Is a SCFE a surgical emergency?

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Elsevier ClinicalKey Clinical Overview

Synopsis Severe pain and inability to bear weight accompanies unstable slipped capital femoral epiphysis and requires urgent treatment with morphine Urgent consultation with an orthopedic surgeon is indicated for the management of slipped capital femoral epiphysis

Synopsis Slipped capital femoral epiphysis is a common hip disorder typically presenting in 10- to 16-year-old obese males with pain in the groin, thigh, hip, or knee, combined with a progressive limp Most often, there is no associated trauma 80% of patients present with unilateral involvement 85% of cases occur with gradual onset of worsening symptoms over course of at least 3 weeks as proximal femoral epiphysis becomes displaced from femoral metaphysis Cause is unknown; associated with obesity, endocrine disorders, and renal osteodystrophy Physical examination will reveal positive impingement sign: passive flexion, adduction, and internal rotation of hip in 90 degrees of flexion resulting in pain Anteroposterior and frog-leg lateral radiographs of the pelvis are diagnostic Urgent orthopedic consultation is indicated in all cases of slipped capital femoral epiphysis for further management Standard management includes operative fixation with 1 or more screws to stabilize epiphysis and prevent further slipage Optimal treatment of stable slipped capital femoral epiphysis is in situ fixation with a single screw Prognosis is generally good for patients with stable slipped capital femoral epiphysis after in situ fixation with screw placement Prognosis for unstable slipped capital femoral epiphysis is guarded, with 24% to 47% of unstable slips developing osteonecrosis within 6 to 18 months Gradual development of degenerative osteoarthritis with any slipped capital femoral epiphysis lesion is likely over several decades

Treatment Surgical management is required Stable slipped capital femoral epiphysis Unstable slipped capital femoral epiphysis Emerging adjuncts to management include: Mild to moderate pain may be treated with acetaminophen and NSAIDs; severe pain may require opioids Stabilization of epiphysis and early fusion of proximal femoral physis will prevent further displacement and deformity Percutaneous in situ single-screw fixation is currently the most accepted treatment Open surgical hip dislocation/reduction and fixation (modified Dunn procedure) is sometimes used with stable, moderate to severe slipped capital femoral epiphysis Open surgical hip dislocation and proximal femoral osteotomy is sometimes used for chronic, stable severe slipped capital femoral epiphysis with impingement Optimal treatment method is controversial Urgent closed or open reduction with decompression and internal fixation is the most commonly utilized treatment Arthroscopically-assisted osteoplasty after in situ fixation Computer navigation assistance during in situ fixation

Treatment Acetaminophen Indicated for symptomatic care for mild to moderate pain Acetaminophen Oral solution; Children and Adolescents weighing less than 60 kg: 10 to 15 mg/kg/dose PO every 4 to 6 hours as needed. Max single dose: 15 mg/kg/dose or 1,000 mg/dose. Max daily dose: 75 mg/kg/day or 4,000 mg/day. Acetaminophen Oral solution; Children and Adolescents weighing 60 kg or more: 325 to 650 mg PO every 4 to 6 hours as needed. Alternatively, 1,000 mg PO every 6 hours as needed. Max single dose: 1,000 mg/dose. Max daily dose: 4,000 mg/day. NSAIDs Indicated for symptomatic care for mild to moderate pain Ibuprofen Ibuprofen Oral suspension; Children 9 to 10 years or weighing 60 to 71 pounds: 250 mg PO every 6 to 8 hours as needed. Max: 1,000 mg/day. Ibuprofen Oral suspension; Children 11 years or weighing 72 to 95 pounds: 300 mg PO every 6 to 8 hours as needed. Max: 1,200 mg/day. Ibuprofen Oral tablet; Children and Adolescents 12 to 17 years: 200 to 400 mg PO every 4 to 6 hours as needed. Max: 1,200 mg/day. Opioids Indicated for symptomatic care for severe pain Morphine Unstable slipped capital femoral epiphysis requires urgent treatment with morphine Morphine Sulfate Solution for injection; Children: 0.05 to 0.2 mg/kg/dose IV every 2 to 4 hours as needed; begin at the lower end of dosage range and titrate to effect. Usual Max: 4 mg/dose; however, dose must be individualized.

Synopsis Knee pain is the only symptom in 10% to 15% of cases; delay in diagnosis can lead to increased complications Examine hip and obtain hip imaging in patients with complaints of knee pain and risk factors for slipped capital femoral epiphysis Consider renal and endocrine (growth hormone and thyroid function) tests, especially in patients younger than 10 years and patients who are not obese Patient should be placed on bedrest and non–weight bearing status if diagnosis is suspected Avoid excessive manipulation attempts of the hip during physical examination Avoid aggressive positioning for radiographs if pain is prohibitive or patient is unable to bear weight (unstable slipped capital femoral epiphysis is suspected) Early diagnosis is crucial to avoid further slip progression and a poor outcome