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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 2  |  Issue : 2  |  Page : 117-119

Slipped capital femoral epiphysis in a healthy 5-year-old child: A case report and literature review


1 Department of Surgery, Division of Orthopedic Surgery, McGill University, Canada; Department of Orthopedic Surgery, University of Dammam, Dammam, Kingdom of Saudi Arabia
2 Department of Surgery, Division of Orthopedic Surgery, McGill University, Canada

Date of Web Publication18-Jul-2014

Correspondence Address:
Saad M Al Qahtani
McGill University Health Centre, C9.173 Montreal General Hospital, 1650 Cedar Avenue, Montreal, Quebec, H3G 1A4, Canada

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DOI: 10.4103/1658-631X.137009

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  Abstract 

Slipped capital femoral epiphysis (SCFE) is an adolescent hip disorder of increasing prevalence, particularly within patients aged younger than 10 years. When present in these younger patients, SCFE is usually associated with metabolic abnormality or endocrinopathy. We present a case of a 5-year-old boy with idiopathic SCFE who underwent staged bilateral pinning in situ using a uniquely modified smooth wire for fixation across the physis. He eventually required bilateral screw revision after outgrowing the initial screws. At follow-up 3 years later, the patient was pain free with satisfactory hardware placement. He will be closely monitored, as he will likely need further surgical revision once he outgrows the second set of fixation screws.

  Abstract in Arabic 

ملخص البحث
يتزايد معدل انتشار إنزلاق الكردوس العاصم للفخذ لدى اليافعين خصوصًا لدى المرضى الذين تقل أعمارهم عن عشر سنوات. وعندما يصاب هؤلاء بهذه المشكلة فإنها عادة ما تكون مرتبطة باضطراب الغدد والتمثيل الغذائي. يعرض الباحثون حالة لطفل في الخامسة يعاني من انزلاق الكردوس العاصم للفخذ لسبب مجهول. وقد أجريت له عملية تثبيت موضعي باستخدام سلك معدل. وقد احتاج المريض فيما بعد لعملية مراجعة براغي التثبيت بسبب استمرار نموه. عند مراجعة المريض بعد ثلاثة سنوات لم يكن يعاني من آلام وكانت المثبتات في موضعها. ستتم متابعة المريض نظرًا لأنه قد يحتاج لمزيد من التدخل الجراحي عندما يتقدم في العمر على مثبتات المراجعة الثانية.
راجع المريض المستشفى بعد ثلاث سنوات ولم يكن يعاني من آلام وكانت المثبتات في موضعها.

Keywords: Paediatric hip, slipped capital femoral epiphysis, limping


How to cite this article:
Al Qahtani SM, Bozzo A, Hamdy R, Janelle C. Slipped capital femoral epiphysis in a healthy 5-year-old child: A case report and literature review. Saudi J Med Med Sci 2014;2:117-9

How to cite this URL:
Al Qahtani SM, Bozzo A, Hamdy R, Janelle C. Slipped capital femoral epiphysis in a healthy 5-year-old child: A case report and literature review. Saudi J Med Med Sci [serial online] 2014 [cited 2020 May 29];2:117-9. Available from: http://www.sjmms.net/text.asp?2014/2/2/117/137009


  Introduction Top


Slipped capital femoral epiphysis (SCFE) is a well-known disorder of the pediatric hip.

SCFE seen below the age of 10 is atypical and usually associated with metabolic abnormalities or endocrinopathies. [1]

In this case report, we present a 5 and 4-month-year-old boy with idiopathic bilateral unstable SCFE [2] who was treated with bilateral pinning in situ.


  Case report Top


This was a case report of a 5-year and 4-month-old male seen in our institute in July 2010 with a chief complaint of mild left hip and knee pain for 5 weeks. One day prior to presentation, the pain became severe and on presentation the patient was not able to stand up and walk. There was no history of trauma or a fall and also no history of fever.

The patient's past medical and surgical history was unremarkable. There was no history of medication use or allergy.

The perinatal history was remarkable only for uncomplicated preeclampsia in the mother.

There is no family history of any metabolic or endocrinological disease.

On examination

On physical examination, the patient's height is 118.7 cm and the weight is 22.8 kg, both are greater than the 90 th percentile. No dysmorphic features are present. The patient was afebrile and the general examination was unremarkable.

Examination of the left hip revealed painful active range of motion with flexion at 90°, abduction 30°, internal rotation of 10° as opposed to 40° of the other side, external rotation of 60° compared with 50° on the right side. There was no local tenderness, erythema nor signs of inflammation.

The left knee was without effusion or swelling, but did have some decreased painful range of motion. The rest of the general examination was normal.

Imaging studies

Pelvic X-ray: Showed evidence of left slipped capital femoral epiphysis [Figure 1].
Figure 1: Hips-Frogleg X-ray: Showed evidence of left slipped capital femoral epiphysis

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Ultrasound: Moderate to large sized effusion with a few low level echoes.

Laboratory results

White blood cells 9.24, C-reactive protein <0.2, erythrocyte sedimentation rate 7.0 thyroid-stimulating hormone 1.8, free T3 10.3.

The laboratory work-up excluded the possibility of an associated endocrinopathy.

Metabolic work-up

The bone mineral density at the lumbar spine showed a Z-score of −0.3 and the tibia peripheral quantitative computed tomography on the right side was 203 and the left side 158 and both normal.

The blood and urine work-up were both normal.

Course of management

The hip was defined as being unstable and surgery was booked for the following day.

The patient underwent a left hip capsulotomy and pinning on July 2010 [Figure 2].
Figure 2: Pelvis X-ray: Showing pinning of the left femoral neck with two K-wires crossing the growth plate into the femoral head. Evidence of left slipped capital femoral epiphysis pinned in situ with widening of the growth plate with normal appearance of the right hip as well as the rest of the pelvis

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When seen 1 week after the surgery, the patient was pain free and attempting to weight bear and ambulate. Clinically, flexion of the left hip is to 90°, abduction 30°, internal rotation 20° and external rotation about 60.

After discussion of the benefits and risks with the parents, the patient was booked for prophylactic pinning of the right hip, scheduled for August 2010.

Follow-up radiographs in December revealed that the wires in the left hip had now both migrated out of the epiphysis. After discussion with the parents, a revision surgery for the left hip was planned.

On January 2011, the revision K-wire fixation with buttress plate of the left hip was carried out.

On June 2012, at the age of 7, the patient presented with intermittent pain of the right knee and slight limping after soccer games. On examination, the patient had a limp free gait and a normal hip and knees exam.

However, X-rays of the right hip showed that the K-wires no longer penetrated the epiphysis. After discussion with the parents, consent was obtained to replace the K-wires on the right side.

On February 2013, the patient underwent a bilateral wire replacement with plate fixation to prevent slip. Post-operative examination was normal [Figure 3].
Figure 3: Pelvis X-ray: Showed good placement of the revised K-wires, screws and plates bilaterally. Showed no slip and open physes

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  Discussion Top


There is growing literature on the contribution of the childhood obesity epidemic to the increasing prevalence of SCFE and to its occurrence at younger ages. [3],[4] Commonly thought to be the realm of metabolic conditions and endocrinopathies, idiopathic SCFE at ages younger than 10 is now being reported more frequently.

The goal of surgical intervention in SCFE is threefold: Restoration of stability of the hip, prevention further progression of the slip and avoidance of avascular necrosis (AVN) or chondrolysis. [3] Recent literature has reported a trend of decreasing rates of the complications of surgical intervention. [3],[5]

There has been considerable work that shows that using multiple Kirschner-wires, although associated with slightly higher rates of AVN, are significantly less likely to interfere with the physis than single cannulated screws. [3],[4],[6] This, as well as the fact that there is considerable growth left in the physes of these atypically young patients, points to the favorable use of K-wires in this patient population.

Young age of presentation is among the predictors for the development of contralateral SCFE. [5] Our patient, as well as the other two case series on patients less than 6 years of age, all underwent prophylactic pinning of the contralateral hip.

What is known is that the ages of 9 years and 6 months and 10 years and 2 months, for girls and boys respectively, represent 2.5 standard deviations below the mean age of presentation for SCFE. [3]

Azzopardi et al. in 2010 reported a case series of children with SCFE that were aged 10 years or younger. Four of the patients in this series needed to be re-operated after pin back out due to proximal femur growth while five patients did not require a second surgery. [3]


  Conclusion Top


The literature supports surgery as the best treatment option even for younger patients. However, the need for revision surgery is unavoidable in this patient subset. Given these two facts, we propose that when consent is obtained for the first surgery, the parents be informed of the almost certain need for revision surgeries.

Alternatively, perhaps this is a calling for a growing rod to be developed for hip procedures, given their established use in spinal surgeries and osteogenesis imperfecta patient.

 
  References Top

1.Loder RT, Wittenberg B, DeSilva G. Slipped capital femoral epiphysis associated with endocrine disorders. J Pediatr Orthop 1995;15:349-56.  Back to cited text no. 1
    
2.Loder RT, Richards BS, Shapiro PS, Reznick LR, Aronson DD. Acute slipped capital femoral epiphysis: The importance of physeal stability. J Bone Joint Surg Am 1993;75:1134-40.  Back to cited text no. 2
    
3.Azzopardi T, Sharma S, Bennet GC. Slipped capital femoral epiphysis in children aged less than 10 years. J Pediatr Orthop B 2010;19:13-8.  Back to cited text no. 3
    
4.Druschel C, Sawicki O, Cip J, Schmölz W, Funk JF, Placzek R. Biomechanical analysis of screw fixation vs. K-wire fixation of a slipped capital femoral epiphysis model. Biomed Tech (Berl) 2012;57:157-62.  Back to cited text no. 4
    
5.Novais EN, Millis MB. Slipped capital femoral epiphysis: Prevalence, pathogenesis, and natural history. Clin Orthop Relat Res 2012;470:3432-8.  Back to cited text no. 5
    
6.Woelfle JV, Fraitzl CR, Reichel H, Nelitz M. The asymptomatic contralateral hip in unilateral slipped capital femoral epiphysis: Morbidity of prophylactic fixation. J Pediatr Orthop B 2012;21:226-9.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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