Slipped Upper Femoral Epiphysis

Slipped Upper Femoral Epiphysis (aka SUFE, Slipped Capital Femoral Epiphysis, SCFE)

Acute Slipped Upper Femoral Epiphysis requires urgent surgery to pin the femoral head and prevent further slippage. Ideally, we would like to catch them all at an early stage before a severe slip occurs. The more severe the slip, the worse the prognosis is from arthritis or avascular necrosis. More severe slips require more invasive surgery.
SUFE is more common in boys and typically occurs in the pre/peripubertal period around age 8-17. Obesity is a risk factor. It is thought that slippage (of the metaphysis relative to the epiphysis) occurs due to overstressing at the growth plate (physis) before closure has occurred. An underlying endocrine problem (e.g. hypothyroidism, growth hormone deficiency) may predispose to SUFE in younger patients.
SUFE usually presents with pain in the groin, thigh and / or knee. The diagnostic pitfall is that some present with knee pain only (due to shared innervation of the hip and knee joint from the obturator nerve). Unfortunately, some cases are missed as examination is focussed on the knee (which should be normal) whilst the hip is not assessed. It is therefore mandatory to examine the hip in any child with knee pain.
Examination of the hip may reveal reduced ROM (especially loss of internal rotation on prone hip rotation with knees flexed) and pain on movement. Another diagnostic pitfall is that some patients present with mild pain and may only present with a mild limp with subtle external foot rotation or positive Trendelenburg test.