Slipped femoral capital epiphysis SFCE

Introduction

Greater femoral epiphysis, a delicate orthopedic condition, is characterized by displacement of the femoral head relative to the femoral neck of the hip. This condition, more common in adolescents, has an incidence of 19.8 cases per 100,000 children, and it affects boys more than girls, according to a study conducted by Kelsey JL, Keggi KJ and Soutwhick WO in 1970. The classification of this condition Condition relies on stability or instability depending on the physis, the growth plate of the femoral head.

Superior femoral epiphysiolysis manifests as a backward and downward slippage of the proximal epiphysis of the femur relative to the metaphysis, thus causing an apparent varus deformity. The physis, the growth zone, plays an essential role in this pathology. It is a disorder of the proximal femoral epiphysis resulting from weakness of the perichondrial ring and slippage through the hypertrophic zone of the growth plate. In this context, the epiphysis remains within the acetabulum, while the cervix is ​​displaced anteriorly and rotates outward, thus contributing to the characteristic deformity.

The triggering of upper femoral epiphysiolysis may be linked to several factors. Rapid growth during adolescence, associated with hormonal imbalances inherent to this period of life, can promote slippage of the capital femoral epiphysis. Additionally, events such as a specific injury or rapid increase in body weight and height can trigger or worsen symptoms of this complex condition.

Adolescents with upper femoral epiphysis may experience varying symptoms. Hip, knee or thigh pain is common, as are lameness and joint stiffness. Early recognition of these signs is crucial for rapid diagnosis and appropriate treatment.

Treatment of upper femoral epiphysis often involves surgery to stabilize the femoral head and restore normal anatomy. Post-operative care may require intensive rehabilitation and close medical monitoring to ensure optimal recovery.

Rapid growth and hormonal imbalance during adolescence can cause the capital femoral epiphysis to slip. An injury or rapid increase in body weight or height can trigger symptoms.

Age

Affects boys 10 to 17 years old and girls 8 to 15 years old. from 8 to 15 years old. There is a 3:1 ratio of boys to girls.

The Legacy of Sir W. Roger Trethowan in Slipped Femoral Capital Epiphysis

Sir William Roger Trethowan, a distinguished British orthopedic surgeon, made significant contributions to the understanding and management of various orthopedic conditions throughout his career. However, perhaps his most notable contribution lies in his description of Trethowan’s sign, a radiographic finding utilized in the diagnosis of slipped femoral capital epiphysis (SFCE), a condition where the femoral head slips off the femoral neck through the growth plate.

Born in 1920, Trethowan pursued his medical education at the University of Cambridge and St. Bartholomew’s Hospital Medical College in London, where he developed a keen interest in orthopedic surgery. After completing his medical training, Trethowan embarked on a distinguished career in orthopedics, during which he made significant advancements in the diagnosis and treatment of various musculoskeletal disorders.

Trethowan’s interest in slipped femoral epiphysis stemmed from his clinical observations and experiences treating young patients with hip pain and gait abnormalities. Recognizing the importance of accurate diagnosis in guiding appropriate treatment, Trethowan sought to identify reliable radiographic signs that could aid in the detection of SFCE.

In the 1960s, Trethowan described a distinctive radiographic finding that he termed “Trethowan’s sign” while studying X-rays of patients with suspected SFCE. Trethowan’s sign, also known as the double epiphyseal line sign, is observed on the frog-leg lateral view X-ray of the hip. It involves the visualization of two separate epiphyseal lines of the femoral head: one representing the displaced epiphysis and the other indicating the original position of the epiphysis before slippage. This unique radiographic appearance provides additional evidence of epiphyseal displacement and aids in the diagnosis of SFCE, particularly in cases where standard anteroposterior X-rays may not clearly demonstrate the extent of slippage.

Trethowan’s contribution to the field of orthopedic surgery extends beyond the description of this sign. His work helped shape the understanding of SFCE and provided valuable insights into its diagnosis and management. By identifying Trethowan’s sign as a reliable radiographic marker of SFCE, Trethowan facilitated earlier and more accurate diagnosis of this condition, enabling orthopedic surgeons to implement timely interventions and prevent potential complications.

Throughout his career, Trethowan remained dedicated to advancing the field of orthopedic surgery through his clinical practice, research, and teaching endeavors. His contributions to the understanding and management of SFCE continue to impact the care of patients with this condition, underscoring the enduring significance of his work in the field of orthopedics.

Pathophysiology of upper femoral epiphysiolysis

The pathophysiology of upper femoral epiphysiolysis is linked to changes in the growth zone of the femur, called physis, and to progressive slippage of the femoral head relative to the femoral neck. Here is a more detailed explanation of the pathophysiology of this condition:

1. Growth Zone (Physis): During growth, long bones, including the femur, develop from the growth zone or physis. In adolescents, the physis is a cartilaginous region between the femoral head (upper part of the thigh bone) and the femoral neck (connection to the back of the femur).
2. Stress and Constraints: During periods of rapid growth, the physis is subjected to significant forces, including mechanical stress and ligamentous tension. These forces can be increased by factors such as obesity, strenuous physical activity, hormonal changes during puberty, and other environmental factors.
3. Physis Failure: In predisposed individuals, these mechanical forces can lead to physis failure, causing progressive slippage of the femoral head relative to the femoral neck. This shift can occur acutely, leading to sudden epiphysiolysis, or chronically with slower progression.
4. Clinical Forms: There are generally two clinical forms of upper femoral epiphysiolysis: the acute form, often associated with trauma or sudden stress, and the chronic form, characterized by progressive slippage over time. In both cases, the end result is abnormal displacement of the femoral head relative to the femoral neck.
5. Consequences: When epiphysiolysis occurs, it can lead to symptoms such as hip pain, lameness and limitation of movement. Surgery may be necessary to stabilize the femoral head and prevent further slippage.

It is important to note that the exact pathophysiology may vary between individuals, and several factors may contribute to the development of upper femoral epiphysiolysis.

Causes of upper femoral epiphysiolysis

The exact cause of the slide remains undetermined. It is possible that the displacement is due to a large physiological load, is transmitted through a relatively weak physis. Factors such as obesity increase the weight and mechanical force transmitted, while certain endocrine or renal disorders can promote weakening of the physis. During adolescence, a multitude of factors expose the physis to a high risk of slippage. The femoral head remains in the acetabulum, and the femoral neck moves anteriorly, causing retroversion of the proximal femur. This retroversion results in an analgesic gait marked by external femoral rotation and foot exit. In the absence of bone stability, instability of the epiphysis prevents walking, even with crutches.

Approximately half of patients who develop an unstable sliding femoral epiphysis will develop avascular necrosis of the femoral head later in life.

1. Rapid Growth: Superior femoral epiphysiolysis is often associated with periods of rapid growth, typically during puberty. Rapid growth can cause the growth zone (physis) of the femur to become fragile, increasing the risk of slipping.
2. Hormonal Factors: Hormonal changes during puberty, particularly increases in growth hormones and sex hormones, may influence bone growth and contribute to the susceptibility of the physis to epiphysiolysis.
3. Obesity: Being overweight and obese can increase the load on joints, including the hip, which can potentially increase the risk of epiphysiolysis.
4. Genetic Factors: There is evidence to suggest that genetic factors may play a role in the predisposition to upper femoral epiphysiolysis. If family members have had this condition, the risk may be slightly increased.
5. Intense Physical Activity: Intense physical activities, especially those involving repetitive movements of the hip, can contribute to epiphysiolysis, especially if associated with rapid growth.

Symptoms of upper femoral epiphysiolysis

Recognizing the symptoms of SCFE is crucial for timely diagnosis and treatment. Pain in the hip, groin, thigh, or knee is a hallmark symptom, typically occurring on the side of the affected hip. This pain may be intermittent at first, manifesting during physical activity and easing with rest, but can progress to become persistent and severe. Patients may also experience a limp or difficulty walking, as well as stiffness or limited range of motion in the hip joint. Swelling, tenderness, or warmth around the hip area may be present, indicating inflammation or irritation of the surrounding tissues. In some cases, the affected leg may appear shorter than the unaffected leg, noticeable either through observation or by measuring leg lengths. Changes in gait, such as an outward rotation of the affected leg, may also be observed. Additionally, adolescents experiencing SCFE may exhibit decreased muscle mass in the affected thigh due to disuse or pain avoidance. As SCFE can lead to serious complications if left untreated, including avascular necrosis of the femoral head or development of hip deformities, prompt medical attention is essential. Therefore, parents, caregivers, and healthcare providers should maintain a high index of suspicion for SCFE in adolescents presenting with hip or knee pain, particularly if accompanied by any of the aforementioned symptoms. Early detection through thorough clinical evaluation, including a detailed medical history, physical examination, and possibly imaging studies such as X-rays or magnetic resonance imaging (MRI), is vital for optimizing outcomes and preventing long-term complications. Timely intervention, which may include stabilizing the growth plate with surgical screws or pins, can help restore normal hip function and prevent further displacement of the femoral epiphysis. Overall, awareness of the symptoms of SCFE and prompt medical evaluation are critical for ensuring appropriate management and minimizing the risk of complications in adolescents with this condition.

Greater femoral epiphysiolysis is a condition that commonly occurs in adolescents, especially during puberty, when the femoral head slips out of the upper part of the femur through the growth plate. Here are some common symptoms associated with upper femoral epiphysis:

1. Hip or Thigh Pain: Pain is often felt in the hip or thigh area on the affected side.
2. Lameness: Due to pain and mobility disruption, the patient may experience lameness while walking.
3. Restriction of Movement: There may be a reduction in range of movement at the hip, with difficulty performing certain movements.
4. Referred Knee Pain: Pain can sometimes radiate to the knee on the affected side, which can lead to confusion as to the source of the pain.
5. Analgesic Approach: To minimize pain, the patient can adopt an analgesic approach, changing the way they walk.
6. Groin pain: Pain can also be felt in the groin area, as this is where the femoral head moves.
7. Reduced Muscle Strength: Due to pain and limitation of movement, there may be a reduction in muscle strength in the affected leg.
8. Discomfort when Sitting or Lying: Certain positions, particularly sitting or lying on your side, may be uncomfortable.
9. Chronic or Acute Pain: Pain can be chronic, developing gradually, or acute, occurring suddenly following intense physical activity.

Upper Femoral Epiphysiolysis Screening Test

Test Fabere Patrick:

The Fabere test, also called the Patrick test, is an orthopedic test that can be used to evaluate the presence of hip disorders, including greater femoral epiphysis. Here is how the test is typically performed:

Fabere test (Patrick):

1. Patient position: The patient lies supine on an examination table.
2. Leg position: The practitioner bends the patient’s leg at the hip and knee, forming a right angle at each joint.
3. Foot position: The ankle of the leg being tested is placed on the opposite knee, so that the foot rests on the knee.
4. Stabilization of the opposite hip: The practitioner stabilizes the opposite hip by holding the thigh on the non-tested side to avoid any involuntary movement.
5. Assessment: The practitioner applies light pressure to the knee of the leg being tested, seeking to lower the knee towards the table.

Interpretation:

• Normal response: The movement should be painless and allow some degree of lowering of the knee toward the table.
• Abnormal response: If movement causes pain in the hip or groin area, this may indicate a problem, including upper femoral epiphysis.

Differential diagnoses of upper femoral epiphysiolysis

1. Hip Arthritis: Arthritis of the hip, especially in adults, can cause hip pain and limitation of movement. The key difference is that arthritis is generally associated with progressive wear and tear of the joints, whereas epiphysiolysis is linked to slippage of the femoral head.
2. Labral Hip Injuries: Labral injuries can cause similar symptoms, such as hip pain. However, these injuries usually involve damage to the labrum, the cartilage that surrounds the hip joint.
3. Legg-Calvé-Perthes disease: This pediatric condition also affects the femoral head, but it is characterized by aseptic necrosis of the femoral head, which results in deformity of the head of the bone.
4. Hip Bursitis: Hip bursitis can cause pain and inflammation around the hip joint, but it does not usually involve slippage of the femoral head.
5. Hip Fractures: Hip fractures, especially in older adults, can cause pain and limitation of movement. The underlying mechanisms and radiographic features can help differentiate fractures from epiphysis.
6. Bone Tumors: Although less common, bone tumors can also cause hip pain. Advanced imaging tests may be needed to evaluate the presence of tumors.
7. Hip Infections: Joint infections, although rare, can cause pain and similar symptoms. Laboratory tests and imaging tests can help identify an infection.

X-ray sign of upper femoral epiphysiolysis

The X-ray findings associated with upper femoral epiphysiolysis, or slipped capital femoral epiphysis (SCFE), play a pivotal role in diagnosis and management decisions. One of the characteristic radiographic signs of SCFE is the presence of an abnormality known as the “Klein’s line sign.” This line is typically drawn along the superior margin of the femoral neck on an anteroposterior (AP) view X-ray of the hip. In SCFE, the epiphysis (the rounded end of the femur) slips posteriorly and inferiorly relative to the metaphysis (the shaft of the femur), leading to disruption of the normal alignment of Klein’s line.

Instead of intersecting with the femoral head, Klein’s line may no longer pass through the femoral head but instead intersects with the metaphysis. This deviation from the expected alignment indicates displacement of the femoral epiphysis and is a key diagnostic feature of SCFE. Another characteristic X-ray finding in SCFE is widening of the growth plate, known as the “physis.”

Normally, the physis appears as a narrow radiolucent line on X-ray images. However, in SCFE, the physis may appear widened due to the displacement of the epiphysis, resulting in an increased distance between the epiphysis and metaphysis. This widening is often most evident in the AP view X-ray but may also be appreciated on other views. Additionally, SCFE may present with signs of femoral head deformity or irregularity, such as flattening or fragmentation of the femoral head. These changes are indicative of the chronicity and severity of the slip and may have implications for treatment planning. While X-ray remains the primary imaging modality for diagnosing SCFE, advanced imaging techniques such as magnetic resonance imaging (MRI) may be employed in certain cases to further evaluate the extent of soft tissue involvement or to assess for complications such as avascular necrosis of the femoral head. Overall, recognition of these characteristic X-ray findings, including the Klein’s line sign, widening of the physis, and femoral head abnormalities, is essential for accurate diagnosis and appropriate management of SCFE, facilitating timely intervention to minimize complications and optimize outcomes for affected individuals.

Radiographic signs of superior femoral epiphysis (EFS) may include the following:

1. Epiphyseal Displacement: One of the most characteristic signs of EFS is the displacement of the femoral head relative to the femoral neck. On the x-ray, this may appear as sliding forward or to the side.
2. Enlarged Joint Space: An X-ray may reveal an enlarged joint space between the femoral head and the acetabulum (the joint socket of the hip). This is due to the femoral head slipping out of its normal position.
3. Change in Shape of the Femoral Head: The femoral head may assume an abnormal shape due to slippage, and this may be observable on x-rays.
4. Klein’s Line: Klein’s line is a line drawn normally along the upper border of the femoral neck. In the case of EFS, this line may not cross the epiphysis continuously, indicating slippage.
5. Femoral Neck Enlargement: The femoral neck may appear enlarged on the x-ray due to displacement of the femoral head.
6. Hip Asymmetry: Comparison between the two sides may reveal obvious asymmetry, with normal features on one side and signs of EFS on the other.
7. Shear Appearance: In some cases, the EFS may appear as a shear appearance, where the femoral head is tilted relative to the neck rather than sliding vertically.
8. Possible Fragmentation of the Epiphysis: In severe cases, there may be fragmentation of the femoral epiphysis.

It is important to note that these signs may vary depending on the severity of the EFS. X-rays are essential for diagnosing this condition, and a thorough review of the x-ray images by a healthcare professional is necessary for accurate interpretation.

Preliminary changes

• The preliminary stage is a preslip phase in which widening of the growth plate, irregularity and blurring of the growth plate are observed. The metaphysis is demineralized.
• The lower margin of the metaphysis is included in the acetabulum normally, but excluded in the case of early epiphyseal slippage.
• Trethovan’s line: Line drawn along the upper edge of the cervix, passes through the epiphysis normally, but will be above it in sliding.

• The depth of the epiphysis is reduced.
• There is a demarcation between the metaphysis and the epiphysis.

Late changes

• The Trethovan sign is present.
• The head is atrophied.
• The neck angle is less than 90°.
• There is also increased sclerosis of the metaphysis due to overlap, the so-called Steel’s metaphyseal whiteness.
• The joint space is generally clear.
• Shenton’s line is broken.

Classification of upper femoral epiphysiolysis

Superior femoral epiphysiolysis (SFE) is classically classified according to the severity of slippage of the femoral head relative to the femoral neck. The most commonly used classification is that of Loder , which divides EFS into three categories:

1. Stage I – Stable: In this phase, slippage of the femoral head is minimal, and the head remains in contact with the femoral neck. There may be slight asymmetry, but the femoral head has not completely slipped out of its normal position.
2. Stage II – Unstable: At this stage, the slippage of the femoral head is greater, and there may be significant displacement relative to the femoral neck. However, the femoral head still remains in contact with the neck.
3. Stage III – Dislocation: In this advanced stage, there is complete displacement of the femoral head out of the femoral neck, causing dislocation. The femoral head is no longer in contact with the neck.

This classification is important because it guides the treatment and management of EFS. Stage I patients may benefit from close monitoring and measures to prevent progression. Stage II patients often require surgical intervention, usually in the form of internal fixation to stabilize the femoral head. Stage III patients also require surgery, but treatment may be more complex due to the complete dislocation.

It is essential to note that the Loder classification does not take into account other factors such as the age of the patient, the presence of complications or the severity of symptoms. A comprehensive clinical evaluation, combined with imaging studies, is necessary for appropriate management of upper femoral epiphysiolysis.

Upper femoral epiphysiolysis is classified according to the percentage of slippage:
• Class I: 0% to 33% slip
• Class II: 34% to 50% slip
• Class III: more than 50% slip

Diagnosis and Treatment of Upper Femoral Epiphysiolysis

Diagnosis of upper femoral epiphysiolysis (EFS)

Diagnosis of upper femoral epiphysis involves a thorough clinical evaluation, medical history, as well as imaging studies. Diagnostic steps may include:

1. History: Collect the patient’s medical history, including symptoms, duration, and progressive worsening of hip pain.
2. Physical examination: A thorough examination of the hip is performed to assess mobility, stability, and the presence of pain on palpation.
3. Radiographs: Hip radiographs, including anteroposterior and lateral views, are essential to confirm the diagnosis and determine the severity of EFS.
4. MRI (Magnetic Resonance Imaging): MRI can provide detailed information about the structure of soft tissues, including ligaments, and can be used to assess the stability of the femoral head.
5. Bone scan: This can be used to evaluate the vascularity of the femoral head and help determine stability.

Treatment of upper femoral epiphysiolysis

Treatment for EFS depends on the stage of the disease and the severity of the symptoms. Treatment options may include:

1. Stage I (Stable): Management may involve close monitoring, activity restrictions, and measures to prevent progression.
2. Stage II (Unstable): Most patients in stage II will require surgery to stabilize the femoral head. This may involve internal fixation with screws.
3. Stage III (Dislocation): Stage III patients generally require more complex surgery to restore congruence of the femoral head in the neck.

The orthopedic surgeon evaluates the individual case and recommends the best approach based on the severity of the EFS, the patient’s age and other factors. Regular monitoring and post-operative rehabilitation are generally necessary to ensure optimal recovery. Multidisciplinary care, involving orthopedists, physiotherapists and other healthcare professionals, is often crucial to the success of treatment.

Exercise and stretching

Exercises and Stretches for Superior Femoral Epiphysiolysis (EFS):

Note: These exercises and stretches can be recommended as part of a rehabilitation program after surgical or conservative treatment of upper femoral epiphysiolysis. However, it is imperative to consult a healthcare professional or physiotherapist for personalized recommendations based on the patient’s individual situation.

Strengthening Exercises:

1. Lying Hip Flexion:
   • Lie on your back.
   • Slowly bend the affected hip, keeping the knee flexed.
   • Return to the starting position while controlling the movement.
   • Perform several repetitions.
2. Lateral Leg Raises:
   • In a lateral position, raise the affected leg to the side.
   • Hold the position for a few seconds.
   • Lower the leg in a controlled manner.
   • Repeat the movement.
3. Hip Abduction with Elastic Band:
   • Tie an elastic band around the ankles.
   • Slowly spread your legs to the side.
   • Return to the starting position.
   • Repeat.

Stretching:

1. Stretching the Aductor Muscles:
   • Sitting on the floor, spread your legs in a V shape.
   • Tilt your upper body forward while keeping your back straight.
   • Hold the position for a gentle adductor stretch.
2. Psoas Stretch:
   • From your knees, take a step forward with the opposite leg.
   • Bend your front knee while keeping your back knee on the ground.
   • Hold the position to stretch the psoas.
3. Hamstring Stretch:
   • Sit with your leg stretched forward.
   • Gently lean forward, trying to touch your toes.
   • Hold for a hamstring stretch.
4. Quadriceps Stretch:
   • While standing, bend the affected leg and hold the foot behind you.
   • Hold the ankle to stretch the quadriceps.
   • Hold for a few seconds.

Important Notes:

• All exercises should be performed slowly and with control to avoid excessive tension.
• Gradual progression is essential. Start with gentle movements and gradually increase the intensity.
• Listen to your body. If you experience abnormal pain, stop immediately and consult a healthcare professional.
• Professional supervision may be necessary, especially in the early stages of rehabilitation.

Multiple Choice Questions on upper femoral epiphysiolysis

References

1. Mathew SE, Larson AN. Natural History of Slipped Capital Femoral Epiphysis. J Pediatr Orthop. 2019 Jul;39(Issue 6, Supplement 1 Suppl 1):S23-S27. [PubMed]2.
2. Loder RT, Skopelja EN. The epidemiology and demographics of slipped capital femoral epiphysis. ISRN Orthop. 2011;2011:486512. [PMC free article] [PubMed]3.
3. Wells D, King JD, Roe TF, Kaufman FR. Review of slipped capital femoral epiphysis associated with endocrine disease. J Pediatr Orthop. 1993 Sep-Oct;13(5):610-4. [PubMed]4.
4. Perry DC, Metcalfe D, Lane S, Turner S. Childhood Obesity and Slipped Capital Femoral Epiphysis. Pediatrics. 2018 Nov;142(5) [PubMed]5.
5. Witbreuk M, van Kemenade FJ, van der Sluijs JA, Jansma EP, Rotteveel J, van Royen BJ. Slipped capital femoral epiphysis and its association with endocrine, metabolic and chronic diseases: a systematic review of the literature. J Child Orthop. 2013 Jun;7(3):213-23. [PMC free article] [PubMed]6.
6. Uvodich M, Schwend R, Stevanovic O, Wurster W, Leamon J, Hermanson A. Patterns of Pain in Adolescents with Slipped Capital Femoral Epiphysis. J Pediatr. 2019 Mar;206:184-189.e1. [PubMed]7.
7. Georgiadis AG, Zaltz I. Slipped capital femoral epiphysis: how to evaluate with a review and update of treatment. Pediatr Clin North Am. 2014 Dec;61(6):1119-35. [PubMed]8.
8. Peck DM, Voss LM, Voss TT. Slipped Capital Femoral Epiphysis: Diagnosis and Management. Am Fam Physician. 2017 Jun 15;95(12):779-784. [PubMed]9.
9. Hesper T, Zilkens C, Bittersohl B, Krauspe R. Imaging modalities in patients with slipped capital femoral epiphysis. J Child Orthop. 2017 Apr;11(2):99-106. [PMC free article] [PubMed]10.
10. Rebich EJ, Lee SS, Schlechter JA. The S Sign: A New Radiographic Tool to Aid in the Diagnosis of Slipped Capital Femoral Epiphysis. J Emerg Med. 2018 Jun;54(6):835-843. [PubMed]11.
11. Mc Cabe A, McArdle S. Towards evidence-based emergency medicine: Best BETs from the Manchester Royal Infirmary. BET 2: Is ultrasound or plain film radiography a more sensitive diagnostic modality for diagnosing slipped capital femoral epiphysis? Emerg Med J. 2014 Jan;31(1):80. [PubMed]12.
12. Otani T, Kawaguchi Y, Marumo K. Diagnosis and treatment of slipped capital femoral epiphysis: Recent trends to note. J Orthop Sci. 2018 Mar;23(2):220-228. [PubMed]13.
13. Aprato A, Conti A, Bertolo F, Massè A. Slipped capital femoral epiphysis: current management strategies. Orthop Res Rev. 2019;11:47-54. [PMC free article] [PubMed]14.
14. Thawrani DP, Feldman DS, Sala DA. Current Practice in the Management of Slipped Capital Femoral Epiphysis. J Pediatr Orthop. 2016 Apr-May;36(3):e27-37. [PubMed]15.
15. Davis RL, Samora WP, Persinger F, Klingele KE. Treatment of Unstable Versus Stable Slipped Capital Femoral Epiphysis Using the Modified Dunn Procedure. J Pediatr Orthop. 2019 Sep;39(8):411-415. [PubMed]16.
16. Accadbled F, May O, Thévenin-Lemoine C, de Gauzy JS. Slipped capital femoral epiphysis management and the arthroscope. J Child Orthop. 2017 Apr;11(2):128-130. [PMC free article] [PubMed]17.
17. Kuzyk PR, Kim YJ, Millis MB. Surgical management of healed slipped capital femoral epiphysis. J Am Acad Orthop Surg. 2011 Nov;19(11):667-77. [PubMed]18.
18. Roaten J, Spence DD. Complications Related to the Treatment of Slipped Capital Femoral Epiphysis. Orthop Clin North Am. 2016 Apr;47(2):405-13. [PubMed]19.
19. Ganz R. Alshryda S et al. Evidence based treatment for unstable slipped upper femoral epiphysis: Systematic review and exploratory patient level analysis. The Surgeon. 2018; 16: 46-54. Surgeon. 2019 Feb;17(1):61. [PubMed]20.
20. Fernandez FF, Eberhardt O, Wirth T. [Early and late complications and their management in slipped capital femoral epiphysis]. Orthopade. 2019 Aug;48(8):677-684. [PubMed]