Legg-Calve-Perthes disease and slipped capital femoral epiphysis: Clinical sciences

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Introduction0:00–0:50

Legg-Calvé-Perthes disease, or LCPD, and slipped capital femoral epiphysis, or SCFE for short, are distinct hip conditions that commonly cause limp in children.
In LCPD, a disrupted blood supply causes deformation of the femoral head and subsequently leads to osteonecrosis. On the other hand, in SCFE, a weakness of the growth plate causes displacement of the femoral head from the femoral neck.
It’s important to identify and treat both of these conditions quickly to ensure better functional outcomes and reduce the risk of hip osteoarthritis.
Based on history, exam, and imaging findings, you can differentiate between LCPD and SCFE.If your patient presents with a chief concern suggesting either LCPD or SCFE, you should first perform a focused history and physical exam.

LCPD - H&P0:50–2:13

Children with LCPD are usually less than 8 years old and classically present with a painless limp, which is usually unilateral.
However, patients with more severe disease may develop a painful limp and could report pain in the hip, as well as the groin, thigh, or knee.
LCPD is more common in biologically male children, and there could be a family history of LCPD.Now here’s a clinical pearl to keep in mind!
Whenever a child reports pain in a specific joint, always be sure to examine the joints directly above and below, since pain can refer to adjacent joints.
For instance, if a child reports knee pain, you should examine the knee, as well as the hip and ankle.The physical exam of a child with LCPD will often reveal limited internal rotation and abduction of the affected hip.
While your patient is standing or walking, you might notice the Trendelenburg sign, which is a pelvic tilt caused by hip muscle weakness.
The hip could also be tender to palpation, and in more severe cases, the affected leg could even be noticeably shorter than the unaffected leg.
Finally, you might notice a smaller circumference due to atrophy of the anterior thigh muscle.These findings should make you suspect LCPD.

LCPD - Imaging2:13–3:06

Your next step is to order imaging of the hips. Be sure to order bilateral X-rays, since LCPD may rarely affect both hips, even if the limp is only present on one side!
Sometimes, the X-rays may seem normal, so you may also need to order an MRI to help make the diagnosis. Classic X-ray findings in LCPD include widening of the joint space and, in more severe disease, flattening or fragmentation of the femoral head.
On the flip side, an MRI can reveal decreased perfusion of the femoral head. Either of these imaging findings will confirm the diagnosis of LCPD.Once you diagnose LCPD, management depends on the degree of femoral head involvement.

LCPD - Management3:06–3:56

For limited cases with full range of motion, begin with conservative management, which includes NSAIDs, limited weight bearing, and physical therapy.
On the flip side, patients with more extensive involvement or decreased range of motion may require surgical consultation; specifically, from pediatric orthopedics.
Surgical management may include Petrie casting, which is a type of abduction brace that keeps the femoral head positioned within the acetabulum as it heals.
More severe disease might require a surgical procedure in order to properly realign the hip, such as a femoral or pelvic osteotomy.Now, let’s return to the focused history and physical exam, but this time let’s consider children with signs and symptoms suggesting slipped capital femoral epiphysis.

SCFE - H&P3:56–4:52

Affected children are typically older than 10 years and are most often adolescents in the middle of a linear growth spurt.
Patients frequently present with a limp and report pain in the hip, groin, thigh, or knee. Some risk factors for SCFE include obesity, a personal history of hypothyroidism or other endocrinopathies, trauma or radiation therapy, and a family history of SCFE.
Additionally, the physical exam will reveal limited internal rotation, abduction, and flexion of the hip. In many cases, you will notice the child’s leg externally rotating as you passively flex the hip.
In some cases, the hip could even be tender to palpation. This spectrum of findings should lead you to suspect SCFE.

SCFE - Imaging4:52–6:20

To confirm your suspicion, you’ll need to order imaging of both hips, because SCFE can often occur bilaterally, even if the limp is only present on one side.
You should order a bilateral X-ray, and sometimes, you may also need to order an MRI, which can detect early disease more readily than the X-ray.
Radiographs typically show displacement of the femoral head in relation to the femoral neck. On the flip side, MRI findings include a widening of the physis, which is also called the growth plate; as well as surrounding edema.
The presence of these imaging findings confirms the diagnosis of SCFE.Now here’s another clinical pearl to keep in mind!
The name slipped capital femoral epiphysis is literally describing a femoral head that has slipped off the femur, just like a scoop of ice cream slipping off a cone!
However, this name is misleading, because in SCFE, the femoral head sits securely in its proper place within the acetabulum, while it’s the femoral neck that moves out of place as the result of mechanical strain on the growth plate.
The femoral neck is displaced anterolaterally and superiorly, which gives the relative appearance of a posterior and inferior displacement of the femoral head.Alright, once you diagnose SCFE, immediately proceed with management in order to prevent the slip from worsening!

SCFE - Management6:20–7:07

First, make your patient non-weight bearing, and promptly consult the surgical team, specifically pediatric orthopedics, for surgical management.
Patients with SCFE usually require in situ fixation of the femoral head to the femoral neck, using a large screw.Let’s wrap this up with one last clinical pearl!
SCFE often occurs bilaterally, so always be sure to examine both hips and review imaging studies carefully. Even when SCFE is confirmed to be unilateral, some pediatric orthopedists may recommend bilateral fixation in order to prevent SCFE from developing on the unaffected side.
Alright, as a quick recap… LCPD and SCFE are distinct hip disorders that often present with a limp. LCPD is most common in children under 8 years old, and X-ray reveals flattening or fragmentation of the femoral head.

Review7:07–7:49

Conservative management includes NSAIDS, limited weight bearing, and physical therapy. However, in severe cases, you should consult your surgery team.
On the other hand, SCFE is more common in children over 10 years old, and X-ray shows a displacement of the femoral head from the femoral neck.
All children with SCFE need to be made non-weight bearing and require urgent surgical consultation for in situ fixation of