Introduction
Slipped upper femoral epiphysis (SUFE) is an important adolescent hip disorder encountered in orthopaedic surgical practice.1 2 SUFE can be categorised as a Salter-Harris type fracture,3 characterised by the slippage of the proximal femoral metaphysis anteriorly and superiorly relative to the epiphysis.4 The epiphysial plate is usually widened due to the presence of an unusually large hypertrophic zone. This increased area of hypertrophy effects the normal cartilaginous architecture, making it less organised and can result in weak areas, where slippage can occur.5 6
On history and clinical examination, the signs and symptoms of SUFE include hip pain with potential radiation to the knee, shortening of the affected limb, pain on internal rotation and an antalgic, out-toeing gait.2 It has an overall incidence of 10.8 per 100 000, though this may be higher in African-American and Hispanic cohorts.2 7 8
SUFE has become increasingly prevalent in the last decade due to the epidemic of obesity and the associated incline in the number of children who fall into the 95th percentile of their weight category.9 Traditionally, the age of presentation with SUFE was in children between 10 and 16 but over the last decade, the average age of presentation has dropped; this has been theorised to be associated with the faster maturation of children in modern society.8 There may or may not be a history to trauma.
SUFE is often suspected with the presentation of an acutely limping child and this diagnosis is often confirmed with clinical examination and X-ray.10 An accurate diagnosis combined with immediate treatment is critical to prevent complications such as avascular necrosis.11 Despite explanations of the condition and its treatment provided by the orthopaedic surgeon caring for the child, many fearful parents will turn to the internet as a ‘quasi-second opinion’.12 Previous studies have shown that 93% of parents in Canada will have consulted the internet about their child’s symptoms before they have even presented to the emergency department.13 14 Thus, it is of the upmost importance that the information on the internet be as inclusive and accessible to parents as possible to ensure adequate health literacy.
Health literacy is defined as the ‘ability to interpret and understand basic information with such competence as to be able to apply the information to the enhancement of health’.15 Poor standards of health literacy is associated with higher inpatient hospital service utilisation,16 increased postoperative complications,17 reduced postoperative compliance with rehabilitation,18 missed appointments and lower patient satisfaction.19 The key to improving health literacy is to ensure that health consumers have the ability to understand the materials available to them.20
According to the United States Department of Health and Human Services (USDHSS), the average American reads at an eighth grade level or lower.20 21 Previous USDHSS reports state that over 88% of Americans having a level of health literacy that is incompatible with understanding the surgical management of orthopaedic pathologies such as SUFE, resulting in negative postoperative outcomes and high economic costs.21–23 To encourage inclusivity and accessibility, the USDHSS has recommended that health education material be written at a reading grade level (RGL) of no higher than the sixth grade.23 24 However, previous studies have shown that this level is frequently exceeded, resulting in negative health outcomes.20 23–27
Based on our literature search, we have not found any previous study which has sought to determine the accessibility of information about SUFE on the internet. The aim of this study, therefore, was to assess the readability of information of the internet using specific readability scoring systems and to determine the RGL of each website analysed. Considering that modern society is multicultural, we also noted the presence or absence of translation services on each website.