Slipped Capital Femoral Epiphysis (SCFE)

Also known as: SCFE (slipped capital femoral epiphysis), Slipped capital femoral epiphysis, Slipped upper femoral epiphysis (SUFE), Capital femoral epiphyseal slip, Proximal femoral epiphysiolysis, Femoral head epiphyseal slip, Slipped hip growth plate

Last updated: December 18, 2024

Slipped capital femoral epiphysis (SCFE) is a hip disorder in adolescents where the femoral head can shift relative to the femoral neck through the growth plate, either gradually (stable) or suddenly (unstable), often moving backward and downward. It may disrupt hip mechanics and affect blood supply, raising risk of avascular necrosis. Symptoms include hip or groin pain, thigh or knee pain, and limping. Outcomes vary and are influenced by timing of diagnosis.

Key Facts

•Slipped capital femoral epiphysis (SCFE) refers to a pediatric hip disorder in which the femoral head (capital epiphysis) displace relative to the femoral neck through the proximal femoral growth plate (physis)
•Hip or groin pain that worsens with activity and occurs at rest, sometimes described as deep or aching
•Diagnosed through history, physical exam, and imaging
•First-line treatment includes exercise, weight management, and activity modification

What It Is

Slipped capital femoral epiphysis (SCFE) typically refers to a pediatric hip disorder in which the femoral head (capital epiphysis) may displace relative to the femoral neck through the proximal femoral growth plate (physis). The displacement can be gradual (stable) or sudden (unstable), and it often involves posterior and inferior translation of the epiphysis relative to the metaphysis. SCFE can disrupt normal hip biomechanics and may compromise blood supply to the femoral head, which can increase the risk of avascular necrosis. The condition generally occurs during adolescence when the growth plate may be relatively vulnerable to shear forces.

Affected Anatomy

This condition affects several structures in and around the joint:

•Proximal femoral physis (capital femoral growth plate)
•Femoral head (capital epiphysis) including subchondral bone
•Femoral neck (metaphysis) and its cortical bone
•Hip joint articular cartilage of the femoral head and acetabulum
•Acetabulum (including the acetabular labrum)
•Hip joint capsule and synovium
•Retinacular vessels supplying the femoral head (branches associated with the medial femoral circumflex artery)
•Proximal femur periosteum and surrounding soft tissues (including iliopsoas and short external rotators)

Common Symptoms

Symptoms can vary in intensity and may change over time. Common experiences include:

•Hip or groin pain that may worsen with activity and can occur at rest, sometimes described as deep or aching
•Referred pain to the thigh or knee that may lead to delayed recognition of a hip source
•Limping or altered gait that can include an externally rotated foot progression angle
•Decreased hip range of motion, often with limited internal rotation and abduction
•Pain or mechanical symptoms during hip movement, with discomfort that may increase during flexion and internal rotation maneuvers
•Outward turning of the leg at rest or during walking, which can reflect altered femoral alignment
•Sudden escalation of pain with inability to bear weight in more severe or unstable presentations
•Stiffness and reduced participation in sports or routine activities due to discomfort and limited motion

Causes and Risk Factors

Multiple factors can contribute to the development of this condition:

Causes

•Mechanical shear stress across a weakened proximal femoral physis, which can be influenced by rapid growth and body weight
•Endocrine or metabolic influences that may alter physeal strength and maturation, including thyroid, growth hormone, or gonadal axis abnormalities
•Anatomic and biomechanical factors that can increase shear forces at the growth plate, such as femoral retroversion or altered proximal femoral geometry
•Trauma or minor injury that can precipitate symptoms or destabilize a previously stable slip, particularly in susceptible physes
•Idiopathic factors in which no single precipitating cause is identified, which can be common in typical adolescent presentations

Risk Factors

•Adolescence during periods of rapid growth, often in early to mid-teen years
•Higher body weight or obesity, which can increase mechanical load across the proximal femoral physis
•Male sex, which can be more commonly affected in many cohorts
•Endocrine disorders (such as hypothyroidism, growth hormone abnormalities, or hypogonadism) that may be associated with atypical age of onset or bilateral disease
•Chronic kidney disease and renal osteodystrophy, which can affect bone and physeal integrity
•Family history or underlying skeletal maturation differences that may influence physeal vulnerability
•Prior radiation exposure or conditions affecting bone quality, which can alter growth plate resilience
•Contralateral hip risk after an initial SCFE, as bilateral involvement can occur either simultaneously or sequentially

How It's Diagnosed

Diagnosis typically involves a combination of clinical assessment and imaging studies:

•Clinical history and symptom characterization, including onset pattern (gradual versus sudden), weight-bearing tolerance, and presence of referred knee pain
•Physical examination including gait assessment and hip range of motion testing, often noting limited internal rotation and obligate external rotation with hip flexion
•Assessment of stability based on ability to bear weight, which can help categorize presentations as stable or unstable and may correlate with complication risk
•Plain radiographs of the pelvis and hips, typically including anteroposterior (AP) pelvis and frog-leg lateral views when clinically appropriate, to evaluate physeal alignment and slip severity
•Radiographic measurements and signs (such as Klein’s line and evaluation of epiphyseal displacement) that can support diagnosis and grading
•Advanced imaging (MRI) when radiographs are inconclusive or when early “pre-slip” changes are suspected, as MRI can show physeal edema and early displacement
•Evaluation for associated conditions in atypical presentations (for example, laboratory assessment for endocrine or renal disorders) when clinical context suggests increased risk

Treatment Options

Treatment approaches range from conservative measures to surgical interventions, often starting with the least invasive options:

Self-Care and Activity Modification

•Activity modification and limitation of weight-bearing that can be used as interim management while definitive evaluation and planning occur
•In-situ pinning (percutaneous screw fixation) of the affected hip, which can stabilize the physis and is commonly used for many stable slips
•Open reduction and internal fixation techniques for selected severe slips, which can aim to improve alignment while balancing risks to femoral head blood supply
•Prophylactic fixation of the contralateral hip in higher-risk individuals, which can be considered in contexts such as endocrine disorders or high likelihood of bilateral disease
•Monitoring and management of complications (such as femoroacetabular impingement, chondrolysis, or avascular necrosis) that can influence longer-term function

Physical Therapy and Exercise

•Physical therapy and rehabilitation after stabilization, which can focus on restoring range of motion, strength, and gait mechanics as tolerated

Medications

•Pain management strategies that may include non-opioid analgesics as part of supportive care, with selection and monitoring typically individualized

Surgery

•Management approaches for unstable SCFE that can include urgent surgical stabilization, with technique selection generally based on severity and surgeon assessment
•Osteotomy procedures (such as proximal femoral osteotomy) in selected cases to address residual deformity and improve hip mechanics

Prognosis and Recovery

The course of this condition varies between individuals:

•Outcomes can vary based on slip severity, stability at presentation, and timing of diagnosis, with earlier recognition generally associated with improved hip preservation potential.
•Stable SCFE treated with timely stabilization often has favorable functional outcomes, although residual deformity can contribute to later femoroacetabular impingement and cartilage wear.
•Unstable SCFE can carry a higher risk of avascular necrosis of the femoral head, which may lead to persistent pain and degenerative changes over time.
•Bilateral involvement can occur, and contralateral slipping may develop months to years after the initial presentation, particularly in higher-risk groups.
•Long-term risk of early hip osteoarthritis can increase when deformity persists or when complications such as chondrolysis occur, and some individuals may later require reconstructive procedures.

Open Reduction and Internal Fixation (ORIF)(Procedure)
Legg-Calvé-Perthes Disease (Perthes Disease)(Condition)
Hip Osteoarthritis(Condition)

Frequently Asked Questions

Common symptoms include: Hip or groin pain that may worsen with activity and can occur at rest, sometimes described as deep or aching; Referred pain to the thigh or knee that may lead to delayed recognition of a hip source; Limping or altered gait that can include an externally rotated foot progression angle; Decreased hip range of motion, often with limited internal rotation and abduction; Pain or mechanical symptoms during hip movement, with discomfort that may increase during flexion and internal rotation maneuvers.

Diagnosis typically involves: Clinical history and symptom characterization, including onset pattern (gradual versus sudden), weight-bearing tolerance, and presence of referred knee pain; Physical examination including gait assessment and hip range of motion testing, often noting limited internal rotation and obligate external rotation with hip flexion; Assessment of stability based on ability to bear weight, which can help categorize presentations as stable or unstable and may correlate with complication risk; Plain radiographs of the pelvis and hips, typically including anteroposterior (AP) pelvis and frog-leg lateral views when clinically appropriate, to evaluate physeal alignment and slip severity.

Treatment options range from conservative measures to surgical interventions, including: Activity modification and limitation of weight-bearing that can be used as interim management while definitive evaluation and planning occur; Pain management strategies that may include non-opioid analgesics as part of supportive care, with selection and monitoring typically individualized; In-situ pinning (percutaneous screw fixation) of the affected hip, which can stabilize the physis and is commonly used for many stable slips; Management approaches for unstable SCFE that can include urgent surgical stabilization, with technique selection generally based on severity and surgeon assessment; Open reduction and internal fixation techniques for selected severe slips, which can aim to improve alignment while balancing risks to femoral head blood supply.