Complete slipping of the capital femoral epiphysis after hematogenous osteomyelitis =================================================================================== * Puneet Monga * C.S. Jagannath * Rajeev Verma * V.K. Sharma The cause of slipped capital femoral epiphysis is mostly unknown (idiopathic), although it may be associated with endocrine disorders (e.g., hypothyroidism or administration of growth hormone), renal osteodystrophy, malnutrition and radiation therapy.1 The association of septic arthritis of infancy with epiphyseal separation is a known entity;2 however, occurrence in adolescents is unusual. An 11-year-old premenarchal, nonobese girl presented with pain in the left hip for 1 month. She came to us because of inability to bear weight on the affected lower limb for 1 month. She had been trying to walk using a stick for support. There was no history of trauma. She had been admitted to the pediatric ward of the hospital 2 months earlier for management of pyopneumothorax, for which chest tube drainage was needed and antibiotics were administered parenterally. Associated pain in the left hip at that time was not thoroughly investigated and subsided within 1 week. Examination revealed an afebrile girl of average build and nutrition, weighing 22 kg. Radiography revealed a complete separation of the capital femoral epiphysis. Under general anesthesia, the hip was exposed via a Smith-Petersen approach. The capital femoral epiphysis appeared completely separated, and the femoral neck revealed cloacae. Infected granulation tissue was present inside the hip joint (which, on histopathologic examination showed a chronic inflammatory reaction). The soft tissues were thoroughly debrided. After reduction, the epiphysis was pinned using threaded Moore’s pins. Antibiotics were given parenterally for 2 weeks then orally for another 4 weeks. The girl was kept in a plaster of Paris hip spica for 6 weeks. Gradual weight-bearing using axillary crutches was instituted over the next 6 weeks. The pins were removed at 1 year, after ascertaining that epiphysiodesis had occurred. Follow-up at 2 years revealed a satisfactory functional outcome3 (painless stable hip, > 70° range of motion and ability to perform activities of daily living). There was 2 cm shortening of the affected limb. Radiography revealed epiphysiodesis in coxa vara with resorption of the femoral neck and evidence of avascular necrosis of the capital femoral epiphysis (Fig. 1). ![FIG. 1](http://canjsurg.ca/https://www.canjsurg.ca/content/cjs/46/1/59.2/F1.medium.gif) [FIG. 1](http://canjsurg.ca/content/46/1/59.2/F1) FIG. 1 Radiograph of the hips 1 year after open reduction for slipped capital femoral epiphysis in the left hip. There is epiphysiodesis in coxa vara with resorption of the femoral neck and evidence of avascular necrosis of the capital femoral epiphysis. Complete slipping of the capital femoral epiphysis secondary to hematogenous osteomyelitis is hitherto unreported in adolescent children. There are various pointers to the cause of the slip being secondary to osteomyelitis. These are the absence of trauma, absence of any endocrinologic abnormality in a nonobese patient, association with a significant source of metastatic infection (pyopneumothorax) and a temporal relationship in the evolution of symptoms. The intraoperative finding of cloacae in the femoral neck and the presence of infected granulation tissue are definitive evidence of osteomyelitis. In this case, the diagnosis of the slip was missed initially while the patient was being treated for chest infection. This is an all too common error in slipping of the capital femoral epiphysis, and may delay the diagnosis for months or years.4 A high level of awareness among pediatricians is recommended and a low threshold should be kept for obtaining a hip radiograph in children with hip pain. A similar case of incomplete slipping of the capital femoral epiphysis secondary to septic arthritis of the hip in an adolescent has been reported. 5 It was managed by incision, drainage and in situ pinning. Our case differs because in our patient there was no history of trauma, complete separation of the epiphysis, delayed treatment, open reduction and a satisfactory functional outcome. Our rationale for choosing open reduction and pinning was governed by our attempts to achieve débridement, obtain tissue for biopsy and culture, restore normal anatomy and achieve epiphysiodesis. The girl eventually had a satisfactory functional outcome despite radiologic evidence of avascular necrosis of the capital femoral epiphysis. ## Footnotes * (Presented at the Annual Conference of the Indian Orthopaedic Association, 2001, Ahmedabad, India) ## References 1. 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 1983;180:188–97. [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=6354545&link_type=MED&atom=%2Fcjs%2F46%2F1%2F59.2.atom) 2. Choi IH, Pizzutillo PD, Bowen JR, Dragann R, Malhis T. Sequalae and reconstruction after septic arthritis of the hip in infants. J Bone Joint Surg Am 1990;72: 1150–65. 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