Slipped Capital Femoral Epiphysis in Adolescents

What is a slipped capital femoral epiphysis?

Slipped capital femoral epiphysis (SCFE) refers to a fracture of the growth plate of the proximal end of the femur. This subsequently causes the ‘ball’ aspect of the bone to slightly ‘slip’ off the rest of the femur. According to the American Academy of Orthopaedic Surgeons, SCFE is one of the most common disorders of the hip in adolescents. It is often associated with a period of accelerated growth and usually occurs between 11 to 12 years of age in girls and 12 to 13 years in boys.

What causes a slipped capital femoral epiphysis?

Onset of SCFE can either occur gradually over several months, or in the case of trauma such as a muscle tear while doing sport, there can be a sudden onset of SCFE.

Although the exact cause is unknown, there appears to be a link between puberty hormones and increased bodyweight. SCFE tends to occur during the period of a growth spurt in early adolescence.

Obesity is the most significant risk factor for SCFE. Other metabolic conditions including hypothyroidism and osteodystrophy also increase the risk of developing SCFE, and it tends to be more common in males than females.

Symptoms of SCFE in Adolescents

Adolescents primarily report symptoms of pain in the groin, hip, thigh, or knee when SCFE occurs. In some circumstances, even though SCFE is a condition that affects the hip, it is important to be aware that some children only present with pain in the knee.

Often children with SCFE may continue walking on the affected leg after injury which indicates ‘stable’ SCFE. However, the affected leg may appear slightly shorter, and the child will walk with a limp. If the child is unable to weight-bear and had a sudden onset of symptoms, this indicates ‘unstable’ SCFE.

Range of motion of the hip will be significantly affected if SCFE is present. Internal rotation, flexion and abduction of the injured hip will be decreased, while external rotation and adduction may be increased. Generally, all of these movements of the hip will be painful.

Often adolescents with SCFE will also have difficulty lifting their leg and may hear or feel clicking in their hip. Diagnosis will be confirmed on X-ray imaging.

How is a slipped capital femoral epiphysis treated?

Surgery is required for slipped capital femoral epiphysis to stabilise the ‘slip’ and prevent further displacement. If an unstable SCFE is suspected, then immediate surgery is necessary.

The goal of timely surgery is to reduce complications such as avascular necrosis (tissue death due to reduced blood supply) and early onset of osteoarthritis.

For a stable SCFE, surgeons will often opt for an in-situ fixation surgical procedure, where a single screw is placed across the growth plate. However, in the case of a severe SCFE or in the case of instability, open reduction with internal fixation may be necessary as the head of the femur will have to be realigned. There is a higher risk of avascular necrosis in this case.

Physiotherapy after Surgery for SCFE

After surgery the first goal is to manage the pain, and ice and electrical stimulation may be used. It is essential in the early stages after surgery to restore range of motion of the hip and continuous passive motion (CPM) of the hip is recommended.

Partial weight-bearing up to 20kg, using crutches and the assistance of a therapist will be required and the patient must remain at a 20kg limit for weight-bearing until 3 weeks post-surgery. Weight-bearing may gradually be increased after this.

After 6 weeks, once full range of motion has been achieved and the patient is pain-free, full weight-bearing may commence.

A physiotherapist will be able to guide the patient through a strength, balance and proprioception programme based on these guidelines to allow optimal recovery.

Citations

1. Capital Realignment for Moderate and Severe SCFE Using a Modified Dunn Procedure, Kai Ziebarth MD, (L.O.E 2B)

2. Loder RT, Richards BS, Shapiro PS, Reznick LR. Acute slipped capital femoral epiphysis: the importance of physeal stability. J bone joint surg 1993;75A:1134-1140. (L.O.E. 2A)