Slipped Upper Femoral Epiphysis (SUFE)

SUFE. Hip disease in children. Undergraduate Orthopedic.

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 C oxa V ara -> 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 O n 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

11. DIAGNOSIS Diagnosis based on clinical examination and radiological investigations

12. 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

13. 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.

14. 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

15. 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

16. 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

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