01Approach to the Critical Patient/attcp27

Immediate priorities

›Unstable SCFE recognition

›Inability to bear weight at all — defines unstable SCFE

›AVN rate up to 47–50% in unstable cases

›Requires urgent orthopedic surgery consultation within hours

›Strict non-weight-bearing initiated immediately

›Crutches or wheelchair pending surgical fixation

›No forceful passive reduction attempts — AVN risk

›Surgical fixation target within 24 hours for unstable SCFE

›If surgery impossible within 24 hours, delay beyond 72 hours may paradoxically reduce AVN risk

›Class I expert consensus recommendation

Missed diagnosis prevention

›Knee pain pitfall

›Isolated knee or distal thigh pain in 23% of presentations

›Classic missed-diagnosis scenario for SCFE

›Normal knee exam in adolescent demands hip evaluation

›Hip examination mandatory in any adolescent with lower extremity pain

›Internal rotation deficit most sensitive finding

›Drehmann sign highly characteristic

Escalation triggers

›Consultation and escalation criteria

›Confirmed or suspected SCFE — orthopedic surgery required for all

›Surgical condition with no conservative alternative

›Do not discharge without orthopedic contact

›Age < 10 or > 16 years — endocrinology consult

›Underlying endocrinopathy in atypical-age patients

›TSH, free T4, PTH, vitamin D, IGF-1 panel

›Fever with hip pain — septic arthritis exclusion

02History/hx63

Presentation pattern

›Classic presentation

›Obese adolescent with dull, aching hip, groin, thigh, or buttock pain

›Age range 8–16 years during rapid linear growth

›Pain worsens with hip flexion activities

›Activities provoking pain

›Squatting

›Prolonged sitting

›Bicycle riding

›Limp

›Antalgic or Trendelenburg pattern

›May be painless in mild slippage

Pain location and character

›Pain referral patterns

›Knee or distal thigh as sole complaint in 23%

›Major pitfall for missed diagnosis

›Hip exam required even when knee is chief complaint

›Low back pain referral pattern possible

›Buttock pain referral

›Groin pain referral

›Pain character

›Dull and poorly localized

›Worsens with activity, improves with rest

Onset classification

›Temporal presentation types

›Chronic — weeks to months of vague pain

›Most common presentation

›Gradual functional limitation

03Physical Exam/exam38

Gait and stance

›Gait assessment

›Antalgic gait — shortened stance phase on affected side

›Trendelenburg gait with gluteal weakness

›External foot progression angle at rest

›Painless limp possible in mild or early slips

›May have normal gait in very mild cases

›Weight-bearing status determines stable vs. unstable classification

Range of motion

›Hip ROM examination

›Internal rotation deficit — most sensitive finding

›Reduced or absent passive internal rotation

›Compare bilaterally in every case

›Drehmann sign — obligatory external rotation and abduction with passive hip flexion

›Highly characteristic of SCFE

›Pathognomonic in correct clinical context

›FADIR test — flexion, adduction, internal rotation

›Reproduces hip, thigh, or knee pain

›Sensitivity at least 59%

Inspection and palpation

›Inspection findings

›External rotation of affected leg at rest

›Leg-length discrepancy in significant slips

›Gluteal and thigh muscle atrophy in chronic cases

›Palpation

›Nonspecific hip musculature tenderness

›Knee exam typically nontender — distinguishes from knee pathology

04Differential Diagnosis/ddx43

Life-threatening mimics

›Septic arthritis

›Cannot-miss diagnosis with overlapping presentation

›Fever, elevated inflammatory markers, refusal to bear weight

›ICD-10 M00.851 — septic arthritis of right hip

›Joint aspiration required if septic arthritis suspected

›WBC > 50,000 cells/mcL in joint fluid strongly suggests sepsis

›SCFE and septic arthritis may coexist

Orthopedic conditions in the differential

›Legg-Calvé-Perthes disease

›Avascular necrosis of the femoral head

›Typical age 4–10 years (younger than SCFE)

›ICD-10 M91.10 — juvenile osteochondrosis of femoral head

›Transient synovitis

›Self-limited, typically ages 3–8 years

›Normal inflammatory markers

›ICD-10 M67.351 — transient synovitis, right hip

›Femoral neck stress fracture

›Activity-related in adolescent athletes

›MRI required when radiograph negative

›ICD-10 M84.352A

Infectious and inflammatory

›Osteomyelitis

›Fever, focal bony tenderness, elevated ESR and CRP

›Blood cultures prior to antibiotics

›MRI most sensitive for early osteomyelitis

›Reactive arthritis

›Preceding genitourinary or gastrointestinal infection

05Laboratory Tests/lt36

Infection exclusion panel

›Inflammatory markers

›Complete blood count

›Leukocytosis suggests septic arthritis or osteomyelitis

›Thrombocytosis in inflammatory conditions

›Erythrocyte sedimentation rate

›Elevated in septic arthritis and osteomyelitis

›Normal or mildly elevated in SCFE

›C-reactive protein

›Markedly elevated in septic arthritis (>20 mg/L typical)

›More sensitive than ESR for acute bacterial infection

Endocrine evaluation

›Atypical-age workup (under 10 or over 16 years, or height/weight below 10th percentile)

›Thyroid-stimulating hormone and free T4

›Hypothyroidism is common underlying cause in atypical SCFE

›Treat endocrinopathy in addition to surgical fixation

›Parathyroid hormone

›Renal osteodystrophy assessment

›Elevated in secondary hyperparathyroidism

›25-hydroxyvitamin D

›Deficiency is independent risk factor for SCFE (RR 1.42)

›Supplementation indicated if deficient

›IGF-1 and growth hormone

›Growth hormone deficiency and excess both implicated

›IGF-1 screening for growth hormone axis disorders

›Comprehensive metabolic panel

›Renal function for renal osteodystrophy

›Calcium and phosphate for metabolic bone disease

06Diagnostic Tests/dt64

Scoring Systems

›Loder stability classification

›Stable SCFE — patient able to bear weight with or without crutches

›Most clinically important classification for prognosis

›96% satisfactory outcomes with in situ fixation

›Unstable SCFE — patient unable to bear weight even with crutches

›AVN rate 47–50% regardless of treatment timing

›Urgent surgical fixation required within 24 hours

›Southwick slip angle severity grading

›Measured on frog-leg lateral radiograph

›Mild: less than 30 degrees

›Moderate: 30–50 degrees

›Severe: greater than 50 degrees

›Guides surgical planning and implant selection

›Severe slips may require modified Dunn osteotomy

›In situ fixation standard for mild and moderate stable slips

MRI

›MRI indications and utility

›Equivocal plain radiographs with high clinical suspicion

›Detects physeal edema before frank displacement ("pre-slip")

›Identifies early avascular necrosis postoperatively

›Protocol

›Coronal and axial sequences through both hips

›STIR sequences for physeal edema and AVN detection

›Diagnostic performance

›More sensitive than plain radiograph for early SCFE

›Required for stress fracture exclusion if radiograph negative

›Postoperative monitoring

07Disposition/dispo39

Admission criteria

›Inpatient admission indications

›Unstable SCFE — unable to bear weight

›Surgical fixation within 24 hours target

›NPO, IV analgesia, strict non-weight-bearing

›Septic arthritis cannot be excluded

›Joint aspiration and IV antibiotics

›Pediatric orthopedic surgery and infectious disease consult

›Bilateral SCFE identified

›Staged or simultaneous bilateral fixation planning

›Pediatric orthopedic surgery admission

Outpatient surgical pathway

›Outpatient or same-day surgery for stable SCFE

›Recent evidence supports outpatient in situ fixation at high-volume centers

›No difference in complication rates vs. inpatient

›Significant cost savings demonstrated

›Requirements for outpatient pathway

›Stable SCFE with weight-bearing ability

›Reliable family with transportation

›High-volume pediatric orthopedic center

Transfer criteria

›Transfer to pediatric orthopedic center

›All confirmed or suspected SCFE cases without on-site pediatric orthopedic surgery

›Non-weight-bearing transport

›Spine board or stretcher for unstable SCFE

›Transfer timing

›Unstable SCFE: emergent transfer within hours

›Stable SCFE: urgent transfer within 24 hours

08Treatment/t75

Immediate non-operative measures

›Non-weight-bearing

›Strict non-weight-bearing upon diagnosis or strong suspicion

›Crutches for patients who can use them

›Wheelchair for those who cannot manage crutches

›Bed rest during inpatient observation

›No ambulation until surgical fixation

›Falls precautions in pediatric inpatient setting

Analgesia

›Pain management pre-operative

›Acetaminophen — first-line

›Weight-based dosing: 15 mg/kg orally every 4–6 hours

›Maximum 75 mg/kg per day, not exceeding 4 g per day

›NSAIDs — adjunct analgesia

›Ibuprofen 10 mg/kg orally every 6–8 hours

›Maximum 40 mg/kg per day

›Avoid in renal impairment and perioperative period per surgeon guidance

›Opioid analgesia for unstable SCFE with severe pain

›Morphine 0.05–0.1 mg/kg IV every 4–6 hours

›Titrate to pain control with respiratory monitoring

Surgical treatment — stable SCFE

›In situ single cannulated screw fixation — standard of care

›Single cannulated screw across physis without reduction

›96% satisfactory outcomes reported

›Lowest long-term complication rate among surgical options

›Screw positioning

›Central screw placement perpendicular to physis

›Minimum 5 threads across physis

›Do not cross the articular cartilage

›Evidence level

›Level I evidence supports in situ fixation for stable SCFE (Loder RT, Dietz FR, 2012)

›Class I recommendation based on systematic review

Surgical treatment — unstable SCFE

›Options for unstable SCFE — no clear consensus

›In situ fixation without reduction

›Avoids iatrogenic AVN from manipulation

›Preferred by many centers for moderate slips

›Gentle reduction plus in situ fixation

›Only if performed gently without forceful manipulation

›Risk of AVN with manipulation must be weighed

›Modified Dunn osteotomy for severe unstable SCFE

›High-risk procedure requiring experienced surgeon

›Restores anatomy but higher complication rate

›Timing

›Target within 24 hours of presentation

›If delay beyond 24 hours unavoidable, delay to beyond 72 hours may reduce AVN risk

›Expert consensus recommendation

Prophylactic contralateral pinning

›Contralateral prophylactic fixation considerations

›High-risk indications for prophylactic contralateral screw

›Age under 10 years

›Underlying endocrine disorder

›Severe obesity

›Vitamin D deficiency

›Contralateral slip rate

›15.3% overall rate without prophylactic pinning

›Median time to contralateral slip approximately 190 days

›Decision requires individualized risk-benefit discussion

›Shared decision-making with family

›Pediatric orthopedic surgeon judgment

Contraindicated interventions

›Interventions to avoid

›Forceful closed reduction

›Significantly increases AVN risk

›Manipulation is contraindicated in all SCFE cases

›Weight-bearing prior to surgical fixation

›Converts stable to unstable or worsens slip

›Increases AVN and complication risk

›Physical therapy prior to fixation

›Contrainidcated in active, unrepaired SCFE

›Rehabilitation initiated only postoperatively

Postoperative rehabilitation

›Gradual return to activity protocol

›Phase 1: Protected weight-bearing with crutches 6–8 weeks

›Full weight-bearing per surgeon protocol at 6–8 weeks

›Physical therapy initiated after clearance

›Phase 2: Progressive strengthening 2–4 months

›Hip abductor and extensor strengthening

›Gait retraining

›Phase 3: Return to sport approximately 6 months

›Physician and physical therapist clearance required

›Contact sports and high-impact activity last to resume

09Special Populations/sp37

Pregnancy

›SCFE in pregnancy — extremely rare scenario

›Adolescent pregnancy increases obstetric complexity of surgical fixation

›Radiation exposure from fluoroscopy requires shielding

›Supine positioning for surgery may require uterine displacement after 20 weeks

›Anesthetic considerations

›Regional anesthesia preferred over general when feasible

›Fetal monitoring during procedure if viable gestation

›Surgical urgency unchanged by pregnancy

›Delay to fix SCFE is not acceptable due to pregnancy

›Obstetrics and anesthesia comanagement required

Geriatric

›Older adolescent and young adult considerations

›SCFE above age 16 suggests underlying endocrinopathy

›Full endocrine workup mandatory

›Treat underlying cause concurrently

›Physeal closure reduces SCFE risk but does not eliminate it

›Incomplete physeal closure at 16–18 years

›SCFE rarely reported up to age 18

›Long-term complications more likely with delayed diagnosis

›Early osteoarthritis

›Femoroacetabular impingement

›Leg-length discrepancy

Pediatrics

›Age-specific considerations

›Under age 10 — atypical age strongly implies endocrinopathy

›Full hormonal workup required

›TSH, free T4, IGF-1, PTH, 25-OH vitamin D, CMP

10Background/b72

Epidemiology

›Incidence and demographics

›Incidence approximately 10.8 per 100,000 children per year

›Most common hip disorder in adolescents

›One of the most commonly missed diagnoses in children

›Age distribution

›Range 8–16 years correlating with rapid linear growth

›Peak: girls age 11–13, boys age 13–15

›Sex ratio

›Male to female ratio 1.5:1

›Male predominance across all populations

›Racial disparities

›Higher incidence in Black, Hispanic, and American Indian/Alaska Native children

›Systematic review confirmed racial disparities across populations (Bouchard MD et al., JBJS Reviews 2025)

›Risk factor prevalence

›Obesity prevalence correlation

›Obesity RR 3.45 for SCFE development

›BMI above 95th percentile most common risk factor

›Bilateral occurrence

›25–60% of cases involve both hips simultaneously or sequentially

›Contralateral slip rate 15.3% in those initially unilateral

Pathophysiology

›Structural failure mechanism

›Proximal femoral physis weakening

›Posterior-inferior displacement of epiphysis relative to metaphysis

›Physis structurally weakest during pubescent growth spurt

›Biomechanical factors

›Increased physeal shear stress from obesity

›Retroversion of femoral neck increases shear load on physis

›Hormonal imbalance reduces physeal collagen cross-linking strength

›Avascular necrosis mechanism

›Disruption of blood supply to femoral head epiphysis

›Lateral epiphyseal vessels at highest risk in displacement

›AVN occurs in up to 47–50% of unstable SCFE cases

›Prevention is the primary surgical goal

›Gentle handling and avoidance of forceful reduction

›Prompt fixation reduces ongoing vascular traction

›Hormonal influences

›Pubescent hormonal milieu weakens physeal collagen

›Growth hormone and IGF-1 cause physeal hypertrophy

›Sex steroids normally strengthen physis — deficiency predisposes to slip

›Endocrine disorders that weaken the physis

›Hypothyroidism reduces physeal tensile strength

›Hypogonadism — reduced sex steroid strengthening effect

›Growth hormone excess — physeal hypertrophy without adequate strengthening

Therapeutic Considerations

›Evidence base for in situ fixation

›Systematic review supports single-screw in situ fixation for stable SCFE

›Lowest complication profile of all surgical options

›Loder RT, Dietz FR, J Pediatr Orthop 2012 — Level I evidence synthesis

›Outpatient surgery evidence

›JAAOS 2025 and 2026 studies demonstrate outpatient stable SCFE fixation is safe

›No difference in complication rates vs. inpatient settings

›Significant cost reduction demonstrated

›Contralateral slip risk factors and prevention

›Comprehensive analysis of 3,528 cases (Momtaz D et al., JBJS 2024)

›Overall contralateral slip rate 15.3%

›Younger age, endocrine disorders, severe obesity, low vitamin D increase risk

›Tobacco exposure associated with contralateral slip (OR 2.43)

›Prophylactic pinning decision threshold

›High-risk profile patients benefit from contralateral pinning

›Low-risk patients can be monitored with serial imaging

›Long-term complications

›Avascular necrosis

›Most serious early complication, irreversible

›Prevented by avoiding forceful manipulation

›Chondrolysis

›Destruction of articular cartilage, often post-fixation

›Risk increased with screw penetrating articular surface

›Femoroacetabular impingement

›Residual deformity causes cam-type impingement

›Risk of early osteoarthritis in adulthood

›Leg-length discrepancy

›Occurs with significant slippage or growth disturbance

›Managed with physeal arrest monitoring

11Patient Discharge Instructions/pdi28

copy discharge instructions

›Discharge instructions for Slipped Capital Femoral Epiphysis (SCFE)

›Your child has been diagnosed with a slipped capital femoral epiphysis, a condition where the ball of the hip joint slides off its normal position on the thigh bone

›This is a surgical condition and surgery will be arranged

›Your child must not put weight on the affected leg until surgery is completed

›Activity restrictions

›No weight-bearing on the affected leg — use crutches or a wheelchair at all times

›No sports, running, or physical education until cleared by your orthopedic surgeon

›No forceful movement or manipulation of the hip

›Pain management at home

›Acetaminophen (Tylenol) as directed for pain

›Ibuprofen (Advil, Motrin) as directed if not contraindicated

›Do not use pain medication as a reason to attempt walking

›Follow-up appointment

›Orthopedic surgery appointment has been arranged — attend as scheduled

›Surgery is required and will be discussed at your appointment

›Bring a list of all current medications to your appointment

›Return to emergency department immediately if

›Your child cannot bear any weight and was previously able to (worsening)

›New or worsening pain in the hip, groin, thigh, or knee on either side

›New pain or limp in the opposite hip

›Fever above 38.5 degrees Celsius with hip pain

›Sudden inability to move the hip

›Severe pain not controlled with Tylenol or Advil

›Long-term monitoring

›The opposite hip must be monitored — approximately 15% of children develop a slip on the other side

›Report any new hip or knee pain on either side immediately

›Weight management is important for reducing risk of complications

12References/r33

Guidelines and key sources

›Webb CW, Liu R, Bouchereau-Lal N. Slipped Capital Femoral Epiphysis: Rapid Evidence Review. American Family Physician. 2025.

›Primary evidence source for clinical presentation, imaging, and management

›PMID 41118186

›Peck DM, Voss LM, Voss TT. Slipped Capital Femoral Epiphysis: Diagnosis and Management. American Family Physician. 2017.

›Comprehensive review of diagnostic and management principles

›PMID 28671425

›Loder RT, Richards BS, Shapiro PS, et al. Acute Slipped Capital Femoral Epiphysis: The Importance of Physeal Stability. Journal of Bone and Joint Surgery. 1993.

›Foundational Loder stability classification paper

›PMID 8354671

Surgical evidence

›Loder RT, Dietz FR. What Is the Best Evidence for the Treatment of Slipped Capital Femoral Epiphysis? Journal of Pediatric Orthopedics. 2012.

›Systematic review supporting in situ single-screw fixation

›PMID 22890456

›Nowicki P, Carveth S, Miller K, et al. In Situ Screw Fixation for Stable SCFE Is Safely Treated in Both Inpatient and Outpatient Settings. JAAOS. 2025.

›Supports outpatient surgical pathway for stable SCFE

›PMID 40339137

›Brown EA, Wilson DR, Lawrence HW, et al. Outpatient Management of SCFE Is Common, Safe, and Saves Costs. JAAOS. 2026.

›Single-institution and national database evidence for outpatient approach

›PMID 42007901

Epidemiology and risk factors

›Momtaz D, Mirghaderi P, Gonuguntla R, et al. Rate and Risk Factors for Contralateral Slippage in SCFE: A Comprehensive Analysis of 3,528 Cases. JBJS. 2024.

›Contralateral slip rate 15.3%, risk factors including tobacco (OR 2.43) and diabetes (OR 1.67)

›PMID 38271486

›Zusman NL, Goldstein RY, Yoo JU. Quantifying Risk Factors for Slipped Capital Femoral Epiphysis and Postslip Osteonecrosis. Journal of Pediatric Orthopedics. 2024.

›Vitamin D deficiency RR 1.42, obesity RR 3.45 for SCFE

›PMID 37773028

›Bouchard MD, Vescio BG, Munir M, et al. Epidemiology of SCFE in Children and Adolescents: A Systematic Review. JBJS Reviews. 2025.

Evidence & Review

Evidence & Review