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Slipped Upper Femoral Epiphysis following Treatment with Human
M. W. FIDLER and C. G. D. BROOK
J Bone Joint Surg Am. 1974;56:1719-1722.
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Publisher Information The Journal of Bone and Joint Surgery
20 Pickering Street, Needham, MA 02492-3157
Slipped Upper Femoral Epiphysis following
Treatment with Human Growth Hormone
BY M. W. FIDLER, F.R.C.S.*, AND C. 0. D. BROOK, M.D.t, LONDON, ENGLAND
From the Hospitalfor Sick Children and the Institute of Child Health,
University of London, London
Although Harris, in 1950, described the anatomical basis for slipped epiphysis in rats
treated with growth hormone, slipping of the upper femoral epiphysis during treatment
with human growth hormone in children has not previously been reported.
CASE I . In 1962 a seven-year-old boy who had signs of puberty when he was four years old was first seen at
the Hospital for Sick Children. Craniopharyngioma was diagnosed, and the child was treated with radiotherapy
followed by administration of cortisone and thyroxine. In I 963, progressive spastic paraplegia developed from
an intramedullary expanding lesion which was treated successfully with radiotherapy.
The patient’s growth ceased in 1966. Growth-hormone deficiency was revealed by the insulin-induced
hypoglycemia test, and in May 197 1 he began receiving injections of ten milligrams of human growth hormone
In September 197 ,1 the patient was referred to the Royal National Orthopaedic Hospital for a complaint of
stiff. painful hips and a waddling gait. present for eight weeks. Clinical and examinations
revealed bilateral slipped upper femoral epiphysis (Figs. I-A and I-B). His chronological age was sixteen and
his skeletal age, fourteen years. The epiphyseolyses were stabilized with Newman’s pins and the deformities
were corrected by bilateral biplane trochanteric osteotomy His
. subsequent progress was satisfactory: the
epiphyses and osteotomies united (Fig. 2) and normal physical
activities were resumed. Growth-hormone
therapy was discontinued in April 1972.
CASE 2. An eight-year-old girl had a craniopharyngioma removed in 1964 and postoperative radiotherapy
was administered. In 1968, at the age oftwelve years, she was seen at the Hospital for Sick Children because of
poor growth. Her skeletal age at that time was nine years and growth-hormone deficiency was diagnosed by the
Figs. 1-A and I-B: Case . Anteroposterior
1 and lateral roentgenograms showing bilateral slipped upper
* University College Hospital, Gower Street, London, WCIE 6AU, England.
t Middlesex Hospital, London, W1N 8AA, England.
VOL. 56-A, NO. 8, DECEMBER 1974 1719
1720 M. W. FIDLER AND C. G. D. BROOK
insulin-induced hypoglycemia test. She began to receive human growth hormone. ten milligrams twice weekly.
on October 22. 1969.
On November 26. I 969, she was admitted to the Royal Portsmouth Hospital with a history of a limp and a
painful left hip of one week’s duration. Examination disclosed slipping of the left upper femoral epiphysis (Figs.
3-A. 3-B, and 3-C). which was stabilized by Moore’s pins.
In November, 1970. the patient had a urinary-tract infection. The right hip was painful and roentgenograms
showed slight slipping of the right upper femoral epiphysis. Her hip symptoms receded during bed rest and there
was no further displacement of the epiphysis. Thereafter her progress was satisfactory. By August 1973, the
epiphyseolyses were healing. The pins were removed in October 1973 because of irritation ofthe skin. At that
time the patient was still receiving growth hormone.
Hypopituitarism causes delayed maturation of epiphyseal growth plates. Bilateral
slipped upper femoral epiphysis has been reported in six patients so affected Both
children reported here had retardation of skeletal age when their epiphyseolyses occurred.
Case I . Anteroposterior roentgenogram showing the united. stabilized epiphyses and correction of deformities
by suhtrochanteric osteotomles.
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SLIPPED UPPER FEMORAL EPIPHYSIS 1721
FIG. 3-B FIG. 3-C
Figs. 3-A, 3-B, and 3-C: Case 2. Anteroposterior and lateral roentgenograms showing the left slipped upper
femoral epiphysis. The right epiphysis is undisplaced.
The boy (Case I ) had a skeletal age of fourteen years at the chronological age of sixteen
years, and the girl (Case 2) had a skeletal age of ten years at the chronological age of
thirteen years. Skeletal ages were determined from roentgenograms of the left hand and
wrist 2 Apart from delayed maturation these epiphyses appeared normal.
Harris noted that in rats growth hormone causes changes in the epiphyseal growth
plate within four weeks. There is increased proliferation ofthe second ofthe four layers of
cells in the growth plate, followed by thickening and decreased shearing strength of the
VOL. 56-A, NO. 8, DECEMBER 1974
1722 M. W. FIDLER AND C. G. D. BROOK
third layer through which the slipping occurs. These changes may be reversed by the ad-
ministration of sex hormones. The patient in Case 1 had been receiving human growth
hormone for two months before bilateral hip symptoms developed; the patient in Case 2
had a history of minor injury on the left side thirteen weeks before admission. The slipping
could have been initiated at that time, but it was not until four weeks after starting
human growth-hormone treatment that significant symptoms developed. There was no
history of injury to the right hip, in which the slipped epiphysis was noted thirteen months
after the start of human growth-hormone therapy. A decrease in shearing strength in
human epiphyses similar to that shown by Harris in rats would be consistent if human
growth hormone were administered for longer than four weeks, as in our two patients. The
bilateral epiphyseal displacement in these children could, therefore, have been related not
only to the effects of hypopituitarism, but also to the relative excess of growth hormone
following treatment. Involvement of both hips suggests a systemic cause for the displace-
Of 267 hypopituitary children taking part in the Medical Research Council trial of
human growth-hormone treatment, only the two patients reported here had bilateral
slipped epiphysis. Although the incidence of bilateral slipped upper femoral epiphysis in
hypopituitary children not receiving human growth hormone is unknown, the incidence in
hypopituitary children being treated with human growth hormone is relatively high. The
over-all annual incidence of slipped upper femoral epiphysis has been variously estimated
at between two and thirteen per 100,000 and it was bilateral in only twenty-three of the
100 cases reported by Burrows.
NOTE: We wish to thank Mr. G. C. Lloyd-Roberts for his help and advice in he preparation of this article. We would also like to thank Professor
J. M. Tanner. Mr. J. D. Allison and Mr. A. Catterall for permission to publish details of the children under their care. and the Medical Research
Council Working Party controlling the trial of human growth hormone. for permission to publish this report.
1. BURROWS, H. J.: Slipped Upper Femoral Epiphysis. Characteristics of a Hundred Cases. J. Bone and Joint
Surg. 39-B: 641-658,
, Nov. 1957.
2. GREULICH, W. W., and PYLE, S. I. : Radiographic Atlas of Skeletal Development of the Hand and Wrist.
Stanford, California, Stanford University Press, 1959.
3. HARRIS, W. R.: The Endocrine Basis for Slipping of the Upper Femoral Epiphysis. An Experimental Study.
J. Bone and Joint Surg., 32-B: 5-11, Feb. 1950.
4. HENRIKSON, BJORN:The Incidence of Slipped Capital Femoral Epiphysis. Acta Orthop. 40:
5. KELSEY, J. L. ; KEGGI, K. J.; and SOUTHWICK, W. 0. : The Incidence and Distribution of Slipped Capital
Femoral Epiphysis in Connecticut and Southwestern United States. J. Bone and Surg. I 203-
Joint , 52-A:
1216, Sept. 1970.
6. L6FGREN, L.: Slipping the
of Upper Femoral Epiphysis, Signs of Endocrine Disturbance, Size of Sella Tur-
cica. Two Illustrative Cases of Simultaneous Slipping of the Upper Femoral Epiphysis and Tumour of the
Hypophysis. Acta Chir. Scandinavica, 106: 153-165, 1953.
7. NEWMAN, P. H.: The Surgical Treatment of Slipping of the Upper Femoral Epiphysis. J. Bone and Joint
Surg. 42..B: 280-288,
, May 1960.
8. SEMPLE, J. C. , and GOLDSCHMIDT, R. G.: Epiphyseal Maturation and Slipping Femoral Epiphysis a
Hypopituitary Dwarf. Orthopaedics: Oxford, 2: 31-42, 1969.
9. TISSINK, J. : In Proceedings of the Netherlands Orthopaedic Society. J. Bone and Joint , 46-B:
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