SCFE: Slipped Capital Femoral Epiphysis

Slipped Capital Femoral Epiphysis(SCFE):

  • a disorder of paediatric & adolescent
  • the displacement of capital femoral epiphysis relative to the femoral neck
  • an instability of proximal femoral growth plate
  • an accurate diagnosis & immediate treatment needed to prevent complication
  • Boys> girls (3:2); Obese Children; Age(average)- Boys:12.7 yrs & Girls: 11.2 yrs (with some variations in different text)
  • Left hip> Right hip; B/L in 17-50%
  • Risk factors: Obesity, Metabolic endocrine disorder, Femoral Retroversion, H/o- radiation to the hip area.


  • PathoAnatomy- Expansion of hypertrophic zone with widening of physeal plate; Weakness/instability of the perichondral ring & abnormal cartilage maturation in the hypertrophic zone- a weak point
  • Mechanism– Changing of the orientation of proximal physis normally from horizontal to oblique during preadolescence & adolescence hip forces change from compression forces to shear forces
    -Slippage through the weakened area of hypertrophic zone by mechanical forces acting on susceptible physis.
  • Proximal epiphysis remains in the acetabulum; the distal part(neck): anterior displacement & external rotation

Associated Medical Conditions:

  • Endocrine disorders:

    -osteodystrophy of chronic renal failure (deranged BUN & creatinine)
    -Growth hormone abnormalities (h/o-Growth hormone(GH) treatment)

  • Bilateral SCFE- more common in the younger pts. with metabolic/endocrine disorders
  • Indications for endocrine workup
    -child age < 10 yrs old
    -Wt. < 50th percentile

Types & Classifications:

  • Acute– symptoms< 3wks; Chronic– > 3wks; Acute on Chronic– acute exacerbation; Pre-slip– not obvious on x-ray
  • LODER Classification: Stable– pt can bear wt. with/without support; risk of Osteonecrosis <10%
    Unstable– unable to bear wt.; greater risk of Osteonecrosis (40-50%)


Wt. bearing
Possible Not possible
Severity of slip Less severe More severe
Effusion Absent Present
Good Prognosis 96% 47%
Osteonecrosis <10% 50%
  • SOUTHWICK Angle Classification: Mild300; Moderate-30-500; Severe500
  • Grading (percentage of slip): Grade I– 0-33%; Grade II– 34-50%; Grade III– >50%.

Clinical Symptoms & Signs:

  • Symptoms: Obese Child with Groin & Thigh Pain(MC); many children also have knee pain
    -presentation- may be acute or longer (for weeks to months)
    -H/O- trauma- ±
  • Sign: -hip pain on movement & decreased/loss of hip motion
    -Wt. bearing- variable (Stable vs Unstable)
    -If pt ambulatory: abnormal gait- antalgic, externally rotated/out-toeing or Trendelenburg gait
    -if chronic: thigh muscle atrophy
  • Examination of opposite hip- must


  • AVN femoral head
  • Fracture neck of femur(NOF)
  • Stress fracture NOF
  • Proximal femur fracture
  • Groin injury
  • Osteitis pubis

Radiological Studies:

  • X-ray: AP & Frog-leg lateral views of B/L hips
    AP viewKlein line– normally should intersect the epiphysis-if not
    SCFE (Trethowan’s sign);

    Trethowan Sign & the Line of Klein

    -Growth plate widening- epiphysiolysis;
    -Sickle shaped head
    -Metaphyseal blanch sign of Steel– due to overlapping metaphysis & epiphysis
    -Herndon’s hump-? in chronic cases
    Frog-leg Lateral View– best view for mild case;

    -Measurement of Southwick Angle to determine the degree of slip

    Fig: Measurement of Southwick angle- the difference between the affected & the normal side: 44 degree

    Fig: Measurement of Southwick angle- the difference between the affected & the normal side: 44 degree

  • MRI: may diagnose preslip condition if x-ray is normal; ed signal of metaphyseal area with widened growth plate.

Treatment: on emergency basis if acute

Pre-op management: Immediate bed rest & no wt bearing; preparation for surgery- Blood investigations & PAC


  • In situ percutaneous cannulated screw fixation of affected hip:-both stable & unstable hips
    Fixation of opposite hip in high risk pt. (obese, endocrine disorders, early age- <12 in male; <10 in female)
  • Reduction of Epiphysis & fixation- controversial; only in unstable high grade cases- high risk of osteonecrosis
  • Epiphysiodesis combined with early Imhauser intertrochanteric osteotomy
  • Dunn procedure
  • Proximal Femoral Osteotomy: for deformity correction in chronic severe slip with pain/limited function
    -Intertrochanteric Osteotomy (Imhauser),
    -Subtrochanteric osteotomy (Sothwick)


  • Osteonecrosis– 40-50% in high grade unstable slip; 4-6% due to surgery- more risk if two screws used
  • SCFE in Opposite hip: 20-80%; risk factors- male child, obesity, endocrine disorders, early age
  • Chondrolysis:  destruction of articular cartilagejoint space narrowing; by Intra-articular penetration of implant (0-2%)
  • Proximal femur deformity: treated by Osteotomy: – Intertrochanteric Osteotomy (Imhauser); Subtrochanteric osteotomy (Sothwick)
  • Progression of slip– in some cases with single screw fixation (1-2%)
  • Others- Chronic pain, Infection, Degenerative changes of the joint, Implant related proximal femur facture.