Often atraumatic or associated with a minor injury, slipped upper femoral epiphysis is one of the most common adolescent hip disorders and represents a unique type of instability of the proximal femoral growth plate. Four separate clinical groups are seen:
- Pre-slip: wide epiphyseal line without slippage.
- Acute form: slippage occurs suddenly, normally spontaneously.
- Acute-on-chronic: slippage occurs acutely where there is already existing chronic slip.
- Chronic: steadily progressive slippage (the most common form).
- Incidence is 30-60/100,000 children per year.
- Most commonly it occurs in boys of 10-17 years of age. Peak age is 13 years for boys and 11.5 years for girls.
- It is the most common hip disorder in adolescents.
- The left hip is more commonly affected than the right; it is bilateral in 20-40% of cases.
- it is three times as common in boys.
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- Mechanical: local trauma, obesity.
- Inflammatory conditions: neglected septic arthritis.
- Hypothyroidism, hypopituitarism, growth hormone deficiency, pseudohypoparathyroidism.
- Previous radiation of the pelvis, chemotherapy, renal osteodystrophy-induced bone dysplasia.
- Discomfort in the hip, groin, medial thigh or knee (knee pain is referred from the hip joint) during walking; pain is accentuated by running, jumping, or pivoting activities.
- Pre-slip: slight discomfort.
- Severe pain such that the child is unable to walk or stand.
- Alterations in gait, including a limp on the affected side, external rotation of the leg, and trunk shift.
- Hip motion is limited, especially internal rotation and abduction, due to pain.
- Acute-on-chronic: pain, limp and altered gait occurring for several months, which suddenly becomes very painful.
- Mild symptoms with the child able to walk with altered gait. In a significant number of cases knee pain is reported as the only symptom.
- External rotation of the leg during walking. Range of motion of the hip shows reduced internal rotation with additional external rotation.
- When flexed up, the hip tends to move in an externally rotated position.
- Mild-to-moderate shortening of the affected leg.
- Atrophy of the thigh muscle may be noted.
Other causes of hip pain - for example:
Anteroposterior and 'frog-leg' lateral X-rays show widening of epiphyseal line or displacement of the femoral head.
- Earliest findings include globular swelling of the joint capsule, irregular widening of the epiphyseal line and decalcification of the epiphyseal border of the metaphysis.
- Epiphysis normally extends slightly cephalad to the upper border of the femoral neck.
- Small amounts of slippage can be detected by the epiphyseal edge, becoming flush with the superior border of the neck.
- Sometimes, however, the only evidence of epiphyseal injury is slight widening of the growth plate.
- Associated injuries are common with slipped capital femoral epiphysis; patients should be evaluated for possible pelvic fractures.
- Avoid moving or rotating the leg. The patient should not be allowed to walk.
- Provide analgesia and immediate orthopaedic referral if the diagnosis is suspected.
- The patient should be scheduled for surgery immediately.
- Surgical closure of the epiphysis, usually by inserting screws percutaneously.
- Corrective osteotomy is usually reserved for treatment of severe deformities after the patient has stopped growing.
- Chondrolysis (degeneration of the articular cartilage), avascular necrosis of the epiphysis, and long-term effects of altered femoral head anatomy.
- Chondrolysis is seen in 5-8% of slips, and is associated with specific risk factors: African-American race, female gender, screw penetration of articular cartilage, body cast immobilisation, femoral neck osteotomy, and severe slips.
- Avascular necrosis of the epiphysis occurs in 10-25% of cases, and is associated with attempts to reduce a displaced epiphysis before treatment and with osteotomy of the femoral neck.
- Prognosis depends on the initial degree of epiphyseal slippage.
- The end result is good to excellent in 94-96% of cases if fragments are displaced by less than one third of the diameter of the femoral neck.
- With increasing displacement, complications increase and up to 45% of patients have a fair-to-poor surgical result.
Further reading & references
- Slipped Capital Femoral Epiphysis, Wheeless' Textbook of Orthopaedics, Accessed April 2010
- Slipped capital femoral epiphysis, MedlinePlus
- Walter KD et al; Slipped Capital Femoral Epiphysis, eMedicine, Dec 2009
- Loder RT; Slipped capital femoral epiphysis. Am Fam Physician. 1998 May 1;57(9):2135-42, 2148-50.
- Lehmann CL, Arons RR, Loder RT, et al; The epidemiology of slipped capital femoral epiphysis: an update. J Pediatr Orthop. 2006 May-Jun;26(3):286-90.
- Kenny P, Higgins T, Sedhom M, et al; Slipped upper femoral epiphysis. A retrospective, clinical and radiological study of fixation with a single screw. J Pediatr Orthop B. 2003 Mar;12(2):97-9.
- Tokmakova KP, Stanton RP, Mason DE; Factors influencing the development of osteonecrosis in patients treated for slipped capital femoral epiphysis. J Bone Joint Surg Am. 2003 May;85-A(5):798-801.
|Original Author: Dr Colin Tidy||Current Version: Dr Richard Draper|
|Last Checked: 20/12/2010||Document ID: 958 Version: 22||© EMIS|
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