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Radiograph (anteroposterior (AP) and frog-lateral view) of a 13-year-old male SCFE patient. While the SCFE can be missed on AP films (a), the slip is obvious on frog-lateral view (b; arrow).
Source publication
Background:
Slipped capital femoral epiphysis (SCFE) is a frequent disorder of the adolescent hip, which may lead to avascular necrosis (AVN) of the femoral head, chondrolysis and early osteoarthritis due to the post-slip deformity of the proximal femur. To warrant the best possible outcome for the affected (and contralateral) hip, early diagnosis...
Contexts in source publication
Context 1
... radiography is the first-choice imaging modality in patients with suspected SCFE. Usually, anteroposterior (AP) pelvis and frog-lateral views of both hips are obtained ( Fig. 1). Radiographs of the contralateral side should always be included to rule out the bilateral involvement of SCFE. Further, the contralateral hip may serve as a con- trol for the affected side. Notably, in acute, unstable slips rotation of the affected hip may cause pain (especially for frog-lateral view), increase the slip severity and, ...
Context 2
... promise to objec- tively assess the cartilage status in a reproducible manner (Fig. 9). Further, including the value of radial imaging and three-dimensional reconstruction, these techniques will possibly help to guide surgical treatment according to the individual disease/deformity and to monitor surgical and non-surgical treatment strategies (Fig. 10). ...
Citations
... 검사는 고관절 통증을 호소하는 환자에서 초기 소견이 불분명할 경우 시행되는 경우가 있는데, 골단 전위를 시사하는 골단과 골간단 사이 끊어짐(anterior physeal slip)을 볼 수 있으나, 대개 단순 방사선 사진에서 진단할 수 있는 경우가 더 흔하다(29). 고관절 전산화단층촬영 (이하 CT) 검사와 자기공명영상(MRI) 검사는 단순 방사선 사진에서 대퇴골두 변위가 애매할 때 (pre-slips) 또는 수술 후 합병증을 평가할 때 사용될 수 있다(14,27). ...
... More recently, the use of Magnetic Resonance (MR) and Computer Tomography (CT) have showed a great potential in SCFE early diagnosis and severity assessment respectively. However, their use is still limited in clinical settings due to CT irradiation and MR costs and availability [11]. ...
Rationale and objectives
Imaging plays a key role in Slipped Capital Femoral Epiphysis diagnosis and severity assessment. In the last two decades, signs and measurements emerged in literature showed potential to help in SCFE diagnosis and tailoring treatment. The purpose of this review is to collect and discuss new imaging signs, measurements, and techniques according to investigations published after 2000 to improve SCFE diagnosis.
Material and methods
The PubMed, Scopus, and Science Direct databases were used to search for relevant articles related to imaging in SCFE diagnosis from January 2000 to March 2023. Article selection and review was performed by two board-certified radiologists). Article quality assessment were conducted by authors using QUADAS-2 and SANRA evaluation tools.
Results
The research resulted in a total of 2577 articles. After duplicates removal and abstract analysis, 28 articles were finally selected for full-text analysis. Seventeen articles were focused on Radiographs, 6 on CT, 1 on both Radiographs and CT, 4 on MRI. No study focused on ultrasound was selected.
Conclusions
Use of modified Klein's line and S-sign may improve radiographs accuracy in daily routine. Lucency sign may help in early diagnosis on radiographs. Preoperative CT may be useful in planning a tailored treatment predicting SCFE severity and instability. MRI is the most accurate modality to diagnose SCFE at early stage. Nevertheless, it cannot be used to predict the risk of contralateral SCFE. Risk prediction can be assessed with radiographs, using a new rapid mOBS. Further investigation and validation of these sign is needed.
... Diagnosis of SCFE is done based on a combination of physical examination and X-rays. The severity of SCFE is evaluated using the Southwick slip angle [4].. SCFE can be classified into two subtypes based on the stability of the physis: stable and unstable. The stable type refers to patients who can bear weight, while the unstable type refers to those who are unable to walk [5]. ...
Background
Accurate repositioning of the femoral head in patients with Slipped Capital Femoral Epiphysis (SCFE) undergoing Imhäuser osteotomy is very challenging. The objective of this study is to determine if preoperative 3D planning and a 3D-printed surgical guide improve the accuracy of the placement of the femoral head.
Methods
This retrospective study compared outcome parameters of patients who underwent a classic Imhäuser osteotomy from 2009 to 2013 with those who underwent an Imhäuser osteotomy using 3D preoperative planning and 3D-printed surgical guides from 2014 to 2021. The primary endpoint was improvement in Range of Motion (ROM) of the hip. Secondary outcomes were radiographic improvement (Southwick angle), patient-reported clinical outcomes regarding hip and psychosocial complaints assessed with two questionnaires and duration of surgery.
Results
In the 14 patients of the 3D group radiographic improvement was slightly greater and duration of surgery was slightly shorter than in the 7 patients of the classis Imhäuser group. No difference was found in the ROM, and patient reported clinical outcomes were slightly less favourable.
Conclusions
Surprisingly we didn’t find a significant difference between the two groups. Further research on the use of 3D planning an 3D-printed surgical guides is needed.
Trial registration
Approval for this study was obtained of the local ethics committees of both hospitals.
... These include the Klein's line, modified Klein's line and the S-sign. 11,[16][17][18][19] The Klein's line is a tangent drawn on the lateral margin of the femoral neck on an anteroposterior (AP) pelvic radiograph (equivalent to a ventrodorsal [VD] extendedleg pelvic view). A positive result is when the line does not intersect the epiphysis. ...
... A positive result is when the line does not intersect the epiphysis. 11,16,17 Owing to poor sensitivity of the Klein's line in cases of mild epiphyseal displacement, the modified Klein's line method was developed. This involves a Klein's line being drawn bilaterally and the amount of epiphyseal intersection measured. ...
... A positive result is one where the affected side has reduction in epiphyseal intersection >2 mm in comparison to the unaffected limb. [16][17][18] A further method to improve diagnostic sensitivity is the S-sign. This is measured on a frog-leg lateral pelvic radiograph and is a curvilinear line drawn from the lesser trochanter, continuing along the femoral neck, across the line of the physis and wrapping around the femoral head to the midpoint. ...
Objectives
The aim of the present study was to investigate whether diagnostic assessment methods used on radiographs in humans with slipped capital femoral epiphysis (SCFE) can be used in cats.
Methods
The ventrodorsal (VD) extended-leg and VD frog-leg pelvic radiographs of 20 cats with SCFE without fully displaced femoral capital epiphyses (FCE), eight cats with fully displaced FCE and five control cats with normal pelvic anatomy were assessed by five observers on two separate occasions 3 months apart. The Klein’s line and modified Klein’s line were assessed on each VD extended-leg radiograph, and the S-sign was assessed on each VD extended-leg and VD frog-leg radiograph.
Results
Excluding cases of fully displaced FCE, the S-sign on the VD frog-leg radiographs more accurately diagnosed SCFE than the S-sign on the VD extended-leg radiographs and the Klein’s line (92.4% vs 88.8% vs 60.6%, respectively), and had the greatest sensitivity (93.9% vs 79.2% vs 30.6%, respectively). The S-sign on the VD extended-leg radiographs had greater specificity than the Klein’s line and S-sign on the VD frog-leg radiographs (99.2% vs 97.9% vs 90.9%, respectively). The modified Klein’s line detected SCFE in 40.2% of cases that were negative for the Klein’s line.
Conclusions and relevance
The S-sign in both VD extended-leg and VD frog-leg views successfully detected SCFE in cats and can be used to increase early diagnosis and treatment in cats with SCFE that have only subtle radiographic changes.
... [ 99m Tc] Tc-Methylene diphosphonate (Tc-MDP) bone scintigraphy is an established functional imaging modality for visualization of bone metabolism and remodeling; while available literature does not definitely clarify its applicability in SCFE. 1 While plain radiography (anteroposterior and frog lateral views) is the choice for diagnosing slipped capital femoral epiphysis in suspected individuals, 2 bone scan is capable of discovering the disease and finding secondary complications in patients with ambiguous symptoms. Patient was a known case of Down syndrome with BMI equal to 31 who presented with claudication; symptoms and complaints were all localized in left knee. ...
Bone scan is highly sensitive whole‐body imaging with relative low radiation in patients with non‐localized skeletal symptoms. Patient is 12‐year‐old boy with Down syndrome, suffering recent claudication and exacerbated left knee pain unable to walk even with crutches. Three‐dimensional Single photon emission computed tomography/Computed tomography (SPECT/CT) detected left slipped capital femoral epiphysis (SCFE) and secondary Avascular necrosis (AVN).
... I dessa fall kan ytterligare kirurgi med femurosteotomier och på sikt även proteskirurgi bli aktuellt. Vid kvarstående formförändrad caput finns även en risk för inskränkt rörlighet och femuroaceta bulärt impingement [24,28,35]. Oavsett graden av fy seolys är det viktigt med regelbundna uppföljande be sök för att kunna följa höftledens utveckling. ...
... Whilst these signs may be useful, radiology is the proven standard modality of diagnosing SCFE [6]. Radiographs of the contralateral side should always be included to rule out bilateral SCFE [15]. Whilst MRI is more sensitive than conventional radiography in diagnosing SCFE [15], it was inconclusive in our case, and diagnosis was mainly secondary to the clinical findings. ...
... Radiographs of the contralateral side should always be included to rule out bilateral SCFE [15]. Whilst MRI is more sensitive than conventional radiography in diagnosing SCFE [15], it was inconclusive in our case, and diagnosis was mainly secondary to the clinical findings. ...
... Plain-film radiography, typically AP pelvis and frog leg lateral views of both hips, is the gold standard for confirming an SCFE diagnosis; both are essential views to measure epiphyseal-diaphyseal angle of SCFE [6]. The radiographic signs of SCFE include: widening and irregularities of the physis; relative loss of height of the epiphysis on AP projections; loss of the anterior concavity of the femoral neck on lateral views; the 'metaphyseal blanch sign' (a crescent-shaped area of increased density at the proximal and medial femoral neck due to projection of the posterior femoral head, which is displaced posteriorly, inferiorly and medially in relation to the metaphysis); cystic changes at the metaphysis, remodeling, and periost reactions in chronic SCFE; chondrolysis with simultaneous femoral and acetabular subchondral bone changes [15]. ...
Slipped capital femoral epiphyses (SCFE) is considered to be a very common disorder among adolescent age group. Multiple risk factors have been reported such as obesity, endocrine disorders, vitamin D deficiency, and panhypopituitarism. The diagnosis of SCFE is important especially in its early stages as this would prevent complications and delay in surgical intervention. The diagnosis is mainly done by radiological imaging and clinical evaluation. However, clinical evaluation is often overlooked. Herein, we present a case of a seven-year-old with SCFE that was diagnosed late due to negative radiological imaging and received late surgical intervention. Therefore, it is recommended that orthopedic surgeons use their clinical sense and examination skills to diagnose SCFE promptly, in order to maintain a short follow-up window to prevent any delay in surgical management and to observe for any progression, even if the radiological findings are normal.
... 41,42 Likewise, patients with SUFE are exposed to radiation in their initial anteriorposterior (AP) pelvis and frog-leg projections followed by images taken during surgery and routine follow-up X-rays. 43 Adolescent idiopathic scoliosis (AIS) investigation and surveillance involves a full evaluation of the spine on the AP/ posterior-anterior (PA) and lateral views extending from the base of the skull to the pelvis. 44,45 A study investigating the amount of ovarian radiation absorbed in young patients with scoliosis discovered that these patients received an average of 14 X-rays and 180 μSv cumulative ovarian dose per patient over 44-months. ...
Introduction In recent times the benefits of using gonadal shielding have been brought into question. Several professional bodies have released positional statements in support of ceasing the use of gonadal shields. However, in Australia the regulatory authority for radiation has not commented to date. This literature review aims to explore the risks and benefits of using lead protection and to establish the current state of the use of gonadal shields in clinical practice. Methods A search of the literature was conducted using online databases under the subject “Medical Imaging and Radiation Sciences”. Key terms and phrases included “lead protection”, “plain film imaging”, “lead shielding”, “gonadal shielding”, “X-ray”, “radiography”, “pelvic radiography”, “radiation protection”, “methods”, “education” and “gonadal shielding”. Articles pertaining to radiation therapy, literature reviews and those not in English were excluded. Results and Discussion Gonad shields are often poorly used despite agreement of what constitutes accurate and inaccurate shielding. Inaccurate shielding relates to both inappropriate size and inaccurate positioning of shields. Retrospective studies demonstrated a higher incidence of inaccurate gonadal shield placement in females compared to males. Inaccurate shielding had implications for patients such as obscuration of important anatomy and pathology and increased radiation dose if repeat X-rays were required to correct positioning errors. Shield design innovation was identified as a future area of research that could assist with overcoming these errors. Where gonad shielding was found to be of benefit in patients with conditions that require regular follow-up imaging. This is especially important in conditions affecting children and adolescents who have increased radiosensitivity and longer life expectancy. Conclusion Studies have demonstrated high incidence of inaccurately positioned gonad shields for female patients, which leads to repeated X-ray images and increased dose to patients. However, shielding has been shown to be beneficial for patients requiring frequent X-ray examinations to reduce cumulative radiation dose. Establishing a standardised protocol regarding the application of gonadal shields, supported by regulatory agencies, is imperative.
... Simple AP and Frog leg lateral views are adequate in assessing the slip. However, in acute presentation, wherein hip abduction is not possible to obtain the frog-leg lateral view, a CT scan of the pelvis comes to the rescue [15,16]. Management of SCFE is based on two factors, namely, the grade of the slip (Southwick angle) and the stability (stable/unstable) of the slip [1,14]. ...
Introduction:
Slipped capital femoral epiphysis (SCFE) is commonly managed by in situ screw fixation. However, higher grades of slips require restoration of normal anatomy of the femoral head without compromising the blood supply.
Case report:
A 16-year-old adolescent male presented with the left hip pain and progressive limping for 4 days with no history of previous trauma. On examination, the patient had severe tenderness and gross restriction of movements. Radiological examination revealed Grade 2 acute on chronic SCFE with unstable slip. Modified Dunn procedure through Ganz surgical hip dislocation facilitated the complete restoration of normal anatomy without avascular necrosis of femoral head changes at 2 years of follow-up.
Conclusion:
Ganz safe surgical dislocation of the hip is safe for the femoral head, preserving its blood supply in toto and the modified Dunn procedure facilitated the complete restoration of normal anatomy even in acute on chronic type of SCFE cases.
... Typical radiographic evaluation of SCFE identifies characteristic findings reflective of displacement of the epiphysis, including widening of the physis when compared to the contralateral side, relative posterior displacement of the epiphysis on the frog lateral, and apparent decreased epiphyseal height (due to posterior displacement). 39 Historically, Klein's line has been utilized in the diagnosis of SCFE on plain radiographs. Using the anterior-posterior (AP) view, a line is drawn tangent and parallel to the superior surface of the femoral neck through the epiphysis. ...
... 2). 5,39 More recent literature however suggests that Klein's line is not sensitive enough to detect all slips and should not be over-relied upon, specifically in the case of mild slips or hips in a pre-slip phase. Green et al. 40 proposed a modified Klein's line, in which a similar line was drawn on the contralateral hip and a difference of 2 mm suggests a possible slip with greater sensitivity. ...
... However, it is more frequently used after index treatment in the assessment of hip perfusion for diagnosis of avascular necrosis (AVN). 39 Computed tomography (CT) is useful for 3D reconstruction of severe deformity, but again, is typically reserved for templating cases where a corrective osteotomy is likely to be performed. 39 In the acute setting, the use of MRI and CT in SCFE remains controversial due to potential for treatment delay. ...
Purpose: The purpose of this review is to discuss the insights into slipped capital femoral epiphysis (SCFE) gained during the last decade, including a proposed rotational pathomechanism, the importance of epiphyseal morphology, subclinical endocrinopathies and atypical SCFE, and updates to current management practices. Pathophysiology: Growing literature has highlighted the importance of the epiphyseal tubercle as a ‘keystone’ stabilizer of the proximal femoral epiphysis. Both anatomic and clinical studies recently demonstrated that the epiphysis rotates around the epiphyseal tubercle during SCFE. Clinical endocrinopathies contribute to the pathogenesis of SCFE, though recently the effects of subclinical endocrine derangements such as hyperinsulinism and leptin abnormalities have been demonstrated to play a role in SCFE. Diagnosis: The standard diagnostic tools for SCFE remain the antero-posterior pelvis and frog-leg lateral radiograph. The importance of imaging bilateral hips is well known, due to the increased incidence of contralateral slip development in SCFE patients. Additionally, due to increased knowledge of atypical SCFE, patients with positive age-weight or age-height testing are also recommended to undergo further endocrine workup due to the high likelihood of atypical SCFE in these patients. Management: In-situ pinning remains the gold standard treatment of SCFE. Use of two-screws is mainly reserved for unstable or severe slips, while one-screw fixation remains the standard for mild-moderate slips. Contralateral prophylactic pinning is typically considered in those patients at high risk for contralateral slip, including those with endocrine risk factors, skeletal immaturity via modified oxford bone age, or aberrant radiographic parameters such as posterior epiphyseal tilt or posterior sloping angle. Novel techniques including intraoperative epiphyseal perfusion monitoring have provided insight into reducing complications such as avascular necrosis and have shown the benefit of intracapsular hematoma decompression for unstable SCFE. Open surgical management via the modified Dunn procedure should be cautiously considered, as high rates of osteonecrosis have been reported due to the vulnerable blood supply of the proximal femoral head.
