What's the Scoop

"What's the scoop"

Author: Brandon Godfrey, MD

Peer-reviewer: Katie Dolbec, MD

Final editor: Alex Tomesch, MD

A 13-year-old obese female has had a limp for 3.5 weeks. Her x-ray is shown below.

Image 1. Case courtesy of Dr. Subhan Iqbal and Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 2056

1. What is your diagnosis?

2. What is your management in the ED?

3. What is your disposition?

4. What is the treatment?

5. Extra radiographic pearl

-- see below for answers --

1. What is your diagnosis?

Slipped capital femoral epiphysis (also known as slipped upper femoral epiphysis), SCFE for short. 

Image 2. Case courtesy of Rahul Setia and Assoc Prof Frank Gaillard, Radiopaedia.org, rID 8109

• Pearl: If there is concern for Slipped Capital Femoral Epiphysis (SCFE), obtain an AP view and a frog leg lateral view, which is the more sensitive view for SCFE. or Perthes disease. The Line of Klein should run from the femoral neck and intersect the lateral aspect of the femoral head [1]. 

2. What is your management in the ED?

The patient should immediately be made non-weight bearing. A pediatric orthopedic surgeon should be consulted to evaluate this patient while in the ED. The patient should receive crutches to assist with ambulation.

3. What is your disposition?

Disposition will be dependent on your institution and the location of your emergency department. Admission vs. discharge can depend on the degree of displacement or angulation [2]. If the SCFE is determined to be stable and the child is discharged, prompt outpatient follow up must be arranged. Even if a child is discharged with crutches and close follow up, there is still a risk of a stable SCFE transforming into an unstable one [3].

4. What is the treatment?

Treatment for SCFE is operative with placement of a percutaneous screw [2,3]. This will secure the femoral head and prevent further slipping [2]. 

• Pearl: There may also be cases where prophylactic contralateral screw placement is indicated. A SCFE is bilateral in 40-61% of cases [2]. 60% of patients will present with simultaneous bilateral slips and 40% will present with sequential slips usually within 18 months of each other [3]. This is why it is important to evaluate both sides for signs of SCFE.

5. Extra radiographic pearl…

Image 1. Case courtesy of Dr. Subhan Iqbal and Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 2056, annotation by Brandon Godfrey 

The S-sign was more accurate at identifying SCFE than Klein's line (92.4% vs 79.2% respectively). A normal S sign can be seen above in the right hip with the abnormal S sign present in the left hip. A combination of the S-sign and Klein's line has a sensitivity of 96.5% and specificity of 85% for diagnosing SCFE and was more diagnostic for this condition than just utilizing Klein's line [4].

References:

1. Setia R, Gaillard F. Line of Klein. https://radiopaedia.org/articles/line-of-klein?lang=us. Accessed May 29, 2021.

2. Monseau AJ, Balcik BJ. Pelvis, Hip and Thigh. In: Waterbrook A, ed. Sports Medicine for the Emergency Physician A Practical Handbook. Cambridge University Press; 2016: 167-207.

3. Glavas P.P., Horn B.D. (2012) Slipped Capital Femoral Epiphysis. In: Abzug J., Herman M. (eds) Pediatric Orthopedic Surgical Emergencies. Springer, New York, NY. https://doi-org.ezproxy4.library.arizona.edu/10.1007/978-1-4419-8005-2_13

4. Rebich EJ, Lee SS, Schlechter JA. The S Sign: A New Radiographic Tool to Aid in the Diagnosis of Slipped Capital Femoral Epiphysis. J Emerg Med. 2018 Jun;54(6):835-843. doi: 10.1016/j.jemermed.2018.01.023. Epub 2018 Mar 15. PMID: 29550284.

Additional reading on SCFE can be found at WikiSM.

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