Synopsis
Recognise an adolescent proximal-femoral physeal slip from hip or referred knee symptoms, stop further displacement immediately and coordinate urgent in-situ stabilisation and contralateral surveillance.
- SUFE usually affects an adolescent and may present as isolated thigh or knee pain; always examine both hips when the knee findings do not explain the limp.
- The affected leg rests externally rotated and hip flexion produces obligatory external rotation with loss of internal rotation.
- Stable means the child can bear weight with or without crutches; unstable means they cannot, and the osteonecrosis risk is substantially higher.
- First-line imaging is bilateral AP pelvis plus frog-leg lateral views for a clearly stable slip; use a cross-table lateral rather than forced frog-leg positioning when unstable.
- Immediately make every suspected case non-weight-bearing and obtain same-day orthopaedic review; never ask the child to walk for diagnostic confirmation.
- First-line definitive treatment for most stable slips is percutaneous single-screw fixation in situ without intentional reduction.
- Unstable or severe slips require senior paediatric-hip planning; capsular decompression and any gentle reduction or open realignment are specialist decisions.
- Investigate atypical age or habitus for endocrine or renal disease and monitor the opposite hip until physeal closure.
Key red flags
An adolescent with hip, groin, thigh or unexplained knee pain and an out-turned foot has SUFE until adequate bilateral hip imaging excludes it.
Loss of weight-bearing ability, even with crutches, defines an unstable presentation and markedly increases osteonecrosis risk.
Obligatory external rotation as the hip flexes is a high-yield sign and should stop further provocative examination.
Acute pain after weeks or months of limp suggests an acute-on-chronic slip that can progress suddenly.
Presentation before age ten, after sixteen, with short stature or low body weight warrants endocrine or renal-bone investigation.
Persistent or new pain in the opposite hip requires immediate reassessment because bilateral disease is common.
Investigation priorities
Identify physeal widening, epiphyseal displacement, asymmetry and contralateral disease.
Management branches
An adolescent has compatible hip, thigh or knee pain, external rotation or limited internal rotation.
- Make the child strictly non-weight-bearing and use bed, trolley or wheelchair transfer.
- Give age- and weight-appropriate analgesia and document hip, knee and distal neurovascular findings without forceful motion.
- Obtain bilateral AP and stability-appropriate lateral radiographs and contact paediatric orthopaedics the same day.
- Use MRI for persistent pre-slip suspicion while maintaining protection; do not trial walking after normal films.
Imaging confirms a slip and the child could bear weight with or without crutches before assessment.
- Maintain non-weight-bearing until surgery and classify chronicity, severity and contralateral findings.
- Perform percutaneous single-screw in-situ fixation without intentional forceful reduction in the standard stable case.
- Confirm extra-articular screw position in multiple planes and give explicit postoperative loading instructions.
- Follow physeal closure, head-neck shape, chondrolysis, osteonecrosis and contralateral symptoms.