Management of Atypical Slipped Capital Femoral Epiphysis

Abstract

Atypical slipped capital femoral epiphyseal (SCFE) is associated with endocrine or metabolic disorders and radiation therapy. In this review, we use case examples of hyperparathyroidism, hypothyroidism, and growth hormone deficiency, as well as renal osteodystrophy, radiation-induced, and valgus SCFE to inform the nuances of these unusual cases. From this, we learn that routine laboratory screening of "typical" patients with SCFE is not cost-effective. Patients with atypical SCFE are often short in stature, underweight, and present either older or younger than the typical age range of idiopathic SCFE. Patients fitting these criteria should undergo an endocrine workup. While uncommon, prompt recognition of atypical SCFE is crucial, as coordinated care with pediatric subspecialists is necessary. In situ fixation with cannulated screws is the most common fixation method, and bilateral fixation is recommended.

Key concepts: •Patients younger than 10 or older than 16 years of age and patients with height, weight, or BMI below the 50^th percentile should undergo laboratory screening for atypical SCFE.•Patients presenting with a valgus slip should undergo screening labs for atypical SCFE.•Patients presenting with a unilateral SCFE with underlying endocrinopathy, metabolic disorder, or when associated with radiation therapy should undergo bilateral fixation.

Figure 1

AP and frog leg lateral radiographs demonstrating bilateral SCFEs with physeal widening in the proximal femur and the greater trochanter as well as femoral neck sclerosis in a 13-year-old male with hyperparathyroidism pre (A-B) and post (C-D) in situ percutaneous fixation. (Images courtesy of Mihir M. Thacker, MD, Nemours Children's Hospital, Delaware).

Figure 2

Examples of endocrinopathy-related SCFE (A, B). Hypothyroidism with hair thinning (A, B). Panhypopituitarism (C, D). Hypogonadism in a male (testosterone deficiency) and gynecomastia (E, F).

Figure 3

Radiographs of 15-year-old female with bilateral, right acute-on-chronic, and left chronic SCFEs, who was later diagnosed with MEN2A. Radiographs from initial presentation (A-B), after acute exacerbation of right hip pain and inability to weight bear (C), following in situ percutaneous fixation (D-E), and after bilateral surgical hip dislocations with osteochondroplasty and relative femoral neck lengthening for residual femoroacetabular impingement (F-G). (Images courtesy of Mihir M. Thacker, MD, Nemours Children's Hospital, Delaware).

Figure 4

15-year-old male with renal osteodystrophy resulting in lower extremity deformity, bowing and genu valgum (A), and acute moderate right SCFE and mild left SCFE at time of presentation (B-C) and following in situ fixation (D-E). (Images courtesy Mihir M. Thacker, MD, Nemours Children's Hospital, Delaware).

Figure 5

Coronal (A) and Axial (B) MRI pelvis cuts demonstrating widening of the right posterolateral physis in a patient with post-radiation SCFE. AP (C) and frog leg lateral (D) after bilateral percutaneous fixation for post-radiation induced SCFE. (Images courtesy of Mihir M. Thacker, MD, Nemours Children's Hospital, Delaware).

Figure 6

8.5-year-old girl with precocious puberty, pre-diabetes, advanced bone age, and left valgus SCFE (A-B), who underwent bilateral in situ screw placement (C-D). (Images courtesy of Mihir M. Thacker, MD, Nemours Children's Hospital, Delaware)

Figure 7

Treatment algorithm for the workup of atypical SCFE at presentation.

Figure 8

Valgus SCFE screw trajectory noted by white line. The more valgus the slip, the closer the entry point is to the neurovascular bundle. (Images courtesy of Mihir M. Thacker, MD, Nemours Children's Hospital, Delaware).