Slipped upper femoral epiphysis
Updates to Article Attributes
Slipped upper femoral epiphysis (SUFE) is also known as aslipped capital femoral epiphysis (SCFE) is a relatively common condition affecting the physis of the proximal femur in adolescents. It is one of commonest hip abnormalities in adolescence and is bilateral in ~20% of cases.
Epidemiology
The age of presentation is somewhat dependent on gender. Typically boys present later (10-17 years) than girls (8-15 years) 2. Obesity is a significant risk factor. It is more common in common in boys than girls and more common in Afro-Caribbeans than than Caucasians.
Clinical presentation
Clinically patients present with hip pain progressing to a limp and even leg length discrepancy.
Pathology
SUFE is essentially a type ISalter Harris growth plate injury due to repeated trauma on a background of mechanical and probably hormonal predisposing factors.
During growth, there is widening of the physeal plate which is particularly pronounced during a growth spurt. In addition, the axis of the physis alters during growth and moves from being horizontal, to being oblique. As the physis becomes more oblique, shear forces across the growth plate increase resulting in an increase risk of fracture and resultant slippage.
Conditions that may predispose a child to a SCFE include:
Radiographic features
In the pre-slip phase, there is a widening of the growth plate with irregularity and blurring of the physeal edges and demineralisation of the metaphysis. This is followed by the acute slip which is posteromedial. In a chronic slip, the physis becomes sclerotic and widened - coxa magna.
Plain film
The slip that occurs is posterior posteriorand to a lesser extent medial medial, and therefore is more easily seen on the frog-leg lateral view rather than the AP hip view. A line drawn up the lateral edge of the femoral neck (line of Klein) fails to intersect the intersect the epiphysis during the during the acute phase (Trethowan's Sign). Additionally, because the epiphysis moves posteriorly, it appears smaller because of projectional factors. The metaphysis also displaces displaces, but laterally laterally, and therefore may not overlap posterior lip of the acetabulum as it should normally normally (loss of triangular sign of Capener) 5.
Alignment of the epiphysis with respect to the femoral metaphysis can be used to grade the degree of slippage: see SUFE grading.
CT
Is a sensitive and an accurate method of measuring the degree of upper femoral epiphyseal tilt and detecting the disease in its early stage. Reconstructive and 3D images may allow viewing of the relationship of femoral head to the metaphysis in three planes.
A metaphyseal blanch sign is an increase in density in the proximal metaphysis. It represents an attempt of healing process that occurs before the visible displacement of the epiphysis.
MRI
Early marrow oedema and slippage is seen as increased signal on T2-weighted imaging. MRI can be used to examine the contralateral hip can be considered for follow-up imaging of the contralateral hip.
Marrow oedema is non-specific and while it may indicate early bone changes in SUFE, there are other numerous causes, e.g. infection or tumour.
Ultrasound
Findings are nonspecific and may a include hip joint effusion.
Treatment and prognosis
Treatment of unstable SUFE has over the years progressively shifted exclusivley towards surgical pinning, with conservative management (e.g. limitation of activity and casting) no longer recommended.
Treatment of the contralateral hip is more controversial. Bilateral SUFE is relatively common (~20%) and stabilisation of the unstable side can in fact precipitate slip on the contralateral side. As such prophylactic pinning is recommended by some 3.
If significant deformity is present then osteotomies and even joint replacement may be required.
Potential complications include
Complications
- long term degenerative osteoarthritis: ~90%
- avascular necrosis of the femoral head (10-15%): increased incidence with the number of attempted reductions and with multiple screws for pinning 3
- chondrolysis (7-10%): acute
cartilage necrosiscartilage necrosis - deformity
- limb length discrepancy
Differential diagnosis
When the slip is evident and no secondary degenerative changes are present then the diagnosis is usually readily made. Ideally however the diagnosis is made early in which case the differential is that of a painful hip and includes:
-<p><strong>Slipped upper femoral epiphysis (SUFE)</strong> is also known as a <strong>slipped capital femoral epiphysis (SCFE)</strong> is a relatively common condition affecting the <a href="/articles/growth-plate">physis</a> of the proximal <a href="/articles/femur">femur</a> in adolescents. It is one of commonest hip abnormalities in adolescence and is bilateral in ~20% of cases.</p><h4>Epidemiology</h4><p>The age of presentation is somewhat dependent on gender. Typically boys present later (10-17 years) than girls (8-15 years) <sup>2</sup>. Obesity is a significant risk factor. It is more common in boys than girls and more common in Afro-Caribbeans than Caucasians.</p><h4>Clinical presentation</h4><p>Clinically patients present with hip pain progressing to a limp and even leg length discrepancy.</p><h4>Pathology</h4><p>SUFE is essentially a type I <a href="/articles/salter-harris-fractures">Salter Harris growth plate injury</a> due to repeated trauma on a background of mechanical and probably hormonal predisposing factors.</p><p>During growth, there is widening of the physeal plate which is particularly pronounced during a growth spurt. In addition, the axis of the physis alters during growth and moves from being horizontal, to being oblique. As the physis becomes more oblique, shear forces across the growth plate increase resulting in an increase risk of fracture and resultant slippage.</p><p>Conditions that may predispose a child to a SCFE include:</p><ul>- +<p><strong>Slipped upper femoral epiphysis (SUFE)</strong> is also known as a <strong>slipped capital femoral epiphysis (SCFE)</strong> is a relatively common condition affecting the <a href="/articles/growth-plate">physis</a> of the proximal <a href="/articles/femur">femur</a> in adolescents. It is one of commonest hip abnormalities in adolescence and is bilateral in ~20% of cases.</p><h4>Epidemiology</h4><p>The age of presentation is somewhat dependent on gender. Typically boys present later (10-17 years) than girls (8-15 years) <sup>2</sup>. Obesity is a significant risk factor. It is more common in boys than girls and more common in Afro-Caribbeans than Caucasians.</p><h4>Clinical presentation</h4><p>Clinically patients present with hip pain progressing to a limp and even leg length discrepancy.</p><h4>Pathology</h4><p>SUFE is essentially a type I <a href="/articles/salter-harris-fractures">Salter Harris growth plate injury</a> due to repeated trauma on a background of mechanical and probably hormonal predisposing factors.</p><p>During growth, there is widening of the physeal plate which is particularly pronounced during a growth spurt. In addition, the axis of the physis alters during growth and moves from being horizontal, to being oblique. As the physis becomes more oblique, shear forces across the growth plate increase resulting in an increase risk of fracture and resultant slippage.</p><p>Conditions that may predispose a child to a SCFE include:</p><ul>
-</ul><h4>Radiographic features</h4><p>In the pre-slip phase, there is a widening of the growth plate with irregularity and blurring of the physeal edges and demineralisation of the <a href="/articles/metaphysis">metaphysis</a>. This is followed by the acute slip which is posteromedial. In a chronic slip, the physis becomes sclerotic and widened - <a href="/articles/coxa-magna">coxa magna</a>.</p><h5>Plain film</h5><p>The slip that occurs is posterior<em> </em>and to a lesser extent medial, and therefore is more easily seen on the <a href="/articles/frogleg-lateral-view">frog-leg lateral view</a> rather than the AP hip view. A line drawn up the lateral edge of the femoral neck (<a href="/articles/line-of-klein">line of Klein</a>) fails to intersect the epiphysis during the acute phase (<a href="/articles/trethowan-sign-1">Trethowan's Sign</a>). Additionally, because the epiphysis moves posteriorly, it appears smaller because of projectional factors. The metaphysis also displaces, but laterally, and therefore may not overlap posterior lip of the acetabulum as it should normally (loss of triangular sign of Capener) <sup>5</sup>.</p><p>Alignment of the epiphysis with respect to the femoral metaphysis can be used to grade the degree of slippage: see <a href="/articles/sufe-grading">SUFE grading</a>.</p><h5>CT</h5><p>Is a sensitive and an accurate method of measuring the degree of <a href="/articles/upper-femoral-epiphyseal-tilt">upper femoral epiphyseal tilt</a> and detecting the disease in its early stage. Reconstructive and 3D images may allow viewing of the relationship of femoral head to the metaphysis in three planes.</p><p>A <a href="/articles/metaphyseal-blanch-sign">metaphyseal blanch sign</a> is an increase in density in the proximal metaphysis. It represents an attempt of healing process that occurs before the visible displacement of the epiphysis.</p><h5>MRI</h5><p>Early marrow oedema and slippage is seen as increased signal on T2-weighted imaging. MRI can be used to examine the contralateral hip can be considered for follow-up imaging of the contralateral hip.</p><p>Marrow oedema is non-specific and while it may indicate early bone changes in SUFE, there are other numerous causes, e.g. infection or tumour.</p><h5>Ultrasound</h5><p>Findings are nonspecific and may a include hip joint effusion.</p><h4>Treatment and prognosis</h4><p>Treatment of unstable SUFE has over the years progressively shifted exclusivley towards surgical pinning, with conservative management (e.g. limitation of activity and casting) no longer recommended.</p><p>Treatment of the contralateral hip is more controversial. Bilateral SUFE is relatively common (~20%) and stabilisation of the unstable side can in fact precipitate slip on the contralateral side. As such prophylactic pinning is recommended by some <sup>3</sup>.</p><p>If significant deformity is present then osteotomies and even joint replacement may be required.</p><h6>Potential complications include</h6><ul>-<li>long term degenerative osteoarthritis: ~90%</li>- +</ul><h4>Radiographic features</h4><p>In the pre-slip phase, there is a widening of the growth plate with irregularity and blurring of the physeal edges and demineralisation of the <a href="/articles/metaphysis">metaphysis</a>. This is followed by the acute slip which is posteromedial. In a chronic slip, the physis becomes sclerotic and widened - <a href="/articles/coxa-magna">coxa magna</a>.</p><h5>Plain film</h5><p>The slip that occurs is posterior<em> </em>and to a lesser extent medial, and therefore is more easily seen on the <a href="/articles/frogleg-lateral-view">frog-leg lateral view</a> rather than the AP hip view. A line drawn up the lateral edge of the femoral neck (<a href="/articles/line-of-klein">line of Klein</a>) fails to intersect the epiphysis during the acute phase (<a href="/articles/trethowan-sign-1">Trethowan's Sign</a>). Additionally, because the epiphysis moves posteriorly, it appears smaller because of projectional factors. The metaphysis also displaces, but laterally, and therefore may not overlap posterior lip of the acetabulum as it should normally (loss of triangular sign of Capener) <sup>5</sup>.</p><p>Alignment of the epiphysis with respect to the femoral metaphysis can be used to grade the degree of slippage: see <a href="/articles/sufe-grading">SUFE grading</a>.</p><h5>CT</h5><p>Is a sensitive and an accurate method of measuring the degree of <a href="/articles/upper-femoral-epiphyseal-tilt">upper femoral epiphyseal tilt</a> and detecting the disease in its early stage. Reconstructive and 3D images may allow viewing of the relationship of femoral head to the metaphysis in three planes.</p><p>A <a href="/articles/metaphyseal-blanch-sign">metaphyseal blanch sign</a> is an increase in density in the proximal metaphysis. It represents an attempt of healing process that occurs before the visible displacement of the epiphysis.</p><h5>MRI</h5><p>Early marrow oedema and slippage is seen as increased signal on T2-weighted imaging. MRI can be used to examine the contralateral hip can be considered for follow-up imaging of the contralateral hip.</p><p>Marrow oedema is non-specific and while it may indicate early bone changes in SUFE, there are other numerous causes, e.g. infection or tumour.</p><h5>Ultrasound</h5><p>Findings are nonspecific and may a include hip joint effusion.</p><h4>Treatment and prognosis</h4><p>Treatment of unstable SUFE has over the years progressively shifted exclusivley towards surgical pinning, with conservative management (e.g. limitation of activity and casting) no longer recommended.</p><p>Treatment of the contralateral hip is more controversial. Bilateral SUFE is relatively common (~20%) and stabilisation of the unstable side can in fact precipitate slip on the contralateral side. As such prophylactic pinning is recommended by some <sup>3</sup>.</p><p>If significant deformity is present then osteotomies and even joint replacement may be required.</p><h5>Complications</h5><ul>
- +<li>long term degenerative <a title="Osteoarthritis" href="/articles/osteoarthritis">osteoarthritis</a>: ~90%</li>
-<li>chondrolysis (7-10%): acute cartilage necrosis</li>- +<li>chondrolysis (7-10%): acute cartilage necrosis</li>
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