Childhood and Adolescent Pathology Series Part 2 – Hip Pain

In today’s blog we’re going to look into some of the hip pathologies seen in children and adolescents. Specifically, we will focus on two hip pathologies that can present similarly, in Perthes disease and Slipped Upper Femoral Epiphysis or SUFE for short. Let’s take a dive into how these conditions usually present, and identify some similarities and differences.

Perthes Disease

Perthes disease is an idiopathic pathology that affects children in the 4-10 year age range, with boys five times more likely to be diagnosed than girls. It occurs due to a disruption of blood flow to the head of the femur (thigh bone). The lack of blood flow to this area causes bone cell death (called avascular necrosis) which results in changes to the shape of the femoral head. It is important that this condition is caught as early as possible as this will help to reduce the degree to which the femoral head changes shape – an important consideration, as severe morphological changes can lead to increased osteoarthritis risk in adulthood. Having said this, most of those diagnosed with Perthes disease will have a full recovery without significant consequences later in life.

Signs and symptoms include:

• pain in the hip, groin and/or knee,
• having a limp during walking or an altered running style,
• having a shorter affected leg, and
• limited range of motion of hip.

Often, knee pain can be one of the only symptoms of Perthes disease and as such it is often misdiagnosed initially. Once accurately diagnosed, treatment is mostly straight forward as the disease is usually self limiting. Depending on the severity of the case, most children will have activity modifications in place (i.e. reduced impact) and frequent check-ups with their physician to make sure things are progressing in the right direction. For those who have severe femoral head changes, surgery may be an option.

So Perthes Disease is hip pain that affects a younger demographic, let’s look at another hip pathology that presents similarly but affects those who are a little older.

Slipped Upper Femoral Epiphysis

Slipped Upper Femoral Epiphysis (SUFE) occurs when there is a ‘slipping’ of the femoral head off the neck of the femur. This occurs through the weaker growth plate area that we’ve talked about in the first blog in this series. SUFE’s usually affect boys more than girls (around 2.5 times) in the 10-14 year age range, although it can occur anywhere from 9-16 years old. Most often the person with a SUFE will be overweight or very tall for their age. This seems to be related to the increased relative load travelling through the growth plate in these cases which leaves the young person more susceptible to a slip. As there can be quite a significant shift or slip, blood flow to the head of the femur can be disrupted and result in avascular necrosis (as was the case in Perthes Disease) and as such, it is important to have timely referral and treatment.

Signs and Symptoms of a SUFE include:

• Walking with a limp
• Walking with the toes pointed out
• Insidious onset of pain in hip, groin and/or knee
• Note: in some cases, there can be an acute incident causing sharp pain in the hip
• Limited range of movement of the hip

As with Perthes, knee pain can often times be the only symptom of a SUFE so it is important to get a thorough assessment in order to diagnose and address the problem. If the provisional diagnosis of a SUFE is made, it is important you seek further medical attention promptly in order to get X-ray confirmation. Due to the risk of avascular necrosis, surgery is usually opted for in order to pin the head of the femur safely in place. As the chances of a SUFE happening bilaterally is quite high, it is also common for the other side to be prophylactically pinned even if it does not show signs or symptoms of a SUFE at that time. Prognosis for a SUFE is dependent on severity and potential loss of blood flow, with the likelihood of osteoarthritis or other hip related morphology issues increasing with the degree of change.

As you can see, these two hip pathologies present quite similarly. They are often delayed in their diagnosis due to the issue masquerading as knee pain. Accurate and timely diagnosis is important in reducing the complications both short and long-term. In the next blog, we will look into some other common pathologies that also affect other growth plates in the lower limbs.