Slipped capital femoral epiphysis (SCFE or skiffy, slipped upper femoral epiphysis, SUFE or , coxa vara adolescentium) is a

medical Medicine is the science and Praxis (process), practice of caring for patients, managing the Medical diagnosis, diagnosis, prognosis, Preventive medicine, prevention, therapy, treatment, Palliative care, palliation of their injury or disease, ...

term referring to a fracture through the growth plate (physis), which results in slippage of the overlying end of the femur (

metaphysis The metaphysis (: metaphyses) is the neck portion of a long bone between the epiphysis and the diaphysis. It contains the growth plate, the part of the bone that grows during childhood, and as it grows it ossifies near the diaphysis and the ep ...

). Normally, the head of the

femur The femur (; : femurs or femora ), or thigh bone is the only long bone, bone in the thigh — the region of the lower limb between the hip and the knee. In many quadrupeds, four-legged animals the femur is the upper bone of the hindleg. The Femo ...

, called the caput femoris in Latin, should sit squarely on the femoral neck. Abnormal movement along the growth plate results in the slip. The term slipped capital femoral epiphysis is actually a

misnomer A misnomer is a name that is incorrectly or unsuitably applied. Misnomers often arise because something was named long before its correct nature was known, or because an earlier form of something has been replaced by a later form to which the nam ...

, because the

epiphysis An epiphysis (; : epiphyses) is one of the rounded ends or tips of a long bone that ossify from one or more secondary centers of ossification. Between the epiphysis and diaphysis (the long midsection of the long bone) lies the metaphysis, inc ...

(end part of a bone) remains in its normal

anatomical position Anatomical terminology is a specialized system of terms used by anatomists, zoologists, and health professionals, such as doctors, surgeons, and pharmacists, to describe the structures and functions of the body. This terminology incorpor ...

in the

acetabulum The acetabulum (; : acetabula), also called the cotyloid cavity, is a wikt:concave, concave surface of the pelvis. The femur head, head of the femur meets with the pelvis at the acetabulum, forming the Hip#Articulation, hip joint. Structure The ...

(hip socket) due to the ligamentum teres femoris. It is actually the metaphysis (neck part of a bone) which slips in an anterior direction with

external rotation Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relative ...

. SCFE is the most common hip disorder in adolescence. SCFEs usually cause groin pain on the affected side, but sometimes cause knee or thigh pain. One in five cases involves both hips, resulting in pain on both sides of the body. SCFEs occurs slightly more commonly in

adolescent Adolescence () is a transitional stage of human physical and psychological development that generally occurs during the period from puberty to adulthood (typically corresponding to the age of majority). Adolescence is usually associated w ...

males Male (symbol: ♂) is the sex of an organism that produces the gamete (sex cell) known as sperm, which fuses with the larger female gamete, or ovum, in the process of fertilisation. A male organism cannot reproduce sexually without access to ...

, especially young black males, although it also affects

females An organism's sex is female (symbol: ♀) if it produces the ovum (egg cell), the type of gamete (sex cell) that fuses with the male gamete (sperm cell) during sexual reproduction. A female has larger gametes than a male. Females and male ...

. Whilst it can occur in any child, the major risk factor is childhood obesity. Symptoms include the gradual, progressive onset of thigh or knee pain with a painful limp. Hip motion will be limited, particularly

internal rotation Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relativ ...

. Running, and other strenuous activity on legs, will also cause the hips to abnormally move due to the condition and can potentially worsen the pain. Stretching is very limited.

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 obturator nerve in human anatomy arises from the ventral divisions of the second, third, and fourth lumbar nerves in the lumbar plexus; the branch from the third is the largest, while that from the second is often very small. Structure The o ...

. The pain may occur on both sides of the body (bilaterally), as up to 40 percent of cases involve slippage on both sides. In cases of bilateral SCFEs, they typically occur within one year of each other. 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 Gait is the pattern of Motion (physics), movement of the limb (anatomy), limbs of animals, including Gait (human), humans, during Animal locomotion, locomotion over a solid substrate. Most animals use a variety of gaits, selecting gait based on s ...

, decreased range of motion. Often the range of motion in the hip is restricted in

, abduction, and

flexion Motion, the process of movement, is described using specific anatomical terminology, anatomical terms. Motion includes movement of Organ (anatomy), organs, joints, Limb (anatomy), limbs, and specific sections of the body. The terminology used de ...

. A person with a SCFE may prefer to hold their hip in flexion and

Complications

Failure to treat a SCFE may lead to: death of bone tissue in the femoral head (

avascular necrosis Avascular necrosis (AVN), also called osteonecrosis or bone infarction, is death of bone tissue due to interruption of the blood supply. Early on, there may be no symptoms. Gradually joint pain may develop, which may limit the person's abilit ...

), degenerative hip disease (hip

osteoarthritis Osteoarthritis is a type of degenerative joint disease that results from breakdown of articular cartilage, joint cartilage and underlying bone. A form of arthritis, it is believed to be the fourth leading cause of disability in the world, affect ...

), gait abnormalities and chronic pain. SCFE is associated with a greater risk of

arthritis Arthritis is a general medical term used to describe a disorder that affects joints. Symptoms generally include joint pain and stiffness. Other symptoms may include redness, warmth, Joint effusion, swelling, and decreased range of motion of ...

of the hip joint later in life. 17–47 percent of acute cases of SCFE lead to the death of bone tissue (

osteonecrosis Avascular necrosis (AVN), also called osteonecrosis or bone infarction, is death of bone tissue due to interruption of the blood supply. Early on, there may be no symptoms. Gradually joint pain may develop, which may limit the person's abili ...

) effects.

Cause

In general, SCFE is caused by increased force applied across the epiphysis, or a decrease in the resistance within the physis to shearing. Obesity is the by far the most significant risk factor. A study in Scotland looked at the weight of 600,000 infants, and followed them up to see who got SCFE. This study identified that obese children had an almost twenty times greater risk than thin children, with a 'dose-response'- so the greater the weight of the child, the greater the risk of SCFE. In 65 percent of cases of SCFE, the person is over the 95th percentile for weight.

Endocrine disease Endocrine diseases are disorders of the endocrine system. The branch of medicine associated with endocrine disorders is known as endocrinology. Types of disease Broadly speaking, endocrine disorders may be subdivided into three groups: # Endocri ...

s may also contribute (though are far less of a risk than obesity), such as

hypothyroidism Hypothyroidism is an endocrine disease in which the thyroid gland does not produce enough thyroid hormones. It can cause a number of symptoms, such as cold intolerance, poor ability to tolerate cold, fatigue, extreme fatigue, muscle aches, co ...

hypopituitarism Hypopituitarism is the decreased (''hypo'') secretion of one or more of the eight hormones normally produced by the pituitary gland at the base of the brain. If there is decreased secretion of one specific pituitary hormone, the condition is know ...

, and

renal osteodystrophy Renal osteodystrophy is defined as an alteration of bone in patients with chronic kidney disease (CKD). It is one measure of the skeletal component of the systemic disorder of chronic kidney disease-mineral and bone disorder (CKD-MBD). The term ...

. Sometimes no single cause accounts for SCFE, and several factors play a role in the development of a SCFE i.e. both mechanical and

endocrine The endocrine system is a messenger system in an organism comprising feedback loops of hormones that are released by internal glands directly into the circulatory system and that target and regulate distant organs. In vertebrates, the hypotha ...

(hormone-related) factors. Skeletal changes may also make someone at risk of SCFE, including femoral or acetabular retroversion, those these may simply be chronic skeletal manifestations of childhood obesity.

Pathophysiology

SCFE is a Salter-Harris type 1 fracture (fracture through the

physis Physis (; ; pl. physeis, φύσεις) is a Greek philosophical, theological, and scientific term, usually translated into English—according to its Latin translation "natura"—as "nature". The term originated in ancient Greek philosophy, a ...

or growth plate) through the proximal femoral physis, which can be distinguished from other Salter-Harris type 1 fractures by identifying prior epiphysiolysis, an intact (in chronic SCFE) or partially torn (in acute SCFE) periosteum, and the displacement being slower. Stress around the hip causes a shear force to be applied at the growth plate, with metaphysis anteriorly translating and externally rotating, while epiphysis remains within acetabulum. An intrinsic weakness in the physis with a high axial load is the hypothesized mechanism. Obesity is the most important predisposing factor in the development of SCFE (working by increasing axial load). The physis being more vertical and weak, perichondrial ring being thin and unlocking of interlocking mamillary processes - in adolescence - contributes to high incidence. The condition is also more common in boys. The fracture occurs at the hypertrophic zone of the physeal cartilage. Stress on the hip causes the epiphysis to move posteriorly and medially, relative to the metaphysis. Although it is not the epiphysis that displaced, 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 (as in an attempted reduction, especially a forceful one) frequently results in

and the acute loss of articular cartilage (

chondrolysis Chondrolysis CD Code is the process of breakdown of cartilage. It can occur as a result of trauma (traumatic chondrolysis). Intra-articular infusions of certain local anesthetic agents such as bupivacaine, lidocaine, ropivacaine and levobupivacain ...

) because of the tenuous nature of the blood supply.

Diagnosis

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. SCFEs may be initially overlooked, because the first symptom is knee pain, referred 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", visible with Klein's line. The severity of the disease can be measured using the Southwick angle.

Classification

* Atypical/Typical * Loder classification ** Stable ** Unstable, practically defined as when the patient is unable to ambulate even with

crutches A crutch is a mobility aid that transfers weight from the human leg, legs to the upper body. It is often used by people who cannot use their legs to support their weight, for reasons ranging from short-term injuries to lifelong disabilities. Hi ...

* Temporal ** Acute ** Chronic ** Acute-on-chronic * Radiological ** Grade I = 0–33% slippage ** Grade II = 34–50% slippage ** Grade III = >50% slippage

Treatment

The disease can be treated with external in-situ pinning or open reduction and pinning. Consultation with an

orthopaedic surgeon Orthopedic surgery or orthopedics ( alternative spelling orthopaedics) is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal ...

is necessary to repair this problem. Pinning the unaffected side prophylactically is not recommended for most patients, but may be appropriate if a second SCFE is very likely. Once SCFE is suspected, the patient should be non-

weight bearing In orthopedics, weight-bearing is the amount of weight a patient puts on an injured body part. Generally, it refers to a leg, ankle or foot that has been fractured or upon which surgery Surgery is a medical specialty that uses manual and ins ...

and remain on strict

bed rest Bed rest, also referred to as the rest-cure, is a medical treatment in which a person lies in bed for most of the time to try to cure an illness. Bed rest refers to voluntarily lying in bed as a treatment and not being confined to bed because of ...

. In severe cases, after enough rest the patient may require physical therapy to regain strength and movement back to the leg. A SCFE is an orthopaedic emergency, as further slippage may result in occlusion of the blood supply and

(risk of 25 percent). Almost all cases require surgery, which usually involves the placement of one or two pins into the femoral head to prevent further slippage. The recommended screw placement is in the center of the epiphysis and perpendicular to the physis. Chances of a slippage occurring in the other hip are 20 percent within 18 months of diagnosis of the first slippage and consequently the opposite unaffected femur may also require pinning. The risk of reducing this fracture includes the disruption of the blood supply to the bone. 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.

Epidemiology

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, and mild trauma. The left hip is more often affected than the right. Over half of cases may have involvement on both sides (bilateral).

References

External links

{{DEFAULTSORT:Slipped Capital Femoral Epiphysis Chondropathies Skeletal disorders Rare diseases Medical terminology