Slipped capital femoral epiphysis usually occurs in children going through a pubertal growth spurt, possibly because the immature proximal femoral physis is unable to bear the shear stress. It commonly occurs in adolescents between 10 and 16 years. Slipped capital femoral epiphysis in adults is uncommon, with only 10 cases reported in the literature. This article presents a case of a 29-year-old man with craniopharyngioma diagnosed when he was 19. He underwent surgery with subtotal tumor excision and postoperative radiotherapy, but received no further treatment for the panhypopituitarism concomitant with the tumor. He reported sudden onset of left hip pain after riding a bicycle and underwent surgical fixation 5 days later. He also underwent hormone replacement therapy, including prednisolone, thyroxin, desmopressin, and testosterone, and regular clinical follow-up. His hip function recovered with a painless gait. At 18-month follow-up, neither osteonecrosis nor contralateral slipped capital femoral epiphysis was noted. Furthermore, bilateral proximal femoral physes were also closed. For stable slippage as in this case, in situ pinning fixation is a commendable method. A high index of suspicion of endocrinal disorder and proper management are essential for successful treatment of adult slipped capital femoral epiphysis.
Slipped capital femoral epiphysis occurs in children going through a pubertal growth spurt, possibly because the immature proximal femoral physis is unable to bear the shear stress. It commonly occurs in adolescents between ages 10 and 16 years. Slipped capital femoral epiphysis occurs more frequently in obese children with male predominance. The left hip is affected twice as often as the right whereas the bilateral involvement ranges from 25% to 40%.1 Several etiological factors have been suggested for slipped capital femoral epiphysis, such as local trauma,2 obesity,3,4 endocrine disorders (such as hypothyroidism, hypopituitarism, and hyperparathyroidism),5-7 genetic factors,8 etc. Slipped capital femoral epiphysis may also complicate the course of growth hormone therapy.9,10 This article presents a case of a 29-year-old man who had craniopharyngioma associated with panhypopituitarism, including hypogonadotropic hypogonadism and growth hormone deficiency.
A 29-year-old man with abnormal sexual development first presented with negative pubic hair and axillary hair, penis hypodevelopment, and bilateral undescending testes at age 14 years. Blurred vision and bitemporal hemianopia were noted at 19 years. Skull plain radiographs and computed tomography (CT) of the cranium revealed a sellar tumor. He underwent subtotal tumor excision at 19 years. The pathology report showed craniopharyngioma.
Postoperatively, he underwent radiotherapy. The endocrinology studies showed panhypopituitarism, including central diabetes insipidus, hypothyroidism, adrenocorticotropic hormone deficiency, hypogonadotropic hypogonadism, and growth hormone deficiency. He was 165 cm tall, weighed 55 kg, and had a body mass index (BMI) of 20.2 kg/m2. He continued to grow tall in the following 10 years. When he was 29 years old, he was 179 cm tall and weighted 70 kg with a BMI of 21.8 kg/m2. He reported a sudden onset of left hip pain after riding a bicycle. The pain had persisted for 5 days with aggravation.
On physical examination, a shortened and externally rotated right leg with left hip in slight flexion was revealed. He walked into our clinic without crutches or other walking support although he reported left hip pain. Neurovascular status was normal. Further image studies showed open bilateral proximal femoral physes and left femoral head epiphysis slipped posteriorly and medially (Figure 1). The skeletal bone age was 14 years and 6 months, compared to the patient age of 29 years and 7 months.
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|Figure 1: AP (A) and lateral (B) radiographs showing a slipped capital femoral epiphysis of the left hip with posterior and medial displacement of the femoral head epiphysis. Coronal gradient echo T2-weighted MRI (C). Note the left hip effusion (short white arrow) and the widening of the left growth plate (white dotted arrow). |
Intraoperatively, a fracture table was used for traction and slippage reduction was attempted. However, it remained unreduced. The patient then underwent immediate in situ fixation with 1 cannulated screw (7.5 mm in diameter) under fluoroscopy (Figure 2). Neither joint aspiration nor capsulotomy was performed intraoperatively. The patient began ambulating with 2 crutches 3 days postoperatively. He also underwent hormone replacement therapy, including prednisolone, thyroxin, desmopressin, and testosterone, and regular clinical follow-up. His hip function recovered smoothly with a painless gait.
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|Figure 2: AP (A) and lateral (B) radiographs showing immediate in situ fixation with 1 cannulated screw for left femoral head slipped capital epiphysis. |
During 18-month follow-up, neither osteonecrosis nor contralateral slipped capital femoral epiphysis was noted. Furthermore, the bilateral proximal femoral physes were also closed on radiographs (Figure 3).
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|Figure 3: AP (A) and lateral (B) radiographs. After 18-month follow-up, the left femoral head remodeled well and preserved a good shape. Neither femoral head osteonecrosis nor contralateral slipped capital femoral epiphysis was noted. Bilateral proximal femoral physes were also closed. |
Slipped capital femoral epiphysis occurs during young adolescence, especially during the growth spurt. The combination of reduced growth plate stability at this age and rapid increasing mechanical overload on the physis due to body weight gain is considered the etiology of slipped capital femoral epiphysis. Overweight children during pubertal growth spurt (between age 9 and 16 years) are generally considered to be most at risk.11,12 Obese children usually have reduced femoral anteversion that can result in increased mechanical shear stress on the upper femoral epiphysis. In addition, growth plates can have physiological weakness during this rapid growth period. The exact mechanism is unknown. However, bone remodeling during rapid turnover may reduce the skeleton strength. Since bone strength is determined by bone quantity and bone quality, another possibility of weak bone strength may be related to suboptimal bone quality associated with the endocrine disorders, as in this patient. Some investigators believe that hormone imbalances such as hypothyroidism, hyperparathyroidism, or hypogonadism all contribute to weak bone.3,5-7
Bone mass index-related mechanical load seems to play another important factor in slipped capital femoral epiphysis patients. Patients presenting with slipped capital femoral epiphysis have higher than average body mass indexes with values in the overweight or obese range. Patients with bilateral slipped capital femoral epiphysis have a significantly greater mean body mass index than children with unilateral slipped capital femoral epiphysis.3 A combination of these factors predisposes overweight adolescents to develop slipped capital femoral epiphysis.
Craniopharyngiomas are the most common hypothalamic-pituitary tumors in children (80%), accounting for 6% to 9% of pediatric brain tumors. They also occur in adults.13 The absence of a pituitary stimulus to testicular maturation hinders the pubertal development of secondary sexual characteristics as our patient presented. However, the secreted growth hormone is usually sufficient so the patient continued to grow for a longer-than-normal period. The closure of the growth plates usually does not occur until the third decade of life in untreated cases.14
Slipped capital femoral epiphysis in adults is limited and commonly associated with endocrinal disturbances. In a search of the literature from 1960 to 2009, 10 cases of slipped capital femoral epiphysis in adults older than 20 years were reported. The associated endocrinopathies were also recorded. Five sustained panhypopuitary disorders consisting of 2 craniopharyngiomas,5,12 one pituitary microadenoma,15 one histiocytosis,5 and 1 hemosiderosis.16 Four sustained hypothyroidism17-20 and the other post-irradiation hypoestrogenism.16 According to the literature mentioned above, hormone replacement therapy and definite surgical management are indicated and effective in adult slipped capital femoral epiphysis. For stable slippage, meaning the patient can walk dependently or independently, in situ pinning fixation is a commendable method. A high index of suspicion toward endocrinal disorder and proper management are essential in successful treatment of adult slipped capital femoral epiphysis.
Prophylactic pinning or other fixation procedures for an asymptomatic hip in slipped capital femoral epiphysis remain controversial. Many authors stay in a low threshold for prophylactic operations on pathologic slipped capital femoral epiphysis related to endocrinopathy or renal disease. However, there is a lack of evidence of hip slippage predictions.21 Prophylactic operations on the asymptomatic hips would elicit possible complications of fixation (eg, chondrolysis, avascular necrosis, and infection).22 Close follow-up and protected weightbearing are sufficient for prevention of neglected contralateral hip slippage.
- Canale ST. Campbells Operative Orthopaedics. 10th ed. Philadelphia, PA: Mosby; 2003:1481-1484.
- Causey AL, Smith ER, Donaldson JJ, Kendig RJ, Fisher LC III. Missed slipped capital femoral epiphysis: illustrative cases and a review. J Emerg Med. 1995; 13(2):175-189.
- Bhatia NN, Pirpiris M, Otsuka NY. Body mass index in patients with slipped capital femoral epiphysis. J Pediatr Orthop. 2006; 26(2):197-199.
- Prichett JW, Perdue KD. Mechanical factors in slipped capital femoral epiphysis. J Pediatr Orthop. 1988; 8(4):385-388.
- Wells D, King JD, Roe TF, Kaufman FR. Review of slipped capital femoral epiphysis associated with endocrine disease. J Pediatr Orthop. 1993; 13(5):610-614.
- Yang WE, Shih CH, Wang KC, Jeng LB. Slipped capital femoral epiphyses in a patient with primary hyperparathyroidism. J Formos Med Assoc. 1997; 96(7):549-552.
- Loder RT, Wittenberg B, DeSilva G. Slipped capital femoral epiphysis associated with endocrine disorders. J Pediatr Orthop. 1995; 15(3):349-356.
- West LA, Ballock RT. High incidence of hip dysplasia but not slipped capital femoral epiphysis in patients with Prader-Willi syndrome. J Pediatr Orthop. 2004; 24(5):565-567.
- Blethen SL, Rundle AC. Slipped capital femoral epiphysis in children treated with growth hormone. A summary of the National Cooperative Growth Study experience. Horm Res. 1996; 46(3):113-116.
- Wang SY, Tung YC, Tsai WY, Chien YH, Lee JS, Hwu WL. Slipped capital femoral epiphysis as a complication of growth hormone therapy. J Formos Med Assoc. 2007; 106(2 Suppl):S46-50.
- Manoff EM, Banffy MB, Winell JJ. Relationship between body mass index and slipped capital femoral epiphysis. J Pediatr Orthop. 2005; 25(6):744-746.
- Huang KC, Hsu RW. Slipped capital femoral epiphysis in a 23-year-old mana case report. Acta Orthop. 2007; 78(5):696-697.
- Harris WR. The endocrine basis for slipping of the upper femoral epiphysis. An experimental study. J Bone Joint Surg Br. 1950; 32(1):5-11.
- Meuric S, Brauner R, Trivin C, Souberbielle JC, Zerah M, Sainte-Rose C. Influence of tumor location on the presentation and evolution of craniopharyngiomas. J Neurosurg. 2005; 103(5 Suppl):421-426.
- Feydy A, Carlier RY, Mompoint D, Rougereau G, Patel A, Vallee C. Bilateral slipped capital femoral epiphysis occurring in an adult with acromegalic gigantism. Skeletal Radiol. 1997; 26(3):188-190.
- 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 Relat Res. 1983; (180):188-197.
- Nourbakhsh A, Ahmed HA, McAuliffe TB, Garges KJ. Case report: Bilateral slipped capital femoral epiphysis and hormone replacement. Clin Orthop Relat Res. 2008; 466(3):743-748.
- Hennessy MJ, Jones KL. Slipped capital femoral epiphysis in a hypothyroid adult male. Clin Orthop Relat Res. 1982; (165):204-208.
- Al-Aswad BI, Weinger JM, Schneider AB. Slipped capital femoral epiphysis in a 35-year-old man. Clin Orthop Relat Res. 1978; (134):131-134.
- Epps CH Jr, Martin ED. Slipped capital femoral epiphysis in a sexually mature myxedematous female. JAMA. 1963; 183(4):287-289.
- Donamamrdi GA, Metcalfe J, Rajan R, Jones S, Femandes JA. Contralateral slip prediction in slipped capital femoral epiphysis : is bone age the answer? Acta Orthop Belg. 2007; 73(3):327-331.
- Castro FP Jr, Bennett JT, Doulens K. Epidemiological perspective on prophylactic pinning in patients with unilateral slipped capital femoral epiphysis. J Pediatr Orthop. 2000; 20(6):745-748.
Drs Hu and Hsueh are from the Department of Orthopedic Surgery, National Taiwan University Hospital, Yun-lin Branch, Douliou City, Drs Jian and Yang are from the Department of Orthopedics, College of Medicine, National Taiwan University Hospital, Taipei, and Dr Lin is from the Department of Orthopedics, Hsin Chu General Hospital, Department of Health, Executive Yuan, Taiwan.
Dr Hu, Jian, Hsueh, Lin, and Yang have no relevant financial relationships to disclose.
Correspondence should be addressed to: Rong-Sen Yang, MD, PhD, Department of Orthopedics, National Taiwan University Hospital, No 7, Chung-Shan South Rd, Taipei, Taiwan (firstname.lastname@example.org).