Edition 65 - 2017, September / Images

Images in Pediatric Endocrinology: BILATERAL SLIPPED CAPITAL FEMORAL EPIPHYSIS – Ed. 65

Betty Rubio, Flor Soto y Noelia Dujovne

Servicio de Endocrinología. Hospital de Pediatría Juan. P Garrahan, Buenos Aires, Argentina

im65a

  1. At left, in bilateral displacements of the capital femoral over the growth plate is observed with discrete widening of both femoral necks, left predominance.
  2. Dislocation of the left hip – General decreased of bone density

Clinical Case

This is a 13-year-old boy, born at term with adequate weight for gestational age. At 12 year, 11 months of age, after a diagnosis of bilateral slipped capital femoral epiphysis was made. He required surgical correction (hip osteotomy and fixation with right hip pins). Unfortunately, follow up was not favorable and he was admitted again because of left hip luxation. Weight 53 Kg (0.85 SD), Height 141 cm (-1.27 SD, BMI 26.6 (Z >+2). Because of his obesity, he was then referrer to the Nutrition and to the Endocrinology Services of Hospital de Pediatria Garrahan. At initial physical examination, we observed a prostrate patient with a blunt fascies, and myxedema with significant generalized xerosis. The thyroid gland was firm at palpation, but no cervical adenopathy was detected. Axilarche was absent. Tanner´s sexual development was as follows: VP1 and G2. Scrotal testes had 8+/10 ml.
Since clinical signs, strongly suggested severe hypothyroidism the following laboratory worked up was ordered:
Results show Severe Primary Hypothyroidism secondary to autoimmnunity, as well as hypercholesterolemia and anemia (Tables).
He also had normal serum ACTH, as well as pre-pubertal serum gonadotropins and testosterone, compatible with the clinical findings. Testis volumes, however, were increased, as reported in macro-orchidism secondary to hyper-thyroidotropinism without virilization.
In order to complete studies in this patient with severe hypothyroidism and bilateral hip epiphysiolysis we ordered the following:
im65b

  • Cardiologic evaluation:  anteroposterior pericardial effusion Grade II.
  • Thyroid gland: global decrease in size, both thyroid lobes and isthmus with defused ultrasound structure, without vascularization (doppler color). Testis ultrasound showed two scrotal testes of normal prepubertal size, and normal epididymis. Right testis: 2.5 x 1.3 x 2 cm; Volume 3.6 cc and left testis 1.7 x1.8 x 2.7 cm. volume 4.5 cc.
  • Bone age: 7 years, 6 months (5 years below chronological age).
  • Surgical intervention was postponed until normalization of thyroid function, anemia, and metabolic profile. Patient received 48 h. methyl-prednisolone followed by levothyroxine supplementation. Levothyroxine dose was gradually increased until euthyroidism was reached. Definitive surgical correction of hip displacement was then carried out. One month later, patient was finally discharged. Outpatient control recommendation was indicated.

Comments

Slipped capital femoral epiphysis (SCFE) is a hip condition that occurs in teens and pre-teens who are still growing. For reasons that are not well understood, the ball at the head of the femur (thighbone) slips off the neck of the bone in a backward direction. This causes pain, stiffness, and instability in the affected hip. The condition usually develops gradually over time and is more common in boys than in girls.

Hip epiphysiolisis (slipped capital femoral epiphysis, SCFE) is the gradual and rotative pathologic displacement of the growth plate in the proximal femur epiphysis (1) The average age of presentation is 13,5 years in boys and 12 years in girls (2). It is more common in boys and it is associated with overweight and hypothyroidism (3).

Thyroid hormones play a fundamental role, direct and indirect, in bone metabolism and healing (4). T3 acts in the process of chondrocyte maturation in the growth plate, and it also has an important role in the interstitial matrix favoring the synthesis of type II collagen (5). In a review of 85 patients with SCFE, a statistically significant increase in the prevalence of bilateral presentation (61%) was reported in patients with endocrine disorders, comparing with those without endocrinopathies (37%) (6).

Several reports suggest that thyroid disorders should be screened in patients with atypical presentations, such us below 10 years or above 16 years of age, bilateral SCFE, and stunted growth (1, 6, 7. 8). Moreover, severe hypothyroidism favors delays in healing and lack of joint union. Adequate treatment and euthyroidism favour a favorable clinical evolution. These patients should be diagnosed early, and furthermore, they should be managed by an interdisciplinary team.

BIBLIOGRAPHY:

  1. Moyer J. Slipped capital femoral epiphysis and associated hypothyroidism. A review of the literature with two classic case examples. J Pediatr Endocrinol Metab 2016
  2. Loder RT. The demographics of slipped capital femoral epiphysis. An international multicenter study. Clin Orthop 1996; 322:8-27
  3. Mann D. Endocrine disorders and orthopedic problems in children. Current opinion in pediatrics 1996; 8:68-70
  4. Gogakos AI, Duncan Bassett JH, Williams GR. Thyroid and bone. Arch Biochem Biophys 2010; 503:129–36.
  5. Loder RT, Wittenberg B, DeSilva G. Slipped capital femoral epiphysis associated with endocrine disorders. J Pediatr Orthop 1995; 15:349–56.
  6. Heyerman W, Weiner D. Slipped epiphysis associated with hypothyroidism. J Pediatr Orthop 1984; 4:569–73.
  7. Razzano CD, Nelson C, Eversman J. Growth hormone levels in slipped capital femoral epiphsys. J Bone Joint Surg Am 1972;54:1224–1229.
  8. McAfee PC, Cady RB. Endocrinologic and metabolic factors in atypical presentations of slipped capital femoral epiphysis. Report of four cases and review of the literature. Clin Orthop 1983;180:188–97

Posted in Edition 65 - 2017, September, Images
Previous Editions
Images
Instructivo para mandar imágenes
CLICK AQUI
RSS Feed