Highlights & Basics
- Slipped capital femoral epiphysis may present with an acute/insidious onset of pain and limp.
- The disorder is typically seen in the adolescent age group.
- Associated systemic disease may be present.
- Obligatory external rotation on hip flexion is a key examination finding.
- Recommended surgical treatment is in situ pinning; prophylactic fixation of the contralateral hip may be necessary when concomitant metabolic disease is present.
Quick Reference
History & Exam
Key Factors
Other Factors
Diagnostics Tests
Treatment Options
Definition
Epidemiology
Etiology
Pathophysiology
Images
Klein lines are drawn along the superior cortex of the femoral neck. A normal Klein line will intersect the epiphysis. An abnormal Klein line does not intersect the epiphysis, as the femoral neck has moved proximally and anteriorly relative to the epiphysis
Unstable SCFE of the right hip. Anteroposterior preoperative radiograph
Unstable SCFE of the right hip. Frog-leg lateral preoperative radiograph
Unstable SCFE of the right hip fixed with 2 screws. Left hip prophylactic fixation with a single screw. Anteroposterior postoperative radiograph
Unstable SCFE of the right hip fixed with 2 screws. Left hip prophylactic fixation with a single screw. Frog-leg lateral postoperative radiograph
Citations
Perry DC, Arch B, Appelbe D, et al. The British Orthopaedic Surgery Surveillance study: slipped capital femoral epiphysis: the epidemiology and two-year outcomes from a prospective cohort in Great Britain. Bone Joint J. 2022 Apr;104-B(4):519-28.[Abstract][Full Text]
Aprato A, Conti A, Bertolo F, et al. Slipped capital femoral epiphysis: current management strategies. Orthop Res Rev. 2019;11:47-54.[Abstract][Full Text]
Sucato DJ. Approach to the hip for SCFE: the North American perspective. J Pediatr Orthop. 2018 Jul;38 Suppl 1:S5-12.[Abstract][Full Text]
Wright J, Ramachandran M. Slipped capital femoral epiphysis: the European perspective. J Pediatr Orthop. 2018 Jul;38 Suppl 1:S1-4.[Abstract][Full Text]
1. Loder RT, Aronsson DD, Dobbs MB, et al. Instructional course lecture: slipped capital femoral epiphysis. J Bone Joint Surg Am. 2000 Aug;82-A(8):1170-88.
2. Mathew SE, Larson AN. Natural history of slipped capital femoral epiphysis. J Pediatr Orthop. 2019 Jul;39(6):S23-7.[Abstract][Full Text]
3. Shank CF, Thiel EJ, Klingele KE, et al. Valgus slipped capital femoral epiphysis: prevalence, presentation, and treatment options. J Pediatr Orthop. 2010 Mar;30(2):140-6.[Abstract]
4. Fahey JJ, O'Brien ET. Acute slipped capital femoral epiphysis: review of the literature and report of ten cases. J Bone Joint Surg Am. 1965 Sep;47:1105-27.[Abstract]
5. Loder RT, Aronson DD, Greenfield ML. The epidemiology of bilateral slipped capital femoral epiphysis: a study of children in Michigan. J Bone Joint Surg Am. 1993 Aug;75(8):1141-7.[Abstract]
6. Loder RT. Controversies in slipped capital femoral epiphysis. Clin Orthop North Am. 2006 Apr;37(2):211-21.[Abstract]
7. Loder RT, Richards BS, Shapiro PS, et al. Acute slipped capital femoral epiphysis: the importance of physeal stability. J Bone Joint Surg Am. 1993 Aug;75(8):1134-40.[Abstract]
8. Kallio PE, Mah ET, Foster BK, et al. Slipped capital femoral epiphysis. Incidence and clinical assessment of physeal instability. J Bone Joint Surg Br. 1995 Sep;77(5):752-5.[Abstract][Full Text]
9. Lehmann CL, Arons RR, Loder RT, et al. The epidemiology of slipped capital femoral epiphysis: an update. J Pediatr Orthop. 2006 May-Jun;26(3):286-90.[Abstract]
10. Ravinsky R, Rofaiel J, Escott BG, et al. Epidemiology of Slipped Capital Femoral Epiphysis in Ontario, Canada. J Pediatr Orthop. 2019 Mar;39(3):e165-e167.[Abstract][Full Text]
11. Beharry AC, Quan Soon CH, Augustus M, et al. Increasing incidence of slipped capital femoral epiphysis in Trinidad and Tobago: a 50-year review. Trop Doct. 2023 Jan;53(1):85-90.[Abstract][Full Text]
12. Ripatti L, Kauko T, Kytö V, et al. The incidence and management of slipped capital femoral epiphysis: a population-based study. Acta Orthop Belg. 2023 Dec;89(4):634-8.[Abstract][Full Text]
13. Perry DC, Arch B, Appelbe D, et al. The British Orthopaedic Surgery Surveillance study: slipped capital femoral epiphysis: the epidemiology and two-year outcomes from a prospective cohort in Great Britain. Bone Joint J. 2022 Apr;104-B(4):519-28.[Abstract][Full Text]
14. Perry DC, Metcalfe D, Costa ML, et al. A nationwide cohort study of slipped capital femoral epiphysis. Arch Dis Child. 2017 Dec;102(12):1132-1136.[Abstract][Full Text]
15. Kim NT, Min JJ, Ji E, et al. Epidemiology and demographics of slipped capital femoral epiphysis in South Korea: a nationwide cohort study. PLoS One. 2023;18(3):e0283123.[Abstract][Full Text]
16. Murray AW, Wilson NI. Changing incidence of slipped capital femoral epiphysis: a relationship with obesity? J Bone Joint Surg Br. 2008 Jan;90(1):92-4.[Abstract]
17. Perry DC, Metcalfe D, Lane S, et al. Childhood Obesity and Slipped Capital Femoral Epiphysis. Pediatrics. 2018 Nov;142(5):.[Abstract][Full Text]
18. Loder RT. The demographics of slipped capital femoral epiphysis. An international multicenter study. Clin Orthop Relat Res. 1996 Jan;(322):8-27.[Abstract]
19. Zusman NL, Goldstein RY, Yoo JU. Quantifying risk factors for slipped capital femoral epiphysis and postslip osteonecrosis. J Pediatr Orthop. 2024 Jan 1;44(1):e30-4.[Abstract]
20. Herngren B, Stenmarker M, Vavruch L, et al. Slipped capital femoral epiphysis: a population-based study. BMC Musculoskelet Disord. 2017 Jul 18;18(1):304.[Abstract][Full Text]
21. Halverson SJ, Warhoover T, Mencio GA, et al. Leptin Elevation as a Risk Factor for Slipped Capital Femoral Epiphysis Independent of Obesity Status. J Bone Joint Surg Am. 2017 May 17;99(10):865-872.[Abstract][Full Text]
22. Loder RT, Hensinger RN, Alburger PD, et al. Slipped capital femoral epiphysis associated with radiation therapy. J Pediatr Orthop. 1998 Sep-Oct;18(5):630-6.[Abstract][Full Text]
23. Aprato A, Conti A, Bertolo F, et al. Slipped capital femoral epiphysis: current management strategies. Orthop Res Rev. 2019;11:47-54.[Abstract][Full Text]
24. Farrier AJ, Ihediwa U, Khan S, et al. The seasonality of slipped upper femoral epiphysis--meta-analysis: a possible association with vitamin D. Hip Int. 2015 Nov-Dec;25(6):495-501.[Abstract]
25. Loder RT, Schneble CA. Seasonal variation in slipped capital femoral epiphysis: new findings using a National children's hospital database. J Pediatr Orthop. 2019 Jan;39(1):e44-9.[Abstract]
26. Firth GB, Foster M, Pieterse C, et al. Effect of seasonal variation on the peak presentation of slipped capital femoral epiphysis. A comparison of children in Johannesburg, South Africa and London, UK. J Pediatr Orthop B. 2020 May;29(3):268-74.[Abstract]
27. Matava MJ, Patton CM, Luhmann S, et al. Knee pain as the initial symptom of slipped capital femoral epiphysis: an analysis of initial presentation and treatment. J Pediatr Orthop. 1999 Jul-Aug;19(4):455-60.[Abstract]
28. Nisar A, Salama A, Freeman JV, et al. Avascular necrosis in acute and acute-on-chronic slipped capital femoral epiphysis. J Pediatr Orthop B. 2007 Nov;16(6):393-8.[Abstract]
29. Aadalen RJ, Weiner DS, Hoyt W, et al. Acute slipped capital femoral epiphysis. J Bone Joint Surg Am. 1974 Oct;56(7):1473-87.[Abstract]
30. Flynn JM, Widmann RF. The limping child: evaluation and diagnosis. J Am Acad Orthop Surg. 2001 Mar-Apr;9(2):89-98.[Abstract]
31. Hesper T, Zilkens C, Bittersohl B, et al. Imaging modalities in patients with slipped capital femoral epiphysis. J Child Orthop. 2017 Apr;11(2):99-106.[Abstract][Full Text]
32. Causey AL, Smith ER, Donaldson JJ, et al. Missed slipped capital femoral epiphysis: illustrative cases and a review. J Emerg Med. 1995 Mar-Apr;13(2):175-89.[Abstract]
33. Scham SM. The triangular sign in the early diagnosis of slipped capital femoral epiphysis. Clin Orthop Relat Res. 1974;(103):16-7.
34. Steel HH. The metaphyseal blanch sign of slipped capital femoral epiphysis. J Bone Joint Surg Am. 1986 Jul;68(6):920-2.[Abstract]
35. Loder RT, Greenfield ML. Clinical characteristics of children with atypical and idiopathic slipped capital femoral epiphysis: description of the age-weight test and implications for further diagnostic investigation. J Pediatr Orthop. 2001 Jul-Aug;21(4):481-7.[Abstract]
36. Frick SL. Evaluation of the child who has hip pain. Othop Clin North Am. 2006 Apr;37(2):133-40.[Abstract]
37. Sucato DJ. Approach to the hip for SCFE: the North American perspective. J Pediatr Orthop. 2018 Jul;38 Suppl 1:S5-12.[Abstract][Full Text]
38. Wright J, Ramachandran M. Slipped capital femoral epiphysis: the European perspective. J Pediatr Orthop. 2018 Jul;38 Suppl 1:S1-4.[Abstract][Full Text]
39. Aronsson DD, Loder RT, Breur GJ, et al. Slipped capital femoral epiphysis: current concepts. J Am Acad Orthop Surg. 2006 Nov;14(12):666-79.[Abstract]
40. Ziebarth K, Zilkens C, Spencer S, et al. Capital realignment for moderate and severe SCFE using a modified Dunn procedure. Clin Orthop Relat Res. 2009 Mar;467(3):704-16.[Abstract][Full Text]
41. Slongo T, Kakaty D, Krause F, et al. Treatment of slipped capital femoral epiphysis with a modified Dunn procedure. J Bone Joint Surg Am. 2010 Dec 15;92(18):2898-908.[Abstract]
42. Vanhegan IS, Cashman JP, Buddhdev P, et al. Outcomes following subcapital osteotomy for severe slipped upper femoral epiphysis. Bone Joint J. 2015 Dec;97-B(12):1718-25.[Abstract]
43. Gorgolini G, Caterini A, Efremov K, et al. Surgical treatment of slipped capital femoral epiphysis (SCFE) by Dunn procedure modified by Ganz: a systematic review. BMC Musculoskelet Disord. 2022 Feb 7;22(suppl 2):1064.[Abstract][Full Text]
44. National Institute for Health and Care Excellence. Open reduction of slipped capital femoral epiphysis. Jan 2015 [internet publication].[Full Text]
45. Meier MC, Meyer LC, Ferguson RL. Treatment of slipped capital femoral epiphysis with a spica cast. J Bone Joint Surg Am. 1992 Dec;74(10):1522-9.[Abstract]
46. Parsch K, Weller S, Parsch D. Open reduction and smooth Kirschner wire fixation for unstable slipped capital femoral epiphysis. J Pediatr Orthop. 2009 Jan-Feb;29(1):1-8.[Abstract]
47. Davis RL 2nd, Samora WP 3rd, Persinger F, et al. Treatment of unstable versus stable slipped capital femoral epiphysis using the modified dunn rocedure. J Pediatr Orthop. 2019 Sep;39(8):411-5.[Abstract]
48. Lowndes S, Khanna A, Emery D, et al. Management of unstable slipped upper femoral epiphysis: a meta-analysis. Br Med Bull. 2009;90:133-46.[Abstract]
49. Gage JR, Sundberg AB, Nolan DR, et al. Complications after cuneiform osteotomy for moderately or severely slipped capital femoral epiphysis. J Bone Joint Surg Am. 1978 Mar;60(2):157-65.[Abstract]
50. Hall JE. The results of treatment of slipped femoral epiphysis. J Bone Joint Surg Br. 1957 Nov;39-B(4):659-73.[Abstract]
51. Swarup I, Goodbody C, Goto R, et al. Risk Factors for Contralateral Slipped Capital Femoral Epiphysis: A Meta-analysis of Cohort and Case-control Studies. J Pediatr Orthop. 2020 Jul;40(6):e446-e453.[Abstract][Full Text]
52. Park S, Hsu JE, Rendon N, et al. The utility of posterior sloping angle in predicting contralateral slipped capital femoral epiphysis. J Pediatr Orthop. 2010 Oct-Nov;30(7):683-9.[Abstract]
53. Buchan SJ, Lindisfarne EA, Stabler A, et al. The free-gliding screw for slipped capital femoral epiphysis : is it safe, does it glide, and does age matter? Bone Joint J. 2023 Feb;105-B(2):215-9.[Abstract]
54. Winger BJ, Dobbe AM, Cheng TL, et al. Who benefits from allowing the physis to grow in slipped capital femoral epiphysis? J Pediatr Orthop. 2023 Jul 1;43(6):e427-32.[Abstract]
55. Tudisco C, Caterini R, Farsetti P, et al. Chondrolysis of the hip complicating slipped capital femoral epiphysis: long-term follow-up of nine patients. J Pediatr Orthop B. 1999 Apr;8(2):107-11.[Abstract]
56. Sink EL, Zaltz I, Heare T, et al. Acetabular cartilage and labral damage observed during surgical hip dislocation for stable slipped capital femoral epiphysis. J Pediatr Orthop. 2010 Jan-Feb;30(1):26-30.[Abstract]
57. Larson AN, Sierra RJ, Yu EM, et al. Outcomes of slipped capital femoral epiphysis treated with in situ pinning. J Pediatr Orthop. 2012 Mar;32(2):125-30.[Abstract]
58. Swarup I, Williams BA, Talwar D, et al. Rates of contralateral SCFE in the United States: analysis of the pediatric health information system. J Pediatr Orthop. 2020 Aug;40(7):e587-91.[Abstract]
59. Ziebarth K, Domayer S, Slongo T, et al. Clinical stability of slipped capital femoral epiphysis does not correlate with intraoperative stability. Clin Orthop Relat Res. 2012 Aug;470(8):2274-9.[Abstract]
60. Sankar WN, McPartland TG, Millis M, et al. The unstable slipped capital femoral epiphysis: risk factors for osteonecrosis. J Pediatr Orthop. 2010 Sep;30(6):544-8.[Abstract]
61. Palocaren T, Holmes L, Rogers K, et al. Outcome of in situ pinning in patients with unstable slipped capital femoral epiphysis: assessment of risk factors associated with avascular necrosis. J Pediatr Orthop. 2010 Jan-Feb;30(1):31-6.[Abstract]
62. Chen RC, Schoenecker PL, Dobbs MB, et al. Urgent reduction, fixation, and arthrotomy for unstable slipped capital femoral epiphysis. J Pediatr Orthop. 2009 Oct-Nov;29(7):687-94.[Abstract]
63. Tosounidis T, Stengel D, Kontakis G, et al. Prognostic significance of stability in slipped upper femoral epiphysis: a systematic review and meta-analysis. J Pediatr. 2010 Oct;157(4):674-80.[Abstract]
64. Veramuthu V, Munajat I, Islam MA, et al. Prevalence of avascular necrosis following surgical treatments in unstable slipped capital femoral epiphysis (SCFE): a systematic review and meta-analysis. Children (Basel). 2022 Sep 11;9(9):1374.[Abstract][Full Text]
65. American College of Radiology. ACR Appropriateness Criteria. Osteonecrosis. 2022 [internet publication].[Full Text]
66. Ramachandran M, Ward K, Brown RR, et al. Intravenous bisphosphonate therapy for traumatic osteonecrosis of the femoral head in adolescents. J Bone Joint Surg Am. 2007 Aug;89(8):1727-34.[Abstract]
67. Raney EM, Freccero DM, Dolan LA, et al. Evidence-based analysis of removal of orthopaedic implants in the pediatric population. J Pediatr Orthop. 2008 Oct-Nov;28(7):701-4.[Abstract]
