Slipped Upper Femoral Epiphysis

Background

  • One of the most common adolescent hip problems (around 10/100,000 children per year)
    • The epiphysis usually slips posteriorly relative to the diaphysis of the femur
  • Most common in boys and occurs usually around the growth spurt in adolescence (mean age 13)
    • More common in overweight children; left hip slightly more prevalent
    • Whilst weight and mechanical factors (as well as others e.g. hypothyroidism; hypopituitarism; radiation treatment) may play a role, SUFE represents an underlying instability of the proximal growth plate- the exact cause of which is unknown

Classification

  • The most important classification is whether the joint is
    • Stable (90%) i.e. the patient is still able to weight bear (function relatively unimpaired)
    • Unstable (10%) the patient is unable to weight bear- requires urgent management
  • Other classifications include
    • time-based i.e. acute (symptoms for < 3 weeks); chronic and acute on chronic
    • Southwick angle classification (measurement of the difference between both hips in the femoral head-shaft angle on the frog radiograph)
      • Mild <30°; Moderate 30-50° and severe >50°
    • Grading by degree of slippage
      • I (Up to a third); II (up to a half); III (more than half)

Presentation

  • Most commonly presents with hip and/or groin pain
    • Often an acute event but may present but can have had mild symptoms preceding this
    • Can present as radiated knee pain
    • Worse on movement/weight bearing
    • May cause antalgic gait
    • May limit hip movement- particularly internal rotation and abduction (indeed the leg may rest in external rotation/adduction)
  • Differential
    • Perthes disease
    • Septic arthritis
    • Developmental dysplasia
    • Synovitis

Investigation

  • X-rays
    • An x-ray of the pelvis will usually detect a SUFE
      • Trethowan’s sign
        • Klein’s line (the line drawn up the lateral edge of the neck of the femur) should intersect the femoral head. It fails to do so in SUFE due to slip.
      • You may also see widening of the growth plate (epiphysiolysis) and blurring of the proximal femoral metaphysis (overlapping of the metaphysis and displaced epiphysis)
  • Occasionally, where diagnosis is in doubt, a CT or MRI may help confirm the diagnosis

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Management

  • Surgical management of the affected side
    • Percutaneous fixation with cannulated screw(s)
  • There is some controversy as to whether to fix the other side also (bilateral in up to 20% of cases)- currently not recommended
  • Without fixation, particularly in unstable cases, there is a risk of osteoarthritis; chondrolysis (breakdown of cartilage and subsequent bony degeration/damage) and avascular necrosis of the femoral head
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