Slipped upper femoral epiphysis (SUFE), although a relatively rare condition, poses serious health issues for adolescents affected by it. It can affect young people during one of the most crucial stages of their growth, potentially leaving them with long-term damage to their mobility if it is not treated correctly.

As such, understanding its key symptoms is crucial, as early detection and treatment can significantly impact your child's outcome. In this blog post, we will highlight the basics of SUFE and its symptoms and risk factors, and explain why it is so important to ensure that this condition is identified as soon as possible. If the condition is misdiagnosed, you may be able to make a claim for compensation.

What is slipped upper femoral epiphysis?

SUFE, also known as slipped capital femoral epiphysis (SCFE), is a condition that affects the hip joint, where the ball at the head of the femur (thigh bone) slips off the neck of the bone in a backward direction. This slippage usually happens gradually, resulting from weakness in the proximal femoral growth plate, and is often related to adolescent growth spurts.

As such, SUFE is the most common hip disorder in adolescents, primarily affecting children between 10 and 16 years of age. According to the NHS, there are around 10.8 cases of slipped capital femoral epiphysis for every 100,000 children, with the typical age of onset being 11 to 12 in girls and 12 to 13 in boys.

SUFE cases are not usually caused by an injury, but instead develop over time. Usually, a SUFE is classified as:

• Stable - a stable SUFE causes some stiffness or pain in the knee or groin area, and may result in a limp that causes a child to walk with a foot outward. The pain and limp may come and go, and will often feel worse with activity, but should subside with rest. With a stable SUFE, a child can still walk (sometimes with crutches) but may experience discomfort. 
• Unstable - unstable SUFEs are more severe conditions that occur suddenly, resulting in greater pain. A child will not be able to walk on the affected side, and the SUFE may restrict blood flow to the hip joint, leading to tissue death in the ball of the joint. 

What are the symptoms of SUFE?

The symptoms of SUFE can initially be subtle, often dismissed as growing pains or the aftermath of a minor injury. However, they become more noticeable as the condition progresses.

• Limping - the first sign of SUFE is usually a limp, often without any accompanying pain. The child may walk with a limp to avoid putting weight on the hip or knee area. This limp can be more pronounced after physical activities, or at the end of the day.
• Pain - the child may experience pain in their hip, but it can also spread to their groin, thigh or knee. This referred pain, particularly in the knee, can sometimes cause confusion in diagnosis, as the problem may initially seem to originate elsewhere in the leg. The pain associated with SUFE can vary from mild to severe, and is often exacerbated by physical activity.
• Restricted mobility - over time, the affected leg may turn outwards, and the child may have difficulty moving the hip, particularly in bending and rotating it. The range of motion of the affected hip can be less than that of the unaffected hip.
• Unequal leg length - in some cases, the affected leg may appear shorter due to the slippage of the femoral head. However, this symptom is more commonly observed in advanced cases of SUFE.

If you spot these symptoms in your child, they should not be ignored. It is imperative to seek immediate medical attention, as early diagnosis of SUFE can significantly improve the prognosis and reduce the risk of long-term complications.

What causes SUFE and its risk factors?

While the exact cause of SUFE is unknown, it is recognised that the condition tends to occur during periods of rapid growth, such as during puberty, when the body undergoes significant changes. The fast growth of the femoral head compared to the slower maturing growth plate might make the area vulnerable to slippage.

In addition, certain factors have been identified that increase a child's risk of developing SUFE. These include:

• Age and sex - the age range with the highest incidence of SUFE is between 10 and 16 years old, coinciding with the typical timing of the adolescent growth spurt. It has also been observed that SUFE is more common in boys than girls.
• Obesity - overweight children are at a higher risk of developing SUFE. The excess weight can put extra pressure on the hip joint, potentially leading to the slippage of the femoral head.
• Hormonal imbalances - certain medical conditions that result in hormonal imbalances, including endocrine disorders like hyperthyroidism or growth hormone treatment, can put a child at a higher risk of SUFE. Children with chronic illnesses such as kidney disease, which can also disrupt the balance of hormones, may also be at an increased risk.
• Radiation or chemotherapy - children who have undergone radiation therapy to the pelvis or chemotherapy are at an increased risk of SUFE.
• Family history - children with a history of SUFE in their family are at greater risk of also developing the condition.

Understanding these risk factors allows for better preventive strategies and vigilance in monitoring children who may be more susceptible to SUFE. As such, it is vital for the child's doctor to consider their complete medical history to determine whether or not they might be at greater risk.

How should SUFE be treated?

Once a diagnosis of SUFE is made, treatment is required without delay to prevent further slippage and reduce the risk of complications. The main goal of treatment is to stabilise the position of the femoral head and restore the normal alignment of the hip joint. The approach to treatment depends on the severity of the slip and the child's overall health.

• Pre-surgical management - once SUFE has been initially diagnosed, the child will need to avoid putting weight on the affected leg, using crutches or a wheelchair to move around, to ensure that no further damage is done before surgery can be performed.
• Surgical treatment - surgery helps to prevent further slippage by securing the femoral head in its current position. There are two main types of surgical interventions:
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• Post-surgical care - after surgery, the child will usually need to use crutches or a wheelchair for a while, until they can walk without pain. Regular follow-up appointments will be necessary to check the position of the femoral head and ensure the hip is healing correctly. Physical therapy is often recommended to strengthen the muscles around the hip and restore range of motion.
• Treatment of the other hip - if SUFE occurs on one side, there is an elevated chance that it will affect the other side as well. As a preventive measure, some doctors may suggest stabilising the unaffected hip with in-situ pinning, particularly in children who have not yet gone through puberty.

It is crucial to remember that early diagnosis and prompt treatment of SUFE can significantly improve the child's prognosis and reduce the risk of long-term complications, such as hip deformity and early-onset arthritis. Therefore, any child presenting with hip, groin, thigh or knee pain should be evaluated promptly by a healthcare professional, especially if they have one or more risk factors for SUFE.

The dangers of misdiagnosing or failing to spot SUFE symptoms

SUFE is a serious condition that requires immediate attention. One of the inherent challenges with SUFE is that it can easily be mistaken for more common and less severe conditions, such as a sprain or growing pains, particularly as the initial symptoms may be subtle.

Misdiagnosing or failing to diagnose SUFE can have severe consequences, as the condition can progress without proper treatment. Here are some of the main risks associated with a delayed diagnosis or misdiagnosis:

1. Further slippage - if SUFE is not promptly diagnosed and treated, the femoral head can continue to slip, potentially leading to more severe slips. This can cause significant deformity and disability, requiring more complex surgical intervention.
2. Hip deformity - a delay in diagnosis can lead to irreversible changes in the shape of the child's hip joint, resulting in hip deformity. This may lead to a limp or difference in leg lengths, affecting the child's mobility and quality of life.
3. Decreased range of motion - the longer the condition goes untreated, the more it can impact the range of motion in the hip. This can result in stiffness and difficulty moving the hip joint, which can impact everyday activities such as walking, running and even sitting.
4. Avascular necrosis - this is one of the most serious complications of a misdiagnosed or untreated SUFE. Avascular necrosis occurs when the blood supply to the femoral head is disrupted, causing the bone tissue to die. This can lead to the collapse of the femoral head, causing severe pain and disability.
5. Early-onset arthritis - chronic hip pain and early-onset arthritis are potential long-term consequences of a delayed diagnosis of SUFE. The abnormal positioning of the hip joint can increase wear and tear, leading to premature degenerative changes.
6. Psychological impact - the physical complications of misdiagnosed SUFE can have significant psychological implications too. Reduced mobility, chronic pain and physical deformity may lead to emotional distress, impacting the child's self-esteem and mental health.

Therefore, it is crucial that healthcare professionals are vigilant in monitoring for SUFE in children and adolescents presenting with hip, thigh or knee pain. By being proactive in carrying out a physical examination and ensuring that patients are treated early, they can significantly improve outcomes and help prevent these serious complications.

Can you claim compensation for a SUFE misdiagnosis or delayed diagnosis?

If a medical professional has failed to diagnose SUFE, or there has been a significant delay in diagnosis, it might be possible to make a claim for medical negligence. For a claim to be successful, it needs to be demonstrated that the healthcare provider failed to deliver the standard of care reasonably expected and that this directly resulted in harm or a worse outcome for the patient.

If you suspect that your child's SUFE was misdiagnosed or not diagnosed quickly enough, it's essential to consult with a medical negligence solicitor who can evaluate your case and guide you through the process of making a claim.