Slipped Capital Femoral Epiphysis
Overview:
Slipped Capital Femoral Epiphysis (SCFE) is the most common hip pathology in adolescents, it involves displacement at the epiphyseal plate (growth plate) involving the epiphysis and metaphysis. The capital femoral epiphysis is the head of the femur. The metaphysis is the neck of the femur. It is an injury resulting from a shear stress to the neck of the femur resulting in a forward and upward displacement in relation to the head of the femur. There are two classifications of slips, a stable slip and an unstable slip. Patient's with stable slips can weight bear with or without crutches. Patients with unstable slips are unable to weight bear because of pain.
Causes:
-Typically occurs during adolescents while child is going through a growth spurt
-Related to hormonal factors including weakening of epiphyseal plate
-Slip occurs prior to menarche in females
-Occurs in patients with renal failure or post radiation treatment, most often idiopathic
-Can be caused by major trauma, although this is extremely rare
-May be due to trauma, inflammatory conditions, or endocrine disorders.2
Risk Factors:
-Boys account for 60% of cases
-Overweight/obesity
-Increased body mass index (BMI)
-African-American ethnicity
-Femoral retroversion
-Increased physeal slope
-Endocrine disorders
-Metabolic disorders
-Nutritional deficiencies
-Radiation therapy
-Chemotherapy
-Growth hormone therapy
-Genetic predisposition
-Although still under investigation, children may be at risk if Vitamin D synthesis is impaired and further complicated by seasonal variation
-Presence of SCFE in one hip increases likelihood of other hip involvement.1 Bilateral involvement occurs up to 60% of the time, when it does occur contralateral slipped epiphysis is generally seen within 18 months of initial slipped epiphysis.2
Pathogenesis:
-Slip occurs in most fragile part of epiphyseal plate, usually larger in patients with this pathology
-Patients have varus angle typically occurring between head and neck of femur
-Valgus SCFE rarely occurs when metaphysis realigns in a posterior/inferior direction and epiphysis shifts in anterior superior direction
Contraindications/Precautions:
-Orthopedic medical emergency: slip progression, avascular necrosis, or chondrolysis are possible complications. Development of osteoarthritis (OA) later in life
-Potential mechanical complication is femoroacetabular impingement
Examination:
Patient Presentation
-Patients with SCFE generally report pain in the hip, groin, thigh, or knee. Approximately 15% of those with SCFE will have medial knee pain and distal thigh pain. 46% of these will have initial symptoms of medial knee or distal thigh pain.
-Patients with SCFE usually report symptoms to be dull, vague, and intermittent.
-95% of patients with SCFE are obese or overweight.
-In 60% of cases, patients are male
History
Mechanism of Injury
-The onset of SCFE is generally insidious; patient may recall mild trauma.
-Complaints of intermittent general knee, thigh, or groin pain lasting for longer than 3 weeks.
-Ask patient when symptoms began, any exacerbation/remission periods, and what the patient's age is.
Medical History
-Ask about past and current medical management, including physical therapy and the patient's response.
-Document patient's use of home remedies or alternative therapies and patient response.
Medications
-Ask about medications patient has been prescribed and if they are being taken.
Diagnostic Tests/Imaging/Tests and Measures
-- Radiographs (X-rays) needed
--Lab test may be ordered to rule out neoplastic, infectious, or hormonal disorders
--Bone scans typically used during acute cases only
--Ultrasound can be used to detect fluid
--CT Scans are used diagnostically in certain patients
--MRIs may be used for early detection due to ability to identify pre-slip conditions
Assessment/Outcome Measures
--Balance: should be normal
--Circulation: should be normal
--Functional Mobility: observe for deficits during sit-to-stand and ambulation
--Gait: Trendelenberg sign may be present
--Palpation: Tenderness over the anterior hip may be present; Mild atrophy of the thigh and gluteal muscles may be observed secondary to chronic disuse
--Observation: hips held in slight flexion, abduction and external rotation generally indicate hip effusion
--Range of motion: Limited hip internal rotation is universally found in patients with SCFE; Full pain free range of motion in the lumbar spine and knee would be found
--Reflex testing: should be normal
--Sensory testing: should be normal
--Special Tests: Thomas Test, assess hip flexor flexibility; Faber/Patrick Test
Classic sign of SCFE: with patient in supine, clinician flexes patient's hip and the lower extremity falls into significant abduction and external rotation
Clinical Bottom Line:
There is no role for nonoperative treatment.2 A physical therapist may see a patient with signs and symptoms of SCFE before a physician. If this occurs the physical therapist must refer the patient to a physician for immediate medical attention as SCFE is viewed as an orthopedic medical emergency.1
See SCFE References
Slipped Capital Femoral Epiphysis (SCFE) is the most common hip pathology in adolescents, it involves displacement at the epiphyseal plate (growth plate) involving the epiphysis and metaphysis. The capital femoral epiphysis is the head of the femur. The metaphysis is the neck of the femur. It is an injury resulting from a shear stress to the neck of the femur resulting in a forward and upward displacement in relation to the head of the femur. There are two classifications of slips, a stable slip and an unstable slip. Patient's with stable slips can weight bear with or without crutches. Patients with unstable slips are unable to weight bear because of pain.
Causes:
-Typically occurs during adolescents while child is going through a growth spurt
-Related to hormonal factors including weakening of epiphyseal plate
-Slip occurs prior to menarche in females
-Occurs in patients with renal failure or post radiation treatment, most often idiopathic
-Can be caused by major trauma, although this is extremely rare
-May be due to trauma, inflammatory conditions, or endocrine disorders.2
Risk Factors:
-Boys account for 60% of cases
-Overweight/obesity
-Increased body mass index (BMI)
-African-American ethnicity
-Femoral retroversion
-Increased physeal slope
-Endocrine disorders
-Metabolic disorders
-Nutritional deficiencies
-Radiation therapy
-Chemotherapy
-Growth hormone therapy
-Genetic predisposition
-Although still under investigation, children may be at risk if Vitamin D synthesis is impaired and further complicated by seasonal variation
-Presence of SCFE in one hip increases likelihood of other hip involvement.1 Bilateral involvement occurs up to 60% of the time, when it does occur contralateral slipped epiphysis is generally seen within 18 months of initial slipped epiphysis.2
Pathogenesis:
-Slip occurs in most fragile part of epiphyseal plate, usually larger in patients with this pathology
-Patients have varus angle typically occurring between head and neck of femur
-Valgus SCFE rarely occurs when metaphysis realigns in a posterior/inferior direction and epiphysis shifts in anterior superior direction
Contraindications/Precautions:
-Orthopedic medical emergency: slip progression, avascular necrosis, or chondrolysis are possible complications. Development of osteoarthritis (OA) later in life
-Potential mechanical complication is femoroacetabular impingement
Examination:
Patient Presentation
-Patients with SCFE generally report pain in the hip, groin, thigh, or knee. Approximately 15% of those with SCFE will have medial knee pain and distal thigh pain. 46% of these will have initial symptoms of medial knee or distal thigh pain.
-Patients with SCFE usually report symptoms to be dull, vague, and intermittent.
-95% of patients with SCFE are obese or overweight.
-In 60% of cases, patients are male
History
Mechanism of Injury
-The onset of SCFE is generally insidious; patient may recall mild trauma.
-Complaints of intermittent general knee, thigh, or groin pain lasting for longer than 3 weeks.
-Ask patient when symptoms began, any exacerbation/remission periods, and what the patient's age is.
Medical History
-Ask about past and current medical management, including physical therapy and the patient's response.
-Document patient's use of home remedies or alternative therapies and patient response.
Medications
-Ask about medications patient has been prescribed and if they are being taken.
Diagnostic Tests/Imaging/Tests and Measures
-- Radiographs (X-rays) needed
--Lab test may be ordered to rule out neoplastic, infectious, or hormonal disorders
--Bone scans typically used during acute cases only
--Ultrasound can be used to detect fluid
--CT Scans are used diagnostically in certain patients
--MRIs may be used for early detection due to ability to identify pre-slip conditions
Assessment/Outcome Measures
--Balance: should be normal
--Circulation: should be normal
--Functional Mobility: observe for deficits during sit-to-stand and ambulation
--Gait: Trendelenberg sign may be present
--Palpation: Tenderness over the anterior hip may be present; Mild atrophy of the thigh and gluteal muscles may be observed secondary to chronic disuse
--Observation: hips held in slight flexion, abduction and external rotation generally indicate hip effusion
--Range of motion: Limited hip internal rotation is universally found in patients with SCFE; Full pain free range of motion in the lumbar spine and knee would be found
--Reflex testing: should be normal
--Sensory testing: should be normal
--Special Tests: Thomas Test, assess hip flexor flexibility; Faber/Patrick Test
Classic sign of SCFE: with patient in supine, clinician flexes patient's hip and the lower extremity falls into significant abduction and external rotation
Clinical Bottom Line:
There is no role for nonoperative treatment.2 A physical therapist may see a patient with signs and symptoms of SCFE before a physician. If this occurs the physical therapist must refer the patient to a physician for immediate medical attention as SCFE is viewed as an orthopedic medical emergency.1
See SCFE References