Neonatal Distal Femoral Epiphysiolysis-A case report and review of the literature.

Bolink SAAN¹, Kerens B², Staal HM³, Robben SGF⁴ ,van Rhijn LW⁵

Abstract:

The authors present a case of a premature neonate, born after caesarian section, with a distal femoral epiphysiolysis. This very rare condition can easily go undiagnosed or misdiagnosed with no pathological findings on conventional X-rays. Using ultrasonography as a diagnostic tool in this case, timely and accurate diagnosis was possible, resulting in appropriate treatment to avoid permanent deformities and dysfunction of the affected limb.

J.Orthopaedics 2010;7(1)e4

Keywords:

epiphysiolysis; epiphysial fracture; distal femur; neonate.

Introduction:

Distal femoral epiphysiolysis (DFE) in the newborn infant is a very uncommon event. This is in contrast to DFE in older children of which more cases have been reported. Over the past 50 years, only 8 reports, with 11 cases of DFE in the newborn child have been described in European and American literature. [1-8] We present a case of neonatal distal femoral epiphysiolysis and describe the use of ultrasonography as a diagnostic tool.

Case Report:

A male patient, weighting 1730g, was born at 31+² weeks pregnancy by caesarian section. After preterm broken membranes, oligohydramnion caused fetal distress which initiated the preterm operative delivery. On day one after birth, the premature neonate presented with minor spontaneous movement (pseudoparalysis) of the right leg. Physical examination showed a red and edematous right upper leg with both right knee and hip maintained in flexion. On palpation of the femur and with passive motion of the leg, visible discomfort was obvious. On conventional X-rays, there were no evident signs of fracture visible, besides the presence of a minimal metaphyseal avulsion fragment at ventral side of the distal femur (figure 1).

Figure 1: Lateral and anteroposterior X-ray of the right leg showing a minimal metaphyseal avulsion fragment on ventral side of the distal femur.

Because of the clinical findings ultrasonography was performed, showing severe ventrally dislocation of the right distal femoral epiphysis with periostal hematoma (figure 2 and 3).

Figure 2: Ultrasonography of the left femur showing normal distal epiphysis.

Figure 3: Ultrasonography of the right femur showing periostal hematoma and ventrally displaced distal epiphysis with intact periosteum and perichondrium.

The diagnosis DFE was made. Manual reposition of the epiphysis with ultrasonographic control was not possible 4 days after birth. Therefore, a conservative treatment was initiated with a plaster cast for comfort during 1 week. Ultrasonographic control showed no progression of dislocation. At 3 weeks after birth, a control X-ray was made, showing diffuse callus formation around the distal femur (figure 4).

Figure 4: Lateral and anteroposterior X-ray of the right leg 3 weeks after birth showing diffuse callus formation around the distal femur.

The cause of the epiphyseal dislocation in this case remains uncertain. Since there was no callus formation on the X-rays, and movement of the fracture while performing ultrasonography 4 days after birth, it is unlikely that the fracture was older than 1 week. The X-rays made at 3 weeks after birth, showing evident callus formation, confirm this hypothesis. Therefore, the fracture was most likely due to a trauma during operative delivery or shortly after birth. In available literature, neonatal DFE has been reported as a complication of delivery. [2,3,4,6,7] Risk factors for obstetric bone injuries in general include malpresentation often leading to obstructed labour, operative deliveries and lack of antenatal care. [9] In this case there was a normal presentation and good antenatal care. However, because of the oligohydramnion, the fetus could have been entrapped in the uterus causing a problem during operative delivery. A cause postpartum is very unlikely because the patient was admitted to the neonatal intensive care unit with constant monitoring.

Discussion :

Distal femoral epiphysiolysis in the newborn infant is a very uncommon event. This suggests that the condition is being underdiagnosed. Little is known about the consequences of this condition in the newborn child. However, in older children epiphyseal fractures of the distal femur have a high incidence of complications, particularly of growth arrest, and treatment favors a conservative approach. [10,11]

Diagnosis of a DFE in the newborn may be difficult with clinical signs of inflammation and can be missed easily on conventional X-rays because the bone matrix in neonates consists of large amounts of cartilage. Therefore, the condition can go undiagnosed or misdiagnosed as septic arthritis, osteomyelitis, paralysis or lymphedema, without appropriate treatment. But still, with no findings on X-rays, there should be a high index of suspicion for this condition.

Other methods than ultrasonography to diagnose epiphysiolysis in neonates are MRI, joint aspiration that reveals haemarthrosis and the presence of fat glubules, and arthrography that shows the displacement of the epiphysis on the metaphysis. Ultrasonography however, is a rather fast, easy to use, patient friendly and cheap diagnostic tool. Because of its ability to visualize the nonossified skeleton in neonates, its dynamic capabilities, its accuracy, and its lack of nonionizing radiation, it has been widely utilized for several decades in pediatric orthopaedics in the diagnosis and follow-up of hip dysplasia. [12] Furthermore, ultrasonography of the distal femoral epiphysis in particular, is considered as a useful and reliable bedside tool for the assessment of skeletal maturity in newborns. [13]

Conclusion:

We present a case of a premature neonate, born after caesarian section, with a distal femoral epiphysiolysis. This rare condition can easily go undiagnosed or misdiagnosed with no pathological findings on conventional X-rays. Recognition by using ultrasound allows timely and accurate diagnosis and appropriate treatment, avoiding permanent deformities and dysfunction of the affected limb.

Reference :

1. Fracture-separation of the distal femoral epiphysis in a premature neonate. Eliahou R, Simanovsky N, Hiller N, Simanovsky N. Journal of Ultrasound in Medicine. 2006 Dec;25(12):1603-5

2. Epiphysiolysis in the distal femur as a birth injury in Cesearean section. Trier H. Ugeskr Laeger. 1992 May 25;154(22):1574-5 Article in Danish

3. Bilateral distal femoral epiphyseal fractures following home delivery: a case report. Journal of the Arkansas Medical Society. 1988 Feb;84(9):364-6. McCollough FL, McCarthy RE.

4. Traumatic separation of the distal femoral epiphysis in the newborn.  Banagale RC. Kuhns LR. Journal of Pediatric Orthopedics. 3(3):396-8, 1983 Jul.

5. Traumatic separation of the epiphysis of the lower end of the femur. Padovani JP, Rigault P, Raux P, Lignac F, Guyonvarch G. Rev Chir Orthop Reparatrice Appar Mot. 1976 Mar;62(2):211-30. Article in French

6. Obstetrical detachment of lower femoral epiphysis. Monteleone M, Scillone GB, Cristiani G. Clin Ortop. 1974 Apr-Jun;25(2):75-83 Article in Italian.

7. Typical obstetric epiphysiolysis of the distal humeral epiphysis in a newborn infant.  Bumbic  S. Srpski Arhiv Za Celokupno Lekarstvo. 98(11):1341-5, 1970 Nov. Article in Serbian

8. Neonatal distal femoral physeal fracture requiring closed reduction and pinning. Mangurten HH, Puppala B, Knuth A. Journal of Perinatology. 2005 Mar;25(3):216-9

9. Bone injuries during delivery. Bhat BV, Kumar A, Oumachigui A. Indian J Pediatr. 1994 Jul-Aug;61(4):401-5.

10. Predicting the outcome of Physeal Fractures of the Distal Femur. Arkader et al. Journal of pediatric orthopaedics. 2007 Sept 27(6), pp 703-708.

11. Fractures of the distal femoral epiphyses. Factors influencing prognosis: a review of thirty-four cases. J Bone Joint Surg Am. 1977 Sep;59(6):742-51. Lombardo SJ, Harvey JP Jr.

12. Hip ultrasound. Bancroft LW, Merinbaum DJ, Zaleski CG, Peterson JJ, Kransdorf MJ, Berquist TH. Seminars in Musculoskeletal Radiology. 2007 Jun;11(2):126-36

13. Ultrasonographic assessment of bone maturity in newborns. Leshem E. Bialik V. Hochberg Z. Hormone Research. 57(5-6):180-6, 2002.

This is a peer reviewed paper 

Please cite as: Stijn AAN Bolink: Neonatal Distal Femoral Epiphysiolysis-A case report and review of the literature.

J.Orthopaedics 2010;7(1)e4

URL: http://www.jortho.org/2010/7/1/e4

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