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Is ultrasound or plain film radiography a more sensitive diagnostic modality for diagnosing slipped capital femoral epiphysis?

Three Part Question

In [children with Slipped Capital Femoral Epiphysis] has [ultrasound or plain radiography] [greater sensitivity for the diagnosis]?

Clinical Scenario

A 12-year-old boy presents to the emergency department with a history of limp and decreased range of movement at his right hip. You suspect that he may have a slipped capital femoral epiphysis. You wonder whether plain film radiograpy or ultrasound sonography would be a more sensitive diagnostic modality for slipped capital femoral epiphysis.

Search Strategy

Medline using the OVID interface 1946 to October Week 3 2013 AND AND (femur/ OR OR AND (epiphyses/ OR OR AND (ultrasonography.hw. OR OR OR Ultrasonography/ OR ultrasonics/ OR AND (radiography.hw. OR OR Radiography/) AND (diagnosis.hw. OR Diagnosis/ OR Limit to English Language.

Embase using NICE Evidence 1980- date of searching 23.10.2013 AND AND (femur/ OR OR AND (epiphysis/ OR OR AND ( OR OR Ultrasound/ OR AND ( OR Radiography/) AND (Diagnosis/ OR Limit to English Language

The Cochrane Library Issue 10 of 12, October 2013

(slipped:ti,ab,kw AND OR (slipped:ti,ab,kw AND epiphyses.ti,ab,kw OR epiphysis,ti,ab,kw)

Search Outcome

Eleven papers were found in Medline, 12 in Embase and five in Cochrane. Three were relevant to the three-part question

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Magnano et al
Symptomatic overweight patients aged between 9 and 15 years21 Symptomatic overweight patients (15 boys and 6 girls) aged 9–15 years with anteroposterior radiographs; frog leg images were not acquired in 3 cases only. Ultrasonography was performed in 19 cases and the images acquired with 5–7.5 MHz probes on the sagittal plane parallel to the femoral neck. MRI was performed in 9 cases, with coronal and sagittal T1 SE and T2* GE images Sensitivity 66% for anteroposterior radiography with 6 false negativesSmall numbers
Sensitivity80% for combined anteroposterior and frog leg images (3 false negatives)
Sensitivity95% for US (1 false negative)
Sensitivity88% for MRI (1 false negative)
Terjesen T
8 patients with non-acute slipped capital femoral epiphysisComparison of ultrasonography with radiography for diagnosis of slipped capital femoral epiphysisVisualisation by ultrasoundOccurred in 7 out of 8 patientsSmall numbers
Kallio et al
Patients with recent Slipped Capital Femoral Epiphysis (SCFE) admitted to the Adelaide Children's HospitalProspective Study from December 1988 to May 1990 Comparing ultrasonography with radiography in the initial diagnosis and in the classification of SCFE. 21 consecutive patients with 26 episodes of SCFE admitted to Adelaide Children's Hospital were included in the study.Diagnostic accuracy of sonography and radiographyIn the 32 episodes of hip pain, 26 with SCFE and six irritable hips, sonographic diagnosis was correct in 31. The one patient with a false negative result had normal radiographs and sonographs, but was diagnosed as a preslip type of SCFE from the clinical signs and a positive bone scan. The frog lateral radiographs failed to demonstrate the SCFE in two cases Small numbers


Ultrasonography is accurate and harmless to the patient even if frequently repeated. The sonographic measurement of physeal displacement is free from projectional errors of radiological methods. These papers suggest that ultrasound is more sensitive in diagnosing minimal slips.

Editor Comment

GE, gradient echo; SCFE, slipped capital femoral epiphysis; SE, spin echo

Clinical Bottom Line

Ultrasonography is considered to be more sensitive than radiography for diagnosing slipped capital femoral epiphysis based on the results of small studies.


  1. Magnano GM, Lucigrai G, De Filippi C et al. Diagnostic imaging of the early slipped capital femoral epiphysis. Radiol Med. 1998;95:16–20.
  2. Terjesen T. Ultrasonography for diagnosis of slipped capital femoral epiphysis. Comparison with radiography in 9 cases. Acta Orthop Scand. 1992;63:653–7.
  3. Kallio PE, Lequesne GW, Paterson DC, et al. Ultrasonography in slipped capital femoral epiphysis. Diagnosis and assessment of severity. J Bone Joint Surg Br. 1991;73:884–9.