This document discusses slipped capital femoral epiphysis (SCFE), a condition where the capital femoral epiphysis is displaced from the metaphysis through the physeal plate. It most commonly affects obese adolescents aged 10-16 years old. The causes are multifactorial and may include increased weight, femoral retroversion, endocrine disorders, and trauma. Clinically, patients present with groin or thigh pain and have a decreased range of motion on examination. Treatment options include non-operative measures like bed rest or traction or operative fixation with pins or screws to stabilize the epiphysis and promote physeal closure. The goals of treatment are to prevent further slippage and restore hip function without complications like avascular necrosis.

1. SLIPPED CAPITAL FEMORAL EPIPHYSIS
DR RITESH JAISWAL
M.B.B.S D.Ortho DNB (Ortho) M.N.A.M.S M.Ch (Ortho)
Fellowship in Joint Replacement ( Mumbai )
Fellow AO Trauma ( Switzerland )

2. INTRODUCTION
PATHOLOGY
ETIOLOGY
CLINICAL PRESENTATION
INVESTIGATIONS
CLASSIFICATIONS
DIFFERENTIAL DIAGNOSIS
TREATMENT
COMPLICATIONS

3. INTRODUCTION
SCFE
- also known as slipped upper femoral
epiphysis, SUFE
- most common adolescent hip disorder
- capital femoral epiphysis is displaced
from the metaphysis through the
physeal plate
- misnomer as head is held in the
acetabulum by the ligamentum teres,
and actually the proximal femoral
neck and shaft that move anteriorly
and rotate externally relative to the
femoral head.

4. - Mostly a varus relation exists between the head and
neck, but occasionally the slip is into valgus, with
the head displaced superiorly and posteriorly in
relation to the neck
- Incidence is about 2 cases per 100,000.
- Age 10 to 14 years in girls
10 to 16 years in boys
- Most of the children with SCFE have open triradiate
cartilage and are Risser 1
- 70 % of affected patients have delayed skeletal
maturation.

5. - Skeletal age may lag behind chronologic age by as
much as 20 months.
- There is a male predominance of 2.5:1.
- The left hip is twice as often affected as the right
hip.
- Affected patients have a tendency toward obesity.
- Almost half of affected patients are above the 95th
percentile in weight for their age.
- The incidence of bilateralness of SCFE is generally
accepted as being 25%.

7. RESERVE ZONE
- Composed of Chondrocytes
- Type 2 collagen is maximum
- Oxygen tension is LOW
PROLIFERATIVE ZONE
- Chondrocytes form Matrix
- Oxygen tension is HIGH
- Rich Vascular supply
- Majority of Longitudinal growth
of growth plate occurs in this zone
HYPERTROPHIC ZONE
- Avascular
- Oxygen tension is LOW
- Chondrocytes prepare matrix for
mineralization and Calcification
- SLIP occurs through this Zone
( Weakest part of plate )

8. PATHOLOGY
Pathological Changes :
- characteristic of synovitis, with hypertrophy and
hyperplasia of the synovial cells, villus formation, increased
vascularity, and round cell infiltration.
Light microscopic studies
- Physis is widened and irregular, sometimes reaching 12 mm in width
(normal is 2.6 to 6 mm).
- Normally, the resting zone accounts for 60 to 70% of the width of the
physis, whereas the hypertrophic zone accounts for only 15 to 30%
of the width.
- In SCFE, the hypertrophic zone may constitute up to 80% of the
physis width.

9. - Actual slip takes place through the zone of hypertrophy, with
occasional extension into the calcifying cartilage.
Histologic studies :
Shows that the slip occurs through the weakest structural area of
the plate, the hypertrophic zone

11. ETIOLOGY
- The origin of SCFE is unknown.
- Caused either by altering the strength of the
zone of hypertrophy or by affecting the shear
stress to which the plate is exposed.

12. Factors which lead to increased shear
forces across the physis and set the stage for
developing SCFE:
1. Increased weight (>80th centile)
2. Femoral retroversion (>10°)
3. Increased physis height due to a widened
hypertrophic zone
4. A more vertical slope of the physis
5. Perichondial ring ( Retaining collar around
physis) is relatively thinned at this age
5. Trauma.

13. Factors which lead to Weak physis :
1. Renal failure osteodystrophy (95% bilateral)
2. Previous radiation therapy
3 Endocrine disorders (65% bilateral):
- a. Hypothyroidism (usually SUFE is the first presenting feature)
- b. Growth hormone deficiency
- c. Growth hormone excess
- d. Panhypopituitarism
- e. Craniopharyngioma
- f. Hypogonadism
- g. Hyperparathyroidism
- h. Multiple endocrine neoplasias
- i. Turner’s syndrome.

14. Endocrine Factors
- Estrogen strengthens and testosterone
weakens the physis
- The most common endocrinopathies in
children with SCFE are hypothyroidism,
panhypopituitarism, growth hormone (GH)
abnormalities, and hypogonadism
- Other endocrine causes of SCFE include
hyperparathyroidism or hypoparathyroidism

15. - The increased prevalence of hypothyroidism in
children with Down syndrome is a likely
explanation for the increased risk of SCFE in
these children
- SCFE has been noted to be most common in
children around the time of puberty.
- It may be that the abnormalities in the
complex interplay of hormones at puberty
puts their hips at risk for SCFE

16. Mechanical Factors
- Mechanical forces across the femoral head during gait can be
6.5 times body weight
- Decreased femoral ante-version increases shear force across
the proximal femoral physis.
- Decreased femoral neck shaft angle results in a more vertical
physis, which may increase the shear force across the physis.
- Children with deeper acetabuli appear to be at greater risk for
SCFE, as forces across the physis may be exaggerated,
especially at the extremes of the range of motion.

17. Other Systemic Diseases
- Previous radiation therapy to the region of the
femoral head also increases the risk of SCFE
- Renal osteodystrophy is associated with a 6 to 8
fold increased risk of SCFE due to secondary
hyperparathyroidism
Genetics
Identical twins and has been found to have
Autosomal dominant inheritance with variable
Penetrance in familial cases

18. CLINICAL PRESENTATION
SYMPTOMS
- Groin and thigh pain (most
common presentation)
- knee pain (15-23%)
- motion patients prefer to sit
in a chair with affected leg
crossed over the other
- symptoms are usually
present for weeks to several
months before diagnosis is
made

19. PHYSICAL EXAMINATION
- Abnormal gait
coxalgic, externally rotated gait or Trendelenburg gait
- Decreased hip motion
obligatory external rotation during passive flexion of hip (Drehmann’s sign )
loss of hip internal rotation, abduction, and flexion
- Abnormal leg alignment
externally rotated foot progression angle
- Weakness
thigh atrophy

20. CLASSIFICATIONS
A) FUNCTIONAL by Loder
(according to the patient’s ability to bear weight)
- STABLE
- UNSTABLE
B) CHRONOLOGICAL by Fahey and O'Brian
(according to onset of symptoms )
- PRE SLIP (Prodromal)
- ACUTE (symptoms that persist for <3 weeks) - 10% of SCFE
- CHRONIC (symptoms that persist for >3 weeks - 85% of SCFE
- ACUTE - ON – CHRONIC (chronic with sudden exacerbation)
C ) MORPHOLOGICAL
(according to direction of displacement of the femoral epiphysis relative to the neck )
- POSTERIOR SLIP
- ANTERIOR SLIP

21. FUNCTIONAL CLASSIFICATION
Stable: Patient able to ambulate and bear weight.
Unstable: Patient in severe pain and is unable to ambulate
with or without crutches
unstable group has a significant risk of developing aseptic
necrosis of the epiphysis, which generally leads to a poor long-
term outcome.

22. CHRONOLOGICAL CLASSIFICATION
relating to the onset of symptoms:
PRESLIP :
A patient has symptoms (limb pain following
prolonged standing or walking) but with no
anatomical displacement of the femoral head.
There may be useful radiological evidence, such as
widening and irregularity of the physis, or osteopaenia of
the hemipelvis. This may represent a minimal slip not
easily seen on plain radiograph

23. ACUTE :
There is an abrupt displacement through the
proximal physis with symptoms and signs
developing over a short period of time.
CHRONIC:
Patients with a chronic slip present with pain in
the groin, medial thigh and knee, occurring over
a period >3 weeks (often months to years)

24. ACUTE - ON – CHRONIC
Patients have symptoms of >3 weeks duration
but present with acute symptoms of sudden
onset following a sudden increase in the degree
of slip.

25. MORPHOLOGICAL CLASSIFICATION
according to direction of displacement of the
femoral epiphysis relative to the neck
1. In the majority of cases of SUFE, the
epiphysis is displaced posteriorly and
inferiorly (varus or posterior slip) relative to
the femoral neck.
2. In rare cases, the displacement is either
superior or posterior (valgus or anterior slip).

26. GRADING
Grading is based on
- Severity of the slip on Radiographs either by
: Linear slip displacement (Wilson)
: Angular slip angle (Southwick)

27. WILSON GRADING
Based on displacement of physis in proportion to neck width
Grade I (mild): less than one-third.
Grade II (moderate): between one-third and two-thirds.
Grade III (severe): greater than two thirds

28. SOUTHWICK GRADING
Based on measuring angular displacement by the
Southwick angle on the lateral view of both hips.
• It is measured by drawing a line perpendicular to
a line connecting the posterior and anterior tips
of the epiphysis at the physis. The angle between
the perpendicular line and the femoral shaft line
forms an angle that is termed the lateral head–
shaft angle.
• Southwick angle is the difference between the
slipped and the normal sides’ angles.
• The lateral head–shaft angle is commonly misquoted (and accepted) as
the Southwick angle.

30. Grade I (mild):
angle difference of less than 30°
Grade II (moderate):
angle difference of between 30° and 50°
Grade III (severe):
angle difference of over 50°

31. INVESTIGATIONS
PLAIN RADIOGRAPH (AP and TRUE LATERAL VIEWS)
The diagnosis is usually confirmed on an
anteroposterior (AP) radiograph of the pelvis.
A frog lateral view is not recommended, as it
may displace the slip further .
The hallmarks of SCFE are

32. Trethowan’s sign is positive
A line (Klein’s line) drawn along the superior
border of the femoral neck on the AP view should
pass through the femoral head.
In SCFE, the line passes superior to the head
rather than through the head.

33. 1. The Trethowan sign: the Klein line (red line) does not transect the capital femoral epiphysis
(white arrow) of the L (SCFE) hip, as compared with the healthy R hip; 2. wide, irregular physis
of the L hip; 3. decreased height of the capital epiphysis of the L hip compared to the healthy R
hip; 4. the Capener sign: less overlap between the neck metaphysis and the posterior acetabular
wall of the SCFE hip compared to the R healthy hip; 5. double density (multiple white arrows) of
the neck metaphysis of the SCFE hip due to the overlap between the retroverted capital
epiphysis and the anteverted femoral neck

34. 2. Decreased epiphyseal height, as the head is
slipped posteriorly.
3. Increased distance between the teardrop and
the femoral neck metaphysis.
4. Capener’s sign : on AP pelvic radiographs, in a
normal hip the posterior acetabular margin cuts
across the medial corner of the upper femoral
metaphysis.
In SUFE, the entire metaphysis is lateral to the posterior
acetabular margin.

35. 5. Widening and irregularity of the physeal line
(early sign).
6. Metaphyseal blanch sign of Steel : this is a
crescent-shaped dense area in the metaphysis
due to superimposition of the neck and the head.
7. Remodelling changes with a sclerotic, smooth
superior part of the neck and callus formation on
the inferior border. This is observed in chronic
slips.

36. COMPUTED TOMOGRAPHY
valuable in:
1. Assessing the anatomical
features accurately (e.g.
degree of slip, head–neck
angle, retroversion & severity
of residual deformity )
2. Ruling out penetration of the
hip joint by metal
3. Confirming closure of the
proximal femoral
physis.

37. ULTRASOUND
This may be useful in
diagnosing early slips
by demonstrating a
joint effusion and a
step between the
femoral neck and the
epiphysis

38. MAGNETIC RESONANCE IMAGING
This is valuable in detecting avascular necrosis AVN
however, the metalware can affect the quality of the
image and prevent an accurate diagnosis.
An isotope bone scan is useful in this situation.

39. TREATMENT
GOALS
- To prevent further displacement of the epiphysis
- To promote closure of the Physeal plate
LONG TERM
- restoration of a functional range of motion
- freedom from pain
- avoidance of aseptic necrosis and chondrolysis.
CHOICE OF TREATMENT
- Depends on the type of slip and its severity
- Surgical Expertise

40. TREATMENT OPTIONS
NONOPERATIVE
- Absolute Bed REST
- Traction
- Hip Spica Cast
OPERATIVE
- Percutaneous / Open Pinning in Situ ( PIS )
- Open Reduction Internal Fixation
- Epiphysiodesis
- Osteotomy
- Reconstructive Surgery
- Cheilectomy
- Arthrodesis
- Arthroplasty

41. NON OPERATIVE
- Bed Rest
- Traction ( Controversial )
- Hip Spica Cast
- Only Immobilization is indicated rarely
- Often used adjunct to surgery
- In case surgery C/I or other treatments failed

42. OPERATIVE
PINNING IN SITU ( PIS )
Percutaneous in situ fixation
Goal
- Stabilize the epiphysis from further
slippage
- Promote closure of the proximal
femoral physis
Technique
Reductions
- Forceful reduction is not indicated and
increases risk of AVN
- "serendipitous reduction" is often
obtained with positioning

43. screw fixation
- single cannulated screw sufficient and decreases risk of AVN (compared to
multiple pins) in unstable SCFE
- screw must start on the anterior surface of the neck in order to cross perpendicular
to the physis enter into the central portion of the femoral head (which has slipped
posteriorly) on both the AP and lateral views
- minimum of 3 threads crossing the physis
- screws should be at least 5mm from subchondral bone
in all views

44. * 2 screw constructs have greater biomechanically
stable than the single screw constructs but
benefit of 2 screws needs to be considered in the
face of greater violation of the physis +/- articular
surface
Imaging
use fracture table to obtain good radiographic
visualization rotate under live fluoroscopy to
confirm that pin is not penetrating the hip joint
Postoperative
stable slips are able to bear weight after in situ
pinning unstable slips are made non-weight
bearing

45. Open in situ fixation
Morrissy Technique :
- Patient on fracture table
- Affected limb abducted 10 – 15 deg with IR
- Check True AP and lateral views on C arm
- Standard preparation and draping
- Insert guide wire through anterolateral thigh
- Adjust guide wire in both AP and Lat views
to determine femoral axis and posterior
inclination respectively

46. - Advance guide wire through physis and confirm centre
position in femoral head under C arm.
- After assessing proper depth, measure screw length
and insert cannulated screw .
- 7.3 mm or 6.5 mm, fully threaded, reversed cutting
cannulated screw is then inserted.
- Use AP and lateral views to confirm screw has not
penetrated the joint
- If 2 screws are placed
- first should be in central axis of femoral head
- second below first to avoid superolateral
quadrant
- Second screw should stop atleast 8mm from
subchondral bone

48. After treatment :
- ROM excercises begin day after surgery
- Partial wt bearing day after surgery
- Assisted walking to be continued till all signs
of synovitis goes and patient starts having
painless ROM
- All vigourous activities to be avoided till physis
is closed.
- Screw removal is done after physis closure

49. Contralateral in situ prophylactic pinning
(bilateral in situ fixation)
Indications
- Remains controversial
- Current indications are
- High risk patients (contralateral slip ~ 40-80%)
- Obese males
- Endocrine disorders (e.g. hypothyroidism)
- Initial slip at younger age ( < 10 yrs )

50. MANIPULATION & REDUCTION
- Acute
- Acute on chronic slips
- Severe slips in which PIS not possible
Timming – within 24 hrs of slip
High risk of AVN

51. OPEN REDUCTION
Open reduction, limited osteotomy and internal
Fixation.
Indication :
- Severe acute or chronic slip in which reduction
not possible with closed method
Dunn’s osteotomy involves a trochanteric osteotomy
through the growth plate with shortening of the neck to
prevent the posterior retinacular vessels from stretching
unacceptably at the time of reduction.

52. BONE PEG EPIPHYSIODESIS
- Not done nowdays , due to associated
postoperative complications
- Osteonecrosis
- Chondrolysis
- Infection
- Heterotropic Ossification
- Thigh hypesthesias
Post op immobilization is needed for 6 weeks
to prevent further slips

53. OSTEOTOMY
Moderately or severely displaced chronic slips produces
permanent irregularities in the femoral head and
acetabulum.
Realignment procedure is indicated to restore normal
relationship of femoral head and neck and possibly delay
the onset of degenerative joint disease.
2 basic type osteotomies :
- CLOSING WEDGE OSTEOTOMY –
Through the femoral neck, usually near physis to correct
deformity
- COMPENSATORY OSTEOTOMY –
Through the trochanteric region to produce deformity in
opposite direction

54. CLOSING WEDGE OSTEOTOMY ( FEMORAL NECK )
- SUBCAPITAL CUNEIFORM OSTEOTOMY
- FISH
- DUNN
- BASE OF NECK OSTEOTOMY
- KRAMER
- BARMADA
COMPENSATORY OSTEOTOMY ( TROCHANTER )
- IMHAUSER OSTEOTOMY
- SOUTHWICK OSTEOTOMY

55. The risk of AVN is highest with subcapital and
lowest with intertrochanteric osteotomy.
The slip deformity correction involves flexion,
valgus and internal rotation of the femur to
compensate for the SUFE deformity (extension,
varus and external rotation).

72. Ganz technique
- Patient is positioned one side, with the affected hip uppermost.
- A greater trochanter flip osteotomy is made and the greater
trochanter retracted anteriorly along with the vastus lateralis and
gluteus medius.
- The interval between the gluteus minimus and the piriformis is
developed and the gluteus is retracted superiorly to expose the
capsule
- A z-shaped capsulotomy was made protecting the lateral
retinacular arteries, and the hip joint was subluxated or dislocated
anteriorly by flexion-external rotation-adduction.
- The success of these approaches is closely related to protecting
(or possibly restoring) the blood supply to the femoral head.

74. DIFFERENTIAL DIAGNOSIS

78. COMPLICATIONS
1) OSTEONECROSIS
2) CHONDROLYSIS
3) FEMORAL NECK FRACTURE
4) CONTINUED SLIPPING
5) FEMOROACETABULAR IMPINGEMENT (FAI)

83. THANKS
FOR YOUR
ATTENTION