J R Soc Med 2002;95:356-358
doi:10.1258/jrsm.95.7.356
© 2002 Royal Society of Medicine
Delay in diagnosis of slipped upper femoral epiphysis
S Ankarath FRCS Ed (Tr & Orth)
A B Y Ng MRCS
P V Giannoudis BSc MD
B W Scott FRCS (Orth)
Department of Orthopaedic and Trauma Surgery, St James's University
Hospital, Beckett Street, Leeds LS9 7TF, UK
Correspondence to: Mr S Ankarath, 36 Lowfield Road, Beverley, North Humberside
HU17 9RE, UK E-mail:
sudhi56{at}bigfoot.com
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SUMMARY
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Treatment of slipped upper femoral epiphysis (SUFE) is directed
at
preventing progressive slippage, minimizing deformity and
avoiding avascular
necrosis and chondrolysis. Delay in treatment
adversely affects long-term
outcomes. In a retrospective study
we assessed delays between symptom onset
and evaluation of the
patient in an orthopaedic department. 27 patients aged
10-16
years were grouped by source of referral (general practitioner
or
accident and emergency department), and hips were classified
as stable or
unstable according to ability to bear weight.
The 27 children had 37 affected hips, 31 stable and 6 unstable. In the 20
patients referred by general practitioners, mean delay from symptom onset to
orthopaedic evaluation was 119 days (range 2-504); in the 7 referred from
accident and emergency departments it was 95 days (1-482). In the latter group
the slips were more likely to be acute and unstable. 9 (45%) of the patients
in the general-practitioner group had hip radiography before referral, all
correctly diagnosed though not all the examinations included the recommended
frog-lateral views.
Long delays between onset and diagnosis of SUFE are most likely in patients
with mild symptoms, able to bear weight on the hip. Any adolescent with
undiagnosed hip or knee pain that has lasted more than a week should undergo
radiological investigation of the hip, with frog-lateral as well as
anteroposterior views.
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INTRODUCTION
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Slipped upper femoral epiphysis (SUFE) is one of the common
causes of hip
pain in
adolescence
1. The
presentation is often
subtle and clinicians need to bear the condition
constantly
in mind. Untreated SUFE tends to progress, with increasing risk
of
hip deformity and osteoarthritis. Hence early diagnosis and
treatment is
essential for good long-term results. Yet long
delays still arise between
onset of symptoms and diagnosis.
We have examined the records of a
teaching-hospital orthopaedic
department to elucidate these delays.
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METHODS
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We examined the medical records and radiographs of all 30 children
who had
been treated surgically for SUFE in St James's University
Hospital, Leeds,
over the past 7 years. 3 children who were
referred from other hospitals were
excluded because we could
not determine the interval before presentation to
the initial
hospital. The slips were divided into stable and unstable
according
to the patient's ability to bear weight on the
hip
2. Patients
were
also grouped into acute (symptoms <3 weeks), chronic
(symptoms
3 weeks)
and
acute-on-chronic
1.
The degree of slip
was measured by calculating the head—shaft angle on a
lateral
radiograph and was graded as mild (<30°), moderate (30-50°)
or
severe
(>50°)
3
(
Figure 1). All measurements
were made
by the senior author to limit interobserver variation. Delay
in
diagnosis was recorded as the time from initial symptom to
evaluation by an
orthopaedic surgeon. All patients with SUFE
were treated in a standard manner
with a single percutaneous
in-situ pin
(
Figure 2). They were followed
up in paediatric
outpatient clinics with clinical and radiological assessments
until
the proximal femoral epiphysis fused. Any patient with complications
directly
related to the condition or its operative treatment was followed
up
for longer as indicated.
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Figure 1. Measurement of the extent of epiphyseal displacement on the lateral
radiograph. The degree of slip is reflected by the angle between the
perpendicular of a line drawn along the long axis of the femoral neck and a
line produced from the anterior to the posterior border of the epiphysis
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Figure 2. Anteroposterior radiograph showing mild slip of the right hip fixed with a
single percutaneous screw, and prophylactic fixation of the left hip
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The patients were put in two groups according to the source of primary
referral. Group 1 were direct orthopaedic referrals from a general
practitioner, either with a confirmed radiological diagnosis of SUFE or with a
history of hip or leg pain which proved on further evaluation in hospital to
be due to SUFE. Group 2 were patients who had their diagnosis confirmed after
presenting directly in the emergency department.
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RESULTS
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Of the 27 patients in groups 1 and 2, 17 were boys; mean age
of the
children was 12.8 years (range 10-16). 37 hips were affected.
The most common
presenting symptom was pain localized to the
hip region (14 children); in 10
children the first complaint
was of thigh discomfort and 3 others had knee
pain.
20 patients were originally seen by a general practitioner (group 1), 7 in
an emergency department. Table
1 shows the distribution of presentations and severity in these
two groups. In group 1 there was a higher proportion of stable or chronic
SUFE—perhaps because those with severe pain went directly to the
hospital emergency department. For 9 (45%) of the patients in group 1 the
diagnosis had already been confirmed radiographically at the time of referral;
in 4 the diagnosis had been made with anteroposterior views alone and in 5
with additional frog-lateral views. All 9 of these patients had stable slips.
The single patient in group 1 with an unstable hip (acute painful limp) was
referred urgently to hospital without radiography. In group 2 all patients had
radiographs when first seen.
In the general-practitioner group the mean time from onset of symptoms to
definitive diagnosis was 119 days (range 2-504, median 102). In group 2 it was
95 days (range 1-482, median 73). The mean delay between referral and
orthopaedic assessment was 5 days (range 3-8).
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DISCUSSION
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The initial symptoms of SUFE are often vague—an ache in
the thigh or
pain around the ipsilateral
knee
4. The fact
that,
in this study, delays in diagnosis were somewhat greater in
the
general-practitioner group probably reflects a tendency
for those with acute
pain to go direct to hospital. The final
outcome in SUFE is closely related to
delay in diagnosis and
the degree of the
slip
5,6;
and the severity of the slip is related
to the duration of
symptoms
7.
Cowell
5 described
poorer short-term
clinical results in those with delayed diagnosis, especially
a
delay of more than six months. For the general-practitioner
group in this
series, the mean delay of four months before evaluation
in an orthopaedic
department exceeds that reported by Green
et
al.
8 in the USA, but
clearly it will be influenced by the
proportion of acute and unstable cases.
It is satisfying that
in nearly half these cases the general practitioner sent
the
patient for radiography and thus established the correct diagnosis.
Other
general practitioners may have hesitated because of concern
about radiation
hazards in this age group.
This study clearly shows that there is still a delay in establishing the
diagnosis of SUFE in the community. We believe that obese older children and
young adolescents with hip, thigh or knee pain should have their hips examined
clinically and if there is any likelihood of SUFE, should undergo radiographic
assessment of both hips. Sometimes either the patient or the parents will
relate the onset of symptoms to some trivial trauma, and where soft-tissue
injury is suspected to be the cause of symptoms, there is an argument for
delaying radiological assessment for about two weeks provided there are no
clinical signs of SUFE. If the pain does not improve, a radiological
evaluation with anteroposterior and frog-lateral views of the hip is then
indicated. It is important to look for subtle signs of SUFE in a radiograph.
In a normal antero-posterior radiograph of the hip, a line drawn along the
upper border of the femoral neck should cut off a segment of the superior
epiphysis. In a minor slip, this line will skirt the superior margin of the
femoral epiphysis (Figure 3),
indicating postero-inferior displacement of the femoral epiphysis. Alertness
to the possibility of SUFE, in any adolescent with hip, thigh or knee pain,
will lead to earlier diagnosis and improve long-term outcomes.
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Figure 3. Minor slip. A line drawn along the upper femoral neck in an
antero-posterior radiograph does not cut off a segment of epiphysis on the
left side
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J R Soc Med,
January 9, 2002;
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[Full Text]
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