Slipped upper femoral epiphysis (SUFE) is a displacement of the proximal femoral growth plate in adolescents. Boys are more commonly affected than girls. Risk factors include obesity, delayed puberty, and unusually rapid growth. The weakened growth plate slips due to the stress of weight bearing. This causes the femoral head to displace forward and rotate externally. Complications can include avascular necrosis, chondrolysis, and deformities like coxa vara if not treated. Diagnosis is made through x-rays and imaging. Treatment ranges from pinning for minor slips to surgery to reposition the femoral head for severe slips.

1. Slipped Upper Femoral
Epiphysis (SUFE)
Presented By Siti Nur Rifhan Kamaruddin

2. DEFINITION
• Displacement of the proximal femoral epiphysis is
uncommon and usually confined to children
going through the pubertal growth spurt.
• Boys affected more > girls
• If one side slips, there is a 30% risk of the other
side slipping as well
Definition: Slippage of the overlying epiphysis of
proximal femur posteriorly & inferiorly due to
weakness of the growth plate in relation to
metaphysis.

3. ETIOLOGY
• The cause of SUFE is not known.
• Trauma may be the precipitating cause but often there
is also an underlying abnormality.
• Risk Factor : Unusually tall children
: Obese
: Delayed gonadal development
• Theory : There is imbalance between pituitary
growth & gonadal imbalance. Thus, during puberty
growth spurt the immature physis might be too
weak to resist stress – imposed by increased body
weight.

4. PATHOLOGY
• Following physeal disruption, the femoral shaft
rolls into external rotation and femoral neck is
displaced forwards.
• Epiphysis remains seated in the acetabulum.
• If slip is severe, the anterior retinacular vessels are
torn.
• At back of femoral neck, periosteum is lifted from
bone with the vessels intact -> this may be the
only source of blood supply to femoral head.
• Damage to these vessels lead to AVN

5. • Physeal distruption  premature fusion of
the epiphysis
• This is accompanied by bone remodeling.
• Although there may be a permanent external
rotation deformity and apparent Coxa Vara ->
adaptive changes often ensure good joint
functions even without treatment.

6. CLASSIFICATION
Types of Classification. Based on :
• Onset
- Acute
- Chronic
- Acute on Chronic
• Functional
- Stable
- Unstable
• Morphological
- Mild
- Moderate
- Severe

7. Acute :
• Pain and weakness. Symptoms <2 weeks
• Single episode of trauma
• On X-ray : Displaced epiphysis. No remodeling.
Chronic:
• Intermittent pain in groin & thigh. Symptoms > 2weeks to years
• On X-ray : Remodeling and healing seen.
Acute on Chronic:
• Symptoms last longer than 1 month and there is recent sudden
exacerbation pain following trauma
CLASSIFICATION BASED ON SYMPTOMS

8. Functional Classification
LODER Classification:
Stable SUFE
• Pt can walk with or
without crutches.
Unstable SUFE
• Pt cannot ambulate at
all regardless of
duration of symptoms
• This type carries a
higher rate of
complication
(i.e Avascular Necrosis)

9. Morphological Classification
Degree of displacement of the capital femoral
Epiphysis from the femoral neck
Mild : < 30 degree
Moderate : 30-60 degree
Severe : > 60 degree

10. CLINICAL FEATURES
• Pt is usually a boy of 14/15 years old
• Pain in the groin, anterior thigh or knee
• He may be limping
• Sudden onset
• Two-thirds of Pts are overweight &
sexually underdeveloped or unusually
tall and thin.
On Examination
• External rotation of the affected leg
• The affected left is shorter by 1/2cm
• Limited abduction and internal rotation

12. DIAGNOSIS
• Diagnosis based on clinical examination and
radiological investigations

13. INVESTIGATIONS
• X –Rays
- AP and frog lateral views
• Ultrasonography
- Useful in detection of early slips, joint effusion
• CT Scan
- Useful in documenting presence of decreased
upper femoral neck
• MRI Scan
- Useful to assess AVN

15. COMPLICATIONS
• Avascular Necrosis
- Most serious complication.
- In severe cases, SUFE causes the blood supply to
femoral head become limited  gradual collapse
of the bone.
- When bone collapses  Articular cartilage also collapses
- Without cartilage, bone rubs against bone  Painful
arthritis.
- AVN more likely to occur in unstable SUFE.
• Chondolysis
- Rare but serious complication.
- Articular cartilage on the hip joint degenerates very rapidly
leading to pain, deformity & permanent loss of motion in
the joint.

16. • Slipping at the opposite hip
- Occurs in 30% of cases – sometimes while
Pt is in bed.
- Always check in the opposite hip with X-ray
• Coxa Vara deformity
- May occur if displacement is not reduced and
epiphysis fuses in its deformed position.
- The Pt limps but usually it’s painless
- Osteotomy is needed to prevent Osteoarthritis
• Secondary Osteoarthritis
- Likely to occur if displacement is not reduced
- Very likely to occur if there is AVN

17. TREATMENT
Minor Displacement
• Displacement of less < one-third Epiphyseal width
• Treated by accepting the position & fixing the
epiphysis with two thin threaded pins or screws.
• Always done under X-Ray control
Moderate Displacement
• Displacement of one-third to one-half the
epiphyseal width

18. Severe Displacement
• Displacement is more than one-half the
epiphyseal width
• Surgery : Exposing the slip – remove a small
piece of the femoral neck to allow replacement
of epiphysis and pinning

19. REFERENCES
• Apley and Solomon’s Concise System of
Orthopedics and Trauma 4th Edition. CRC Press
• SCFE. Kevin D. Walter. Emedicine Medscape
http://emedicine.medscape.com/article/91596-
overview