Slipped capital femoral epiphysis in primary hyperparathyroidism - Case report with literature review

Abstract

Primary hyperparathyroidism is not common in children and adolescents. Association of slipped capital femoral epiphysis and hyperparathyroidism is rare. We report the case of a 15-year-old boy who presented with pain in both hips and limping. He was diagnosed to have bilateral slipped capital femoral epiphysis (SCFE) and underwent cancellous screw fixation of both hips. He had proximal myopathy and pain at multiple points over the chest. Examination revealed an emaciated patient with genu valgum, rachitic rosary, Harrison's sulcus, and bony tenderness over the ribs. Investigations showed PTH-dependent hypercalcemia with serum calcium levels reaching >17 mg/dL and electrocardiography showing QTc shortening. Imaging revealed parathyroid adenoma. The work up for multiple endocrine neoplasia syndromes (MEN) was negative. Serum calcium was controlled by medical management and patient underwent expedited surgery. Postoperatively serum calcium levels normalized and patient became better biochemically and clinically including resolution of skeletal changes on follow-up. Only 12 cases of SCFE associated with primary hyperparathyroidism have been reported worldwide till date including the current case. The literature has been reviewed and it indicates that SCFE is associated with late adolescent age and severe hyperparathyroidism (severe bone disease, higher parathormone, serum calcium, and alkaline phosphatase levels).

Slipped Capital Femoral Epiphysis Associated with Endocrinopathy

“…This is not only cost-effective, but efficient as well as sensitive and specific for identifying underlying endocrine disease 18 . Multiple reports and case series have noted abnormalities in these parameters 26,29 . In their series, Burrow et al recommended that all patients presenting with an SCFE with height of <10th percentile be chemically screened for endocrine disease 18 .…”

“…Grade of Recommendation* All children presenting with a confirmed SCFE should have height and weight measured at presentation 16,26,29,32 . B…”

“…In the setting of operative stabilization, following or in conjunction with adenoma resection, the orthopaedist should be aware of the potential for hypocalcemia following removal of the offending adenoma 22 , and patients may benefit from calcium supplementation 25 . Additionally, contralateral hip stabilization is recommended because of the risk of a contralateral SCFE, which has been reported to be as high as 100% 5,9,22,23,26,27 . Hyperparathyroidism in SCFE is usually the result of secondary hyperparathyroidism in conjunction with renal osteodystrophy, which is discussed below 23 .…”

“…disease 18 . Multiple reports and case series have noted abnormalities in these parameters 26,29 50 . However, height of ,10th percentile was the most useful screening tool, with a reported 75% sensitivity and a 97% specificity.…”

Diagnosis and Management of Unstable Slipped Capital Femoral Epiphysis

“…Hypothyroidism has been shown to be one of the predominant laboratory findings 36 . Although some reports point to differences in bone mineralization testing results 38,39 (i.e., vitamin D, calcium, and parathyroid hormone) or renal osteodystrophy as a cause 37 , routine screening with these tests is typically not necessary and may not be discriminative in patients with or without SCFEs 74-76 . Other atypical presentations, including Klinefelter syndrome, have been reported 77 .…”