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Slipped Upper Femoral Epiphysis
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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.1 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 (commonest form)
- Incidence is 30-60/100,000 children per year.
- Most commonly 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 commonest hip disorder in adolescents.
- Left hip is more commonly affected than right; bilateral in 20-40% of cases.2
- Three times as common in boys.3
Risk factors
- 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 hip, groin, medial thigh or knee (knee pain is referred from hip joint) during walking; pain accentuated by running, jumping, or pivoting activities.
- Pre-slip: slight discomfort.
- Acute:
- Severe pain such that child is unable to walk or stand.
- Alterations in gait, including limp on affected side, external rotation of leg, and trunk shift.
- Hip motion limited, especially internal rotation and abduction due to pain.
- Acute-on-chronic: pain, limp and altered gait occurring for several months suddenly becomes very painful.
- Chronic:
- Mild symptoms with child able to walk with altered gait. Significant number of cases report knee pain as only symptom.
- External rotation of leg during walking. Range of motion of hip shows reduced internal rotation with additional external rotation.
- When flexed up, hip tends to move in externally rotated position.
- Mild-to-moderate shortening of affected leg.
- Atrophy of thigh muscle may be noted.
Other causes of hip pain, e.g.:
- Acute hip fracture
- Perthes disorder
- Acute transient synovitis
- Osteomyelitis
- Septic arthritis
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 leg. Patient should not be allowed to walk.
- Provide analgesia and immediate orthopaedic referral if the diagnosis is suspected.
- Patient should be scheduled for surgery immediately.
- Surgical closure of the epiphysis usually by inserting screws percutaneously.4
- Corrective osteotomy is usually reserved for treatment of severe deformities after the patient has stopped growing.2
- 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 epiphysis5 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 initial degree of epiphyseal slippage.
- 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.
Document references
- Marano H, Lin D; Slipped Capital Femoral Epiphysis. eMedicine, June 2006.
- Loder RT; Slipped capital femoral epiphysis. Am Fam Physician. 1998 May 1;57(9):2135-42, 2148-50. [abstract]
- 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. [abstract]
- 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. [abstract]
- 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. [abstract]
Internet and further reading
- Slipped Capital Femoral Epiphysis, Wheeless' Textbook of Orthopaedics
- MedlinePlus - SCFE
DocID: 958
Document Version: 21
DocRef: bgp1091
Last Updated: 27 Jun 2008
Review Date: 27 Jun 2010
The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from any commercial conflicts of interest. Find out more about updating.
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