Traumatic Posterior Hip Dislocation and Epiphysiolysis in a High School Football Player with Successful Outcome at 4 Years Follow-up: A Case Report.

CASE: We describe a case of posterior hip dislocation in a 13-year-old boy after a contact football injury with attempted closed reduction resulting in complete separation of the epiphysis from the femoral neck metaphysis with associated femoral head fracture and posterior dislocation of the femoral head. Treatment was emergently performed with a greater trochanteric osteotomy, open reduction internal fixation using cannulated screws, and additional small diameter drill holes in the femoral head to promote blood flow. The patient did well postoperatively and at over 4 years follow-up had no evidence of avascular necrosis and returned to full athletics participation. CONCLUSION: Particular attention should be taken when reducing hip dislocations in the adolescent population who may be predisposed to epiphysiolysis. Preservation of periosteal soft-tissue attachments and the use of small diameter drill holes to promote femoral head blood flow may have contributed to the excellent outcome.

Disarticulation-Associated Femoral Head Separation in Clinically Normal Broilers: Histologic Documentation of Underlying and Predisposing Cartilage Abnormalities.

Routine and quantitative histologic studies on femoral head separation (FHS) associated with coxofemoral joint disarticulation at necropsy were conducted on 125 femoral heads collected from 21- to 50-day-old clinically normal broilers. The study compared groups demonstrating grossly detached femoral heads (DFHs) with those having attached femoral heads (AFHs). Marked microscopic lesions compatible with osteochondrosis (OCD) consistently occurred along the separation surface in the DFH population. The histologic changes consisted of cartilage degeneration and necrosis sometimes forming small clefts or microfractures. Hemorrhage and less frequent inflammatory cells were often present along the separation surfaces. Small foci of OCD in the femur occurred in the AFH group with lesser frequency and severity. The histologic changes were mainly found within the proximal proliferative zone of the physis near the epiphyseal junction. Histomorphometry disclosed significant quantitative reductions in chondrocyte density with increased pyknosis occurring adjacent to the separation site and to a lesser extent in deeper regions of the growth plate for the DFH compared with AFH. Measurements made along the separation surface of the percentage length occupied by osteochondrotic defects and actual separated cartilage disclosed significant differences between evaluation groups. However, determinations of vascular canal areas present within two or more regions of the growth plate revealed a slight and significant increased area for DFH compared with AFH. Severity scores for the occurrence of microthrombi within the growth plate showed no difference between the groups. The pathogenesis of FHS in broilers is related to defective cartilage production or degeneration resulting in increased fragility. This contrasts with the proposed pathogenesis of OCD in mammals, which involves ischemic necrosis due to underlying vascular defects. The results for the FHS-disarticulation model also differ from those reported for glucorticoid-induced femoral head necrosis in broilers. The FHS-associated lesions occurred without histologic evidence of bacterial chondritis or osteomyelitis.

Separación de la cabeza femoral asociada a la desarticulación en pollos de engorde clínicamente normales: documentación histológica de anomalías del cartílago subyacentes y predisponentes. Estudios histológicos de rutina y cuantitativos sobre la separación de la cabeza femoral (FHS) asociados con la desarticulación de la articulación coxofemoral durante la necropsia se realizaron en 125 cabezas femorales recolectadas de pollos de engorde clínicamente normales de 21 a 50 días de edad. El estudio comparó los grupos que demostraron cabezas femorales separadas (DFH) con los que tenían cabezas femorales unidas (AFH). Lesiones microscópicas marcadas compatibles con osteocondrosis (OCD) ocurrieron consistentemente a lo largo de la superficie de separación en la población de aves con cabezas femorales separadas. Los cambios histológicos consistieron en degeneración del cartílago y necrosis, formando a veces pequeñas hendiduras o microfracturas. La hemorragia y la presencia menos frecuente de células inflamatorias estaban presentes a lo largo de las superficies de separación. Se produjeron con menor frecuencia y gravedad, focos pequeños de osteocondrosis en el fémur en el grupo de aves con cabezas femorales unidas. Los cambios histológicos se encontraron principalmente en la zona proliferativa proximal de la fisis cerca de la unión epifisaria. La histomorfometría reveló reducciones cuantitativas significativas en la densidad de condrocitos con un aumento de la picnosis que ocurrió adyacente al sitio de separación y en menor medida en regiones más profundas de la placa de crecimiento en las aves con cabezas femorales separadas en comparación con las aves con cabezas femorales unidas. Las mediciones realizadas a lo largo de la superficie de separación del porcentaje de longitud ocupada por defectos osteocondróticos y con cartílago separado revelaron diferencias significativas entre los grupos de evaluación. Sin embargo, las determinaciones de las áreas del canal vascular presentes dentro de dos o más regiones de la placa de crecimiento revelaron un aumento leve y significativo del área para las aves con cabezas femorales separadas en comparación con las aves con cabezas femorales unidas. Las puntuaciones de severidad para la aparición de microtrombos dentro de la placa de crecimiento no mostraron diferencias entre los grupos. La patogenia de la separación de la cabeza femoral en pollos de engorde se relaciona con la producción o degeneración de cartílago defectuoso que resulta en un aumento de la fragilidad. Esto contrasta con la patogénesis propuesta para la osteocondrosis en mamíferos, que involucra necrosis isquémica debido a defectos vasculares subyacentes. Los resultados para el modelo de desarticulación-separación de la cabeza femoral también difieren de los reportados para la necrosis de la cabeza femoral inducida por glucorticoides en pollos de engorde. Las lesiones asociadas con la separación de la cabeza femoral ocurrieron sin evidencia histológica de condritis bacteriana u osteomielitis.

[Slipped capital femoral epiphysis]. / Épiphysiolyse fémorale supérieure.

Slipped capital femoral epiphysis (SFCE) is a disorder of the hip, characterized by a displacement of the capital femoral epiphysis from the metaphysic through the femoral growth plate. The epiphysis slips posteriorly and inferiorly. SCFE occurs during puberty and metabolic and epidemiologic risk factors, such as obesity are frequently found. Most chronic slips are diagnosed late. Sagittal hip X-rays show epiphysis slip. In case of untreated SCFE, a slip progression arises with an acute slip risk. Treatment is indicated to prevent slip worsening. The clinical and radiological classification is useful to guide treatment and it is predictive of the prognosis. In situ fixation of stable and moderately displaced SCFE with cannulated screws gives excellent results. Major complications are chondrolysis and osteonecrosis and the major sequelae are femoroacetabular impingement and early arthritis.

Digital Chondrolysis and Epiphysiolysis Associated With Snakebite: A Report of 2 Cases.

BACKGROUND: Here, we present 2 cases of the unusual sequelae of a venomous bite to the finger in children resulting in chondrolysis and physeal loss. There have been few isolated case reports documenting this phenomenon. Currently, there is no preventative treatment, and patients should be warned of this possible complication of envenomation. METHODS: Two patients with chondrolysis and physeal loss have been seen in our practice. RESULTS: Chondrolysis and epiphysiolysis occurred in 2 patients. One patient was treated with proximal interphalangeal joint fusion and one is being managed conservatively. CONCLUSION: The toxic action of snake venom may cause loss of the growth plate and chondrolysis in the pediatric hand. LEVEL OF EVIDENCE: Level IV.

Tibia vara and slipped upper femoral epiphysis: is there an association?

Tibia vara and slipped upper femoral epiphysis (SUFE) share a common risk factor, but their relationship is unclear. In both conditions, the patients are usually obese. To the best of our knowledge, there have been only two previous reports in the literature that have described the occurrence of tibia vara and SUFE in three patients. We report a child who was treated for bilateral tibia vara at the age of 3 years and subsequently developed a SUFE at the age of 13 years.

Common overuse injuries in the young athlete.

Pediatric overuse injury is a common complaint presenting to pediatricians. Overuse injury can affect the soft tissues or bone, and results from an imbalance between training and load to the tissues and recovery time. In the skeletally immature athlete, physeal and apophyseal tissue is particularly vulnerable to overuse resulting in different patterns of injury compared to adults. Awareness of age-dependent patterns of overuse is necessary for proper recognition, treatment, and prevention of injury. This article reviews the most common pediatric overuse injuries with emphasis on risk factors, diagnosis, and treatment. Guidelines for prevention are included, as this is the key component for successful management of overuse injury in pediatric athletes.

Slipped capital femoral epiphysis and hypothyroidism in a young adult: a case report.

INTRODUCTION: Slipped capital femoral epiphysis is the most common hip disorder affecting the adolescent population, usually individuals between 8 and 15 years old. However, there are few case reports of older patients in the literature to date. It is believed that the etiology is multifactorial and may include obesity, trauma and, less frequently, endocrine pathologies comprising hypothyroidism, hypogonadism and panhypopituitarism. CASE PRESENTATION: We present the case of a 28-year-old Latino woman diagnosed with hypothyroidism secondary to arachnoidocele associated with skeletal immaturity and slipped capital femoral epiphysis. CONCLUSIONS: It is important to conduct clinical and radiographic studies in these patients to rule out endocrine pathologies, especially hypothyroidism in those of sexual maturity.

Distal humeral epiphysiolysis in the newborn: utility of sonography and differential diagnosis.

Fracture-separation of the distal humeral epiphysis in newborn is a rare entity, usually the result of a traumatic delivery. It can mimic elbow dislocation and, due to the absence of ossification of the epiphysis at that time, cannot be diagnosed radiographically. However, ultrasound is an important diagnostic tool for this purpose because it is able to clearly visualize the cartilaginous epiphysis. In addition, it allows the differential diagnosis with posterior elbow dislocation whose therapeutic management and prognosis are different. We report the case of a preterm newborn in which a fracture-separation of the distal humeral epiphysis was diagnosed with the help of sonography. The purpose of this report is to emphasize the utility of echography as a cheap, available, and noninvasive tool for the evaluation of the nonossified epiphysis in the newborn elbow.

Case report: Bilateral femoral neck fractures in a child and a rare complication of slipped capital epiphysis after internal fixation.

BACKGROUND: Bilateral traumatic femoral neck fractures are uncommon in children. The most commonly reported complications are nonunion, avascular necrosis of the femoral head, and chondrolysis. Slipped capital femoral epiphysis (SCFE) associated with nonunion after percutaneous partially threaded cancellous screw (PTCS) fixation of the fracture is an unreported complication. CASE DESCRIPTION: We describe a 10-year-old boy who had bilateral femoral neck fractures secondary to a fall from a height. The patient was treated with percutaneous PTCS fixation on both sides and achieved union on the right side in 3 months, however, a nonunion and SCFE developed on the left side 5 months after the initial surgery. Management of the nonunion and SCFE with PTCS and nonvascularized fibula graft led to union. Eighteen months after the initial injury, the patient achieved a pain and limp-free gait. LITERATURE REVIEW: A literature review shows avascular necrosis, posttraumatic coxa vara, premature physeal closure, nonunion, chondrolysis, infection, and implant failure as complications of operative management of femoral neck fractures. SCFE has not been previously reported. PURPOSES AND CLINICAL RELEVANCE: This case highlights the need for close followup of adolescent patients with PTCS fixation for femoral neck fractures.

Traumatic epiphysiolysis of the proximal femur.

PURPOSE OF THE STUDY: Several former studies show the treatment of slipped epiphysis of the femoral head (SEFH). Its reason is rather unknown. On the other hand the rare traumatic SEFH takes place due to a real accident. According to the literature these injuries are treated like chronic SEFHs. The aim of this study is to show the differences in pathology and treatment of an acute traumatic SEFH in relationship to the chronic SEFH. PATIENTS AND METHODS: In 8 patients dislocated traumatic SEFHs were reduced anatomically and stabilized by the means of 3 to 4 Kirschner- (K-) wires or two cancellous screws. Each patient got a plaster-cast fixation for about 6 weeks of the ipsilateral hip and leg and was mobilized with two crutches and partial weight bearing for 12 weeks. The implants were removed 24 weeks after surgery. Four patients with not dislocated SEFHs were immobilized or mobilized with two crutches without weight bearing according to their pain sensation. The final examination of both groups took place 2 Vz to 15 years after the initial treatment. RESULTS: Four patients primarily under 10 years of age showed no or minimal radiological signs of a dislocated femoral head and were without any further inconvenience--the suspected SEFHs revealed as hip contusions. 8 children aged 10 years or older at the time of trauma were treated by closed reduction and internal fixation. Complications occurred in three cases--one necrosis of the femoral head because of a perforating K-wire, one subtrochanteric femur fracture after implant removal of a prophylactically stabilized contralateral femoral head and one minimally dislocated femoral head after postoperative too early full weight bearing. DISCUSSION: The traumatic SEFH is very different to the chronic one regarding the pathology and acute treatment. Technical challenges must be solved. Unilateral K-wiring or screwing for 24 weeks and reduced weight bearing for the first 12 weeks after surgery is a sufficient way of treatment of the traumatic SEFH. CONCLUSIONS: In the case of a traumatic SEFH it needs to be reduced anatomically and stabilized by surgical means in the acute phase. A prophylactic stabilization of the opposite intact side is usually not required.

Slipped capital femoral epiphysis: rising rates with obesity and aboriginality in South Australia.

We analysed the incidence of slipped capital femoral epiphysis (SCFE) in South Australia, investigating possible associations between an increased incidence of SCFE, the local indigenous population and the Australian obesity epidemic during the last 20 years. Data including race, age and gender were collected to obtain a profile of the South Australian SCFE patient, and were then compared with epidemiological data for South Australian adolescents. We concluded that the incidence of both obesity and SCFE is increasing. We also noted that the median weight of SCFE patients has increased and the mean age at diagnosis has decreased. Despite weight profiles comparable with those of the general population, we noted that an indigenous child was three times more likely to develop SCFE than a non-indigenous child. As far as we know there is no published literature on the predisposition of Aboriginal Australians to SCFE.

Anterior knee pain in the young athlete: diagnosis and treatment.

The underlying etiology of anterior knee pain has been extensively studied. Despite many possible causes, often times the diagnosis is elusive. The most common causes in the young athlete are osteosynchondroses, patellar peritendinitis and tendinosis, synovial impingement, malalignment, and patellar instability. Less common causes are osteochondritis dissecans and tumors. It is always important to rule out underlying hip pathology and infections. When a diagnosis cannot be established, the patient is usually labeled as having idiopathic anterior knee pain. A careful history and physical examination can point to the correct diagnosis in the majority of cases. For most of these conditions, treatment is typically nonoperative with surgery reserved for refractory pain for an established diagnosis.

Injuries about the hip in the adolescent athlete.

Athletic injuries in or around the hip in the adolescent athlete encompass possible causes such as a single, traumatic event to those of repetitive microtrauma. The injuries may involve the bone or the soft tissues, with former involving the epiphysis, apophysis, metaphysis, or diaphysis, whereas the latter includes muscles and tendons. With the improvements in surgical technique and instrumentation for hip arthroscopy and the development of magnetic resonance arthrography, clinicians have been able to diagnose and treat labral tears, hip instability, snapping hip, loose bodies, chondral injuries, and femoroacetabular impingement. The clinician needs to consider acquired conditions that may have coincidentally become apparent as a result of the adolescent's participation in an organized sports program. These include slipped capital femoral epiphysis, Legg-Calvé-Perthes disease, and pathologic lesions and fractures. This study reviews the more common acute and chronic overuse injuries in or around the hip in the adolescent athlete and discusses hip injury prevention in this active patient population.

Slipped capital femoral epiphysis with severe vitamin D deficiency.

Slipped capital femoral epiphysis is a relatively common disorder in late childhood and early adolescence, with an incidence in the United States of approximately 10 per 100,000. Although clinicians have theorized that contributing factors to the development of slipped capital femoral epiphysis include 25-hydroxyvitamin D deficiency and other nutritional deficiencies, the roles of these factors have not been fully analyzed. This article presents a case of a morbidly obese 13-year-old African-American boy who presented with sudden worsening of chronic hip pain and was diagnosed with stable, bilateral, grade-III slipped capital femoral epiphysis and severe vitamin D deficiency. He was initially treated with bilateral single-screw percutaneous fixation, however, after continued pain and nonunion, a right valgus subtrochanteric osteotomy was performed in association with correction of his severe vitamin D deficiency. This procedure led to improvement of his hip function and successful resolution of the pain. Approximately 3 months after the second operation and vitamin supplementation, the patient had signs of union, and his weight bearing progressed without discomfort. Although the osteotomy provided substantial biomechanical advantage by changing the forces across the physis from shear to compressive, correction of the vitamin D deficiency was critical in providing metabolic capacity for bone healing. Vitamin D plays an important role in bone formation and development, but the level of 25-hydroxyvitamin D is not routinely measured during assessment and treatment of slipped capital femoral epiphysis patients. The early detection and proper treatment of vitamin D may assist in the treatment of patients with slipped capital femoral epiphysis.

Increased risk of Blount disease in obese children and adolescents with vitamin D deficiency.

BACKGROUND: Poor dietary habits and decreased outdoor activity has led to an epidemic of obese children and vitamin D deficiency. The lack of vitamin D alters bone development and mineralization by diminishing physiological levels of calcium and phosphorus. Given vitamin D's role in bone and growth plate mineralization and regulation, we hypothesized that vitamin D deficiency would lead to higher rates of fractures, slipped capital femoral epiphysis (SCFE), and Blount disease in obese youth. METHODS: A retrospective review was performed at the obesity clinic using the obesity database (890 patients). Data obtained included body mass index (BMI), vitamin D levels (25-vitamin D), history of fractures, Blount disease, and/or SCFE. The chart review identified 2 populations of obese patients, those with vitamin D deficiency, <16 ng/mL (198 patients) and those not vitamin D deficient >16 ng/mL (692 patients). Fisher exact, χ², and 2-sample t tests along with logistic regression were used for statistical analysis. A P value ≤0.05 was considered statistically significant. RESULTS: Blount disease was found to have a statistically significant (P<0.05) positive association with patient's sex, BMI, and vitamin D level. Specifically, males were 8.16 times more likely than females to be observed with Blount disease (P=0.01). Patients with very low vitamin D levels were 7.33 times more likely to have Blount disease than patients with higher levels (P=0.002). Each whole number increase in BMI increases the likelihood of Blount disease by 3% (P=0.01). There was no association between increased number of fractures or SCFE with vitamin D deficiency in these obese patients. CONCLUSION: As our findings indicate, BMI and vitamin D levels have a strong association with Blount disease, which may be especially important among males. Ours is the first study to show a relationship between vitamin D deficiency and Blount disease, but further prospective studies are needed with larger numbers to confirm this independent association of vitamin D deficiency with Blount disease. LEVEL OF EVIDENCE: Level III retrospective study.