Slipped Capital Femoral Epiphysis: The Right Clinical Information, Right Where It's Needed

Slipped capital
femoral epiphysis
The right clinical information, right where it's needed
Last updated: Apr 27, 2018

Table of Contents
Summary 3
Basics 4
Definition 4
Epidemiology 4
Aetiology 4
Pathophysiology 5
Classification 5
Prevention 6
Primary prevention 6
Secondary prevention 6
Diagnosis 7
Case history 7
Step-by-step diagnostic approach 7
Risk factors 8
History & examination factors 9
Diagnostic tests 10
Differential diagnosis 10
Diagnostic criteria 12
Treatment 13
Step-by-step treatment approach 13
Treatment details overview 15
Treatment options 16
Follow up 21
Recommendations 21
Complications 21
Prognosis 22
Guidelines 23
Treatment guidelines 23
Evidence scores 24
References 25
Images 29
Disclaimer 31
Summary
◊ May present with an acute/insidious onset of pain and limp.
◊ The disorder is typically seen in the adolescent age group.
◊ Associated systemic disease is a common feature.
◊ 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.
Slipped capital femoral epiphysis Basics
Definition
Slipped capital femoral epiphysis (SCFE) is the most common hip disorder in the adolescent age group.
It occurs when weakness in the proximal femoral growth plate allows displacement of the capital femoral
BASICS
epiphysis. SCFE is a misnomer; it is the metaphysis that displaces anteriorly and superiorly, leading to the
slipped state.[1] [2] Weakness in the growth plate can be caused by a variety of factors, including stress on
the growth plate due to obesity, and endocrine disorders such as panhypopituitarism, hypothyroidism, and
renal osteodystrophy. A period of rapid growth in adolescence may also weaken the epiphyseal plate.[1]
Klein lines are drawn along the superior cortex of the femoral neck. Plain anteroposterior/frog-leg lateral
radiographs show the Klein line not intersecting the femoral head in hips with SCFE. Valgus SCFE is defined
as posterolateral slippage of the proximal femoral epiphysis on the metaphysis.[3]
[Fig-1]
Epidemiology
In 2000, the incidence of SCFE in Scotland was 9.7 cases per 100,000 children per year. This was 2.5
times higher than the incidence in 1981. The mean age at diagnosis decreased over this period.[9] An
increasing incidence and decreasing age at diagnosis has also been seen in Japan.[10] Race differences
have also been noted; in New Zealand, Maori and Pacific children are 3 to 5 times more likely than New
Zealand European children to have SCFE.[11] Race differences have also been noted in the US. In the US,
the overall incidence of SCFE is similar to that reported in Scotland: 10.8 cases per 100,000 children per
year. Incidence is approximately 4 times higher in African-Americans than in white people and 2.5 times
higher in Hispanic people than in white people. Gender differences have also been noted, with rates for
males higher than those for females. US geographical region may be an epidemiological factor with higher
reported incidence rates in the northeast and west than in the midwestern and southern regions of the
US.[12] Average age of onset was reported to be lower in 2006 than when previously studied in 1993.[5]
This may be due to the trend of adolescence commencing earlier than previously. A close correlation was
observed between rising childhood obesity over the last 20 years and an increasing incidence of SCFE.
Average age of onset was 11.6 years for girls and 12.6 years in boys.[9] In a 1993 survey of 1630 children
with SCFE, 47.5% were white, 24.8% African-American, 16.9% Amerindian, 7.4% Indonesian-Malay, 2.1%
native Australian/Pacific Islanders, and 1.3% Indo-Mediterranean.[13]
The incidence of valgus SCFE is estimated to be at around 5% of SCFE cases.[3]
Aetiology
The aetiology of SCFE is unknown in most cases. Obesity is recognised as the most strongly associated
risk factor. Obesity increases the shear stress across the physis, weakens it, and causes the characteristic
displacement in SCFE. Hormonal involvement associated with the adolescent growth spurt may also provide
insight into the aetiology of SCFE. The physis weakens at puberty,[7] possibly due to the effect of circulating
gonadotrophins. The weakening effect of testosterone on the physis offers a causative hypothesis for the
high incidence in males. The lower incidence in female adolescents may be due to oestrogen increasing the
strength of the physis and narrowing its width. SCFE is associated with endocrine disorders, but the vast
majority of children with SCFE are obese.[7] Radiotherapy is also thought to be a risk factor for the condition.
There is no evidence of a genetic predisposition.
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 27, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
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Slipped capital femoral epiphysis Basics
Pathophysiology
The characteristic weakening and widening of the physis are due to a variety of factors such as obesity, rapid
growth during adolescence, and endocrine disorders. These factors induce stress around the hip joint and
BASICS
apply shear force at the growth plate. The growth plate is intrinsically weak. Excess weight, the stress of an
adolescent growth spurt, and changing hormone levels shift the metaphysis anteriorly and superiorly.
Classification
Acute, chronic, acute-on-chronic[4]
This traditional classification system is based on symptom duration:
• Acute: prodromal symptoms lasting <3 weeks prior to an acute fracture-like event
• Chronic: symptoms lasting >3 weeks
• Acute-on-chronic: symptoms lasting >3 weeks with a sudden onset of increased pain and irritation.
Stable/unstable[5]
This classification is based on weight-bearing ability:
• Stable: can bear weight with or without support. This classification accounts for nearly 90% of all
SCFE cases.[6] [7]
• Unstable: unable to bear weight with or without support.
This classification is the most widely accepted.[1] [5] [7] [8]
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 27, 2018.
5
Slipped capital femoral epiphysis Prevention
Primary prevention
Weight management and dietetic measures to control adolescent obesity may help minimise the likelihood of
developing the disorder.
Secondary prevention
Although many surgeons employ a low threshold for prophylactic fixation of the contralateral hip in
pathological SCFE (underlying metabolic disorder or endocrinopathy), there is no consensus in idiopathic
SCFE. Many variables have been investigated to predict subsequent SCFE in unilateral idiopathic SCFE.
These include:
• Gender of patient
• Duration of symptoms
• Obesity
• Trauma
PREVENTION
• Severity of index slip

• Side of the index slip
• Patient age.
The posterior sloping angle (PSA), defined as the angle between the line along the plane of the physis
and the line perpendicular to the femoral neck-diaphyseal axis on axial radiograph, has been shown to be
predictive of a contralateral slip in patients presenting with unilateral SCFE.[30] PSA is more predictive in
girls. Authors recommend prophylactic pinning with a PSA >13.
Chronological or Oxford bone age at presentation has been associated as a predictor for development of
subsequent SCFE. Investigators conclude that prophylactic pinning is beneficial for the long-term outcome
of the hip. However, they recommend clinicians use sound judgment in considering age of patient, sex, and
endocrine status before prophylactic pinning.
A weight loss and management programme may be an effective preventive measure for SCFE. However,
limited empirical evidence is available to support this.
Implant removal is sometimes necessary but has a significant complication rate. The decision to remove
implants should be performed on a case-by-case basis due to the high complication rate. In an evidence-
based analysis of removal of orthopaedic implants in the paediatric population, the complication rate for
SCFE implant removal was 34%, while the complication rate from all reported paediatric orthopaedic
implants excluding that from SCFE patients was 6%.[43] 4[C]Evidence
Slipped capital femoral epiphysis Diagnosis
Case history
Case history #1
A 13-year-old boy presents with hip, groin, thigh, and medial knee pain. He is overweight and recently
experienced an adolescent growth spurt. On physical examination, the affected leg is externally rotated
and there is limited range of motion in the hip joint. He is unable to bear weight on the affected leg.
Step-by-step diagnostic approach

Clinical assessment is focused on a history of hip pain, limp, and a finding of external rotation of the hip
on examination.[14] Assessment of weight-bearing ability is vital as this helps to determine the prognosis
for avascular necrosis as well as the urgency of surgical intervention. Bilateral hip radiology in both antero-
posterior and lateral viewpoints should be requested to confirm diagnosis.
[Fig-2]
[Fig-3]
History
Typical presenting features include medial knee, hip, groin, and/or thigh pain. Pain may be referred to
these regions. Onset may have been acute or insidious. A history of trauma from falls or a sport injury
may be elicited. A diagnosis of SCFE has implications for immediate treatment to prevent slip progression
and avoid complications such as avascular necrosis[15] or chondrolysis.[1] Furthermore, in unstable
SCFE circulation may be compromised if any of the retinacular vessels are disrupted. This may require
emergency surgical treatment.[16]
Valgus SCFE, defined as posterolateral slippage of the proximal femoral epiphysis on the metaphysis,
is more likely to be present in younger and female patients with a higher neck shaft angle than classic
DIAGNOSIS
posteromedial SCFE cases.[3]
Physical examination
In patients <10 years of age, features of panhypopituitarism, the presence of growth hormone deficiency
after supplementation has begun, renal osteodystrophy, and especially hypothyroidism should be
sought. Weight should be measured: if <50th percentile, an endocrine disorder should be suspected as
a contributory risk factor. If >90th percentile, the child has a significant risk factor for SCFE. Obligatory
external rotation is present when the hip joint is flexed. Passive and active flexion of the hip should
be conducted. The affected hip tends to go into external rotation during flexion. Range of movement
is typically restricted. The patient may limp and gait is characteristic for the patient to walk with their
leg externally rotated. Observational gait analysis is therefore recommended. Trendelenburg's test is
positive. The test is performed by the child standing on the affected leg with the knee flexed and the hip
extended.[17] The trunk typically leans towards the affected side.
Investigations
Blood tests including metabolic panel, TFTs, and pituitary hormones (including growth hormone) should
be obtained if there are features suggestive of an underlying disorder. Plain x-rays are generally sufficient
for diagnosis of SCFE. Bilateral films should be obtained because SCFE often occurs in both hips (up to
7
60% of cases).[18] Both antero-posterior and lateral views should be requested. The frog-leg lateral view
is often a better diagnostic tool and can show the posteriorly displaced capital femoral epiphysis.[18] Frog-
leg lateral radiographs show the Klein line not intersecting the femoral head. Valgus SCFE is often difficult
to recognise on AP films. For this reason, it is important to obtain lateral and contralateral comparison
views in children with hip pain.[3]
[Fig-2]
[Fig-3]
[Fig-1]
Urgent referral to orthopaedic surgeon

SCFE should be treated surgically as soon as it is recognised. The patient should be advised not to bear
weight on the affected hip and should be immediately referred to an orthopaedic surgeon. Early surgical
intervention can prevent slip progression and complications such as osteonecrosis.
Risk factors
Strong
puberty
• Average age at onset is 12 years for girls and 13.5 years for boys.[13] Hormonal involvement
associated with the adolescent growth spurt may also provide insight into the aetiology of SCFE. The
physis weakens at puberty,[7] possibly due to the effect of circulating gonadotrophins.
obesity
• SCFE tends to occur in obese adolescents. Weight was ≥90th percentile in 63.2% of children with
SCFE in one study.[13] Obesity increases the shear stress across the physis, weakens it, and causes
the characteristic displacement in SCFE.
DIAGNOSIS
endocrine disorders
• Hypothyroidism, panhypopituitarism, renal osteodystrophy, and growth hormone deficiency (typically
after supplementation has begun) are all associated with the condition. However, the vast majority of
children with SCFE are obese and have no identifiable endocrine disorder.[7]
Weak
male sex
• Gender differences have been noted, with rates for males higher than those for females.
ancestry
• Incidence of SCFE has been reported as 3.94 times higher in African-American children than in white
children and 2.5 times higher in Hispanic children than in white children.[12]
geographic region
• In the US, geographic region may be an epidemiological factor, with higher reported incidence rates in
the northeast and west than in the midwestern and southern regions.[12]
prior radiotherapy
• Also thought to be a risk factor for SCFE.
History & examination factors

Key diagnostic factors
presence of risk factors (common)
• Key risk factors include obesity, puberty onset, and endocrine disorders.
weight (>90th percentile) (common)

• SCFE tends to occur in obese adolescents. Weight ≥90th percentile in 63.2% of children with SCFE in
one study.[13]
gait with affected leg externally rotated (common)

• Observational gait analysis is an important part of diagnosing SCFE.
Other diagnostic factors

groin or knee pain (common)
• Referred pain to other locations is common and can cloud the diagnostic picture.
bilateral hip pain (common)

• SCFE is known to occur bilaterally in 60% of cases.[18]
Trendelenburg's gait (common)

• Results from altered hip mechanics. The child may lean the trunk towards the affected side. The test is
performed by having the child stand on the affected leg with the knee flexed and the hip extended.[17]
restricted range of motion (common)
DIAGNOSIS
• May be evident on passive and active flexion of the hip.
weight (<50th percentile) (uncommon)

• May indicate underlying endocrine disorder.
symptoms of hypothyroidism or panhypopituitarism (uncommon)

• SCFE may be the initial presentation of an endocrine disorder.
renal failure (uncommon)

• SCFE may be the initial presentation of a metabolic disorder such as renal osteodystrophy.[19]
recent trauma (uncommon)

• Children who present with extreme hip pain may have unstable SCFE due to trauma (e.g., sport injury,
falls).[6]
9
Diagnostic tests
1st test to order
Test Result
bilateral antero-posterior x-rays Klein's line does not
intersect the femoral head
• Plain x-rays should be ordered for all patients who are suspected to
have SCFE. On the antero-posterior view, Klein's line, which is drawn
along the superior aspect of the femoral neck, normally intersects
some part of the femoral head in a healthy hip.
frog-leg lateral x-rays Klein's line does not
intersect the femoral
• The frog-leg lateral view is more sensitive than antero-posterior x-
head; Bloomberg's sign
rays for detection of an early slip.[20] Klein's line in this view may be
positive
similar to that in anteroposterior radiographs. The physis will also be
blurred or widened (Bloomberg's sign).
[Fig-1]
Other tests to consider
Test Result
metabolic panel creatinine may be elevated
• Results may reflect a pattern of renal osteodystrophy
serum TFTs TSH may be elevated
• Hypothyroidism is an endocrine disorder associated with SCFE.
serum growth hormone may be low
• May indicate growth hormone deficiency.
Differential diagnosis
DIAGNOSIS
Condition Differentiating signs / Differentiating tests

symptoms
Hip fractures • History of significant trauma. • X-ray shows increased
soft tissue shadow and
displacement of the
epiphysis in any direction.
Avascular necrosis • Age of onset typically seen • In initial stages, MRI may
at 30 to 50 years. show decreased intensity for
• Features of underlying both T1- and T2-weighted
disorder may be present images.
(e.g., SLE, Cushing's
disease).
• Can result from slipped
capital femoral epiphysis in
its own right.

symptoms
Legg-Calve-Perthes' • Clinical features often similar • Plain x-rays may show
disease to slipped capital femoral sclerosis, cysts, or collapse
epiphysis (e.g., onset of of the femoral head.
pain, limp, restricted range of • MRI shows high signal
motion). intensity on T2-weighted
• Age range is typically <10 images and low signal
years old. intensity on T1-weighted
images in the subchondral
region.
Hip dysplasia • Caused by intra-uterine • Shallow, more vertically

loss of contact between oriented acetabulum seen on
the fetal femoral head and plain films.
acetabulum.
• May range from mild,
asymptomatic cases to
severe dysplasia with
congenital hip dislocation.
• Moderate-to-severe
dysplasia may predispose
to early osteoarthritis,
labral tear, or impingement,
and present with findings
secondary to one or more of
these conditions.
• Patients with congenital
dislocation have shortening
of the involved leg and
decreased hip range of
motion.
Osteomyelitis • Typically chronic or acute- • Elevated WBC, CRP, and

on-chronic presentation with ESR.
DIAGNOSIS
vague pain complaints. • Blood cultures may be
• May have at-rest or night positive for infective
pain. organism.
• Constitutional symptoms • Plain film x-rays may show
(fevers, chills, malaise) often changes consistent with
present. chronic osteomyelitis in
• Unremarkable hip some cases.
examination possible if • MRI associated with higher
infectious process involves sensitivity and specificity in
pelvis. select patients.
• MRI shows increased signal
intensity on T2-weighted
images and intra-osseous/
sub-periosteal abscess.
11

symptoms
Septic arthritis • Severe pain with weight- • Plain x-rays may show
bearing activities. increased joint space.
• May be accompanied by • Joint effusion seen on
fevers, chills, and malaise. ultrasound.
• Resting position of hip • Joint aspiration for synovial
flexion, abduction, and fluid analysis and culture
external rotation to relieve may yield positive culture.
pain.
• Pain with passive range of
motion on examination.
Groin pain/pull • Pain on adduction, direct • Tenderness directly over

tenderness in groin. the groin and adductor
tendons; no external rotation
deformity.
Ank ylosing spondylitis • Spondyloarthropathy • Plain film x-rays of the hip

typically seen in young-to- and pelvis may demonstrate
middle-aged men. irregularities of the sacroiliac
• Hip joint involvement is joints with erosive/sclerotic
common, often bilateral. changes.
• Symptoms (stiffness, pain) • Classic bamboo-spine
are worse in the morning and appearance seen on spinal
improve during the course of x-ray.
the day.
• Low back and sacroiliac
joints are also frequently
affected.
Stress fractures • History may indicate overuse • X-rays show oedema or

injury (e.g., endurance stress reaction in the region
athlete or military recruit). of the femoral neck.
DIAGNOSIS
Diagnostic criteria
Plain antero-posterior/frog-leg lateral x-rays: Klein's line drawn along the superior cortex does not intersect
the femoral head.
[Fig-1]
Slipped capital femoral epiphysis Treatment
Step-by-step treatment approach

SCFE should be treated surgically as soon as it is recognised. The patient should be advised not to bear
weight on the affected hip and should be immediately referred to an orthopaedic surgeon. Early surgical
intervention can prevent slip progression and complications such as osteonecrosis.
The aim of treatment in SCFE is to prevent progression of slip. This can be achieved with in situ fixation
of the epiphysis. Prophylactic fixation of the contralateral hip may be necessary and should be considered
on a case-by-case basis. Late deformity of the hip is a chronic and disabling complication that may require
intervention.
Stable slipped capital femoral epiphysis

The mainstay treatment of stable slip is in situ fixation of the epiphysis with a single screw. However, other
treatments including bone graft epiphysiodesis, spica cast, or in situ fixation with multiple pins have been
described.
In situ single-screw fixation is the widely accepted first-line treatment for SCFE. A screw is placed in
the centre of the epiphysis on both the antero-posterior and the lateral view. The benefits of in situ
single-screw fixation include easy technique, low subsequent slip rate, and few complications.[21] Post-
operatively, toe-touch weight bearing is permitted for the first 2 weeks followed by weight bearing as
tolerated.
Surgical dislocation of adult hip[22] without the risk of avascular necrosis has created interest in open
treatment of SCFE to anatomically realign the slip. This treatment is proposed for unstable as well as for
stable SCFE.[23] In late deformity the retroverted proximal femur causes femoro-acetabular impingement.
This treatment should be restricted to select specialised centres until long-term results and outcome
are available. Series of 40[24] and 23[25] patients treated with a modified capital reorientation (Dunn)
procedure performed through a surgical dislocation approach in both stable and unstable SCFE have
shown good results with low complication rates in the hands of surgeons experienced with the technique.
The open reduction allows for the restoration of a more normal proximal femoral anatomy with complete
correction of the slip angle and head-neck offset.
Bone graft epiphysiodesis involves removing a portion of residual physis with drill and curettage, through
a rectangular window on the anterior aspect of the femoral neck. A cylindrical tract is created, which is
filled with autologous graft obtained from the iliac crest. The disadvantages of this technique are:
• A wider extensive exposure

• Blood loss
• Longer hospital stay
• Risk of further slippage until the physis is closed.
Hip spica cast immobilisation is an antiquated technique. It involved immobilising both hips in a hip spica.
Chondrolysis and further slip are the most common complications.[26]
Unstable slipped capital femoral epiphysis

TREATMENT
The treatment of unstable SCFE is similar to that of stable SCFE. Differences include:
• Timing of the surgery

• Decompression of hip joint
13
• Reduction of the SCFE
• Stabilisation with 1 or 2 screws.
One accepted approach is to treat the condition acutely with percutaneous decompression of the hip joint,
incidental repositioning of the slip, and fixation with 2 screws.
Open reduction and internal fixation with the modified Dunn procedure in addition to surgical hip
dislocation allows restoration of proximal femoral anatomy and may decrease the risk of avascular
necrosis (AVN) in unstable SCFE. It has shown low complication rates in the hands of surgeons
experienced with the technique.[24] [25] Further long-term studies are needed to determine if it will be a
better treatment long term than in-situ fixation.
A meta-analysis on the management of unstable SCFE looked specifically at reducing the slip and the
timing of treatment. It concluded that the retrospective studies on which the review was based are open to
bias. A meta-analysis of 4 studies describing the effects of reduction on rates of AVN in unstable SCFEs
found no statistically significant difference between the reduced and unreduced groups. Five studies were
meta-analysed considering the optimal time to treat unstable SCFEs, and found that treatment within 24
hours from the onset of instability was associated with a lower risk of AVN than treatment beyond that
time,[27] 1[C]Evidence
It should be emphasised that unstable SCFEs should be treated within 24 hours, as manipulation after
this time is associated with a higher rate of AVN.
Late deformity and corrective surgery

The retroverted deformity of the femoral head remodels over a period of time. However, disabling
external rotation deformity persists in a few patients, causing gait disturbance and femoro-acetabular
impingement. This leads to pain and restricted range of motion at the hip.
This can be corrected by creating a secondary deformity counteracting the principal deformity through
osteotomy. In SCFE the deformity is in the physis and osteotomy close to the apex of deformity is
preferable. Both femoral neck and inter-trochanteric osteotomies have been performed. Cuneiform
osteotomy performed through the femoral neck achieves better results but is technically demanding and
associated with increased risk of osteonecrosis.[28] [29]
Inter-trochanteric osteotomies such as Southwick's or Imhauser's are surgically less demanding than
cuneiform osteotomy, and the incidence of osteonecrosis is less. In Imhauser's osteotomy an anterior-
based wedge is removed from inter-trochanteric region and the distal fragment is flexed and internally
rotated. This is traditionally fixed with an angled blade plate and more recently with a plate-and-screw
system.
Prophylactic fixation of contralateral hip

Many surgeons have a low threshold for prophylactic fixation of contralateral hip in pathological SCFE
(underlying metabolic disorder or endocrinopathy). Despite this, there is no consensus on prophylactic
fixation of contralateral hip in idiopathic SCFE. Multiple variables, including gender, symptom duration,
obesity, trauma, severity of index slip, laterality, and age, have been studied in relation to developing
TREATMENT
contralateral disease in idiopathic SCFE. Chronological or Oxford bone age at presentation has been
associated as a predictor for development of subsequent slip. The posterior sloping angle (PSA),
defined as the angle between the line along the plane of the physis and the line perpendicular to the
femoral neck-diaphyseal axis on axial radiograph, has been shown to be predictive of a contralateral
slip in patients presenting with unilateral SCFE.[30] PSA is more predictive in girls. Authors recommend
prophylactic pinning with a PSA >13. Prophylactic pinning is also likely to be beneficial for the long-
term outcome of contralateral SCFE in some cases where underlying metabolic disorders are present.
However, clinicians should consider each case on its own merits before offering prophylactic intervention.
Treatment details overview

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Acute ( summary )
unstable SCFE
1st urgent surgical repair
adjunct prophylactic fixation of contralateral hip
stable SCFE
1st in situ screw fixation
2nd open reduction + internal fixation with

surgical hip dislocation
3rd bone graft epiphysiodesis
Ongoing ( summary )
late deformity
1st corrective surgery
TREATMENT
15
Treatment options
Acute
unstable SCFE
1st urgent surgical repair
» The treatment of unstable SCFE is similar

to that of stable SCFE. However, there are
differences regarding timing of the surgery,
decompression of hip joint, incidental reduction
of the SCFE, and stabilisation method with 1 or 2
screws.
[Fig-4]
[Fig-5]
An accepted approach is to operate acutely, with

percutaneous decompression of the hip joint,
incidental repositioning of the slip, and fixation
with 2 screws. Early manipulative reduction of
SCFE is recommended.
» Open reduction and internal fixation with the

modified Dunn procedure in addition to surgical
hip dislocation allows restoration of proximal
femoral anatomy and may decrease the risk of
avascular necrosis (AVN) in unstable SCFE. It
has shown low complication rates in the hands
of surgeons experienced with the technique.[24]
[25] Further long-term studies are needed to
determine if it will be a better treatment long term
than in-situ fixation.
» A meta-analysis on the management of

unstable SCFE has reported that reduction of
slip is not associated with reduction of rates
of AVN compared with unreduction of slip,
and treatment within 24 hours from the onset
of instability is associated with a lower risk
of AVN than treatment beyond that time.[27]
1[C]Evidence
» Many surgeons have a low threshold for

prophylactic fixation of contralateral hip in
pathological SCFE (underlying metabolic
disorder or endocrinopathy). There is
no consensus on prophylactic fixation of
contralateral hip in idiopathic SCFE. Multiple
variables, including gender, symptom duration,
TREATMENT
obesity, trauma, severity of index slip, laterality,

and age, have been studied in relation to
developing contralateral disease in idiopathic
SCFE. Chronological or Oxford bone age
at presentation has been associated as a
Acute
predictor for development of subsequent slip.
The posterior sloping angle (PSA), defined
as the angle between the line along the plane
of the physis and the line perpendicular to
the femoral neck-diaphyseal axis on axial
radiograph, has been shown to be predictive of
a contralateral slip in patients presenting with
unilateral SCFE.[30] PSA is more predictive in
girls. Authors recommend prophylactic pinning
with a PSA >13. Prophylactic pinning is also
likely to be beneficial for the long-term outcome
of SCFE in some cases where underlying
metabolic disorders are present. However,
clinicians should consider each case on its own
merits before offering prophylactic intervention.
stable SCFE
1st in situ screw fixation
» The recommended treatment of stable SCFE

is in situ fixation of the epiphysis with a single
screw. However, other treatments including bone
graft epiphysiodesis, spica cast, or in situ fixation
with multiple pins have been described. In situ
single-screw fixation is the widely accepted
treatment first-line intervention for SCFE. The
screw is placed in the centre of the epiphysis
both on the antero-posterior and lateral aspects.
[Fig-4]
[Fig-5]
Advantages of in situ single-screw fixation

include easy technique, low further slip rate, and
prevention of complications.[21] Post-operatively,
toe-touch weight bearing is permitted for the first
2 weeks followed by weight bearing as tolerated.

TREATMENT

17
Acute
2nd open reduction + internal fixation with
surgical hip dislocation
» Open reduction and internal fixation with

the modified Dunn procedure in addition to
surgical hip dislocation allows restoration of
proximal femoral anatomy and may decrease
the risk of AVN in unstable SCFE. Even in the
clinically stable SCFE, the physis is often mobile,
suggesting that the capital reduction procedure
can be used.[24]
» The technique has shown low complication

rates in the hands of surgeons experienced with
it.[24] [25] Further long-term studies are needed
to determine if it will be a better treatment long
term than in-situ fixation.

TREATMENT

Acute
3rd bone graft epiphysiodesis
» Bone graft epiphysiodesis involves removing a

portion of residual physis with drill and curettage,
through a rectangular window on the anterior
aspect of the neck. A cylindrical tract is created
which is filled with autologous graft obtained
from the iliac crest. The disadvantages of this
technique are a wider extensive exposure, blood
loss, longer hospital stay, and the potential for
further slippage until the physis is closed.

Ongoing
late deformity
1st corrective surgery
» The retroverted deformity of femoral head

remodels over a period of time. However,
disabling external rotation deformity persists in
TREATMENT
some patients, causing gait disturbance and

femoro-acetabular impingement. This in turn
leads to pain and restricted range of motion at
hip.
19
Ongoing
» This can be corrected by creating a secondary
deformity counteracting the principal deformity
through osteotomy. In SCFE the deformity is
in the physis and osteotomy closer to the apex
of deformity is preferable. Both femoral neck
and inter-trochanteric osteotomies have been
performed. Cuneiform osteotomy through the
femoral neck achieves better correction but
is technically demanding and associated with
increased risk of osteonecrosis.[28] [29]
» Inter-trochanteric osteotomies such as

Southwick's or Imhauser's are surgically less
demanding than cuneiform osteotomy and the
incidence of osteonecrosis is less. In Imhauser's
osteotomy an anterior-based wedge is removed
from the inter-trochanteric region and the distal
fragment is flexed and internally rotated. This
is traditionally fixed with an angled blade plate,
although more recently a plate-and-screw
system has been employed.
TREATMENT
Slipped capital femoral epiphysis Follow up
Recommendations
Monitoring
FOLLOW UP
Patients should be followed up 2 weeks following surgery for a wound check. Ability to bear weight
should be assessed at this stage. Appropriate instructions should be given, as non-compliance with
recommended advice is common as pain subsides. X-rays should be ordered periodically during the post-
operative period to ensure that no further slippage has occurred and that closure of the physis has taken
place.
Patient instructions
Crutches should be used for a few weeks following surgery. Longer-term considerations include
monitoring weight and encouraging healthy weight loss if necessary.
Complications
Complications Timeframe Likelihood

chondrolysis short term low
Chondrolysis is defined as acute dissolution of articular cartilage in association with rapid progressive joint
stiffness and pain. Aetiology of chondrolysis is unknown. However, an immunological and autoimmune
theory has been proposed.[21] Chondrolysis can occur in untreated SCFE but usually occurs as a
complication of treatment. Contributory factors are persistent pin penetration of the joint, advanced SCFE
manipulative reduction, prolonged immobilisation in hip spica, and realignment osteotomies.
Chondrolysis in SCFE is exceedingly rare with current treatment methods.
Diagnosis of chondrolysis is made by plain antero-posterior or lateral x-rays of both hips when <50% of
joint space is reduced when compared with the uninvolved hip; and the joint space is <3 mm with bilateral
involvement.
Hip, thigh, and knee pain associated with hip joint stiffness are common presenting features.
Physical examination characteristically reveals restricted range of motion, particularly internal rotation.
Management includes protected weight bearing, physiotherapy to improve range of motion, and anti-
inflammatory medication. The prognosis is better for chondrolysis than for osteonecrosis.[31] 3[C]Evidence
Painful stiff hip can be treated with hip joint distraction, arthrodesis, or arthroplasty.
late deformity long term low
The retroverted deformity of the femoral head remodels over a period of time. However, disabling external
rotation deformity persists in a few patients causing gait disturbance and femoro-acetabular impingement.
This leads to pain and restricted range of motion at the hip. This can be corrected by creating a secondary
deformity counteracting the principal deformity through osteotomy. In SCFE the deformity is in the physis
and osteotomy close to the apex of deformity is preferable. Both femoral neck and inter-trochanteric
osteotomies have been performed. Cuneiform osteotomy performed through the femoral neck achieves
better results but is technically demanding and associated with increased risk of osteonecrosis.[28] [29]
SCFE in the contralateral hip variable high
21
Slipped capital femoral epiphysis Follow up
Complications Timeframe Likelihood

Many surgeons have a low threshold for prophylactic fixation of contralateral hip in pathological SCFE
(underlying metabolic disorder or endocrinopathy). There is no consensus on prophylactic fixation of
FOLLOW UP
contralateral hip in idiopathic SCFE. Multiple variables, including gender, symptom duration, obesity,
trauma, severity of index slip, laterality, and age, have been studied in relation to developing contralateral
disease in idiopathic SCFE. Chronological or Oxford bone age at presentation has been associated as
a predictor for development of subsequent slip. The posterior sloping angle (PSA), defined as the angle
between the line along the plane of the physis and the line perpendicular to the femoral neck-diaphyseal
axis on axial radiograph, has been shown to be predictive of a contralateral slip in patients presenting with
unilateral SCFE.[30] PSA is more predictive in girls. Authors recommend prophylactic pinning with a PSA
>13. Prophylactic pinning is also likely to be beneficial for the long-term outcome of SCFE in some cases
where underlying metabolic disorders are present. However, clinicians should consider each case on its
own merits before offering prophylactic intervention.
osteonecrosis variable medium
Factors associated with osteonecrosis in SCFE include unstable SCFE;[33] [34] [35] [36] [37] forcible
reduction of stable SCFE; pin penetration of posterosuperior quadrant; multiple pins.
In stable SCFE the prevalence of osteonecrosis is low;[5] in unstable SCFE the prevalence has been
quoted as highly variable (3% to 84%).[6] [38] [39] [40] Two studies have found the rate of avascular
necrosis to be approximately 20% in unstable SCFE.[34] [41]
Presenting features include hip, thigh, or knee pain; restricted range of motion of the hip is common,
particularly internal rotation. Collapse of the femoral head, cyst formation, and sclerosis are characteristic
radiological findings.
Treatment is challenging. Preventing collapse of the femoral head and reconstitution of the collapsed
femoral head is the key component of treatment. Protected weight bearing, physiotherapy to maintain
range of motion at hip, anti-inflammatory/analgesic medication, and bisphosphonates2[C]Evidence are
recommended. Surgical treatment involves decompression of the necrotic area and filling with autograft,
allograft, or live fibular graft. Results have been inconsistent.
Prognosis
Prognosis is related to the initial severity of the slip,[31] success of surgery, avoidance of serious
complications, underlying disorders, and bilaterality. A study of stable SCFE cases treated with surgical
dislocation of the hip noted that 87% of cases had some degree of labral damage and 85% of cases had
some degree of cartilage damage.[32]
Slipped capital femoral epiphysis Guidelines
Treatment guidelines
Europe
Open reduction of slipped capital femoral epiphysis

Published by: National Institute for Health and Care Excellence Last published: 2015
GUIDELINES
23
Slipped capital femoral epiphysis Evidence scores
Evidence scores
1. Reduction of the slip and timing of treatment in unstable SCFE: there is poor-quality evidence that
reduction of slip is not associated with reduction on rates of avascular necrosis (AVN) compared with
unreduction of slip, and that treatment within 24 hours from the onset of instability is associated with a
lower risk of AVN than treatment beyond that time.[27]
Evidence level C: Poor quality observational (cohort) studies or methodologically flawed randomized
controlled trials (RCTs) of <200 participants.
2. SCFE outcome with bisphosphonates: there is poor-quality evidence of good to excellent outcome
with bisphosphonate treatment. Of 17 patients treated with IV bisphosphonate therapy in adolescent
osteonecrosis, most had osteonecrosis as a sequela of unstable SCFE.[42]
3. Chondrolysis outcomes: there is poor-quality evidence for these data. Nine patients were followed up
after chondrolysis; 5 of the 9 had mild pain after prolonged activity and all had some restricted motion
at the affected hip.[31]
4. SCFE implant removal: there is poor-quality evidence to support or refute the practice of routine
implant removal in children.[43]
EVIDENCE SCORES
Slipped capital femoral epiphysis References
Key articles
• Loder RT. Controversies in slipped capital femoral epiphysis. Clin Orthop North Am. 2006
REFERENCES
Apr;37(2):211-21. Abstract
• 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
• 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
• 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
References
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. Loder RT. Slipped capital femoral epiphysis. Am Fam Physician. 1998 May 1;57(9):2135-42. Full text
Abstract
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. Full text Abstract
9. 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
10. Noguchi Y, Sakamaki T; Multicenter Study Commitee of the Japanese Pediatric Orthopaedic
Association. Epidemiology and demographics of slipped capital femoral epiphysis in Japan: a
25
multicenter study by the Japanese Paediatric Orthopaedic Association. J Orthop Sci. 2002;7(6):610-7.
Abstract
REFERENCES
11. Stott S, Bidwell T. Epidemiology of slipped capital femoral epiphysis in a population with a high
proportion of New Zealand Maori and Pacific children. N Z Med J. 2003 Oct 24;116(1184):U647.
Abstract
12. 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
13. Loder RT. The demographics of slipped capital femoral epiphysis. An international multicenter study.
Clin Orthop Relat Res. 1996 Jan;(322):8-27. Abstract
14. 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
15. 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
16. 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
17. Flynn JM, Widmann RF. The limping child: evaluation and diagnosis. J Am Acad Orthop Surg. 2001
Mar-Apr;9(2):89-98. Abstract
18. 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
19. 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
20. Frick SL. Evaluation of the child who has hip pain. Othop Clin North Am. 2006 Apr;37(2):133-40.
Abstract
21. 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
22. Ganz R, Gill TJ, Gautier E, et al. Surgical dislocation of the adult hip: a technique with full access to
the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br. 2001
Nov;83(8):1119-24. Abstract
23. Spencer S, Millis MB, Kim YJ. Early results of treatment of hip impingement syndrome in slipped
capital femoral epiphysis and pistol grip deformity of the femoral head neck junction using the surgical
dislocation technique. J Pediatr Orthop. 2006 May-Jun;26(3):281-5. Abstract
24. 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. Full text Abstract
25. 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
REFERENCES
26. 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
27. 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
28. 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
29. Hall JE. The results of treatment of slipped femoral epiphysis. J Bone Joint Surg Br. 1957 Nov;39-
B(4):659-73. Abstract
30. 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
31. 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
32. 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
33. 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
34. 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
35. 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
36. 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
37. 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
38. Peterson MD, Weiner DS, Green NE, et al. Acute slipped capital femoral epiphysis: the value and
safety of urgent manipulative reduction. J Pediatr Orthop. 1997 Sep-Oct;17(5):648-54. Abstract
39. Rattey T, Piehl F, Wright JG. Acute slipped capital femoral epiphysis. Review of outcomes and rates of
avascular necrosis. J Bone Joint Surg Am. 1996 Mar;78(3):398-402. Abstract
27
40. Tokmakova KP, Stanton RP, Mason DE. Factors influencing the development of osteonecrosis
in patients treated for slipped capital femoral epiphysis. J Bone Joint Surg Am. 2003 May;85-
A(5):798-801. Abstract
REFERENCES
41. 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
42. 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
43. 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
Slipped capital femoral epiphysis Images
Images
IMAGES
Figure 1: 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
Image courtesy of John M. Flynn, MD
Figure 2: Unstable SCFE of the right hip. Antero-posterior preoperative x-ray

29
Slipped capital femoral epiphysis Images
Figure 3: Unstable SCFE of the right hip. Frog-leg lateral preoperative x-ray
IMAGES
Figure 4: Unstable SCFE of the right hip fixed with 2 screws. Left hip prophylactic fixation with a single screw.
Antero-posterior post-operative x-ray
Figure 5: Unstable SCFE of the right hip fixed with 2 screws. Left hip prophylactic fixation with a single screw.
Frog-leg lateral post-operative x-ray
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31
Contributors:
// Authors:
Randall T. Loder, MD
George J. Garceau Professor of Pediatric Orthopaedic Surgery
Indiana University School of Medicine, Indianapolis, IN
DISCLOSURES: RTL declares that he has no competing interests.
// Acknowledgements:
Dr Randall T. Loder would like to gratefully acknowledge Dr John M. Flynn, Dr Purushottam A. Gholve, Dr
Danielle B. Cameron, and Dr Patrick O'Toole, previous contributors to this topic. JMF, PAG, DBC, and PO
declare that they have no competing interests.
// Peer Reviewers:
James McCarthy, MD, FAAOS, FAAP

Associate Professor
Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public
Health, Madison, WI
DISCLOSURES: JM declares that he has no competing interests.
D. Philip Thomas, MB, BS, FRCS

Consultant Orthopaedic Surgeon and Honorary Lecturer
University Hospital of Wales, Cardiff, UK
DISCLOSURES: DPT declares that he has no competing interests.
Nicholas M. Clarke, ChM, FRCS

Professor
Consultant Orthopaedic Surgeon, Developmental Origins of Health and Disease (DOHaD), School of
Medicine, University of Southampton, Southampton, UK
DISCLOSURES: NMC has received honoraria for visiting professorships in North America and also for
lectures in respect of congenital hip dysplasia. He is also a founding member of the International Hip
Dysplasia Institute, which has received charitable funding.

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Slipped capital

The right clinical information, right where it's needed

Last updated: Apr 27, 2018

◊ May present with an acute/insidious onset of pain and limp.

◊ The disorder is typically seen in the adolescent age group.

◊ Associated systemic disease is a common feature.

◊ Obligatory external rotation on hip flexion is a key examination finding.

The incidence of valgus SCFE is estimated to be at around 5% of SCFE cases.[3]

• Severity of index slip

Step-by-step diagnostic approach

Urgent referral to orthopaedic surgeon

History & examination factors

weight (>90th percentile) (common)

gait with affected leg externally rotated (common)

Other diagnostic factors

bilateral hip pain (common)

Trendelenburg's gait (common)

restricted range of motion (common)

weight (<50th percentile) (uncommon)

symptoms of hypothyroidism or panhypopituitarism (uncommon)

renal failure (uncommon)

recent trauma (uncommon)

Other tests to consider

Condition Differentiating signs / Differentiating tests

Condition Differentiating signs / Differentiating tests

Hip dysplasia • Caused by intra-uterine • Shallow, more vertically

Osteomyelitis • Typically chronic or acute- • Elevated WBC, CRP, and

Condition Differentiating signs / Differentiating tests

Groin pain/pull • Pain on adduction, direct • Tenderness directly over

Ank ylosing spondylitis • Spondyloarthropathy • Plain film x-rays of the hip

Stress fractures • History may indicate overuse • X-rays show oedema or

Step-by-step treatment approach

Stable slipped capital femoral epiphysis

• A wider extensive exposure

Unstable slipped capital femoral epiphysis

• Timing of the surgery

Late deformity and corrective surgery

Prophylactic fixation of contralateral hip

Treatment details overview

1st urgent surgical repair

adjunct prophylactic fixation of contralateral hip

1st in situ screw fixation

adjunct prophylactic fixation of contralateral hip

2nd open reduction + internal fixation with

adjunct prophylactic fixation of contralateral hip

3rd bone graft epiphysiodesis

adjunct prophylactic fixation of contralateral hip

1st corrective surgery

1st urgent surgical repair

» The treatment of unstable SCFE is similar

An accepted approach is to operate acutely, with

» Open reduction and internal fixation with the

» A meta-analysis on the management of

» Many surgeons have a low threshold for

obesity, trauma, severity of index slip, laterality,

1st in situ screw fixation

» The recommended treatment of stable SCFE

Advantages of in situ single-screw fixation

» Many surgeons have a low threshold for

at presentation has been associated as a

» Open reduction and internal fixation with

» The technique has shown low complication

» Many surgeons have a low threshold for