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Slipped upper femoral epiphysis (SUFE) - Fracture clinics
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.
A SUFE is characterised by the displacement of the capital femoral physis from the metaphysis.
They can be classified according to:
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.
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
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.
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.
All patients with a SUFE or concern for a SUFE need urgent orthopaedic assessment.
All patients with a SUFE need surgical stabilisation. The patient needs to be kept non-weight bearing, and admitted for surgical treatment.
If the child does have a SUFE, he or she will need surgery to stabilise the hip and must be admitted to hospital.
See fracture clinics for other potential complications.
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.