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Slipped upper femoral epiphysis — MSRA MCQ

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ModerateHip and GroinSlipped upper femoral epiphysisMSRA

A 13-year-old boy presents with a 4-week history of intermittent left knee pain and a limp. During the past 48 hours he has developed increasing left groin pain and now avoids full weight-bearing. There has been no significant trauma, fever or preceding viral illness. He has obesity and is otherwise well. The knee is normal on examination. The left hip has painful restriction of internal rotation and flexion; when the hip is flexed, it externally rotates involuntarily. He is afebrile and systemically well. An anteroposterior pelvic radiograph performed at a minor injuries unit earlier today was reported as normal. What is the most appropriate next step?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Arrange same-day emergency orthopaedic assessment for suspected slipped upper femoral epiphysis

Explanation lettering: B = shown as A · C = shown as B · D = shown as C · E = shown as D · A = shown as E

This presentation is strongly suggestive of slipped upper femoral epiphysis (SUFE): an adolescent with obesity, progressive limp, referred knee pain despite a normal knee examination, groin pain and restricted hip internal rotation. Obligatory external rotation on hip flexion is a particularly concerning clinical sign. A normal anteroposterior pelvic radiograph does not safely exclude SUFE; slips may be subtle or better demonstrated on lateral imaging, but imaging should not delay urgent specialist assessment when clinical suspicion is high. D is therefore correct. Suspected SUFE is an orthopaedic emergency because further displacement can compromise femoral-head blood supply and worsen long-term outcome. A is inappropriate because physiotherapy could delay definitive assessment of an unstable physeal injury. B is tempting because transient synovitis can follow viral illness and cause limp, but the age, obesity, several-week course and rotational restriction make SUFE more likely. C may identify an effusion but does not exclude or diagnose SUFE and would delay the required referral. E is unsafe because persistence is not required before escalation where SUFE is suspected.

Reference: NHS: Limping in children (2024) — https://www.nhs.uk/symptoms/limp-in-children/ Right Decisions: MSK physiotherapy referral guidance (accessed August 2026) — https://www.rightdecisions.scot.nhs.uk/borders-ref-help-toolkit/physiotherapy/msk-physiotherapy/msk-physiotherapy/