Is there still a delay in diagnosing slipped capital femoral epiphysis: a retrospective study in Jonkoping County, Sweden, over 18 years

Is there still a delay in diagnosing slipped capital femoral epiphysis: a retrospective study in Jonkoping County, Sweden, over 18 years | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Is there still a delay in diagnosing slipped capital femoral epiphysis: a retrospective study in Jonkoping County, Sweden, over 18 years Jonas Arntsberg, Bengt Herngren This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7805574/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: Slipped capital femoral epiphysis (SCFE) is one of the most common hip disorders in adolescents and often leads to serious long-term complications if not diagnosed early. In Sweden, SCFE has an incidence rate of approximately 4.4 per 10,000 girls and 5.7 per 10,000 boys. Delays in diagnosis, especially when symptoms present as knee pain, are frequent and increase the risk of irreversible joint damage. This study evaluated diagnostic delays and trends in Jonkoping County, Sweden, over 18 years. Methods: This retrospective study analysed all patients treated for SCFE in Jonkoping County between 2007 and 2024. The data collected included patient demographics, symptoms at first healthcare contact, time to diagnosis, and the kind of healthcare personnel involved in the initial consultation. The exclusion criteria included SCFE following infection or high-energy trauma, and patients who sought care outside Jonkoping County. Data were collected from medical records and the Swedish Pediatric Orthopaedic Quality Register. Results: A total of 38 patients, 11 girls and 27 boys, met the inclusion criteria. The majority of children presented with hip or groin pain, leading to a quicker diagnosis. However, delays were more prolonged in patients with atypical symptoms such as knee pain. The median time to diagnosis was 2.4 weeks (range 0–87.6 weeks) in the 2007–2013 cohort and improved to 1.3 weeks (range 0–43.4 weeks) in the 2018–2024 cohort. Conclusion: While the time to diagnosis has improved over time in Jonkoping County, a significant number of children still experience delays in diagnosis, particularly when presenting with atypical symptoms. Educational efforts to enhance the early recognition and diagnosis of SCFE are warranted. pediatric hip slipped capital femoral epiphysis slipped upper femoral epiphysis diagnostic delay Figures Figure 1 Figure 2 Figure 3 Background Slipped capital femoral epiphysis (SCFE) is one of the most common hip disorders in adolescents, and its incidence is increasing (1). It is more common among boys, even though the predominance has decreased over time (2-5). In Sweden, the incidence rate is approximately 4,4 out of 10,000 girls and 5,7 out of 10,000 boys (4), with the most common age being approximately 8–15 years (6). Obesity is associated with earlier disease onset, is a well-known risk factor, and is found in half of affected girls and 75% of affected boys (1, 4, 7). SCFE is a nontraumatic disease, and the most common initial symptoms are limping, groin pain, or thigh/knee pain. Clinical signs can include leg length discrepancy, decreased internal rotation of the hip, and reduced hip flexion (Drehmann sign) (4, 6, 8). The disease progresses until the proximal femoral physis is closed. Therefore, increased displacement will develop with time, with subsequent painful and reduced range of motion (9-11). A more significant displacement might also be associated with a greater risk of damage to posteriorly located retinacular blood vessels in the femoral neck and head, which might cause irreversible damage to the joint (12). Even though early diagnosis and treatment are essential, the time between the onset of symptoms and diagnosis is often too long due to both patient and healthcare professional delays. This is especially true for patients with knee pain instead of hip pain as the primary symptom (4, 11, 13-15). After a diagnosis is established, the standard treatment is in situ surgical fixation with a pin or a screw to prevent further dislocation and either prophylactic fixation of the contralateral hip or close monitoring with surgery as soon as a slip is detected (13, 16, 17). Because diagnosing and treating SCFE early is essential, this study aims to evaluate the degree of healthcare delay and whether there has been any improvement over time in our county. Hypothesis: As our null hypothesis, we assume that during the study period 2007-01-01 - 2024-12-31, no reduced time interval between the date of first contact with the healthcare system with symptoms related to SCFE and the date of diagnosis of SCFE will be observed . Neither will there be any difference in time to diagnosis depending on the type of symptoms presented. Methods This was a retrospective analysis of all patients who underwent primary surgery for SCFE in Jonkoping County, Sweden, between 2007-01-01 and 2024-12-31. The inclusion criterion was a Swedish personal identity number and age between 0 and 17 years at diagnosis. After a child has been diagnosed with SCFE in one hip (the index hip), the time delay for a possible subsequent slip of the contralateral hip is a dependent variable. For that reason, we limited the analysis to the time needed to diagnose SCFE for the index hip. The exclusion criteria were SCFE secondary to infection or high-energy trauma, and patients with primary contact with the health care system outside Jonkoping County. Patient data were collected from a scientific database with a total population of children in Sweden who were treated for SCFE between 2007 and 2013, with the regional board of Jonkoping County as the central authority responsible for personal data. For the patient group primarily treated from 2015 to 2024 in Jonkoping County, a dataset was obtained from the Swedish Pediatric Orthopaedic Quality Register (18) and compared with a data search in our local health data systems of Jonkoping County. Patients treated in 2014 in Jonkoping County were only identified through regional electronic health records. Age, sex, affected hip, date of first contact with the healthcare system, initial symptoms presented, the place and category of health care personnel who assessed the child during this first contact, and the surgery date were collected and analysed. When multiple symptoms were noted at first contact, we chose to include all patients with hip/groin pain in that group, even though the journal, in some cases, included concomitant thigh and knee pain as additional symptoms. The date of primary contact was set as the first physical visit. Since surgery is performed close to the established diagnosis (a maximum delay of 1–2 days), the date of diagnosis was set as the surgery date. Results From 2007 to 2024, 47 children underwent surgery for SCFE in Jonkoping County (Figure 1). Nine were excluded since they didn’t meet the inclusion criteria (n=7) or since we couldn’t get enough information (n=2). Among the included children, more boys than girls were diagnosed, and the boys were older. For both boys and girls, the left hip was more frequently affected (Table 1). Table 1: Demographic information. N=38 Gender Girls Boys Number 11 27 Age at first contact (years) Median (range) 12 (9-13) 14 (8-16) Right hip 5 8 Left hip 6 19 The time from first contact with the healthcare system to surgery ranged from the same day to 613 days. For ten children, the time to diagnosis took more than three months. Four children came to surgery within six months, four children within nine months, and for the remaining two children, it took respectively one year and eight months. Three of the ten children, with a delay to diagnosis of more than three months, presented with knee pain (including the one where it took the longest time), and the remaining seven had hip/groin pain. As shown in Figure 2, it took two weeks or more from the first contact with the healthcare system until diagnosis for a majority of the patients. In 27 out of the 38 analysed children, the symptoms presented were hip or groin pain (Table 2), with a shorter delay to diagnosis compared to children with other symptoms. Table 2: Clinical findings Symptoms Hip/groin pain Thigh pain Knee pain Strain pain/limping All Number 27 2 7 2 38 Delay in weeks Median (Range) 1.3 (0-43.4) 3.6 (0.1-7.1) 10.9 (0.6-87.6) 4.2 (1.9-6.6) 2.4 (0-87.6) Most children (n=33) had a primary health care unit as their place of first contact. Three individuals visited primarily the orthopaedic emergency reception; one was referred from the school health care facility, and one made the first contact at a private orthopaedic clinic. Most frequently, children were attended to by a doctor at the first contact (n=28). Eight met a physiotherapist, and two met a nurse. Regardless of the type of healthcare personnel the child attended, the time to diagnosis varied from the same day or the next day to several months. For the two cases in which a nurse first attended, it took 1.9, respectively, 11.4 weeks to diagnose. Figure 3 is a box plot that contains the time to diagnosis for all cases between the years 2007--2013 (period no. 1) and 2018--2024 (period no. 2), which are distributed into quartiles (where 25% of the cases are below the first quartile, 50% are below the second quartile and 75% are below the third quartile). Period no. 1 consists of 14 cases, and period no. 2 consists of 20 cases. One case for period no. 1 and two for period no. 2 are set as outliers and marked as dots above the rest. The first quartile is challenging to determine out of the figure, with 0.3 weeks for period no. 1 and 0.2 weeks for period no. 2. The third quartile is the upper limit of the colored boxes: 25.4 weeks for period no. 1 and 15.1 weeks for period no. 2. The shortest time to diagnosis for both periods was the same day (0.0 weeks). The longest time (except for the outliers) was 33.1 weeks for period 1 and 26.1 weeks for period 2, and is marked above the boxes with a transverse thin line. For period no. 1, the average time to diagnosis was 14.8 weeks, with a median time of 2.4 weeks (ranging from 0 weeks to 87.6 weeks). For period no. 2, the average time was 9.3 weeks, with a median time of 1.3 weeks (ranging from 0 weeks to 43.4 weeks). Discussion SCFE was more common among boys. However, it affects children growing up in a wide age range. The youngest patient was eight years old, and the oldest patient was 16. The girls were slightly younger, as expected, because of their earlier onset of puberty. The most frequent symptom was hip/groin pain, which also presented a shorter time to diagnosis. A few patients presented with symptoms, including knee pain, thigh pain, strain pain, or limping, which delayed the time to hip X-ray and diagnosis. A majority of the children were diagnosed with SCFE more than two weeks after their first contact with the healthcare system. However, the delay to diagnosis improved between 2018 and 2024 compared with 2007–2013. Most patients were attended to by their primary healthcare physician at first contact. For legal reasons, we were not authorised to assess health care records at local schools. Therefore, we do not know if the children mentioned their symptoms first to their school nurse or doctor, except for one child who was referred to his primary health care unit by the school doctor. The median age was in line with earlier studies (5, 7, 9, 11, 14, 15), and more boys than girls were affected (71% in our study), even though other studies did not find the same gender difference (54,8-65%) (7, 9, 10, 14, 15, 19). For many children, the delay was only one or two days until diagnosis was established. However, the medical charts revealed that slowly evolving pain without direct major trauma often led healthcare personnel to recommend expectant management rather than ordering an X-ray. Neither of the two children whom the nurse attended first were sent for X-rays immediately. This is most likely due to a lack of knowledge about SCFE and possibly also because nurses in Jonkoping County are not allowed to order a radiographic examination. Mathew D. Schur et al. reported that the average time was 17 weeks (range 0--169) in a sample of 481 patients between 2003 and 2012 (19). Kocher et al. reported a median delay of 8 weeks from the onset of symptoms to diagnosis in a sample of patients from 1988--2002 (10). A Swedish report by Örtengren et al., in which 54 patients in southern Sweden between 2001 and 2009 were studied, reported that the median time from symptom onset to diagnosis was 26 weeks, with a median doctors' delay of 4 weeks; however, a longer time was reported when the child presented with knee pain instead of hip pain (14). Perry et al. studied diagnostic delay just as we did. They reported that the diagnostic delay was a median of 2.86 weeks, with hip pain as a symptom; 23 weeks, with knee pain; and 3 weeks, with gait abnormalities, in 596 patients from 1990--2014 (15). The findings of these studies were somewhat similar to ours. However, since Swedish health care for children is free of charge, this might be one reason for our slightly shorter delay. Even though the delay to diagnosis and surgery for a majority of the children was more than two weeks, only one child experienced a delay of more than one year. One child contacted the primary health care unit after experiencing knee pain for some time. No X-ray of the hip was performed until the patient fell almost two years later, and the patient experienced subsequent escalating hip pain. The patient was sent for an X-ray that revealed SCFE, which was believed to be "acute on chronic" (20). The child underwent several subsequent surgical procedures, but owing to the development of avascular necrosis, a total hip replacement was performed two years later. This highlights the importance of further educating healthcare personnel, who will be the first to attend to these children. The two excluded children, whose information was incomplete, were diagnosed before the medical records were digitised. Conclusions The time to diagnosis improved during the study period. This is probably, to some extent, an effect of the digital medical record system, where referrals to X-ray and the orthopaedic clinic since September 2011 have been made directly in the medical record system instead of through a facsimile. However, a significant number of children still experience diagnostic delays, especially when they present with knee pain. Educational efforts, including revising guidelines used by healthcare workers in Jonkoping County, will be implemented soon, highlighting the disease and the importance of hip examination when knee pain is present in children. If abnormalities (decreased range of motion/pain) are found, an emergency X-ray is obligatory, including a frog leg lateral view (Lauenstein). If SCFE is found or suspected, the patient should be referred immediately to the orthopaedic emergency department. Limitations and strengths The main limitation of this study is the small number of children included. Another limitation is that we do not have access to medical records from the local school's health care. Therefore, we do not know whether the children mentioned their problems to anyone before contacting their primary health care unit or the emergency reception. A strength of this study is the long study period, with all patients in Jonkoping County included. Abbreviations SCFE – slipped capital femoral epiphysis Declarations Ethics approval and consent to participate For all patients included in this study from 2007 to 2013, ethical approval was received for this analysis from the Regional Ethical Review Board in Lund, with registration numbers 2013/87 and 2015/30. We applied for the group treated from 2015 to 2024 and received approval from the National Ethical Review Authority in Sweden with registration number 2019-05824. Following this application, we received subsequent consent, and a dataset was then obtained from the Swedish Pediatric Orthopaedic Quality Register (18). For all these patients, informed consent was obtained and documented in the medical records before registration in the corresponding database. In addition, we also received ethical approval from the National Ethical Review Authority in Sweden to include data from our regional electronic health records for children diagnosed with slipped capital femoral epiphysis from Jonkoping County during 2014, registration number 2025-04123-02. However, no informed consent was obtained for patients who were primarily treated for SCFE in Jonkoping County in 2014. The data are presented only at the group level so that no child can be identified, and there were no additional radiographs or control visits for the participants in this study population. Clinical trial number: not applicable Consent for publication – Received as specified under ethical approval. Availability of data and materials - The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request. Competing interests: The authors declare that they have no competing interests Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Futurum – Academy for Health and Care, Jonkoping County Council, Sweden. Authors' contributions: JA Study setup and design, collected and analysed the patient data and wrote the manuscript. BH Study setup and design, data analysis, and manuscript preparation. Both authors read and approved the final manuscript. Acknowledgements: Bo Rolander, statistician at Futurum – Academy for Health and Care, Jonkoping County Council, for helping create the figures. Authors' information (optional) References Castillo C, Mendez M. Slipped Capital Femoral Epiphysis: A Review for Pediatricians. Pediatr Ann. 2018;47(9):e377-e80. Hägglund G, Hansson LI, Sandström S. Familial slipped capital femoral epiphysis. Acta Orthop Scand. 1986;57(6):510-2. Hailer YD. Fate of patients with slipped capital femoral epiphysis (SCFE) in later life: risk of obesity, hypothyroidism, and death in 2,564 patients with SCFE compared with 25,638 controls. Acta Orthop. 2020;91(4):457-63. Herngren B, Stenmarker M, Vavruch L, Hägglund G. Slipped capital femoral epiphysis: a population-based study. BMC Musculoskelet Disord. 2017;18(1):304. Hansson LI, Hägglund G, Ordeberg G. Slipped capital femoral epiphysis in southern Sweden 1910-1982. Acta Orthop Scand Suppl. 1987;226:1-67. Peck DM, Voss LM, Voss TT. Slipped Capital Femoral Epiphysis: Diagnosis and Management. Am Fam Physician. 2017;95(12):779-84. Loder RT, Aronsson DD, Weinstein SL, Breur GJ, Ganz R, Leunig M. Slipped capital femoral epiphysis. Instr Course Lect. 2008;57:473-98. Bünger M, Rahbek O, Rölfing JD, Hansen AK, Hellfritzsch MB, Gottliebsen M. [Slipped capital femoral epiphysis (SCFE) - doctor's delay is still common]. Ugeskr Laeger. 2021;183(38). Rahme D, Comley A, Foster B, Cundy P. Consequences of diagnostic delays in slipped capital femoral epiphysis. J Pediatr Orthop B. 2006;15(2):93-7. Kocher MS, Bishop JA, Weed B, Hresko MT, Millis MB, Kim YJ, et al. Delay in diagnosis of slipped capital femoral epiphysis. Pediatrics. 2004;113(4):e322-5. Matava MJ, Patton CM, Luhmann S, Gordon JE, Schoenecker PL. Knee pain as the initial symptom of slipped capital femoral epiphysis: an analysis of initial presentation and treatment. J Pediatr Orthop. 1999;19(4):455-60. Bittersohl D, Bittersohl B, Westhoff B, Krauspe R. [Slipped capital femoral epiphysis: clinical presentation, diagnostic procedure and classification]. Orthopade. 2019;48(8):651-8. Herngren B, Stenmarker M, Enskär K, Hägglund G. Outcomes after slipped capital femoral epiphysis: a population-based study with three-year follow-up. J Child Orthop. 2018;12(5):434-43. Örtegren J, Österman J, Tiderius CJ. Patients' delay is the major cause for late diagnosis of slipped capital femoral epiphysis. J Pediatr Orthop B. 2021;30(2):105-10. Perry DC, Metcalfe D, Costa ML, Van Staa T. A nationwide cohort study of slipped capital femoral epiphysis. Arch Dis Child. 2017;102(12):1132-6. Mathew SE, Larson AN. Natural History of Slipped Capital Femoral Epiphysis. J Pediatr Orthop. 2019;39(Issue 6, Supplement 1 Suppl 1):S23-S7. Loder RT, Aronsson DD, Weinstein SL, Breur GJ, Ganz R, Leunig M. Slipped capital femoral epiphysis. Instr Course Lect. 2008;57:473-98. The Swedish Pediatric Orthopaedic Quality Register. https://spoq.registercentrum.se/. Assessed 20 May 2025 Schur MD, Andras LM, Broom AM, Barrett KK, Bowman CA, Luther H, et al. Continuing Delay in the Diagnosis of Slipped Capital Femoral Epiphysis. J Pediatr. 2016;177:250-4. Samelis PV, Loukas C, Kantanoleon S, Lalos H, Anoua N, Kolovos P, et al. Causes of Delayed Diagnosis of Slipped Capital Femoral Epiphysis: The Importance of the Frog Lateral Pelvis Projection. Cureus. 2020;12(4):e7718. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 29 Nov, 2025 Reviewers agreed at journal 22 Nov, 2025 Reviewers agreed at journal 19 Nov, 2025 Reviews received at journal 16 Nov, 2025 Reviewers agreed at journal 16 Nov, 2025 Reviewers invited by journal 11 Nov, 2025 Editor invited by journal 14 Oct, 2025 Editor assigned by journal 11 Oct, 2025 Submission checks completed at journal 11 Oct, 2025 First submitted to journal 08 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":30850,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7805574/v1/3965e960f0cc8cdf8d67e1de.png"},{"id":96490860,"identity":"19d9243b-37f5-42e4-951d-aee1d0372a67","added_by":"auto","created_at":"2025-11-21 17:48:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":13245,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eTime to diagnosis from first contact. w=weeks, m=months\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7805574/v1/815485842e5809be7c917d0c.png"},{"id":96603767,"identity":"3d8605df-607a-4745-b1e9-843308dc7564","added_by":"auto","created_at":"2025-11-24 09:11:29","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":28123,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eImproved time to diagnosis\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7805574/v1/f131c3e3419543313a9a82c7.png"},{"id":96607731,"identity":"2ef73a6c-65a8-45e5-a508-c29b2bd273ec","added_by":"auto","created_at":"2025-11-24 09:27:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":469001,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7805574/v1/703558c7-2695-4408-bf66-7e1958a249c6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Is there still a delay in diagnosing slipped capital femoral epiphysis: a retrospective study in Jonkoping County, Sweden, over 18 years","fulltext":[{"header":"Background","content":"\u003cp\u003eSlipped capital femoral epiphysis (SCFE) is one of the most common hip disorders in adolescents, and its incidence is increasing (1). It is more common among boys, even though the predominance has decreased over time (2-5). In Sweden, the incidence rate is approximately 4,4 out of 10,000 girls and 5,7 out of 10,000 boys (4), with the most common age being\u0026nbsp;approximately 8\u0026ndash;15 years (6). Obesity is associated with earlier disease onset, is a well-known risk factor, and is found in half of affected girls and\u0026nbsp;75% of affected boys (1, 4, 7).\u003c/p\u003e\n\u003cp\u003eSCFE is a nontraumatic disease, and the most common initial symptoms are limping, groin pain, or thigh/knee pain. Clinical signs can include leg length discrepancy, decreased internal rotation of the hip, and reduced hip flexion (Drehmann sign) (4, 6, 8).\u003c/p\u003e\n\u003cp\u003eThe disease progresses until the proximal femoral physis is closed. Therefore, increased displacement will develop with time, with subsequent painful and reduced range of motion (9-11). A more significant displacement might also be associated with a greater risk of damage to posteriorly located retinacular blood vessels in the femoral neck and head, which might cause irreversible damage to the joint (12).\u003c/p\u003e\n\u003cp\u003eEven though early diagnosis and treatment are essential, the time between the onset of symptoms and diagnosis is often too long due to both patient and healthcare professional delays. This is especially true for patients with knee pain instead of hip pain as the primary symptom (4, 11, 13-15).\u003c/p\u003e\n\u003cp\u003eAfter a diagnosis is established, the standard treatment is in situ surgical fixation with a pin or a screw to prevent further dislocation and either prophylactic fixation of the contralateral hip or close monitoring with surgery as soon as a slip is detected (13, 16, 17).\u003c/p\u003e\n\u003cp\u003eBecause diagnosing and treating SCFE early is essential, this study aims to evaluate the degree of\u0026nbsp;healthcare delay and whether there has been any improvement over time in our county. \u003cem\u003e\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/em\u003e\u003cstrong\u003eHypothesis:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs our null hypothesis, we assume that during the study period 2007-01-01 - 2024-12-31, no reduced time interval between the date of first contact with the healthcare system with symptoms related to SCFE and the date of diagnosis of SCFE will be observed\u003cem\u003e.\u0026nbsp;\u003c/em\u003eNeither will there be any difference in time to diagnosis depending on the type of symptoms presented.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp skip=\"true\"\u003eThis was a retrospective analysis of all patients who underwent primary surgery for SCFE in Jonkoping County, Sweden, between 2007-01-01 and 2024-12-31.\u003c/p\u003e\n\u003cp skip=\"true\"\u003eThe inclusion criterion was a Swedish personal identity number and age between 0 and 17 years at diagnosis. After a child has been diagnosed with SCFE in one hip (the index hip), the time delay for a possible subsequent slip of the contralateral hip is a dependent variable. For that reason, we limited the analysis to the time needed to diagnose SCFE for the index hip.\u003c/p\u003e\n\u003cp skip=\"true\"\u003eThe exclusion criteria were SCFE secondary to infection or high-energy trauma, and patients with primary contact with the health care system outside Jonkoping County.\u003c/p\u003e\n\u003cp skip=\"true\"\u003ePatient data were collected from a scientific database with a total population of children in Sweden who were treated for SCFE between 2007 and 2013, with the regional board of Jonkoping County as the central authority responsible for personal data. For the patient group primarily treated from 2015 to 2024 in Jonkoping County, a dataset was obtained from the Swedish Pediatric Orthopaedic Quality Register (18) and compared with a data search in our local health data systems of Jonkoping County. Patients treated in 2014 in Jonkoping County were only identified through regional electronic health records.\u003c/p\u003e\n\u003cp\u003eAge, sex, affected hip, date of first contact with the healthcare system, initial symptoms presented, the place and category of health care personnel who assessed the child during this first contact, and the surgery date were collected and analysed. When multiple symptoms were noted at first contact, we chose to include all patients with hip/groin pain in that group, even though the journal, in some cases, included concomitant thigh and knee pain as additional symptoms. The date of primary contact was set as the first physical visit.\u003c/p\u003e\n\u003cp\u003eSince surgery is performed close to the established diagnosis (a maximum delay of 1\u0026ndash;2 days), the date of diagnosis was set as the surgery date.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFrom 2007 to 2024, 47 children underwent surgery for SCFE in Jonkoping County (Figure 1). Nine were excluded since they didn\u0026rsquo;t meet the inclusion criteria (n=7) or since we couldn\u0026rsquo;t get enough information (n=2). Among the included children, more boys than girls were diagnosed, and the boys were older. For both boys and girls, the left hip was more frequently affected (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Demographic information. N=38\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eGirls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eBoys\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eAge at first contact (years)\u003c/p\u003e\n \u003cp\u003eMedian (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e12 (9-13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e14 (8-16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eRight hip\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eLeft hip\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe time from first contact with the healthcare system to surgery ranged from the same day to 613 days. For ten children, the time to diagnosis took more than three months. Four children came to surgery within six months, four children within nine months, and for the remaining two children, it took respectively one year and eight months. Three of the ten children, with a delay to diagnosis of more than three months, presented with knee pain (including the one where it took the longest time), and the remaining seven had hip/groin pain.\u003c/p\u003e\n\u003cp\u003eAs shown in Figure 2, it took two weeks or more from the first contact with the healthcare system until diagnosis for a majority of the patients. In 27 out of the 38 analysed children, the symptoms presented were hip or groin pain (Table 2), with a shorter delay to diagnosis compared to children with other symptoms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 2: Clinical findings\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eSymptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003eHip/groin pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eThigh pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eKnee pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eStrain pain/limping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eAll\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eDelay in weeks\u003c/p\u003e\n \u003cp\u003eMedian (Range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e1.3 (0-43.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3.6 (0.1-7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e10.9 (0.6-87.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e4.2 (1.9-6.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e2.4 (0-87.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u0026nbsp;Most children (n=33) had a primary health care unit as their place of first contact. Three individuals visited primarily the orthopaedic emergency reception; one was referred from the school health care facility, and one made the first contact at a private orthopaedic clinic. Most frequently, children were attended to by a doctor at the first contact (n=28). Eight met a physiotherapist, and two met a nurse. Regardless of the type of healthcare personnel the child attended, the time to diagnosis varied from the same day or the next day to several months. For the two cases in which a nurse first attended, it took 1.9, respectively, 11.4 weeks to diagnose.\u003c/p\u003e\n\u003cp\u003eFigure 3 is a box plot that contains the time to diagnosis for all cases between the years 2007--2013 (period no. 1) and 2018--2024 (period no. 2), which are distributed into quartiles (where 25% of the cases are below the first quartile, 50% are below the second quartile and 75% are below the third quartile). Period no. 1 consists of 14 cases, and period no. 2 consists of 20 cases.\u003c/p\u003e\n\u003cp\u003eOne case for period no. 1 and two for period no. 2 are set as outliers and marked as dots above the rest.\u003c/p\u003e\n\u003cp\u003eThe first quartile is challenging to determine out of the figure, with 0.3 weeks for period no. 1 and 0.2 weeks for period no. 2. The third quartile is the upper limit of the colored boxes: 25.4 weeks for period no. 1 and 15.1 weeks for period no. 2.\u003c/p\u003e\n\u003cp\u003eThe shortest time to diagnosis for both periods was the same day (0.0 weeks). The longest time (except for the outliers) was 33.1 weeks for period 1 and 26.1 weeks for period 2, and is marked above the boxes with a transverse thin line. For period no. 1, the average time to diagnosis was 14.8 weeks, with a median time of 2.4 weeks (ranging from 0 weeks to 87.6 weeks). For period no. 2, the average time was 9.3 weeks, with a median time of 1.3 weeks (ranging from 0 weeks to 43.4 weeks).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSCFE was more common among boys. However, it affects children growing up in a wide age range. The youngest patient was eight years old, and the oldest patient was 16. The girls were slightly younger, as expected, because of their earlier onset of puberty. The most frequent symptom was hip/groin pain, which also presented a shorter time to diagnosis. A few patients presented with symptoms, including knee pain, thigh pain, strain pain, or limping, which delayed the time to hip X-ray and diagnosis. A majority of the children were diagnosed with SCFE more than two weeks after their first contact with the healthcare system. However, the delay to diagnosis improved between 2018 and 2024 compared with 2007\u0026ndash;2013. Most patients were attended to by their primary healthcare physician at first contact.\u0026nbsp;For legal reasons, we were not authorised to assess health care records at local schools. Therefore, we do not know if the children mentioned their symptoms first to their school nurse or doctor, except for one child who was referred to his primary health care unit by the school doctor.\u003c/p\u003e\n\u003cp\u003eThe median age was in line with earlier studies (5, 7, 9, 11, 14, 15), and more boys than girls were affected (71% in our study), even though other studies did not find the same gender difference (54,8-65%) (7, 9, 10, 14, 15, 19).\u003c/p\u003e\n\u003cp\u003eFor many children, the delay was only one or two days until diagnosis was established. However, the medical charts revealed that slowly evolving pain without direct major trauma often led healthcare personnel to recommend expectant management rather than ordering an X-ray. Neither of the two children whom the nurse attended first were sent for X-rays immediately. This is most likely due to a lack of knowledge about SCFE and possibly also because nurses in Jonkoping County are not allowed to order a radiographic examination.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMathew D. Schur et al. reported that the average time was 17 weeks (range 0--169) in a sample of 481 patients between 2003 and\u0026nbsp;2012 (19). Kocher et al. reported a median delay of 8 weeks from the onset of symptoms to diagnosis in a sample of patients from 1988--2002 (10). A Swedish report by \u0026Ouml;rtengren et al., in which 54 patients in southern Sweden between 2001 and 2009 were studied, reported that the median time from symptom onset to diagnosis was 26 weeks, with a median doctors\u0026apos; delay of 4 weeks; however, a longer time was reported when the child presented with knee pain instead of hip pain (14).\u003c/p\u003e\n\u003cp\u003ePerry et al. studied diagnostic delay just as we did. They reported that the diagnostic delay was a median of 2.86 weeks, with hip pain as a symptom; 23 weeks, with knee pain; and 3 weeks, with gait abnormalities, in 596 patients from 1990--2014 (15). The findings of these studies were somewhat similar to ours. However, since Swedish health care for children is free of charge, this might be one reason for our slightly shorter delay.\u003c/p\u003e\n\u003cp\u003eEven though the delay to diagnosis and surgery for a majority of the children was more than two weeks, only one child experienced a delay of more than one year. One child contacted the primary health care unit after experiencing knee pain for some time. No X-ray of the hip was performed until the patient fell almost two years later, and the patient experienced subsequent escalating hip pain. The patient was sent for an X-ray that revealed SCFE, which was believed to be \u0026quot;acute on chronic\u0026quot; (20). The child underwent several subsequent surgical procedures, but owing to the development of avascular necrosis, a total hip replacement was performed two years later. This highlights the importance of further educating healthcare personnel, who will be the first to attend to these children.\u003c/p\u003e\n\u003cp\u003eThe two excluded children, whose information was incomplete, were diagnosed before the medical records were digitised.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe time to diagnosis improved during the study period. This is probably, to some extent, an effect of the digital medical record system, where referrals to X-ray and the orthopaedic clinic since September 2011 have been made directly in the medical record system instead of through a facsimile. However, a significant number of children still experience diagnostic delays, especially when they present with knee pain. Educational efforts, including revising guidelines used by healthcare workers in Jonkoping County, will be implemented soon, highlighting the disease and the importance of hip examination when knee pain is present in children. If abnormalities (decreased range of motion/pain) are found, an emergency X-ray is obligatory, including a frog leg lateral view (Lauenstein). If SCFE is found or suspected, the patient should be referred immediately to the orthopaedic emergency department.\u003c/p\u003e"},{"header":"Limitations and strengths ","content":"\u003cp\u003eThe main limitation of this study is the small number of children included. Another limitation is that we do not have access to medical records from the local school\u0026apos;s health care. Therefore, we do not know whether the children mentioned their problems to anyone before contacting their primary health care unit or the emergency reception.\u003c/p\u003e\n\u003cp\u003eA strength of this study is the long study period, with all patients in Jonkoping County included.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSCFE \u0026ndash; slipped capital femoral epiphysis\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eFor all patients included in this study from 2007 to 2013, ethical approval was received for this analysis from the Regional Ethical Review Board in Lund,\u0026nbsp;with registration numbers 2013/87 and 2015/30. We applied for the group treated from 2015 to 2024 and received approval from the National Ethical Review Authority in Sweden with registration number 2019-05824. Following this application, we received subsequent consent, and a dataset was then obtained from the Swedish Pediatric Orthopaedic Quality Register (18). For all these patients, informed consent was obtained and documented in the medical records before registration in the corresponding database. In addition, we also received ethical approval from the National Ethical Review Authority in Sweden to include data from our regional electronic health records for children diagnosed with slipped capital femoral epiphysis from Jonkoping County during 2014, registration number 2025-04123-02. However, no informed consent was obtained for patients who were primarily treated for SCFE in Jonkoping County in 2014. The data are presented only at the group level so that no child can be identified, and there were no additional radiographs or control visits for the participants in this study population.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Clinical trial number: not applicable\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Consent for publication \u0026ndash; Received as specified under ethical approval.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials - The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests:\u0026nbsp;The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eFunding:\u0026nbsp;The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Futurum \u0026ndash; Academy for Health and Care, Jonkoping County Council, Sweden.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions: JA Study setup and design, collected and analysed the patient data and wrote the manuscript. BH Study setup and design, data analysis, and manuscript preparation. Both authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: Bo Rolander, statistician at Futurum \u0026ndash; Academy for Health and Care, Jonkoping County Council, for helping create the figures.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; information (optional)\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eCastillo C, Mendez M. Slipped Capital Femoral Epiphysis: A Review for Pediatricians. Pediatr Ann. 2018;47(9):e377-e80.\u003c/li\u003e\n \u003cli\u003eH\u0026auml;gglund G, Hansson LI, Sandstr\u0026ouml;m S. Familial slipped capital femoral epiphysis. Acta Orthop Scand. 1986;57(6):510-2.\u003c/li\u003e\n \u003cli\u003eHailer YD. Fate of patients with slipped capital femoral epiphysis (SCFE) in later life: risk of obesity, hypothyroidism, and death in 2,564 patients with SCFE compared with 25,638 controls. Acta Orthop. 2020;91(4):457-63.\u003c/li\u003e\n \u003cli\u003eHerngren B, Stenmarker M, Vavruch L, H\u0026auml;gglund G. Slipped capital femoral epiphysis: a population-based study. BMC Musculoskelet Disord. 2017;18(1):304.\u003c/li\u003e\n \u003cli\u003eHansson LI, H\u0026auml;gglund G, Ordeberg G. Slipped capital femoral epiphysis in southern Sweden 1910-1982. Acta Orthop Scand Suppl. 1987;226:1-67.\u003c/li\u003e\n \u003cli\u003ePeck DM, Voss LM, Voss TT. Slipped Capital Femoral Epiphysis: Diagnosis and Management. Am Fam Physician. 2017;95(12):779-84.\u003c/li\u003e\n \u003cli\u003eLoder RT, Aronsson DD, Weinstein SL, Breur GJ, Ganz R, Leunig M. Slipped capital femoral epiphysis. Instr Course Lect. 2008;57:473-98.\u003c/li\u003e\n \u003cli\u003eB\u0026uuml;nger M, Rahbek O, R\u0026ouml;lfing JD, Hansen AK, Hellfritzsch MB, Gottliebsen M. [Slipped capital femoral epiphysis (SCFE) - doctor\u0026apos;s delay is still common]. Ugeskr Laeger. 2021;183(38).\u003c/li\u003e\n \u003cli\u003eRahme D, Comley A, Foster B, Cundy P. Consequences of diagnostic delays in slipped capital femoral epiphysis. J Pediatr Orthop B. 2006;15(2):93-7.\u003c/li\u003e\n \u003cli\u003eKocher MS, Bishop JA, Weed B, Hresko MT, Millis MB, Kim YJ, et al. Delay in diagnosis of slipped capital femoral epiphysis. Pediatrics. 2004;113(4):e322-5.\u003c/li\u003e\n \u003cli\u003eMatava MJ, Patton CM, Luhmann S, Gordon JE, Schoenecker PL. Knee pain as the initial symptom of slipped capital femoral epiphysis: an analysis of initial presentation and treatment. J Pediatr Orthop. 1999;19(4):455-60.\u003c/li\u003e\n \u003cli\u003eBittersohl D, Bittersohl B, Westhoff B, Krauspe R. [Slipped capital femoral epiphysis: clinical presentation, diagnostic procedure and classification]. Orthopade. 2019;48(8):651-8.\u003c/li\u003e\n \u003cli\u003eHerngren B, Stenmarker M, Ensk\u0026auml;r K, H\u0026auml;gglund G. Outcomes after slipped capital femoral epiphysis: a population-based study with three-year follow-up. J Child Orthop. 2018;12(5):434-43.\u003c/li\u003e\n \u003cli\u003e\u0026Ouml;rtegren J, \u0026Ouml;sterman J, Tiderius CJ. Patients\u0026apos; delay is the major cause for late diagnosis of slipped capital femoral epiphysis. J Pediatr Orthop B. 2021;30(2):105-10.\u003c/li\u003e\n \u003cli\u003ePerry DC, Metcalfe D, Costa ML, Van Staa T. A nationwide cohort study of slipped capital femoral epiphysis. Arch Dis Child. 2017;102(12):1132-6.\u003c/li\u003e\n \u003cli\u003eMathew SE, Larson AN. Natural History of Slipped Capital Femoral Epiphysis. J Pediatr Orthop. 2019;39(Issue 6, Supplement 1 Suppl 1):S23-S7.\u003c/li\u003e\n \u003cli\u003eLoder RT, Aronsson DD, Weinstein SL, Breur GJ, Ganz R, Leunig M. Slipped capital femoral\u0026nbsp;epiphysis. Instr Course Lect. 2008;57:473-98.\u003c/li\u003e\n \u003cli\u003eThe Swedish Pediatric Orthopaedic Quality Register. https://spoq.registercentrum.se/. Assessed 20 May 2025\u003c/li\u003e\n \u003cli\u003eSchur MD, Andras LM, Broom AM, Barrett KK, Bowman CA, Luther H, et al. Continuing Delay in the Diagnosis of Slipped Capital Femoral Epiphysis. J Pediatr. 2016;177:250-4.\u003c/li\u003e\n \u003cli\u003eSamelis PV, Loukas C, Kantanoleon S, Lalos H, Anoua N, Kolovos P, et al. Causes of Delayed Diagnosis of Slipped Capital Femoral Epiphysis: The Importance of the Frog Lateral Pelvis Projection. Cureus. 2020;12(4):e7718.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"pediatric, hip, slipped capital femoral epiphysis, slipped upper femoral epiphysis, diagnostic delay","lastPublishedDoi":"10.21203/rs.3.rs-7805574/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7805574/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003cbr\u003e\nSlipped capital femoral epiphysis (SCFE) is one of the most common hip disorders in adolescents and often leads to serious long-term complications if not diagnosed early. In Sweden, SCFE has an incidence rate of approximately 4.4 per 10,000 girls and 5.7 per 10,000 boys. Delays in diagnosis, especially when symptoms present as knee pain, are frequent and increase the risk of irreversible joint damage. This study evaluated diagnostic delays and trends in Jonkoping County, Sweden, over 18 years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003cbr\u003e\nThis retrospective study analysed all patients treated for SCFE in Jonkoping County between 2007 and 2024. The data collected included patient demographics, symptoms at first healthcare contact, time to diagnosis, and the kind of healthcare personnel involved in the initial consultation. The exclusion criteria included SCFE following infection or high-energy trauma, and patients who sought care outside Jonkoping County. Data were collected from medical records and the Swedish Pediatric Orthopaedic Quality Register.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A total of 38 patients, 11 girls and 27 boys, met the inclusion criteria. The majority of children presented with hip or groin pain, leading to a quicker diagnosis. However, delays were more prolonged in patients with atypical symptoms such as knee pain. The median time to diagnosis was 2.4 weeks (range 0–87.6 weeks) in the 2007–2013 cohort and improved to 1.3 weeks (range 0–43.4 weeks) in the 2018–2024 cohort.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003cbr\u003e\nWhile the time to diagnosis has improved over time in Jonkoping County, a significant number of children still experience delays in diagnosis, particularly when presenting with atypical symptoms. Educational efforts to enhance the early recognition and diagnosis of SCFE are warranted.\u003c/p\u003e","manuscriptTitle":"Is there still a delay in diagnosing slipped capital femoral epiphysis: a retrospective study in Jonkoping County, Sweden, over 18 years","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-21 17:48:45","doi":"10.21203/rs.3.rs-7805574/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-11-29T17:10:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"155989628364500762788963793350234357547","date":"2025-11-22T21:23:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"160414361551138935997989450598923418175","date":"2025-11-19T06:52:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-16T12:23:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"330022931559297366144888227403745657223","date":"2025-11-16T12:09:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-11T10:53:10+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-14T13:55:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-11T07:06:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-11T07:04:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-10-08T08:08:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3e7e8fc7-b83c-403e-87d6-d8a6fdaacb68","owner":[],"postedDate":"November 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-21T17:48:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-21 17:48:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7805574","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7805574","identity":"rs-7805574","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}