13-year-old female patient with a history of intermittent right-sided hip pain for the past 6 months presented to the emergency department after a fall from stairs followed by pain in the right hip. A fracture was suspected and she was referred for right hip/pelvis radiography.
AP (Fig. 1) and frog-leg (Fig. 2) views of pelvis were taken. AP view shows a slightly widened femoral epiphysis on the right side which is very apparent on frog-leg/Lauenstein view as a medio-posterior slippage of the right femoral epiphysis.
Post-operative AP radiograph (Fig. 3) shows surgical fixation of the right femoral epiphysis to its normal position with screw placement.
Background:
Slipped capital femoral epiphysis (SCFE), a nontraumatic fracture through growth plate with anterior displacement of the femoral neck metaphysis relative to the epiphysis, is the most common hip abnormality in adolescents with frequent lifelong sequelae, having a prevalence of 2 cases per 100, 000 children which predominantly affects boys in the age group of 8-15 years, suggesting association with growth spurt and changing orientation of physis from horizontal to oblique. [1] Other factors such as genetics, biomechanical forces, metabolic disorders are postulated to cause slippage by pathological distubances in physis [3]
Clinical perspective:
Frequently presenting symptoms are painful hip or knee or limp which can be misdiagnosed as muscle strain, Osgood-Schlatter disease or flat feet and delay in diagnosis often leads to poor long-term results due to progression in slip severity [1, 3]
Imaging perspective:
Anterior, lateral and frog leg lateral radiographs with gonad protection are performed, which shows widening of the physis with or without demineralization in pre-slip phase. [1] Acute slip is seen as a fracture without sclerosis at the physis, in contrast to acute-on-chronic slip, which shows sclerosis and irregularity around the widened physis with associated remodelling in the femoral neck. Radiologically mild to severe displacement depends on the degree of femoral head displacement compared to the diameter of metaphysis. Line of Klein and metaphyseal blanch sign can help make the diagnosis. [1] USG and MR can also aid in reaching the diagnosis.
Outcome:
Early complication are slip progression, hardware loosening, chondrolysis. AVN (avascular necrosis) is associated with advanced unstable slippage, extensive manipulation, delayed surgery, anterior or many pin placement, subcapital and neck osteotomies. Late complications are 'pistol grip' deformity or CAM-type femoroacetabular impingement leading to articular chondral damage, osteoarthritis, limb length discrepancy [2, 4]
Treatment:
Prevention of early osteoarthritis, avascular necrosis and additional displacement along with achieving optimal functional outcome are the primary goal of treatment which can be achieved by stabilization of the epiphysis with in-situ pin or screw placement. [1, 2, 3] Additional femoral head-neck osteochondroplasty performed in mild SCFE is thought to prevent femoroacetabular impingement too, but further study is needed to determine whether it is justified to prevent articular damage. [2, 3, 4] In moderate to severe SCFE, intertrochanteric or subtrochanteric osteotomies are advised due to excellent results and low occurrence of osteoarthritis and AVN. [1, 3]
Prophylactic pinning of contralateral hip is advocated by some authors but others prefer to closely monitor it for 1-2 years instead. [1, 3]
Teaching points:
It is important to differentiate SCFE from Salter-Harris fracture as treatment is different.
Right-sided slipped capital femoral epiphysis
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In the provided anteroposterior pelvis view and frog-leg lateral X-ray images, mild posteromedial displacement of the right femoral head relative to the femoral neck can be observed (a typical “slippage” appearance), along with widening and irregularity of the growth plate (physis).
No obvious soft tissue swelling is noted, and there is no clear fracture line traversing the entire femoral neck or metaphysis. Compared to the normal contralateral side, the continuity and alignment between the right femoral neck and head are altered, indicating a possible slip or instability at the physis.
In the postoperative (internal fixation) imaging, two screws can be seen inserted to stabilize the epiphysis of the femoral head, reducing the risk of further displacement. The position of the internal fixation is acceptable, with no apparent screw breakage or loosening.
Based on the patient’s age, clinical presentation, and imaging characteristics, the following diagnoses are considered:
1. Slipped Capital Femoral Epiphysis (SCFE): Common in adolescents during rapid growth phases, often presenting with thigh or knee pain. X-rays typically show posterior and inferior displacement of the femoral head relative to the femoral neck.
2. Salter-Harris Type I Epiphyseal Injury: Also associated with separation of the growth plate, typically following acute trauma. However, it usually presents with a clear history of injury, and the pattern of slippage differs from SCFE.
3. Femoral Neck Fracture (less common in adolescents): Would typically occur with significant traumatic force, resulting in a complete fracture line with marked displacement and acute pain—not consistent with the milder “growth plate slip” seen here.
Given the patient is a 13-year-old adolescent with intermittent pain, and imaging shows significant widening of the physis and slippage, SCFE remains the most likely diagnosis.
Combining the patient’s age, clinical presentation (intermittent hip pain worsening with activity), and X-ray findings (slippage between the femoral head and neck, widened physis, and postoperative internal fixation images), the most likely diagnosis is: Right Slipped Capital Femoral Epiphysis (SCFE).
Treatment Plan:
• Surgical Intervention: For confirmed SCFE, “in-situ pinning” or screw fixation is commonly used to stabilize the growth plate and prevent further displacement. In this case, the patient has already undergone internal fixation. If similar slippage signs appear in the contralateral hip during follow-up, prophylactic fixation may be considered.
• Postoperative Management: After surgery, weight-bearing should be protected according to instructions, and regular follow-up X-rays are needed to assess screw position and control of the slip. In cases of marked deformity or severe slippage, corrective osteotomy may be considered.
Rehabilitation and Exercise Prescription (FITT-VP Principle):
1. Early Phase (0–6 weeks postoperatively)
• Frequency: 1–2 sessions of mild activity training per day are recommended.
• Intensity: Should not elicit significant hip pain. Focus on range of motion exercises and basic movements such as straight leg raises.
• Time: 10–15 minutes per session, primarily aiming to restore joint flexibility and muscle strength.
• Type: Passive/active joint mobility exercises, isometric quadriceps training, simple supine bridge exercises, etc.
• Progression: Gradually increase the frequency and duration of exercises as pain and function improve.
2. Mid Phase (6–12 weeks postoperatively)
• Frequency: Rehabilitation exercises 3–4 times per week.
• Intensity: Partial weight-bearing walking or assisted gait with walking aids under professional guidance, as long as there is no pain with weight-bearing.
• Time: Each session should not exceed 30 minutes, with adequate rest intervals.
• Type: Further strengthening of the hip musculature (iliopsoas, gluteal muscles, etc.), balance training, and standing practice.
• Progression: Transition from using crutches or a walker to walking without support based on recovery progress.
3. Late Phase (after 3 months postoperatively)
• Frequency: Maintain 3–5 exercise sessions per week.
• Intensity: Increase weight-bearing and range of motion gradually under physician or physical therapist supervision. Avoid excessive rotational or high-impact activities of the hip.
• Time: 30–45 minutes per session, stopping if hip discomfort arises.
• Type: Low-impact aerobic activities such as swimming or cycling, combined with core stability and lower extremity strength training. Progressing to running or jumping should be done carefully and gradually under professional guidance.
• Progression: Increase exercise intensity and variety as function recovers and bony healing improves, prioritizing both safety and stability.
Throughout the rehabilitation process, regular follow-up with orthopedic and rehabilitation specialists is crucial to monitor growth plate healing and alignment changes in the lower limbs, and to adjust the training program as needed. Patients should seek medical evaluation if they experience significant hip pain, joint range of motion limitations, or weakness, and modify rehabilitation on professional advice.
Disclaimer: This report serves as a reference analysis based on the available imaging and clinical information. It does not replace an in-person consultation or the advice of a professional physician. If you experience any discomfort or have questions, please consult a healthcare professional promptly.
Right-sided slipped capital femoral epiphysis
