SUFE (Slipped Upper Femoral Epiphysis) - Delay In Diagnosing "Can Be Devastating"

Delayed diagnosis of slipped upper femoral epiphysis (SUFE) can result in
lifelong disability and medicolegal claims of more than ВЈ100,000, according
to a report in the latest (Spring 2008) edition of Summons, the magazine of
MDDUS, The Medical and Dental Defence Union of Scotland.


The condition occurs in up to seven individuals per 100,000 and, as such, is
likely to be encountered once or twice in any one GP's career, says Jamie
MacLean, who as lead consultant at Tayside Children's Orthopaedic Service
provides expert reports for MDDUS.


A 2.5 fold increase in the incidence of SUFE has been recently reported,
with a suggested link to the growing problem of childhood obesity, says Mr
MacLean.


SUFE persists as a regular source of medicolegal claims, often in excess of
ВЈ100,000, adds Dr Rob Hendry, a medicolegal adviser at MDDUS. Claims are
unusual but regularly encountered. "Every year we usually see one or two
cases. Where the outcome can be so devastating, it's one or two too many.


"In the practice of medicine there are relatively few conditions in which an
early diagnosis can make a radical difference to the outcome for a patient.
SUFE is one of them. Miss it, and both patient and doctor can live to regret
it. GPs should have a high index of suspicion when it comes to SUFE-like
symptoms."


SUFE occurs typically among children aged between 10 and 16, in twice as
many boys as girls. However, there has been an increase in children as young
as eight presenting with SUFE, and when it occurs at this age, bilateral
disease is more common. SUFE tends to affect obese children, but may also
occur in tall thin individuals.


Conditions associated with increased risk of SUFE in children include a
previous slip on the other side, hypothyroidism, hypogonadism,
panhypopituitarism, primary and secondary hyperparathyroidism and growth
hormone deficiency. Children on steroids, or undergoing chemotherapy or
radiotherapy, may also be at increased risk of SUFE.


SUFE can be 'silent' and painless with deformity developing slowly over
months. Usually the onset of symptoms is insidious. When they follow sport
they can easily be incorrectly attributed to muscle strain.


Most patients have hip or groin pain, but a fifth of patients report
isolated knee or thigh pain, and these are particularly at risk of
misdiagnosis.


"SUFE is a condition that progresses and so it's important to recognise any
increase in the severity of symptoms or signs," says Mr MacLean.


Pain on weight bearing is an important symptom. In five to 10 per cent of
cases the condition can become rapidly progressive, as reflected by an
inability to weightbear. Such cases represent a genuine surgical emergency.
The outcome in this subgroup is invariably very poor unless referred for
treatment immediately.


"Unfortunately, delay in diagnosis occurs both in general practice and
hospital and can have a devastating effect on the outcome - a disabled
adolescent being the end result," says Mr MacLean. Early diagnosis enables
uncomplicated surgical intervention with the expectation of a near to normal
outcome. If misdiagnosed, "individual cases make sad reading, with major
impacts on patients' lives and, indeed, attitudes to life and work," says Mr
MacLean.


Common pitfalls leading to claims include failure to consider the diagnosis,
failure to examine the hip, being falsely reassured by a previous "normal"
X-ray and failing to appreciate the urgency of referral. In this age group
hip, groin, distal thigh or knee pain should always be regarded as a
potential SUFE. Indeed, any child complaining of knee pain in whom the knee
examination is normal should be regarded as a case of SUFE until proven
otherwise.


The loss of earnings potential in patients who cannot pursue their intended
careers subsequent to SUFE accounts for those cases which settle for over
ВЈ100,000, whilst those involving pain and cosmetic problems - invariably
with an increased risk of osteoarthritis - settle at around ВЈ10,000-ВЈ60,000.


MDDUS is a medical defence organisation providing access to
professional indemnity and expert medicolegal advice for doctors, dentists
and other healthcare professionals throughout the UK.


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