Prepubertal onset of slipped capital femoral epiphysis associated with hypothyroidism: a case report and literature review

A Role for Thyroid Testing in Slipped Capital Femoral Epiphysis? 32% Rate of Abnormal Values in Tested Patients

BACKGROUND

Hypothyroidism is a known risk factor for slipped capital femoral epiphysis (SCFE), and prior studies of hypothyroid-associated SCFE have demonstrated an incidence of up to 6%. However, there is limited evidence and no formal practice guidelines regarding whether patients presenting with SCFE should undergo screening for endocrine disorders. This study aims to investigate the incidence of abnormal thyroid function studies in patients presenting with SCFE.

METHODS

This was a retrospective review of all patients aged 0 to 18 years treated for SCFE at a single pediatric hospital from January 2015 to July 2022. On presentation, patients' BMI, thyroid-stimulating hormone (TSH), free T4, vitamin D, creatinine, BUN, and HbA1c levels were documented. Follow-up and treatment for any identified endocrinopathies were noted. In addition, the chronicity, stability, and severity of their slips were recorded.

RESULTS

Ninety-eight patients with 106 hips were included in this study. TSH was obtained at the time of initial presentation in 66% (n=65/98) of patients. Median TSH was 2.99 (range: 0.02 to 919, std dev: 132.4). The normal reference range for our institution is 0.5 to 4.5 mcIU/mL. Thirty-two percent (n=21/65) of patients with a documented TSH had an abnormal value. Of those patients who had an elevated TSH, 3 were diagnosed with clinical hypothyroidism and went on to treatment with levothyroxine (n=3/19, 16%), 2 patients had been started on levothyroxine before presentation (n=2/19, 11%), and 2 patients were followed in endocrinology clinic until their TSH levels had normalized without further intervention (n=2/19, 11%).

CONCLUSIONS

Screening of our SCFE population revealed a 32% incidence of thyroid abnormalities which affected treatment in 24% of those patients. This is a much higher incidence of hypothyroid-associated SCFE than previously demonstrated in the literature and has prompted us to start including thyroid screening studies as a routine part of our workup for all patients with SCFE.

LEVEL OF EVIDENCE

Level III.

Quantifying Risk Factors for Slipped Capital Femoral Epiphysis and Postslip Osteonecrosis

BACKGROUND

Slipped capital femoral epiphysis (SCFE) is a disorder of the proximal femoral physis occurring in late childhood and adolescence. Previously postulated risk factors include obesity and endocrinopathies. The purpose of this investigation was to identify risk factors for developing SCFE, as well as postslip osteonecrosis (ON), among the United States pediatric population.

METHODS

A national database investigation was performed using PearlDiver Technologies, Inc., queried for SCFE and ON using International Classification of Disease codes (2010 to 2020). Regression analyses to determine the risk of developing a SCFE, and ON after a patient has already been diagnosed with a SCFE ("postslip"). Propensity matching between SCFE and control groups generated a pseudo-randomization model to compare the relative risk.

RESULTS

There were 11,465 patients with SCFE available in the database, matched with 134,680 controls. After matching, vitamin D deficiency, obesity, hypothyroidism, and growth hormone use were risk factors for developing SCFE [relative risk ranges from 1.42 (95% CI: 1.21-1.39, vitamin D deficiency) to 3.45 (95% CI: 3.33-3.57, obesity)]. ON risk factors were vitamin D deficiency [1.65 (1.26-2.14)] and hypothyroidism [1.49 (1.10-2.07)].

CONCLUSIONS

This United States national database study quantified risk factors of developing an SCFE and postslip ON. Obesity is the most significant risk factor for the development of a slip, but not ON. Growth hormone use, hypothyroidism, and vitamin D deficiency are also risk factors for SCFE development, whereas only the latter two were associated with ON. These findings demonstrate the public health implications of obesity and comorbid conditions in pediatric hip pathology.

LEVEL OF EVIDENCE

Level III.

Atypical presentations of primary acquired hypothyroidism - a case series

Primary acquired hypothyroidism in children manifests with a myriad of clinical presentations. Clinical features can be insidious in nature, often under the guise of non-specific presentations to other subspecialties prior to referral to the endocrinologist. Growth failure is a hallmark feature in these children alongside their presenting clinical symptomology which needs to be identified through detailed history, physical examination and analysis of the growth charts. In this case series, we discuss 5 atypical presentations of acquired primary hypothyroidism with multisystemic involvement, including musculoskeletal, hepatobiliary, gynaecological and haematological manifestations. This is of importance as untreated hypothyroidism leads to fatigue, decreased physical activity, suboptimal height gain, disordered puberty and poor neurocognitive development in children with long term detrimental outcomes.

Slipped Capital Femoral Epiphysis Pathogenesis and Its Relation to Obesity—Where Do We Stand? A Narrative Review

Slipped capital femoral epiphysis (SCFE) is the most common adolescent hip disorder in children 9–15 years old with an incidence that ranges from 0.33:100,000 to 24.58:100,000. Idiopathic SCFE is strongly associated with obesity, while atypical SCFE is associated with endocrinopathies, metabolic and renal disease, radiation therapy, and chemotherapy. In this review, we summarized the current data regarding the pathogenesis of SCFE and its association to obesity. In the last years, there have been increasing evidence regarding the implication of obesity in the pathogenesis of SCFE, but no definitive mechanism has been proven. The etiology is probably multifactorial, with both mechanical and metabolic factors contributing to the disease, with the later gaining more ground, especially in obese patients. Understanding what causes the disease will help paediatricians and orthopaedists develop more efficient strategies for treating patients and diminishing complication rates.

Slipped Capital Femoral Epiphysis Managed by Ganz Safe Surgical Dislocation of Hip: A Case Report with 2 Years Follow-up

Introduction

Slipped capital femoral epiphysis (SCFE) is commonly managed by in situ screw fixation. However, higher grades of slips require restoration of normal anatomy of the femoral head without compromising the blood supply.

Case Report

A 16-year-old adolescent male presented with the left hip pain and progressive limping for 4 days with no history of previous trauma. On examination, the patient had severe tenderness and gross restriction of movements. Radiological examination revealed Grade 2 acute on chronic SCFE with unstable slip. Modified Dunn procedure through Ganz surgical hip dislocation facilitated the complete restoration of normal anatomy without avascular necrosis of femoral head changes at 2 years of follow-up.

Conclusion

Ganz safe surgical dislocation of the hip is safe for the femoral head, preserving its blood supply in toto and the modified Dunn procedure facilitated the complete restoration of normal anatomy even in acute on chronic type of SCFE cases.

Differences in pathways contributing to thyroid hormone effects on postnatal cartilage calcification versus secondary ossification center development

The proximal and distal femur epiphyses of mice are both weight-bearing structures derived from chondrocytes but differ in development. Mineralization at the distal epiphysis occurs in an osteoblast-rich secondary ossification center (SOC), while the chondrocytes of the proximal femur head (FH), in particular, are directly mineralized. Thyroid hormone (TH) plays important roles in distal knee SOC formation, but whether TH also affects proximal FH development remains unexplored. Here, we found that TH controls chondrocyte maturation and mineralization at the FH in vivo through studies in thyroid stimulating hormone receptor (Tshr^-/-) hypothyroid mice by X-ray, histology, transcriptional profiling, and immunofluorescence staining. Both in vivo and in vitro studies conducted in ATDC5 chondrocyte progenitors concur that TH regulates expression of genes that modulate mineralization (Ibsp, Bglap2, Dmp1, Spp1, and Alpl). Our work also delineates differences in prominent transcription factor regulation of genes involved in the different mechanisms leading to proximal FH cartilage calcification and endochondral ossification at the distal femur. The information on the molecular pathways contributing to postnatal cartilage calcification can provide insights on therapeutic strategies to treat pathological calcification that occurs in soft tissues such as aorta, kidney, and articular cartilage.

Primary Hypothyroidism Presenting as Slipped Capital Femoral Epiphysis in an Adult Patient : A Case Report and Review of Literature

INTRODUCTION

Slipped capital femoral epiphysis (SCFE) is rare in adults and is often associated with endocrine pathology.

CASE REPORT

We report a case of a 21-year-old male presenting with an acute on chronic left hip SCFE who was diagnosed with primary hypothyroidism on the investigation. The patient was treated for hypothyroidism and positional reduction with in-situ fixation was carried out with two cannulated cancellous screws for the SCFE. At the latest follow-up of 30 months, patient remains asymptomatic, euthyroid, with a nearly full range of motion in the hips, significant functional improvement, fused physis on radiographs, and no signs of avascular necrosis.

CONCLUSION

SCFE is a potentially devastating but avoidable complication in children/adults with the endocrine disorder and there may be a possible role for a screening pelvic radiograph in detecting this condition earlier.

Slipped Capital Femoral Epiphysis as a Presentation of Underlying Metabolic Disorders: Pseudohypoparathyroidism and Juvenile Hypothyroidism

Slipped capital femoral epiphysis (SCFE) is an abnormality of the proximal femoral physis typically occurring in adolescents and most commonly associated with obesity, although its exact etiology is unknown. In addition to obesity, other associations and predisposing factors proposed in the literature include trauma, vascular injury or compromise, and immunologic, genetic, and metabolic conditions. While not common, metabolic conditions are known to predispose to SCFE and it is essential for radiologists to recognize SCFE as a possible initial presentation of an underlying metabolic disorder. Understanding imaging findings and identification of atypical presentations of SCFE by radiologists can assist clinicians in guiding workup and lead to expedited treatment to prevent worsening outcomes associated with developmental delay.

Fate of patients with slipped capital femoral epiphysis (SCFE) in later life: risk of obesity, hypothyroidism, and death in 2,564 patients with SCFE compared with 25,638 controls

Background and purpose - Associations between obesity and slipped capital femoral epiphysis (SCFE) during adolescence are described; however, few studies report on the lifetime risk of obesity in patients with SCFE. In addition, with the obesity epidemic in children and adolescents, an increasing incidence of SCFE might be expected. An association of SCFE with hypothyroidism seems ambiguous, and the association between SCFE and depression and all-cause mortality has not yet been evaluated. This study investigates the associations of SCFE with obesity, hypothyroidism, depression, and mortality, and putative changes in the yearly incidence of SCFE.Patients and methods - 2,564 patients diagnosed with SCFE at age 5-16 diagnosed between 1964 and 2011 were identified in the Swedish Patient Register. These were matched for age, sex, and residency with unexposed control individuals. Cox regression models were fitted to estimate the risk of obesity, hypothyroidism, depression, and death, in exposed compared with unexposed individuals.Results - The risk of obesity (HR 9, 95% CI 7-11) and hypothyroidism (HR 3, CI 2-4) was higher in SCFE patients compared with controls. There was no increase in the risk of developing depression (HR 1, CI 1-1.3) in SCFE patients. In contrast, all-cause mortality was higher in SCFE patients than in controls (HR 2, CI 1-2). The incidence of SCFE did not increase over the past decades.Interpretation - Patients with SCFE have a higher lifetime risk of obesity and hypothyroidism and a higher risk of all-cause mortality compared with individuals without SCFE. These findings highlight the lifetime comorbidity burden of patients who develop SCFE in childhood, and increased surveillance of patients with a history of SCFE may be warranted. The incidence of SCFE did not increase over the last decades despite increasing obesity rates.

The Approach to the Child with Joint Complaints

This article focuses on creating an orderly approach to history taking, examination, and ordering appropriate investigations when caring for a child with joint complaints. It classifies complaints as those with and without pain, swelling, or fever and of short or long duration. It recommends an approach to the physical examination and both suggests and discourages various laboratory and imaging studies.