Slipped capital femoral epiphysis
|Slipped capital femoral epiphysis|
|Classification and external resources|
X-ray showing a slipped capital femoral epiphysis, before and after surgical fixation.
Slipped capital femoral epiphysis (SCFE, also known as "Slipped upper femoral epiphysis") is a medical term referring to a fracture through the physis (the growth plate), which results in slippage of the overlying epiphysis. The head of the femur, called the capital, should sit squarely on the femoral neck. Abnormal movement along the growth plate results in the slip.
Often this condition will present in obese adolescent males, especially young black males, and sometimes females, with an insidious onset of thigh or knee pain with a painful limp. Hip motion will be limited, particularly internal rotation.
SCFE (sometimes pronounced "skiffy") is a common cause of hip and knee pain in children ages 10 to 16 caused usually during a growth spurt. It is the most common hip disorder in adolescence. It is the displacement of the upper femoral epiphysis. Slippage occurs through the growth plate (epiphysis between the head and neck of the bone). The femoral epiphysis remains in the acetabulum (hip socket), while the metaphysis (end of the femur) move in an anterior direction with external rotation.
Signs and symptoms
Usually, a SCFE causes groin pain, but it may cause pain in only the thigh or knee, because the pain may be referred along the distribution of the obturator nerve. The pain may occur on both sides of the body (bilaterally) as up to 40 percent of cases involve slippage on both sides. If a SCFE occurs on the other side, it typically happens within one year after the first SCFE. About 20 percent of all cases include a SCFE on both sides at the time of presentation. Signs of a SCFE include a waddling gait, decreased range of motion. Often the range of motion in the hip is restricted in internal rotation, abduction, and flexion. A person with a SCFE may prefer to hold their hip in flexion and external rotation.
In general, SCFE is caused by increased force applied across the ephysis, or a decrease in the resistance within the physis to shearing. No single cause accounts for SCFEs, as several factors play a role in the development of a SCFE, particularly mechanical and endocrine (hormone-related) factors. Mechanical risk factors include obesity, coxa profunda, femoral or acetabular retroversion. Obesity is the most significant risk factor. In 65 percent of cases of SCFE, the person is over the 95th percentile for weight. Endocrine diseases also contribute, such as hypothyroidism, hypopituitarism, and renal osteodystrophy.
SCFE is a Salter-Harris type 1 fracture through the proximal femoral physis. Stress around the hip causes a shear force to be applied at the growth plate. While trauma has a role in the manifestation of the fracture, an intrinsic weakness in the physeal cartilage also is present. The almost exclusive incidence of SCFE during the adolescent growth spurt indicates a hormonal role. Obesity is another key predisposing factor in the development of SCFE.
The fracture occurs at the hypertrophic zone of the physeal cartilage. Stress on the hip causes the epiphysis to move posteriorly and medially. By convention, position and alignment in SCFE is described by referring to the relationship of the proximal fragment (capital femoral epiphysis) to the normal distal fragment (femoral neck). Because the physis has yet to close, the blood supply to the epiphysis still should be derived from the femoral neck; however, this late in childhood, the supply is tenuous and frequently lost after the fracture occurs. Manipulation of the fracture frequently results in osteonecrosis and chondrolysis because of the tenuous nature of the blood supply.
The diagnosis is a combination of clinical suspicion plus radiological investigation. Children with a SCFE experience a decrease in their range of motion, and are often unable to complete hip flexion or fully rotate the hip inward. 20-50% of SCFE are missed or misdiagnosed on their first presentation to a medical facility. This is because the common symptom is knee pain. This is referred pain from the hip. The knee is investigated and found to be normal.
The diagnosis requires x-rays of the pelvis, with anteriorposterior (AP) and frog-leg lateral views. The appearance of the head of the femur in relation to the shaft likens that of a "melting ice cream cone". The severity of the disease can be measured using the Southwick angle.
Consultation with an orthopaedic surgeon is necessary to repair this problem. Untreated cases can result in serious growth abnormalities and permanent disability.
The disease can be treated with external in-situ pinning or open reduction and pinning. The risk of reducing this fracture is disruption of the blood supply. Some also advocate pinning the unaffected side prophylactically.
Once SCFE is suspected, the patient should be non weight bearing and remain on strict bed rest. It should be regarded as an orthopaedic emergency as further slippage may result in occlusion of the blood supply and avascular necrosis (risk 25%). Almost all treatment requires surgery, which usually involves the placement of one or two pins into the femoral head to prevent further slippage. The chances of a slippage occurring in the other hip are 20% within 18 months of diagnosis of the first slippage and consequently the opposite unaffected femur may also require pinning.
It has been shown in the past that attempts to correct the slippage by moving the head back into its correct position can cause the bone to die. Therefore the head of the femur is usually pinned 'as is'. A small incision is made in the outer side of the upper thigh and metal pins are placed through the femoral neck and into the head of the femur. A dressing covers the wound.
Controversies in SCFE surgery remain, and a large UK randomised trial (the highest level of evidence) will shortly take place in the UK to address this further - the British Orthopaedic SCFE Surgery trial.
Failure to treat the condition may lead to: death of bone tissue in the femoral head (avascular necrosis), degenerative hip disease (hip arthritis), gait abnormalities and chronic pain. Death of bone tissue (osteonecrosis) affects 17-47 percent of acute cases of SCFE. SCFE is associated with a greater risk of arthritis of the hip joint later in life.
SCFE affects approximately 1-10 per 100,000 children. The incidence varies by geographic location, season of the year, and ethnicity. In eastern Japan, the incidence is 0.2 per 100,000 and in the northeastern U.S. it is about 10 per 100,000. Africans and Polynesians have higher rates of SCFE.
SCFEs are most common in adolescents 11–15 years of age, and affects boys more frequently than girls (male 2:1 female). It is strongly linked to obesity, and weight loss may decrease the risk. Other risk factors include: family history, endocrine disorders, radiation / chemotherapy, African heritage, and mild trauma.
- Legg–Calvé–Perthes syndrome - another cause of avascular necrosis of the femoral head, seen in younger children than SCFE.
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