Is your child experiencing difficulty in walking or is walking with a limp? Is this happening despite absence of any episode of trauma? Observe your child carefully. If he/she complains of hip stiffness, pain while walking, or restricted and painful movements of the hip joint then he/she could be suffering from slipped capital femoral epiphysis (SCFE).
SCFE is one of the most important pediatric and adolescent hip disorders encountered in clinical practice. An accurate and timely diagnosis with immediate treatment is critical in the condition to avoid complications.
Basics of hip joint
The hip is a ball-and-socket joint. In this joint, the rounded end/ball of the thighbone (femur) fits into the hollow of the bony pelvis. In children who are still growing, there is also a growth plate at the top of the thighbone just under the “ball” portion of the joint. An epiphysis is an area at the end of a long bone that is separated from the main part of the bone by the growth plate. The epiphysis is made of cartilage and is weaker than bone. In the thigh bone, the epiphysis connects the femoral head/the ball to the femur while still allowing the bone to lengthen and grow. During periods of growth spurts in children, the increase in body weight and height can put extra pressure on the joints. It is during these growth spurts just before puberty, that slipped capital femoral epiphysis is most likely to occur.
About SCFE
Slipped capital femoral epiphysis (SCFE) is a condition that affects the hip joint. In this condition, there is a separation/displacement of the ball of the thigh bone (femur) at the upper growing end (growth plate) of the bone resulting in a weakened hip joint. Both the hips may be involved in some children. The cause for SCFE is not well understood. It may result from a weakening in the growth plate, which can occur from trauma or inflammation, or from changes in levels of hormones in the blood, which normally occur around puberty. The separation can cause the top part of the thighbone to eventually lose its blood supply, decay, and collapse. SCFE is clinically characterized by difficulty in walking/walking with a limp, knee or hip pain, stiffness of the hip, outward turning leg, and restriction of hip movements.
SCFE is seen to primarily affect children between the ages of 8 and 15 years. It commonly occurs in children during the periods of accelerated growth shortly after the onset of puberty. Boys are seen to be affected more as compared to girls. The condition is seen to be more common in obese children. It can develop in children with hormonal imbalances due to conditions such as thyroid dysfunctions, kidney disease, or growth hormone deficiency. Other conditions that can increase the risk of developing SCFE are untreated infections of the hip joint, bone disorders, exposure of the pelvis to radiation or chemotherapy, or if the child is taking certain medications such as steroids. Sometimes there is a family history of SCFE.
Symptoms
Mild slip or stable SCFE is the more common type in which the child affected with SCFE can walk with or without crutches. Stiffness of the hip is the first symptom to develop in a child with stable SCFE. Initially the stiffness is seen to get better by rest. The stiffness may then further turn into a limp. The child may also experience pain in the groin, thigh, hip or knee that tends to come and go. As the condition progresses, the child loses some ability to move the affected hip. The involved leg twists out and starts to look shorter than the other leg. The child may find it difficult to do simple tasks such as bending over to tie his or her shoes or play sports.
Unstable SCFE or a more severe slip is very painful and the child might not be able to put weight on the affected side. It is seen to develop in a child after a trauma or a fall. Because the joint can’t move as much, the affected foot and leg may begin to turn outward. An unstable SCFE is also serious because it can restrict blood flow to the hip joint. A stable SCFE can turn into an unstable SCFE, if the child sustains a fall on the affected leg.
Diagnosis
The doctor diagnoses SCFE based on a detailed history, physical examination, and by performing x rays of the hip joint. During physical examination, the doctor will observe the gait or walking pattern, restricted hip motion and pain with attempted hip movement. X ray of the affected hip joint shows displacement/slippage or separation of the head of the thighbone from the rest of the bone. If X ray studies are normal, the doctor may ask for ultrasonography and magnetic resonance imaging (MRI). The MRI is more sensitive than x ray and has the ability to highlight contrasts in soft tissue, which makes it especially useful
in understanding problems with joints and cartilage. The doctor will also look for clinical signs of hormonal disorders and may order for blood tests to assess the thyroid and pituitary glands, and the kidneys.
Treating SCFE
Surgery is needed to stabilize the bone that has slipped. Before the surgery, the doctor will recommend lots of rest and the use of crutches to avoid putting weight on the affected leg to prevent any further slippage. The insitu pinning surgery is a less invasive surgery in which one or two screws are placed through the skin into the thighbone to hold the epiphysis to the top of the thighbone and prevent further slipping. The other surgical procedure is called as the open reduction surgery done in patients with unstable SCFE to align the bone within the hip socket and prevent loss of blood flow to the ball of the thighbone. The doctor may suggest using pins on the unaffected hip to stabilize it even if it has not slipped as the risk is high in some children and they may develop a slip in both hips. The hip is immobilized in a cast for several weeks to 2 months.
Complications
In stable SCFE, there are good chances of complete recovery in the child. Children who have unstable SCFE are at an increased risk of developing complications. Also, a delay in diagnosing the condition can lead to the development of complications. The complication that develops due to lack of blood supply to the bone is termed as avascular necrosis. The other complication occurs due to the decay of the cartilage in the bone and is termed as chondrolysis. In some rare cases, the hip joint may wear away despite prompt diagnosis and treatment.
Outlook
The child may need to use crutches to walk for 4 to 6 weeks after surgery. After open reduction surgery, the child is kept on crutches for 12 weeks and not allowed to bear any weight. If both hips have been treated the child needs to use a wheelchair for the first couple of weeks after surgery. After this period the child can get back to normal activities, and also running and contact sports. Physical therapy is essential after surgery to strengthen the hip and leg muscles.
No one can prevent SCFE, but if the slipped capital femoral epiphysis is caught early, there is a very good chance for full recovery. But one thing that can be done to lessen the risk of SCFE is to maintain a body weight within the normal range as per the person’s age. Maintaining a healthy weight can go a long way in sparing the bones and joints from the excess wear and tear that can weaken and damage them.
