The following patient information sheet is meant to help patients and family better understand a specific pediatric orthopaedic condition. It is not meant to be comprehensive, and only reflects one viewpoint. This page does not replace a medical evaluation by a pediatric orthopaedic surgeon, and your own surgeon may have a different approach to your condition.
What is slipped capital femoral epiphysis?
Slipped capital femoral epiphysis (SCFE) is a condition affecting the hip joint. In the hip joint, the femur (also known as thigh bone) is composed of the femoral head and neck, with the physis (also known as growth plate) forming a junction between these two. A SCFE occurs when the physis is unable to hold the femoral head and neck together, and x-ray images appear as if the femoral head is "slipping" off of the femoral neck.
The radiograph above demonstrates a normal capital femoral epiphysis (femoral head), femoral neck and growth plate on the right. The left side demonstrates a severe SCFE, where the capital femoral epiphysis has "slipped" off of the femoral neck through the weakened growth plate.
Who gets a SCFE?
SCFE most commonly occurs in boys between 12 and 15 years of age, and in girls between 10 and 13 years of age, although older and younger children can also be affected. Being overweight increases the chances of getting a SCFE. Some children with other medical problems, such as hypothyroidism, also have an increased risk. You do not need to have a fall or other injury to develop a SCFE.
How is the diagnosis of a SCFE made?
SCFE most commonly presents in an adolescent child with hip, thigh or knee pain. Although the injury is in hip joint, some children perceive their pain in their thigh and knee. This occurs because the same nerve that provides feeling to the hip joint also provides feeling to the thigh down to the knee. We call this effect "referred pain", and it is similar to how people with myocardial infarction (heart attack) feel pain in their left arm.
Some children feel pain with activity but can still walk, while others cannot walk at all. If your child can still walk he or she should be seen promplty, if he or she cannot walk at all they should be seen in an emergency room. Children who cannot walk often have an "unstable" SCFE, which is discussed more below.
On examination, children with SCFE may walk with their foot pointed outwards. They are painful with movement of their hip, and have difficulty turning their legs in certain directions. These findings are related to the slipped position of the femoral head on the femoral neck.
The diagnosis is confirmed with x-rays. The x-rays should be of the entire pelvis, rather than just one hip. We generally obtain two images, which are called the AP (antero-posterior) and frog lateral views.
How is SCFE treated initially?
When SCFE is diagnosed the treatment is surgical, in order to provide stability between the femoral neck and head. Generally the child is admitted to the hospital, and the procedure is performed within one day. In cases where a walking child is having less pain which has been going on for months, it may be reasonable to schedule the procedure within a few days.
My preferred treatment is as follows:
1. The child is put under general anesthesia
2. The leg is gently manipulated to improve the position of the femoral head on the femoral neck. A forcible manipulation is dangerous to the blood supply to the bone and should be avoided.
3. One or two metal screws are then placed spanning from the femoral neck to the head to hold it in place.
4. In some cases there is concern of too much blood within the capsule which contains the hip joint. In those cases, a small procedure can be performed to open up or drain the capsule to prevent the pressure from becoming too high.
5. For children with unstable SCFE, MRI scans are obtained after surgery to monitor the femoral head.
The fluoroscopic image (x-ray machine used in the operating room) on the right demonstrates two metal screws which have been placed across the growth plate, in order to stabilize the femoral head onto the femoral neck.
What happens after surgery?
Your child generally stays in the hospital for one night, although in some cases can go home the same day. In some cases it is okay to put full weight on the leg, while in other cases it is only okay to touch the foot down to the floor for balance. Your child will be taught how to walk with either crutches or a walker.
Xrays are obtained at approximately 2 weeks, 6 weeks and 12 weeks after surgery, and then at regular intervals for about two years.
Physical therapy may be required help strengthen the hip.
What is an unstable SCFE?
Oftentimes in SCFE there is still some stability between the femoral head and neck, with a slow movement between the two over weeks or months. Unstable SCFE occurs when essentially all stability between the head and neck is lost, and the fragments can freely move. Clinically, the child has more pain and cannot walk. Unstable SCFE is concerning because the instability of the bones can lead to injury to the blood vessels supplying the bone, and lead to a problem called avascular necrosis where the femoral head has lost its blood supply (more on this below).
What problems might my child have in the future, after initial treatment?
SCFE in the Other Hip
After treatment for SCFE, it is very important to watch for symptoms in the other hip. If your child complains of similar pain on the opposite side, this should be addressed promptly to minimize the amount of deformity to the bone, and to avoid development of an unstable SCFE. In some cases, we will treat the opposite hip with a screw at the same time that we treat the SCFE side, in order to avoid this possibility.
Deformity of the Hip
The deformity from the slip can cause problems in the hip even after the SCFE has been stabilized. There are two types of problems that tend to occur:
1. Problems related to the deformity itself: Since the bone is deformed, the hip is placed into a mechanically disadvantaged position. Children often walk with their toes pointing outwards, and can have complaints of pain and or fatigue. If this does not improve with physical therapy, then the deformity can be treated with a femoral osteotomy
2. Problems related with impingement: Impingement occurs when a portion of the femur bumps into a portion of the pelvis bone with hip movement. Children may complain of problems when rising out of a chair or when using stairs. Depending on the situation, your child may benefit from surgery to treat the bony impingement.
The femoral head may lose blood supply. This is called avascular necrosis (AVN), and is a very serious condition. AVN tends to occur in unstable SCFE. After the femoral head loses its blood supply, it can collapse and become deformed. Depending on the severity of AVN, a child can develop early arthritis of the hip which can be disabling.
To monitor for AVN, an MRI is performed 1 month and 2 months after surgery in unstable SCFE to monitor for early signs. If these occur, our approach has been to perform a procedure called bone graft epiphyseodesis. This involves drilling a channel into the femoral head to provide an avenue for blood flow, and then protecting the structure of the hole with a piece of bone from the side of the femur.
AVN can occur as late as two years after SCFE occurs, and thus a child should be followed with serial x-rays until that time.
If a hip has developed AVN, it generally develops deformity that may benefit from further surgery. These treatments generally include complex osteotomies of the pelvis and femur, and safe surgical hip dislocation. The pathology is very complicated and treatment needs to be individualized.