TRAUMATIC PSEUDOANEURYSM/FALSE ANEURYSM OF PERONEAL ARTERY
August 18, 2014
LATERAL MENISCAL TEAR
November 14, 2014

SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE FORMERLY SUFE)

Description:

Slipped capital femoral epiphysis (SCFE) is one of the most common adolescent hip disorders and is characterized by a displacement of the capital femoral epiphysis as a result of anatomic disruption occurring at the proximal femoral physis. [1] This can result in translation of the epiphysis relative to the metaphysis, most commonly in a varus deformity (medial and posterior epiphyseal displacement relative to the metaphysis).[2,3]

It typically presents in adolescents between the ages 8 and 16 years, with a greater incidence in obese populations. [3] The majority are idiopathic, however, atypical SCFEs are usually secondary to endocrine disorders (ie thyroid or parathyroid disease),[4] renal failure,[5] or radiation therapy.[6]  The pain is often referred and felt anteriorly in the thigh to distally into knee as opposed to in the hip or groin itself.

SCFEs can be classified by their stability, acuity, and degree of displacement. The classification of SCFEs by physeal stability most accurately predicts the risk of avascular necrosis (AVN) and rely on clinical and radiographic features.[3,7] Clinically stable SCFEs are defined as slips in which walking and weight-bearing are still possible. [3,7] Radiographically stable SCFEs demonstrate meatphyseal remodeling and the absence of a hip effusion by ultrasonography. [8] Clincally unstable SCFEs are defined occur when the when the patient is unable to weight-bear. [3,7] Radiographically unstable SCFEs are defined by the lack metaphyseal remodeling and the presence of a hip effusion. [8] Stable SCFEs have a minimal risk of AVN compared to unstable SCFEs, whereby the risk is up to 50%. [7]

SCFEs most commonly present chronically, defined as symptoms lasting greater than 3 weeks at presentation. [9] Acute SCFEs present within 3 weeks of symptom onset. [10] Acute on chronic SCFEs occur when an acute exacerbation of symptoms occurs in a patient already experiencing symptoms for greater than 3 weeks. [3]

The severity of SCFEs is also a good prognostic indicator for the future development of degenerative hip disease and severity is classified by the degree of displacement compared to the unaffected side: [11,12]

* mild slips if there is < 30 degrees

* moderate if there is between 30 and 50 degrees

* severe if there is > 50 degree

Exam: [2,7,10,13-15]

Pain can be either localized to the hip, thigh, or knee on the affected side.

Patients usually have an altered gait.

Affected leg most commonly held in an externally rotated position and may be shortened.

Range of motion testing will provoke pain and may decreased internal rotation, abduction, and flexion.

Passively flexing the affected hip from an extended position may induce internal rotation of the affected leg.

Investigations:

XRay: AP view: Widening, lucency, and irregularity of the physis. [16] “Blanch sign of Steel”: metaphysis projected as a semicircular area of increased density on the proximal femoral neck (present in posterior translation of the epiphysis). [17] Alteration to the intersection of Kleins line (line along the femoral neck which normally intersects the lateral portion of the femoral head) with the femoral head.[18]

Lateral/Frog-leg views are usually necessary to confirm the diagnosis.

Most cases can be diagnosed with plain films, however early slips and atypical cases may require additional imaging modalities including ultrasound, CT, and MRI.

Management:

The main goal of treatment is to prevent AVN and chondrolysis.[1,19] All patients with a diagnosed SCFE should be made nonweight-bearing until a consultation with a pediatric orthopedic surgeon for consideration of surgical stabilization. [11]

Dr. David Lawrence (Sept 2, 2014 PR ND)

References:

1. Novais EN, Millis MB (2012) Slipped capital femoral epiphysis: prevalence, pathogenesis, and natural history. Clin Orthop Relat Res 470: 3432-3438.

2. Segal LS, Weitzel PP, Davidson RS (1996) Valgus slipped capital femoral epiphysis. Fact or fiction? Clin Orthop Relat Res: 91-98.

3. Loder RT, Skopelja EN (2011) The epidemiology and demographics of slipped capital femoral epiphysis. ISRN Orthop 2011: 486512.

4. Loder RT, Wittenberg B, DeSilva G (1995) Slipped capital femoral epiphysis associated with endocrine disorders. J Pediatr Orthop 15: 349-356.

5. Loder RT, Hensinger RN (1997) Slipped capital femoral epiphysis associated with renal failure osteodystrophy. J Pediatr Orthop 17: 205-211.

6. Loder RT, Hensinger RN, Alburger PD, Aronsson DD, Beaty JH, et al. (1998) Slipped capital femoral epiphysis associated with radiation therapy. J Pediatr Orthop 18: 630-636.

7. Loder RT, Richards BS, Shapiro PS, Reznick LR, Aronson DD (1993) Acute slipped capital femoral epiphysis: the importance of physeal stability. J Bone Joint Surg Am 75: 1134-1140.

8. Kallio PE, Paterson DC, Foster BK, Lequesne GW (1993) Classification in slipped capital femoral epiphysis. Sonographic assessment of stability and remodeling. Clin Orthop Relat Res: 196-203.

9. Loder RT, Aronson DD, Greenfield ML (1993) The epidemiology of bilateral slipped capital femoral epiphysis. A study of children in Michigan. J Bone Joint Surg Am 75: 1141-1147.

10. Fahey JJ, O’Brien ET (1965) Acute Slipped Capital Femoral Epiphysis: Review of the Literature and Report of Ten Cases. J Bone Joint Surg Am 47: 1105-1127.

11. Southwick WO (1967) Osteotomy through the lesser trochanter for slipped capital femoral epiphysis. J Bone Joint Surg Am 49: 807-835.

12. Carney BT, Weinstein SL (1996) Natural history of untreated chronic slipped capital femoral epiphysis. Clin Orthop Relat Res: 43-47.

13. McPartland TG, Sankar WN, Kim YJ, Millis MB (2013) Patients with unstable slipped capital femoral epiphysis have antecedent symptoms. Clin Orthop Relat Res 471: 2132-2136.

14. Stulberg SD, Cooperman DR, Wallensten R (1981) The natural history of Legg-Calve-Perthes disease. J Bone Joint Surg Am 63: 1095-1108.

15. Wiig O, Terjesen T, Svenningsen S (2008) Prognostic factors and outcome of treatment in Perthes’ disease: a prospective study of 368 patients with five-year follow-up. J Bone Joint Surg Br 90: 1364-1371.

16. Hubbard AM (2001) Imaging of pediatric hip disorders. Radiol Clin North Am 39: 721-732.

17. Steel HH (1986) The metaphyseal blanch sign of slipped capital femoral epiphysis. J Bone Joint Surg Am 68: 920-922.

18. Klein A, Joplin RJ, Reidy JA, Hanelin J (1951) Roentgenographic features of slipped capital femoral epiphysis. Am J Roentgenol Radium Ther 66: 361-374.

19. Krahn TH, Canale ST, Beaty JH, Warner WC, Lourenco P (1993) Long-term follow-up of patients with avascular necrosis after treatment of slipped capital femoral epiphysis. J Pediatr Orthop 13: 154-158.