip pain and suspected fracture or slipped capital femoral epiphysis (SCFE) after a football injury?

Slipped Capital Femoral Epiphysis (SCFE) - Diagnosis and Management

Direct Answer

This 14-year-old obese boy with acute hip pain after trauma most likely has an unstable slipped capital femoral epiphysis (SCFE), which requires emergent surgical fixation to prevent avascular necrosis. 1, 2

Clinical Presentation Analysis

The statement "Treatment involves emergent surgical fixation. Delay in management may result in avascular necrosis" is TRUE for this clinical scenario. 1, 2, 3

Key Clinical Features Present:

• Age and obesity: SCFE occurs most commonly in children 8-15 years of age and is strongly associated with obesity 1, 2
• Acute traumatic onset: The acute presentation after being tackled suggests an unstable SCFE, where the physis has been disrupted 1, 2
• Classic positioning: The extremity is typically shortened and externally rotated (NOT externally rotated, flexed, and abducted as stated in the question) 4

Critical Classification: Stable vs. Unstable SCFE

This patient has an UNSTABLE SCFE based on the acute traumatic mechanism. 1, 2, 3

Unstable SCFE Characteristics:

• Patient cannot bear weight even with crutches due to severe pain 1, 2
• Continuity between epiphysis and metaphysis has been disrupted 3
• High complication rate, particularly avascular necrosis (AVN) 1, 2, 3
• Requires urgent/emergent surgical intervention 1, 2

Stable SCFE (Not This Case):

• Patient can bear weight with or without crutches 1, 2
• Physis remains intact 3
• Lower risk of AVN 1, 2

Immediate Diagnostic Approach

Initial Imaging Protocol:

• Anteroposterior (AP) pelvis view PLUS cross-table lateral view of the affected hip 5, 6
• Do NOT obtain frog-leg lateral views in suspected unstable SCFE - this can worsen the slip 1, 2
• Include bilateral hip imaging to evaluate the contralateral side (20-40% bilateral involvement) 1, 2

If Radiographs Are Negative:

• Approximately 10% of proximal femoral fractures are not identified on initial radiographs 4, 5
• MRI without IV contrast is the next imaging study when clinical suspicion remains high 5, 6

Treatment Algorithm

For Unstable SCFE (This Patient):

Emergent surgical fixation is mandatory. 1, 2, 3

1. Timing: Surgery should occur as soon as possible, ideally within 24 hours 4
2. Surgical approach: In situ screw fixation is the gold standard 7, 1, 2
3. Intraoperative assessment: Recent evidence supports assessing physeal hemodynamics during surgery (confirmation of bleeding after drilling, laser doppler flowmetry) to predict and prevent AVN 3
4. Reduction controversy: There is ongoing debate about whether to attempt closed reduction in unstable SCFE, as manipulation may increase AVN risk 1, 2, 3

Surgical Technique:

• Patient positioned supine on fracture table 7
• Percutaneous approach with 1-cm incision over anterolateral proximal femur 7
• Guidewire advanced into "center-center" of epiphysis under fluoroscopy 7
• 6.5-mm partially threaded cannulated screw inserted 7
• Confirm no joint violation with full range of rotation under fluoroscopy 7

Critical Complications of Delayed Treatment

Avascular necrosis (AVN) is the most devastating complication of unstable SCFE. 1, 2, 3

Risk Factors for AVN:

• Unstable slip (highest risk) 1, 2, 3
• Delay in surgical treatment 4, 1, 2
• Attempted closed reduction 1, 2, 3
• Severe slip angle 7, 1

Other Complications:

• Chondrolysis 1, 2
• Femoroacetabular impingement 1, 3
• Subtrochanteric fracture (rare) 8

Common Pitfalls to Avoid

• Never obtain frog-leg lateral views in acute/unstable presentations - use cross-table lateral instead to avoid worsening the slip 1, 2
• Do not delay surgery for medical optimization unless life-threatening comorbidities exist - delays increase AVN risk 4, 1, 2
• Do not miss the diagnosis by focusing only on knee pain - SCFE commonly presents with referred knee pain 1, 2
• Do not forget to image the contralateral hip - bilateral involvement occurs in 20-40% of cases 1, 2
• Avoid aggressive closed reduction attempts in unstable SCFE as this increases AVN risk 1, 2, 3

Postoperative Management

• Weight-bearing status depends on slip stability: non-weight-bearing initially for unstable slips 7, 1
• Monitor contralateral hip radiographically every 6 months until skeletal maturity 7, 1
• Five-phase rehabilitation protocol for return to activities 1