Clinical Practice Guidelines

Slipped upper femoral epiphysis (SUFE) - Emergency Department

  • Fracture Guideline Index

    See also:  Slipped upper femoral epiphysis (SUFE) - Fracture clinics

    1. Summary
    2. How are they classified?
    3. How common are they and how do they occur?
    4. What do they look like - clinically?
    5. What radiological investigations should be ordered?
    6. What do they look like on x-ray?
    7. Do I need to refer to orthopaedics now?
    8. What is the usual ED management for this injury?
    9. What advice should I give to parents?
    10. What are the potential complications associated with this injury?

    1. Summary

    ED management

    A child presenting with a chronic slipped upper femoral epiphysis (SUFE) will generally walk with an antalgic gait, out-toeing and some shortening of the affected limb.  The child may complain of vague pain in the groin, thigh or knee.

    A very reliable clinical sign of a chronic SUFE, even when mild, is obligatory external rotation of the leg during hip flexion.

    Anteroposterior (AP) and frog lateral pelvis x-rays of both hips should be obtained.

    All patients with a SUFE or concern for a SUFE should be kept non-weight bearing and referred for an urgent orthopaedic assessment in the ED.  The management of SUFE is always surgical.


    2. How are they classified?

    A SUFE is characterised by the displacement of the capital femoral physis from the metaphysis. 

  • They can be classified according to:

    • ability to weight bear
      • Stable - the patient is able to weight bear on the affected leg
      • Unstable - the patient is unable to weight bear on the affected leg, even with crutches
    • duration of symptoms
      • Acute - sudden onset of severe symptoms and inability to weight bear
      • Chronic - gradual onset and progression of symptoms for more than 3 weeks, without sudden exacerbation. This is the most common presentation (85% of patients with SUFE)
      • Acute on chronic - sudden exacerbation of symptoms due to acute displacement of a chronically slipped epiphysis

    3. How common are they and how do they occur?

    The aetiology of SUFE is unknown, but biomechanical and biochemical factors play an important role.

    SUFE is relatively common and occurs between 0.2 and 10 per 100,000 population. It is more common in boys (60%) than girls with the mean age at diagnosis being 13.5 years in boys and 12 years in girls. Approximately 50% of adolescents with SUFE are above the 95th percentile for weight.

    Studies have shown a risk of bilateral slips in 18 -50 % of patients.

    4. What do they look like - clinically?

    A child presenting with a chronic SUFE will generally walk with an antalgic gait, out-toeing and some shortening of the affected limb.

  • If the slip is acute and unstable, these children cannot walk. The child may complain of vague pain in the groin, thigh or knee. SUFE commonly presents with knee pain as the only presenting complaint.

    A very reliable sign of a chronic SUFE, even when mild, is detection of obligatory external rotation during flexion of the hip. As the hip is flexed on the affected side, the thigh will automatically externally rotate and abduct.

  • !

    It is common to see a child with months of symptoms having been treated for knee pain eventually diagnosed with a late SUFE


    5. What radiological investigations should be ordered?

    AP and frog lateral pelvis x-rays of both hips should be ordered. In an unstable, acute SUFE, a frog lateral view is not obtained preoperatively in order to avoid causing pain and because of the potential for displacement of the SUFE. A cross-table lateral x-ray, however, can be ordered.

    6. What do they look like on x-ray?

    Figure 1A_AP SUFE Figure 1B_Lateral_SUFE

    Figure 1: AP and lateral x-rays of a 10 year old boy demonstrating a SUFE. The SUFE is best seen laterally. This child presented with chronic knee pain.

    7. Do I need to refer to orthopaedics now?

    All patients with a SUFE or concern for a SUFE need urgent orthopaedic assessment.

    8. What is the usual ED management for this injury?

    All patients with a SUFE need surgical stabilisation. The patient needs to be kept non-weight bearing, and admitted for surgical treatment.

    9. What advice should I give to parents?

    If the child does have a SUFE, he or she will need surgery to stabilise the hip and must be admitted to hospital.

    10. What are the potential complications associated with this injury?

    • Osteonecrosis - the risk is up to 50% in an unstable SUFE, even with treatment
    • Chondrolysis - this can result from the process of the SUFE itself, but more commonly it is from unrecognised screw/pin penetration from surgical stabilisation. The overall incidence of this is approximately 7%
    • Osteoarthritis - patients with a moderate or severe SUFE have higher risk of early degenerative joint disease
    • Impingement - patients with a severe SUFE have a risk of deformity through the femoral neck when the SUFE is stabilised and healed. This can cause femoral acetabular impingement, and may require further surgical treatment to correct this

    See fracture clinics for other potential complications.

    References (ED setting)

    Aronsson DD, Loder RT, Breur GJ, et al. Slipped capital femoral epiphysis: current concepts. J Am Acad Ortho Surg 2006; 14: 666-79.

    Weigall P, Vladusic S, Torode I. Slipped upper femoral epiphysis in children: delays in diagnosis. Aust Fam Physician 2010; 39(3): 151-3.

    Kay RM. Slipped femoral capital epiphysis. In Lovell and Winter's Pediatric Orthopaedics, 6th Ed, Vol 2. Morrissy RT, Weinstein SL (Eds). Lippincott, Philadelphia 2006. p.1085-124.