Slipped Capital Femoral Epiphysis - Everything You Need To Know - Dr. Nabil Ebraheim

Dr. Ebraheim’s educational animated video describes the condition of slip of the femoral capital epiphysis.

What is the diagnosis? 12 year old African American boy with medial side knee pain.
What will the physician do next? Do an examination of the knee and do not forget to check the hip.
Obligate external rotation of the hip: external rotation and abduction of the thigh with attempted flexion.
Then order X-rays: get an x-ray of the hip. AP view x-ray appears normal.
What do you need to order next? Get frog leg lateral view x-ray.
What is the treatment? Percutaneous in situ screw fixation.
What if the child is 10 years old with knee pain?
What will the physician do next? Do an examination of the knee followed by examination of the hip. Check for limitation of internal rotation of the hip. Which hip? Both hips.
What is the most appropriate study for this patient? Get an x-ray for both hips. AP view and frog leg lateral view x-rays for both hips.
Get metabolic work up for hypothyroidism and BUN/creatinine especially if the patient is less than 10 years old or the patient’s weight is less than 50%. All patients will hypothyroidism develop epiphyseal slip.
Endocrine disorders in young patients= bilateral slip of the capital femoral epiphysis.
Hypothyroidism is the most likely finding with bilateral cases.
What is next? Fix both hips by percutaneous screws in situ.
Slipping of the capital femoral epiphysis usually occurs in:
•Males
•African Americans
•13 years old boys
•12 years old girls
•Can be bilateral in up to 50% of the cases
Young patients could have endocrine disorders such as hypothyroidism or renal problems. Always rule out the possibility of a slipped epiphysis relative to the femoral neck in children with knee pain who are 12-13 years of age. Mechanical failure of the growth plate occurs at the hypertrophic zone. Mechanical stress exceeds the strength of the growth plate.
Early diagnosis is important. The condition is either stable or unstable (Loder classification).
•Stable: the child is able to bear weight with or without crutches. Osteonecrosis occurs in about 5-10% of cases if it is stable.
•Unstable: unable to ambulate even with being on crutches. Osteonecrosis occurs in about 50% of cases if it is unstable. Avoid forcible manipulation.
Symptoms/examination
•Usually groin and thigh pain with knee pain in about 20% of cases
•Obligatory external rotation during flexion of the hip
•Loss of internal rotation of the hip
•Antalgic gait
Diagnosis is difficult. The onset of chronic slip is insidious. The pain is referred to the knee.
Imaging
The condition sometimes does not show well on AP view x-ray (may appear normal).
Must obtain both AP view and frog-leg lateral view x-rays of the hip.
Bilateral in young children 10 years old or younger.
It is best to screen slip of the epiphysis by positioning the patient prone and access the asymmetry with internal rotation of the hip. Kline’s line will show the slip of the epiphysis on AP view x-rays. If X-ray is negative, MRI can be helpful to diagnose the pre-slip condition by showing widening of the growth plate and edema at the metaphysis.
Slipping of the epiphysis may be mild, moderate or severe. The femoral head is posteriorly and inferiorly. The femoral neck displaces anteriorly and externally rotates.
Treatment if using only one screw, start on the anterior neck and cross perpendicular to the physis with a minimum of three threads. Confirm by fluoroscopy that the screw does not penetrate the hip joint. Avoid placing screws in the posterosuperior neck to avoid the blood supply and risk of AVN. Do not place the screw through the greater trochanter. Do pinning of a slip, not pinning of a hip.

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