Slipped Capital Femoral Epiphysis (SCFE)
Slipped capital femoral epiphysis (SCFE) is an unusual but not rare disorder of the adolescent between the ages of 12-14 years. For reasons that are not well understood, the growth plate (epiphysis) of the upper end of the femur (thigh bone) slips off in a backward direction. It develops most frequently shortly before or during accelerated growth and the onset of puberty.
The cause of SCFE is unknown. It occurs 2-3 times more often in males than females and a large number of the patients are overweight for their height. In most cases slipping of the epiphysis is a slow and gradual process, although it may occur suddenly and may be associated with a minor fall of trauma. Symptomatic SCFE, treated early and well, allows for excellent long-term hip function.
History and Physical Findings
The typical patient presents to the office with a history of several weeks/months of hip/knee and an intermittent limp. The appearance of the adolescent is characteristic. He/she walks with a limp. In certain severe cases, the adolescent will be unable to bear any weight on the affected leg. The affected leg is usually externally rotated (turned outward) in comparison to the opposite normal leg. The affected leg may also appear to be shortened.
The physical exam will show that the hip does not have a full, normal range of motion. There is often a loss of complete hip flexion and the ability to fully rotate the hip inward. Because of inflammation present in the hip, there is often pain at the extremes of motion with involuntary muscle guarding and spasm.
The condition is diagnosed based on a careful history and physical examination, observation of the gait/walking pattern, as well as hip x-rays. The x0rays aids in confirming the diagnosis by demonstrating that the upper end of the femur does not line up with the portion called the femoral neck. The growth plate may appear widened and irregular. (See figure 1)
The goal of treatment is to prevent any additional slipping of the femoral head until the growth plate closes. If allowed to continue to slip, further limitation of the hip motion and premature osteoarthritis could develop. Treatment is immediate, within 24-48 hours in most cases. Early diagnosis of SCFE provides the best chance to achieve the treatment goal of stabilizing the hip.
Fixing the femoral head with multiple pins or screws has been the treatment of choice for decades. Depending on the severity of your child's condition, the surgeon will recommend one of the three surgical options. (1) Placing a single screw into the thigh bone and femoral epiphysis, (2) Reducing the displacement and placing one or two screws into the femoral head or (3) Removal of the abnormal growth plate and inserting to aid in preventing any further displacement. (See figure 2)
There are several potential complications associated with a slipped capital femoral epiphysis. The most common are avascular necrosis (AVN) of the femoral head and chondrolysis. AVN means that the blood supply to the femoral head has been permanently altered as a result of the femoral head slipping. To date there is no way of identifying those children at risk or preventing this complication. The full extent of the damage may not be seen on x-ray for as long as 6-24 months following surgery.
Chondrolysis or loss of articular cartridge of the hip joint is a devastating complication of the hip joint is a devastating complication of SCFE. This may produce a stiff hip with a permanent loss of motion, flexion contracture and pain. Permanent loss of motion may be a result of an inflammation in the hip joint, which is still not fully understood by surgeons.
Aggressive physical therapy and anti-inflammatory medications may be prescribed for this rare complication with some return of motion.
Your child will most likely be admitted to the hospital the same day of the evaluation by the pediatric orthopaedist. Surgery is usually performed within 24-48 hours of that admission. Post-operatively your child will be on crutches for weeks to potentially months. Physical therapy will review and demonstrate the use of crutches. Specific instruction regarding your child's weight bearing status and activity restrictions will be given and must be followed closely.
It is important that your child have good follow-up care for the next 18-24 months. Once the condition has stabilized x-rays every 3-4 months are needed to ensure that abnormal growth plate has healed. Your child may be restricted in certain sports and activities during this time of recuperation to minimize the chance of further complications. The fusion must be mature enough to prevent further slippage before vigorous physical activities can begin.