This case study describes a 12-year-old obese male presenting with left thigh pain. Examination revealed tenderness over the left hip on external rotation. Imaging showed slipped upper femoral epiphysis (SUFE) of the left hip. SUFE is a slippage of the femoral head through the weakened growth plate, usually occurring during puberty. It is treated surgically with screws to stabilize the hip, followed by protected weight bearing. Prognosis is generally good with surgical treatment but complications like osteonecrosis can occur without timely intervention.

1. Case Study
SPGH 2015

2. General Details
Name : K. H.
Age : 12 yrs
Sex : Male
Address : Strathbogie, Savanna-la-mar P.O

3. Private Practitioner
PC; pain to left thigh x 5/7
HPC; no h/o trauma, unable to weight bear on
left
Rx. Diclofenac + Referral to OOPD

4. OOPD
PC: left thigh pain
HPC: 1 week duration with aggravation on ambulation.
O/E; Obese child, tenderness Lt. hip on external rotation
V/S: BP-148/104 P- 104 T-98.6 R-20
Labs: Hb 13.0 WBC 8.6 Plt. 960 U+E (N)
Rx….Admit, >labs, physio NWB crutches, bedrest,
Cataflam, pending transfer to CRH

6. SUFEDr. E. M. Regis Jr.
Dept. of Orthopaedics
SPGH
14/12/15

7. Outline
Definition
Anatomy
Incidence
Aetiology
Pathophysiology
Signs/Symptoms
Investigations
Diagnosis
Differential Diagnosis
Treatment
Prognosis
Complications
Conclusion
References

8. Definition
Slipped Upper Femoral Epiphysis (SUFE), aka Skiffy
and SCFE is a unique type of instability of the proximal
femoral growth plate due to weakness which involves
the femoral head slipping off in a posterior direction.
It usually develops shortly after puberty or periods of
accelerated growth.

9. Anatomy
The epiphysis is the
rounded end of a long
bone, at its joint with
adjacent bone(s).

10. Anatomy (continued)
Pressure epiphysis; region of long bone that
forms the joint.
eg. head of femur, part of the hip joint complex.
assist in transmitting weight of human body
and are regions of bone that are under
pressure during movement and locomotion.

11. Incidence
Most common in adolescent (10-16yrs)
Overall US data. ..10.8 cases per 100,000.
Black > Hispanic > White
Male > Female {3:1)
Left hip > Right hip
20% have bilateral involvement at time of presentation.

12. Aetiology
Obesity (major risk factor)
(more shear forces around proximal growth plate in hip)
Genetics; - 5-7% familial involvement
- metabolic endocrine disorders
(hypothyroidism, hypogonadism, growth hormone abnormalities)

13. Pathophysiology
unusually widened epiphyseal growth plate due to
expansion of “zone of hypertrophy”
NORMAL PHYSIS …hypertrophic zone 15-30%
SUFE Patient…..hypertrophic zone 80%

14. Histologically abnormal cartilage maturation,
endochondral ossification & perichondral ring
instability occur, resulting in less organisation
of normal cartilaginous columnar architecture.
Slippage occurs through this weakened areas.

15. Position of proximal physis changes from horizontal to
oblique during preadolescence and adolescence,
redirecting hip forces from compression to shear.
Also there is an association between femoral neck
retroversion and reduced neck shaft angles with SUFE.
These changes increase shear forces across hip, leading
to SUFE.

16. Signs/Symptoms
hip and/or knee pain
intermittent limp/ unable to weight bear (antalgic)
external rotation of limb (out toeing)
apparent shortening
limited R.O.M of hip
loss of complete hip flexion + ability to fully rotate hip inward (painful internal
rotation)
involuntary guarding + spasm

17. Investigations
A. Lab Test (CBC, U&E, thyroid levels, growth
hormone)
B. X-rays (AP + Frog Lateral)
• AP Radiographs
NB. Klein line is drawn straight up the superior aspect of femoral neck. (should intersect the epiphysis), if not likely SUFE.

19. Investigations (continued)
• Frog Leg
NB. Straight line through centre of femoral neck proximally should be at the centre of epiphysis. If line anterior in epiphysis, likely SUFE. (RT)

20. Investigations (continued)
C. MRI
D. CT SCAN
E. Bone Scanning

21. Diagnosis
Detailed History + Complete Physical Examination + Investigation Findings
Classification
Acute (<3 wks)
Chronic (>3 wks)
Acute on Chronic (3+ wks of symptoms with acute exacerbation/ change)
Stable (weight bearing)
Unstable (non weight bearing)
Radiological (displacement of hip in relation to femoral neck)
Type 1 < 33%
Type 11 33-50%
Type 111 >50%

22. Differential Diagnosis
Femoral Head Avascular Necrosis
Femoral Neck Fracture
Femoral Neck Stress Fracture
Femur Injuries + Fractures
Groin Injury
Osteitis Pubis (inflammation of pubis symphysis +
surrounding muscle insertions)

23. Treatment
Surgical intervention with single cannulated screw,
followed by 6-8 wks of protected weight bearing
crutches.
Unstable or Grade III slips may require gentle repositioning to improve alignment

24. Osteotomy of proximal femur as a secondary
procedure may be indicated for repositioning
of femoral head to improve functional R.O.M.

25. Wensaas et al study proved that routine
prophylactic fixation of the contralateral hip is
not indicated.

26. Prognosis
Single screw in situ fixation in (stable) mild to
moderate cases has good to excellent
outcomes. Patients can resume contact sports
& running after closure of growth plate.
20-50% rate of osteonecrosis in (unstable)
severe cases.

27. Complications
Avascular Necrosis
Chondrolysis
Degenerative Osteoarthritis
Hardware Failure
Post Op Infection
Leg Length Inequality

28. Conclusion
Early diagnosis is paramount taking into consideration high
index of suspicion based on history and physical examination.
X-ray findings are usually classic (klein line).
Immediate surgical intervention should follow diagnosis and
work up to aid in prevention of complications. (eg. AVN)
Prognosis is usually good

29. References
Apley’s System of Orthopaedics and Fractures, 9th Edition
http://www.aafp.org/afp/2010/0801/p258.html
http://orthoinfo.aaos.org/topic.cfm?topic=a00052
http://emedicine.medscape.com/article/91596-treatment
www.google.com/images
J Maheshwari (1997), Essential Orthopaedics 2nd Edn. New Delhi, Interprint
www.orthobullets.com
Savanna-la-mar General Public Hospital (SGPH) Docket Office