Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

unstable SCFE

1st line – urgent surgical repair

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ACUTE
|
unstable SCFE
1st line – 

urgent surgical repair

The treatment of unstable SCFE is similar to that of stable SCFE. However, there are differences regarding timing of the surgery, decompression of hip joint, incidental reduction of the SCFE, and stabilisation method with 1 or 2 screws.[Figure caption and citation for the preceding image starts]: Unstable SCFE of the right hip fixed with 2 screws. Left hip prophylactic fixation with a single screw. Antero-posterior post-operative x-rayImage courtesy of John M. Flynn, MD [Citation ends].com.bmj.content.model.Caption@41fcdf8f[Figure caption and citation for the preceding image starts]: Unstable SCFE of the right hip fixed with 2 screws. Left hip prophylactic fixation with a single screw. Frog-leg lateral post-operative x-rayImage courtesy of John M. Flynn, MD [Citation ends].com.bmj.content.model.Caption@679e9068

​One accepted approach is to operate acutely, with percutaneous decompression of the hip joint, gentle repositioning of the slip, and fixation with screws or wires.[46]​ Early manipulative reduction of SCFE is recommended.

Open reduction and internal fixation with subcapital (intraarticular) osteotomy, with or without surgical hip dislocation, allows restoration of proximal femoral anatomy and may decrease the risk of avascular necrosis (AVN) in unstable SCFE. This procedure is associated with low complication rates in the hands of surgeons experienced with the technique.[40][41][42]​​[47]​​​ Further long-term studies are needed to determine if it will be a better treatment long term gentle repositioning with decompression and screw fixation.

Open reduction is a technically demanding technique, and the variability of rates of AVN is such that clear audit of outcomes within any centre undertaking this procedure is advisable.[43][44]​​

Meta-analysis of 4 studies comparing outcomes in reduced or unreduced unstable slipped capital femoral epiphysis found no statistically significant difference in risk of AVN between treatment groups.[48] Meta-analysis of five studies that assessed timing of management found that treatment within 24 hours from the onset of instability was associated with a lower risk of AVN than treatment beyond that time.[48]

Consider – prophylactic fixation of contralateral hip

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ACUTE
|
unstable SCFE
Consider – 

prophylactic fixation of contralateral hip

Additional treatment recommended for SOME patients in selected patient group

Many surgeons have a low threshold for prophylactic fixation of contralateral hip in pathological SCFE (underlying metabolic disorder or endocrinopathy). There is no consensus on prophylactic fixation of contralateral hip in idiopathic SCFE.[13]​[23][38]​​

Many variables have been investigated to predict subsequent SCFE in unilateral idiopathic SCFE. These include: sex, symptom duration, obesity, trauma, severity of index slip, laterality, patient age, modified Oxford bone score, and bone age.[51]

The posterior sloping angle (PSA), defined as the angle between the line along the plane of the physis and the line perpendicular to the femoral neck-diaphyseal axis on axial radiograph, has been shown to be predictive of a contralateral slip in patients presenting with unilateral SCFE.[52] In one study, PSA was more predictive in girls; the authors recommended prophylactic pinning with a PSA >13.[52] According to one meta-analysis, younger patients with a high PSA of the unaffected hip are those most likely to benefit from prophylactic fixation.[51]

Prophylactic pinning is likely to be beneficial for the long-term outcome of SCFE in some cases where underlying metabolic disorders are present. However, clinicians should consider each case on its own merits before offering prophylactic intervention.

stable SCFE

1st line – in situ screw fixation

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ACUTE
|
stable SCFE
1st line – 

in situ screw fixation

In situ single-screw fixation is the widely accepted first-line treatment for SCFE.[37][38]​​ The screw is placed in the centre of the epiphysis both on the antero-posterior and lateral aspects.[Figure caption and citation for the preceding image starts]: Unstable SCFE of the right hip fixed with 2 screws. Left hip prophylactic fixation with a single screw. Antero-posterior post-operative x-rayImage courtesy of John M. Flynn, MD [Citation ends].com.bmj.content.model.Caption@1ba88369[Figure caption and citation for the preceding image starts]: Unstable SCFE of the right hip fixed with 2 screws. Left hip prophylactic fixation with a single screw. Frog-leg lateral post-operative x-rayImage courtesy of John M. Flynn, MD [Citation ends].com.bmj.content.model.Caption@5dcb6143​ Advantages of in situ single-screw fixation include easy technique, low further slip rate, and prevention of complications.[39]

Alternative techniques, including in situ fixation with multiple screws, have also been described.[38]​ Post-operatively, toe-touch weight bearing is permitted for the first 2 weeks followed by weight bearing as tolerated.

Consider – prophylactic fixation of contralateral hip

Back
ACUTE
|
stable SCFE
Consider – 

prophylactic fixation of contralateral hip

Additional treatment recommended for SOME patients in selected patient group

Many surgeons have a low threshold for prophylactic fixation of contralateral hip in pathological SCFE (underlying metabolic disorder or endocrinopathy). There is no consensus on prophylactic fixation of contralateral hip in idiopathic SCFE.[13]​[23][38]​​

Many variables have been investigated to predict subsequent SCFE in unilateral idiopathic SCFE. These include: sex, symptom duration, obesity, trauma, severity of index slip, laterality, patient age, modified Oxford bone score, and bone age.[51]

The posterior sloping angle (PSA), defined as the angle between the line along the plane of the physis and the line perpendicular to the femoral neck-diaphyseal axis on axial radiograph, has been shown to be predictive of a contralateral slip in patients presenting with unilateral SCFE.[52] In one study, PSA was more predictive in girls; the authors recommended prophylactic pinning with a PSA >13.[52] According to one meta-analysis, younger patients with a high PSA of the unaffected hip are those most likely to benefit from prophylactic fixation.[51] 

Prophylactic pinning is likely to be beneficial for the long-term outcome of SCFE in some cases where underlying metabolic disorders are present. However, clinicians should consider each case on its own merits before offering prophylactic intervention.

2nd line – open reduction + internal fixation with/without surgical hip dislocation

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ACUTE
|
stable SCFE
2nd line – 

open reduction + internal fixation with/without surgical hip dislocation

Open reduction and internal fixation is an alternative option that aims to reduce the degree of deformity. It can be performed with a surgical dislocation procedure or via an anterior approach and cuneiform osteotomy of the femoral neck. In small patient series, treatment with a modified capital reorientation (Dunn) procedure, that included surgical hip dislocation in both stable and unstable SCFE, was associated with good results, and low complication rates, in the hands of surgeons experienced with the technique.[40][41] In late deformity the retroverted proximal femur causes femoroacetabular impingement. The open reduction allows for the restoration of a more normal proximal femoral anatomy with complete correction of the slip angle and head-neck offset. However, open reduction is a technically demanding technique, and the variability of rates of avascular necrosis is such that clear audit of outcomes within any centre undertaking this procedure is advisable.[43][44]​ Open reduction should be restricted to select specialised centres until long-term results and outcome are available.

Open reduction is used most frequently for severe slips. Open reduction for moderate slips is more controversial but may be justifiable. Most mild slips are treated with in situ pinning.[13]​[43]​​

Consider – prophylactic fixation of contralateral hip

Back
ACUTE
|
stable SCFE
Consider – 

prophylactic fixation of contralateral hip

Additional treatment recommended for SOME patients in selected patient group

Many surgeons have a low threshold for prophylactic fixation of contralateral hip in pathological SCFE (underlying metabolic disorder or endocrinopathy). There is no consensus on prophylactic fixation of contralateral hip in idiopathic SCFE.[13]​[23][38]​​​​

Many variables have been investigated to predict subsequent SCFE in unilateral idiopathic SCFE. These include: sex, symptom duration, obesity, trauma, severity of index slip, laterality, patient age, modified Oxford bone score, and bone age.[51]

The posterior sloping angle (PSA), defined as the angle between the line along the plane of the physis and the line perpendicular to the femoral neck-diaphyseal axis on axial radiograph, has been shown to be predictive of a contralateral slip in patients presenting with unilateral SCFE.[52] In one study, PSA was more predictive in girls; the authors recommended prophylactic pinning with a PSA >13.[52] According to one meta-analysis, younger patients with a high PSA of the unaffected hip are those most likely to benefit from prophylactic fixation.[51]

Prophylactic pinning is likely to be beneficial for the long-term outcome of SCFE in some cases where underlying metabolic disorders are present. However, clinicians should consider each case on its own merits before offering prophylactic intervention.

3rd line – bone graft epiphysiodesis

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ACUTE
|
stable SCFE
3rd line – 

bone graft epiphysiodesis

Bone graft epiphysiodesis involves removing a portion of residual physis with drill and curettage, through a rectangular window on the anterior aspect of the neck. A cylindrical tract is created which is filled with autologous graft obtained from the iliac crest. The disadvantages of this technique are a wider extensive exposure, blood loss, longer hospital stay, and the potential for further slippage until the physis is closed.

Consider – prophylactic fixation of contralateral hip

Back
ACUTE
|
stable SCFE
Consider – 

prophylactic fixation of contralateral hip

Additional treatment recommended for SOME patients in selected patient group

Many surgeons have a low threshold for prophylactic fixation of contralateral hip in pathological SCFE (underlying metabolic disorder or endocrinopathy). There is no consensus on prophylactic fixation of contralateral hip in idiopathic SCFE.[13]​[23][38]​​​​

Many variables have been investigated to predict subsequent SCFE in unilateral idiopathic SCFE. These include: sex, symptom duration, obesity, trauma, severity of index slip, laterality, patient age, modified Oxford bone score, and bone age.[51]

The posterior sloping angle (PSA), defined as the angle between the line along the plane of the physis and the line perpendicular to the femoral neck-diaphyseal axis on axial radiograph, has been shown to be predictive of a contralateral slip in patients presenting with unilateral SCFE.[52] In one study, PSA was more predictive in girls; the authors recommended prophylactic pinning with a PSA >13.[52] According to one meta-analysis, younger patients with a high PSA of the unaffected hip are those most likely to benefit from prophylactic fixation.[51]

Prophylactic pinning is likely to be beneficial for the long-term outcome of SCFE in some cases where underlying metabolic disorders are present. However, clinicians should consider each case on its own merits before offering prophylactic intervention.

ONGOING

late deformity

1st line – corrective surgery

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ONGOING
|
late deformity
1st line – 

corrective surgery

The retroverted deformity of femoral head remodels over a period of time. However, disabling external rotation deformity persists in some patients, causing gait disturbance and femoro-acetabular impingement. This in turn leads to pain and restricted range of motion at the hip.[37]

This can be corrected by creating a secondary deformity counteracting the principal deformity through osteotomy. In SCFE the deformity is in the physis and osteotomy closer to the apex of deformity is preferable. Both femoral neck and inter-trochanteric osteotomies have been performed. Cuneiform osteotomy through the femoral neck achieves better correction but is technically demanding and associated with increased risk of osteonecrosis.[49][50]

Inter-trochanteric osteotomies such as Southwick's or Imhauser's are surgically less demanding than cuneiform osteotomy and the incidence of osteonecrosis is less. In Imhauser's osteotomy an anterior-based wedge is removed from the inter-trochanteric region and the distal fragment is flexed and internally rotated. This is fixed with either an angled blade plate or a plate-and-screw system.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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