Slipped Capital Femoral Epiphysis

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Associated with obesity and puberty, slipped capital femoral epiphysis (SCFE) is of multifactorial etiology, including physeal cartilage fatigue, genetic predisposition, endocrinologic factors, and trauma. There is a male-to-female predominance of 8:3, and it is more common in blacks than in whites. Peak incidence occurs between 12 and 15 years in males and between 10 and 13 years in females. The child with SCFE may present clinically with either a chronic slip or an acute slip.

With a chronic SCFE, the child complains of pain in the groin referred to the anteromedial thigh and knee. The pain is dull, vague, intermittent or continuous, and is exacerbated by physical activity. It may or may not be related to a history of trivial or significant injury. If walking is observed, the lower limb is held in external rotation, and the gait is antalgic. Typically, the examiner notes that attempts at hip flexion are accompanied by lateral rotation of the thigh. Full flexion is restricted, and the child cannot touch his or her thigh to the abdominal wall. Limb shortening of 1 to 2 cm may be noted, as may disuse atrophy of the muscles of the proximal thigh.

Acute SCFE may be the result of an acute traumatic event or may represent an acute-on-chronic slip in which sudden, severe pain and inability to bear weight develop in a patient who has been experiencing weeks to months of pain in the hip-thigh-knee region. Examining a patient with a suggested acute slip elicits great pain. Marked external rotation of the thigh is noted, as well as readily apparent limb shortening. Great gentleness is required of the examining physician, and the hip should not be forced into maximum range of motion, which can aggravate the displacement of the fracture. The child is not asked to walk to observe the gait.

The differential diagnosis includes septic arthritis, toxic tenosynovitis, Legg-Calve-Perthes disease, and other hip fractures. Differentiating SCFE from septic arthritis is usually not difficult, since the child with SCFE is not febrile or toxically ill appearing and demonstrates no remarkable elevation in peripheral white blood cell (WBC) level or erythrocyte sedimentation rate (ESR). Differentiation from the other entities requires radiographs, including AP films and bilateral "frog-leg" lateral radiographs.

Medial slips of the femoral epiphyses will be noted on the AP views, while the frog-leg lateral films of both hips are used in comparison to detect posterior slips. In the

AP view, a line drawn along the lateral (superior) aspect of the femoral neck should transect the lateral quarter of the femoral epiphysis ( Fig 132..-.3.). The slipped epiphysis will not be transected by the line at all or will be transected less than noted on the unaffected hip. Moderate to severe slips will be detected by this method

(Fig 132:4), while mild slips require the interpretation of the frog-leg lateral x-rays of both hips. If the diagnosis of SCFE is suspected, both types of radiographs are necessary.

FIG. 132-3. A line drawn along the lateral (superior) aspect of the femoral neck fails to transect the lateral quarter of the femoral head in medial SCFE, seen in A and C. The normal anatomic relationship is illustrated in B and D.

Management in the emergency department consists of (1) confirmation of the diagnosis, (2) assurance of absolute non-weight-bearing, (3) orthopedic consultation, and (4) admission to the hospital. No patient with SCFE is treated as an outpatient, even if the intent is to perform surgery the following day. The management of SCFE is operative reduction and fixation, although there exists a certain amount of discussion in the orthopedic literature as to the optimal technical approach. Subsequent immobilization of the hip is maintained for at least 12 weeks, and careful observation for 1 to 2 years thereafter is necessary in anticipation of the development of this condition's most serious complication, avascular necrosis of the femoral head.

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