A 10-year-old male presents to your office with a 1-month history of left groin pain and intermittent left medial thigh pain as well. His symptoms are typically worse with activity, and his parents have noted that he limps. His parents relate that he has had a similar problems in the past. An x-ray of the left hip shows a slipped capital femoral epiphysis (Figures 89-1 and 89-2). The patient is made non-weight bearing, he is immediately admitted to the hospital and Pediatric Orthopedics is consulted for surgical management.

Slipped capital femoral epiphysis (SCFE) is a relatively common disorder of the adolescent hip. “Skiffy” for short, SCFE is failure of the proximal femoral physis during periods of accelerated growth. This failure results in discontinuity arising between the head and neck of the femur. The femoral head stays located in the acetabulum, while the femoral neck migrates superiorly and anteriorly.

Slipped upper femoral epiphysis (SUFE).

• SCFE most commonly occurs in adolescent boys between the ages of 10 and 16 years. It occasionally occurs in girls as well—usually between the ages of 12 and 14 years—but girls are half as likely as boys to have slips.¹

• Annual incidence is estimated at 8.3 unilateral cases and 0.5 bilateral cases per 100,000 children.²

• Slips are more common in obese children³ and they occur 2 to 4 times more frequently in black and Hispanic children than in white children.^1,4

• The left hip is involved twice as frequently as the right hip. Bilateral slips occur 20 percent of the time,¹ usually within 12 to 18 months of the first slip.

• Interestingly, SCFE tends to show seasonal and regional variability. Slips tend to occur more frequently in warm months⁵, and there is a predilection for slips to occur more frequently in the Northeastern and Western US.¹

• Etiological factors for SCFE are thought to be numerous. They include local trauma, mechanical factors (physeal weakness during puberty, stress from obesity),^6,11 endocrine disorders (hypothyroidism, pituitary deficiency),¹ inflammatory conditions, and genetic factors.

• All proposed etiological factors result in a common condition: a weak physis that fails to resist displacement when subjected to sheering stress. Failure occurs in the hypertrophic zone of the physis.⁷

Though the cause of SCFE is has not been fully elucidated, there are a few risk factors that have been identified:

• Male gender.¹

• Adolescent age.

• Obese children.³

• Personal history of hyopothyroidism, growth hormone deficiency, and other pituitary axis abnormalities.⁸

Clinical Features

• Patients with a SCFE will typically report hip, thigh (usually medial), or knee pain of a short duration. Medial thigh and knee pain is thought to be referred pain secondary to irritation of the obturator nerve.

• The pain is usually aggravated by activity and relieved with rest.

• Patients often walk with a limp.

• Patients with severe cases of SCFE are completely unable to bear weight, though this is uncommon.

• Often, the affected leg is externally rotated in comparison to the normal leg.

• On exam, there may be obligate external rotation of the affected hip as it is flexed (Figures 89-3 and 89-4). There may be a slight leg-length discrepancy. Although prior classification systems (based on duration of symptoms and severity of the slip) have been employed, the most commonly accepted system in use today recognizes slips as stable or unstable. Stable slips are those in which the patient is still able to bear weight; unstable slips are those that prevent any form of ambulation. This classification scheme has implications on prognosis and treatment method.⁹