Slipped capital femoral epiphysis (SCFE) is characterized by displacement of the femoral head relative to the neck through the growth plate. While it most frequently affects adolescents during periods of rapid growth, atypical presentations are increasingly recognized in association with endocrine and metabolic disorders ^[1,2]. Endocrine abnormalities such as hypothyroidism, growth hormone imbalance, and hypogonadism can alter physeal biology, predisposing it to mechanical failure even under normal physiological loads ^[1]. Patients with atypical SCFE often present outside the usual age range, with short stature or delayed skeletal maturation, making clinical suspicion essential ^[2,3]. Hypogonadism, in particular, results in reduced sex steroid levels, which play a key role in skeletal development and physeal closure, thereby prolonging vulnerability of the growth plate ^[4].

A 17-year-old male presented with progressively worsening pain in the right hip for 2 weeks, associated with difficulty in ambulation. There was no preceding trauma. Clinical evaluation revealed:

• Short stature for age (<50^th centile)
• High body mass index (40 kg/m²)
• Inability to walk
• Severe right hip tenderness
• Limb in external rotation
• Restricted internal rotation and abduction
• No neurovascular compromise
• Normal contralateral hip examination.

The patient exhibited delayed secondary sexual characteristics. Hormonal evaluation confirmed hypogonadism, suggesting an underlying endocrine aetiology for the atypical presentation. Radiographic assessment confirmed SCFE of the right hip. Left hip being normal (Fig. 1).

Figure 1: Anteroposterior radiograph of the pelvis with both hips showing widening of the proximal femoral physis and displacement of the epiphysis on the right side, consistent with slipped capital femoral epiphysis.

Treatment: 

The patient was initially managed with analgesics and skin traction for 3 days to reduce discomfort and minimise further displacement. Meanwhile, medical treatment for hypogonadism was initiated. Definitive management included:

• Closed reduction under fluoroscopy (Fig. 2).
• Internal fixation using a cannulated cancellous screw (Fig. 3).

Figure 2: Frog-leg lateral view demonstrating posterior and inferior displacement of the capital femoral epiphysis relative to the metaphysis, confirming the diagnosis of slipped capital femoral epiphysis.

Figure 3: Immediate post-operative radiograph showing satisfactory reduction and fixation with a cannulated cancellous screw across the physis.

Post-operative protocol:

• Strict non-weight-bearing for 6 months due to the added risk of failure of fixation and probability of slip in the contralateral hip due to increased stress.
• Gradual progression to full weight-bearing.

Endocrinological treatment included testosterone replacement therapy, which facilitated improved skeletal maturation and eventual physeal closure at the 1-year follow-up (Fig. 4).

Figure 4: Radiograph at 1-year follow-up showing maintained alignment and progressive physeal healing without complications such as avascular necrosis or chondrolysis.

Outcome: 

At 5-year follow-up:

• Radiographs demonstrated complete fusion of the physis (Fig. 5)
• No evidence of avascular necrosis or chondrolysis
• Full, painless range of motion
• Return to unrestricted daily activities.

Figure 5: Radiograph at 5-year follow-up demonstrating complete physeal fusion with maintained femoral head alignment and no degenerative changes.

Such favourable outcomes are consistent with literature emphasising early stabilisation combined with systemic disease management ^[1,5].

SCFE is typically observed between 10 and 16 years of age; however, cases presenting outside this range should raise suspicion for underlying systemic pathology ^[1,3]. Atypical SCFE is frequently associated with endocrine disorders, and its reported prevalence ranges widely, though it remains relatively uncommon ^[1,3]. Several studies highlight the association between endocrine disorders and atypical SCFE:

• Loder et al. reported that endocrine disorders are present in up to 20% of atypical SCFE cases ^[6].
• Wells et al. emphasised delayed skeletal maturity in hypogonadal patients, leading to prolonged physeal vulnerability ^[7].
• Peck suggested routine endocrine screening in patients presenting with atypical features such as short stature or obesity ^[8].

Hormonal imbalances affect the structural integrity of the physis by altering chondrocyte maturation and extracellular matrix composition, thereby increasing susceptibility to shear forces ^[1,9]. Hypogonadism contributes to delayed epiphyseal closure due to deficiency of sex steroids, which are critical for skeletal maturation and bone health ^[4,10]. Obesity, as seen in this patient, further increases mechanical stress across the hip joint, compounding the risk of slip ^[9]. Management strategies consistently recommend:

1. Early surgical stabilization
2. Avoidance of aggressive manipulation
3. Identification and treatment of underlying endocrine pathology.

Long-term outcomes are favourable when both orthopaedic and systemic conditions are addressed. Current evidence supports in situ fixation using cannulated screws as the preferred treatment modality due to its reliability and low complication rates ^[1,5]. Importantly, patients with atypical features such as short stature or endocrine abnormalities should undergo thorough hormonal evaluation ^[2,11]. Recent studies also highlight the role of metabolic and hormonal factors, including vitamin D and endocrine dysfunction, in influencing disease severity and progression ^[11]. Failure to recognise underlying endocrinopathy may result in delayed healing, bilateral involvement, or recurrence ^[2,9]. In the present case, timely orthopaedic stabilisation combined with hormonal therapy resulted in satisfactory physeal closure and excellent long-term functional recovery.

Atypical SCFE associated with hypogonadism requires a comprehensive approach integrating surgical stabilization and endocrine correction. Early diagnosis and multidisciplinary care can lead to excellent long-term outcomes.

Always evaluate for endocrine disorders in atypical SCFE. Combined orthopaedic and hormonal management is key to successful long-term outcomes.