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

Main Category: Bones / Orthopaedics
Also Included In: Pediatrics / Children's Health;  Primary Care / General Practice;  Litigation / Medical Malpractice
Article Date: 13 May 2008 - 2:00 PST

email to a friend   printer friendly   view / write opinions   rate article

Delayed diagnosis of slipped upper femoral epiphysis (SUFE) can result in lifelong disability and medicolegal claims of more than £100,000, 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 £100,000, 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 £100,000, whilst those involving pain and cosmetic problems - invariably with an increased risk of osteoarthritis - settle at around £10,000-£60,000.

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.

http://www.mddus.com