Signs and Symptoms
History
- Determine chronicity of symptoms and whether or not the patient can bear weight
- Often presents with a limp and pain may be increased by physical activity
- Pain in the knee, thigh, groin, or hip (referred pain from the obturator nerve):
- Vague and dull for weeks in chronic SCFE
- Severe and sudden onset in acute SCFE, often in the setting of trauma
Physical Exam
- If stable, presents with limp or exertional limp
- If unstable (patient cannot ambulate), avoid further ambulation attempts
- Commonly presents with leg externally rotated
- Restricted internal rotation, abduction, and flexion (cannot touch thigh to abdomen)
- Anterior hip joint tenderness
- Test: Apply gentle passive hip flexion → if hip externally rotates + abducts → highly suggestive of SCFE
- Gait:
- Antalgic (patient takes short steps on affected side to minimize weight-bearing during “stance” phase of gait)
- Trendelenburg (shift of torso over affected hip; sign of moderate/severe slip)
- Waddling (sign of bilateral SCFE)
Essential Workup
- Plain radiographs:
- Further imaging with aid from consultant
- Orthopedic consultation
Diagnostic Tests & Interpretation
Lab
- If no diagnostic radiographic abnormality, the practitioner may consider the following to help risk stratify possible alternative diagnoses:
- CBC with differential, sedimentation rate, C-reactive protein
- If endocrinopathy suspected, consider thyroid function testing
Imaging
- Both hips should be imaged for comparison
- Some clinicians prefer cross-table lateral view in acute SCFE instead of frog-leg view (theoretical risk of worsening displacement)
- Anteroposterior radiograph:
- Widened or irregular physis
- Bird's beak appearance of the epiphysis “slipping” off of the femoral head
- Klein line: Parallel line drawn from superior border of the femoral neck; line intersects the epiphysis in normal patient
- Lateral radiograph (frog-leg or cross-table)
- CT often not necessary and not shown to be superior to plain radiographs
- MRI is better able to detect early, symptomatic preslips not seen on plain radiography
Diagnostic Procedures/Surgery
If septic hip is suspected, aspiration and fluid analysis may be needed to exclude
Differential Diagnosis
- Legg-Calve-Perthes:
- Typically seen in 4-9-yr-old age range
- Septic arthritis of hip
- Osteomyelitis
- Toxic synovitis
- Femur or pelvic fractures
- Inguinal or femoral hernia
Prehospital
Patient should be immobilized for transport, as with suspected hip fracture or dislocation
Initial Stabilization/Therapy
- Immobilize hip; keep nonweight bearing
- Do not attempt reduction
ED Treatment/Procedures
- SCFE is an urgent orthopedic condition; delay in diagnosis may lead to chronic irreversible hip joint disability
- Consult orthopedics immediately for definitive immobilization or operative intervention
Medication
Pain management as indicated; avoid oral medications if operative intervention is planned
Disposition
Admission Criteria
- Acute, acute on chronic and bilateral SCFE requires orthopedic admission for urgent operative fixation (usually in situ single cannulated screw fixation)
- Chronic SCFE may be managed with delayed operative fixation
Discharge Criteria
None (no role for observation or attempts at closed reduction due to risk of complications, including osteonecrosis or chondrolysis)
Follow-up Recommendations
Should be arranged by orthopedic specialist
- AronssonDD, LoderRT, BreurGJ, et al. Slipped capital femoral epiphysis: Current concepts . J Am Acad Orthop Surg. 2006;14(12):666-679.
- GholvePA, CameronDB, MillisMB. Slipped capital femoral epiphysis update . Curr Opin Pediatr. 2009;21(1):39-45.
- LehmannCL, AronsRR, LoderRT, et al. The epidemiology of slipped capital femoral epiphysis: An update . J Pediatr Orthop. 2006;26(3):286-290.
- LoderRT, DietzFR. What is the best evidence for the treatment of slipped capital femoral epiphysis?J Pediatr Orthop. 2012;32(suppl 2):S158-S165.
- PerryDC, MetcalfeD, CostaML, et al. A nationwide cohort study of slipped capital femoral epiphysis . Arch Dis Child. 2017;102:1132-1136.
- PerryDC, MetcalfeD, LaneS, et al. Childhood obesity and slipped capital femoral epiphysis . Pediatrics. 2018;142:pii: e20181067.
The authors gratefully acknowledge Virag Shah for his contribution to the previous edition of this chapter.