Slipped upper femoral epiphysis

Question 1

An obese 14-year-old boy presents with difficulty running and mild knee and hip pain. There is no antecedent history of trauma. On examination internal rotation is restricted but the knee is normal with full range of passive movement possible and no evidence of effusions. Both the C-reactive protein and white cell count are normal. What is the most likely diagnosis?

Answer 1

Slipped upper femoral epiphysis -

• Commonest adolescent hip disorder.
• It occurs most commonly in obese males.
• It may often present as knee pain which is usually referred from the ipsilateral hip. The knee itself is normal. The hip often limits internal rotation.
• X-rays will show displacement of the femoral epiphysis and the degree of its displacement may be calculated using the Southwick angle.
• Treatment is directed at preventing further slippage which may result in avascular necrosis of the femoral head.

Question 2

What are the various paediatric orthopaedic problems that occur at birth/0-5 years/5-10 years/10-15 years?

Answer 2

CHIPS

CH = 0 y.o (at birth) = congenital problems/DDH
I = 0 - 5 y.o = irritable hip
P = 5 - 10 y.o = Perthes
S = 10 - 15 y.o = SUFE

Question 3

What are the risk factors for SUFE?

Answer 3

• Obese
• Male
• Adolescents

Also associated with hypothyroidism and hypogonadism

Question 4

What are the signs of SUFE on examination?

Answer 4

• Limitation to internal rotation
• May be bilateral in 20%
• No knee problems although pain may be referred 2 months prior to hip slipping

Question 5

What is the management of SUFE?

Answer 5

1. Bed rest + non-weight bearing to avoid avascular necrosis
2. Then internal pinning and fixation of the epiphysis

Question 6

What investgations are used for SUFE diagnosis? Which view should be used?

Answer 6

XRay - showsn femoral head displaced and falling inferolaterallly (like melting ice cream cone)

PA and frog leg lateral (can be missed on AP)

Question 7

Which scoring system is used to classify severity of SUFE on XR?

Answer 7

Southwick angle

Question 8

A 30-year-old man presents with severe pain in the left hip it has been present on and off for many years. He was born at 39 weeks gestation by emergency caesarean section after a long obstructed breech delivery. He was slow to walk and as a child was noted to have an antalgic gait. He was a frequent attender at the primary care centre and the pains dismissed as growing pains. X-rays show almost complete destruction of the femoral head and a narrow acetabulum. What is the most likely diagnosis?

Answer 8

DDH (probably with secondary osteoarthritis) - breech delivery is a risk factor and should have been US scanned. Should have had arthrodesis rather than hip replacement at younger age.

Question 9

What is shown here?

Answer 9

SUFE

Question 10

Where does the epiphysis usually slip?

Answer 10

slips inferiorly and posteriorly

Question 11

What are the complications of SUFE?

Answer 11

avascular necrosis and also risk of secondary osteochondritis.

Question 12

How common is bilateral SUFE? Is it more common in males/females? What age?

Answer 12

bilateral in 20%

boys

peaks 10-16 years.

Question 13

How does SUFE present?

Answer 13

• aching in the thigh or pain in the knee, and also groin
• may just present as persistent knee pain
• examination may not reveal any gross abnormality apart from restriction of abduction or internal rotation of hip, and increased external rotation.

Question 14

Label this pelvic XR.

Answer 14

A - right iliac bone

B - left sacroiliac joint

C - right inferior pubic ramus

D - right femoral capital epiphysis

E - left femoral epiphyseal plate

F - symphisis pubis

Question 15

What is this sign called?

Answer 15

Trethowan’s sign - SUFE; the line of Klein passes above the femoral head