Case series - Slipped capital femoral epiphysis in three members of same family as an unusual presentation

Slipped capital femoral epiphysis in three members of same family ISSN: 2394-0026 (P)Case Series ISSN: 2394-0034 (O) Case series - Slipped capital femoralepiphysis in three members of same family as an unusual presentationMeraj Rentia1*, Krunal kalaria1, Himanshu Singla1, Shreedevi Patel2, B.N. Patel2 1P.G. Student, 2ProfessorRadiology Department, SBKS Medical Institute & Research Centre, Sumandeep Vidyapeeth, Vadodara, Gujarat, India*Corresponding author email: [email protected] to cite this article: Meraj Rentia, Krunal kalaria, Himanshu Singla, Shreedevi Patel, B.N. Patel.Case series - Slipped capital femoral epiphysis in three members of same family as an unusualpresentation. IAIM, 2015; 2(4): 190-194.Available online at www.iaimjournal.comReceived on: 20-03-2015 Accepted on: 30-03-2015AbstractSlipped capital femoral epiphysis is a disorder of the hip that affects children in late childhood andearly adolescence, characterized by medial and posterior displacement of the proximal femoralepiphysis on the metaphysis. Although the diagnosis and treatment of slipped capital femoralepiphysis have been well described, the search for its cause and a method of early identificationcontinues. We have reported here an interesting case of a bilateral slipped capital femoral epiphysisas an unusual presentation in one family - father and two siblings, had no record of any hormonalimbalances or endocrine abnormalities; had good nutrition; and presented with atypicalcharacteristics of slipped capital femoral epiphysis.Key wordsSlipped capital femoral epiphysis, X-ray, Diagnosis of slipped epiphysis.Introduction X-ray. Slipped capital femoral epiphysis (SCFE) is most common in the adolescent period (i.e. boysSlipped capital femoral epiphysis is a disorder of aged 10-16 years and girls aged 12-14 years).the hip that affects children in late childhood Males have 2.4 times the risk compared withand early adolescence. It is characterized by females. The left hip is affected more commonlymedial and posterior displacement of the than the right [1, 2].proximal femoral epiphysis on the metaphysis.This results in the classic varus appearing hip onInternational Archives of Integrated Medicine, Vol. 2, Issue 4, April, 2015. Page 190Copy right © 2015, IAIM, All Rights Reserved.

Slipped capital femoral epiphysis in three members of same family ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)Some hips may slip in a postero-lateral was investigated with X-ray of both lower limbs.displacement, producing an apparent valgus (Photo – 2)deformity and a so-called valgus SCFE. Thisoccurs when shearing forces applied to the Photo – 1: X-ray findings suggestive of bilateralfemoral head exceed the strength of the capital coxa vera deformity with slipped epiphysis.femoral physis. The exact etiology is unknown,but is believed to be secondary to multiplefactors, including obesity which increasesmechanical strain on the physis. The periostealthinning and widening of the physis seen duringrapid adolescent growth acceleration may alsobe a predisposing factor for the weakening ofthe physis. Only small percentage of SCFE (5.2–6.9%) is associated with endocrinopathies suchas hypothyroidism or growth hormonedeficiency. Short stature, early age atpresentation, and the atypical appearance of avalgus SCFE have all been suggested asindicators for endocrinopathy screening [3].Case Series Photo – 2: X-ray findings suggestive of slipped epiphysis with coxa vera deformity.We have presented the 3 cases of slipped capitalfemoral epiphysis in one family: father and twosiblings - daughter and son.Patient - 1The first child (7 years old girl) presented with ahistory of limping gait and difficulty in walking.At presentation, she was diagnosed with astable, mild left hip slipped capital femoralepiphysis. Her medical history was remarkableexcepting the above mentioned complaints inher gait. Patient was investigated with X-rays ofboth lower limbs. (Photo – 1)Patient - 2 Patient - 3The second child (6 years old boy) presented The third patient was father of both children (39with similar history as his sister i.e., limping gait years old) complaint of difficulty in walking andwhile walking. The patient was evaluated with valgus deformity in both knees. (Photo – 3)normal birth history and no developmentalanomaly excepting the difficulty in gait since thetime she learned started walking. Patient camein our department with above complaints andInternational Archives of Integrated Medicine, Vol. 2, Issue 4, April, 2015. Page 191Copy right © 2015, IAIM, All Rights Reserved.

Slipped capital femoral epiphysis in three members of same family ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)Photo – 3: X-ray findings suggestive of slipped Although the cause of slipped capital femoralepiphysis with coxa vera deformity. epiphysis is still debated, most sources agree with regard to its epidemiology and demographics [1, 4]. Most patients with slipped capital femoral epiphysis are obese, with weights above the 95th percentile according to age at the time of diagnosis [3]. The racial predilection of slipped capital femoral epiphysis is 1.0 for Caucasians, 4.5 for Pacific Islanders, 3.9 for African Americans, and 2.5 for Hispanics [1, 8]. Several case series support these demographic representations in their descriptions of the occurrence of more than one case of slipped capital femoral epiphysis in the same family [7, 9, 10, 11].Discussion Our series, however, is unique in the consistent atypical presentation of baseline characteristics.Our case series is unique given the atypical The patients were siblings, both sister andpresentation characteristics: the patients were brother and not obese. These atypicalnon-obese, with bilateral involvement, and no characteristics are important indicators that ifhistory of endocrine problems. According to Kay there is a hereditary or genetic link with slipped[4], after a diagnosis of slipped capital femoral capital femoral epiphysis, the mechanism mayepiphysis has been made in a family member, a transcend the physical characteristics ofsecond family member has been reported to be patients. The patients in our series did not wantaffected in 3% to 7% of reported cases. There to pursue genetic testing.are few reports of slipped capital femoralepiphysis occurring in siblings. Loder, et al. [12] found that slipped capital femoral epiphysis occurs at a higher incidence inSeveral studies have described the genetic children with endocrine disorders, specificallycharacteristics of children presenting with hypothyroidism. Thyroid dysfunction wasslipped capital femoral epiphysis. In the past present in another familial case series of slippedseveral decades, human leukocyte antigen capital femoral epiphysis in Australia [11]. Aftertesting has allowed for inferences about possible we noticed the familial trend in our patients,genetic causes of slipped capital femoral endocrine studies, including thyroid tests, wereepiphysis, but such studies differ by region and performed on the second and third patients.do not identify a distinct genetic marker [5, Their thyroglobulin, thyroid-stimulating6]. The inheritance pattern seen in familial hormone, and T3 levels were normal; the onlyoccurrences of slipped capital femoral epiphysis notable deviation was a decreased serumis thought to be autosomal dominant with creatinine level in both patients.variable penetrance [4, 7]. Loder, et al. [12] also noted that previous use of growth hormone supplementation was an associated factor with slipped capital femoralInternational Archives of Integrated Medicine, Vol. 2, Issue 4, April, 2015. Page 192Copy right © 2015, IAIM, All Rights Reserved.

Slipped capital femoral epiphysis in three members of same family ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)epiphysis [1]. None of our patients were on can affect the different incidence of slippedgonadotropin-releasing hormone supplements capital femoral epiphysis across populations.or had previously taken these substances. However, currently available studies suggestSimilarly, their testosterone and estrogen levels that first degree relatives of patients withwere normal. Systemic diseases, such as renal slipped capital femoral epiphysis are at anosteodystrophy, have commonly been increased risk for the disease, and the affectedassociated with patients with slipped capital families should be educated accordingly, andfemoral epiphysis who have heights less than screened when indicated.the 10th percentile for age; however, none of ourpatients had any signs of systemic diseases or Referenceschondrodysplasias [4]. Finally, none of our 1. Aronsson DD, Loder RT, Breur GJ,patients had undergone previous radiation Weinstein SL. Slipped capital femoraltherapy, which also has been implicated in epiphysis: Current concepts. J Am Acadslipped capital femoral epiphysis [4]. Orthop Surg., 2006; 14(12): 666–679.The cause of slipped capital femoral epiphysis 2. Loder RT, Richards BS, Shapiro PS,most likely involves biochemical and Reznick LR, Aronson DD. Acute slippedbiomechanical factors that combine to weaken capital femoral epiphysis: Thethe physis [1]. All 3 of our patients participated importance of physeal stability. J Bonein similar athletic endeavors such as field Joint Surg Am., 1993; 75(8): 1134–1140.hockey, volleyball, softball, soccer, and skiing,and all described themselves as being “very 3. Loder RT. The demographics of slippedactive” in these sports. The sisters also reported capital femoral epiphysis: Anconsuming well-balanced diets. They ate many international multicenter study. Clinof the same foods and took multivitamins most Orthop Relat Res., 1996; 322: 8–27.days of each week. We have previously reportedon an association between slipped capital 4. Kay RM. Slipped capital femoralfemoral epiphysis and vitamin D deficiency [13]. epiphysis. In: Morrissy RT, Weinstein SL,It was interesting to note, however, there is no eds. Lovell and Winter’s Pediatricprevious research reporting the combination of Orthopaedics. Philadelphia, PA:cardiac abnormalities and slipped capital Lippincott Williams & Wilkins; 2006, p.femoral epiphysis. 1085–1124. 5. Flores M, Satish SG, Key T. Slipped capital femoral epiphysis in identical twins: is there an HLA predisposition?Conclusion Report of a case and review of the literature. Bull Hosp Jt Dis., 2006; 63(3–While familial slipped capital femoral epiphysis 4): 158–160.appears to be associated with mainly autosomal 6. Wong-Chung J, Al-Aali Y, Farid I, Al-Aradidominant mode of inheritance with variable A. A common HLA phenotype in slippedpenetrance in certain populations, we believe capital femoral epiphysis? Int Orthop.,that in most other populations, a multi-factorial 2000; 24(3): 158–159.form of inheritance is more likely, in this disease. 7. Moreira JF, Neves MC, Lopes G, GomesMore studies need to be done to understand the AR. Slipped capital femoral epiphysis: aunderlying genetics of this disease, with the report of 4 cases occurring in onerecognition that local environmental conditions family. Int Orthop., 1998; 22(3): 193– 196.International Archives of Integrated Medicine, Vol. 2, Issue 4, April, 2015. Page 193Copy right © 2015, IAIM, All Rights Reserved.

Slipped capital femoral epiphysis in three members of same family ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)8. Lehmann CL, Arons RR, Loder RT, Vitale capital femoral epiphysis: A report andMG. The epidemiology of slipped capital considerations in management. Aust N Zfemoral epiphysis: An update. J Pediatr J Surg., 1998; 68(9): 647–649.Orthop., 2006; 26(3): 286–290. 12. Loder RT, Wittenberg B, DeSilva G.9. Montsko P, de Jonge T. Slipped capital Slipped capital femoral epiphysisfemoral epiphysis in 6 of 8 first-degree associated with endocrine disorders. Jrelatives. Acta Orthop Scand., 1995; Pediatr Orthop., 1995; 15(3): 349–356.66(6): 511–512. 13. Skelley NW, Papp DF, Lee RJ, Sargent10. Brown D. Seasonal variation of slipped MC. Slipped capital femoral epiphysiscapital femoral epiphysis in the United with severe vitamin D deficiency.States. J Pediatr Orthop., 2004; 24(2): Orthopedics, 2010; 33(12): 921.139–143.11. Diwan A, Diamond T, Clarke R, Patel MK,Murrell GA, Sekel R. Familial slippedSource of support: Nil Conflict of interest: None declared.International Archives of Integrated Medicine, Vol. 2, Issue 4, April, 2015. Page 194Copy right © 2015, IAIM, All Rights Reserved.