Slipped Capital Femoral Epiphysis: Diagnosis and Management

 

Am Fam Physician. 2017 Jun 15;95(12):779-784.

  Patient information: A handout on this topic is available at http://familydoctor.org/condition/slipped-capital-femoral-epiphysis.

Author disclosure: No relevant financial affiliations.

Slipped capital femoral epiphysis (SCFE) is the most common hip disorder in adolescents, occurring in 10.8 per 100,000 children. SCFE usually occurs in those eight to 15 years of age and is one of the most commonly missed diagnoses in children. SCFE is classified as stable or unstable based on the stability of the physis. It is associated with obesity, growth spurts, and (occasionally) endocrine abnormalities such as hypothyroidism, growth hormone supplementation, hypogonadism, and panhypopituitarism. Patients with SCFE usually present with limping and poorly localized pain in the hip, groin, thigh, or knee. Diagnosis is confirmed by bilateral hip radiography, which should include anteroposterior and frog-leg views in patients with stable SCFE, and anteroposterior and cross-table lateral views in unstable SCFE. The goals of treatment are to prevent slip progression and avoid complications such as avascular necrosis, chondrolysis, and femoroacetabular impingement. Stable SCFE is usually treated using in situ screw fixation. Treatment of unstable SCFE also usually involves in situ fixation, but there is controversy about timing of surgery and the value of reduction. Postoperative rehabilitation of patients with SCFE may follow a five-phase protocol.

Slipped capital femoral epiphysis (SCFE) is the most common hip disorder in adolescents, usually occurring between eight and 15 years of age.1,2 SCFE is defined as the posterior and inferior slippage of the proximal femoral epiphysis on the metaphysis (femoral neck), which occurs through the epiphyseal plate (growth plate).1,2 Figure 1 illustrates developing hip anatomy.3 Because of various factors, physicians often miss SCFE when patients initially present with vague symptoms.4,5 In particular, physicians should be careful not to dismiss the patient's symptoms by diagnosing an adductor muscle strain (groin pull); this is rare in an adolescent. The prognosis is related to how quickly SCFE is diagnosed and treated.4,6 Delays in diagnosis can lead to disabling conditions and early-onset degenerative hip arthritis that eventually require hip reconstruction.7,8 SCFE should be considered in children who present with limping and vague pain in the hip, groin, thigh, or knee.1,4,79 These patients should be evaluated with appropriate radiography.

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SORT: KEY RECOMMENDATONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Family physicians should consider SCFE when a child presents with limping and groin, hip, thigh, or knee pain.

C

1, 4, 79

Physical examination findings in patients with SCFE include antalgic gait or nonambulatory decreased internal rotation of the hip and obligate external rotation.

C

1, 5, 9

Radiography should include anteroposterior and frog-leg lateral views for stable SCFE, and anteroposterior and cross-table lateral views for unstable SCFE.

C

1, 10

Single screw fixation is the standard treatment for stable SCFE.

C

1, 5, 10, 32

Rehabilitation for SCFE includes a five-phase protocol that focuses on protection, pain-free ambulation, neuromuscular control, strengthening, and performance enhancement.

C

37


SCFE = slipped capital femoral epiphysis.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Family physicians should consider SCFE when a child presents with limping and groin, hip, thigh, or knee pain.

C

1, 4, 79

Physical examination findings in patients with SCFE include antalgic gait or nonambulatory decreased internal rotation of the hip and obligate external rotation.

C

1, 5, 9

Radiography should include anteroposterior and frog-leg lateral views for stable SCFE, and anteroposterior and cross-table lateral views for unstable SCFE.

C

1, 10

Single screw fixation is the standard treatment for stable SCFE.

C

1, 5, 10, 32

Rehabilitation for SCFE includes a five-phase protocol that focuses on protection, pain-free ambulation, neuromuscular control, strengthening, and performance enhancement.

C

37


SCFE = slipped capital femoral epiphysis.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Classification

Classification of SCFE is based on the stability of the physis.10 If the patient is able

The Authors

show all author info

DAVID M. PECK, MD, CAQSM, is research and education director of the Providence Athletic Medicine Fellowship Program at Providence Hospital, Novi, Mich....

LISA M. VOSS, DO, is a pediatric fellow in the Department of Physical Medicine and Rehabilitation at the University of Michigan, Ann Arbor.

TYLER T. VOSS, DO, is a primary care sports medicine fellow in the Department of Family Medicine at Providence Hospital.

Address correspondence to David M. Peck, MD, Providence Hospital, 26750 Providence Pkwy., Ste. 210, Novi, MI 48374 (e-mail: dmpeck99@aol.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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