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Separation

of the

Upper

Humeral Gigantism

Epiphysis

in

Pituitary
BY GORDON C. ROBIN, MB., CH.B., F.R.F.P.S.,
JERUSALEM,

F.R.C.S.,
ISRAEL

AND

SHIMEON

S.

KEDAR,

M.D..

From

the

Department

of Orthopaedics,

Hadassah

University

Hospital,

.Jer,isale,,t

Separation
occurs

of adolescents.

the

upper Smith and 1953. to

humeral found

epiphysis only forty-three

is

an

uncommon cases
in a

injury large

which
general

in

hospital

between
four

1929 nmle

The
one

injury
fenmie

occurs
in

principally series, and

in males;

Bourdillon three to one.

reporte(l

patients

his

Smith

FIG. Fig. upper 1 : Anteroposterior

1 roentgenogram of the right shoulder

FIG. showing

2 the grossiy displaced

epiphysis Fig. 2: Lateral

of the humerus. roentgenogram

of the right

shoulder.

Most

authors2348 ages
in

agree

that

this

type

of injury
with

is found

in adolescents

between

the
i)etween were

of twelve and eighteen thirteen and fifteen years.


this to and
of

years, Of the
considered humeral however,

the majority eleven cases reported


that epiphysis quoted twenty the limited normally years

of

cases occurring by Aitken, eight


incidence closes as the between usual age was

latter the fact eighteen

age that

group the

; he upper Gray,

age

related sixteen
of closure

years.

Although displacement found


epiphysis of traumatic

the epiphysis. there has been considerable discussion of the upper femoral epiphysis and of any
this
separation disease.

of the pituitary

relationship disease

between
,

we

have

no

reports
and

relationship between separation We, therefore, consider it worth of the upper humeral epiphysis in whom it is postulated of the epiphysis.
CASE REPORT of this hospital

of the upper humeral while to report a case


in a
pituitary giant,

twenty-three secondary

years to delayed

of

age, closure

that

the

bone

lesion

was

A. G. was
after house. an At the

admitted
age of sixteen

to attempt

tile

orthopaedic at suicide been in

department

at associated

tile

age roof

of twenty-three of a three-story

unsuccessful

which
for and

he had
gonadotrophin.

jumped

from
Scondary

the

he had

treated

hypogonadism,

with
sexual

gigantism,
characteristics

by

the
VOL.

administration
44-A,

of methyl
1, JANUARY
1962

testosterone

NO.

189

190

G.

C.

ROBIN

AND

S.

S.

KEDAR

FIG.
A11t(roposterior

3 hips showing a fissure fracture in the right

aCVtah)(llllITl

:111(1

roentgenogram tue open epiphyses

of

the pelvis of the ilium.

and

FIG. Roentgenogram developed under hormone treatment of the but skull there suffer he was showing was

4 a normal little effect pituitary in arresting fossa. growth. no After two Since

years
the no

he had refused
onset
previous On

to proceed with the treatment of treatment he had been known to


suicidal examination attempt. it was distribution of the right noted that

and

since
from

then

had

received psychosis, tall-six

hormones.

a depressive

but
feet, eight

he had

made

exceptionally

inches-with

effeminate
narrow from chest, a fracture

features,
a female

smooth,

hairless

facial
of pubic upper

skin,
hair, humeral

a female type of trunk and atrophic testes. He


epiphysis THE (Figs.
JOURNAL

with
was

a broad
found to be a fissure
JOINT

pelvis
fracture

and

suffering

separation

1 and
OF

2) and
AND

BONE

SURGERY

SEPARATION

OF

THE

UPPER

HUMERAL

EPIPITYSIS

191

FIG. 5 Fig.
the Ol)PIi

1K;.
of the normal acromion and 1 showing the

6 of the humerus coracoid and

5: 1(oentgenogram
e1)i1)hVses (1: i)iagram
Ol)UIi

Fig. process, sis; and

of the of Fig.

arm shiowillg the open epiphyseal line the coracoi(i poce significant features of the roentgenogram: open epiphysis; attaciied of the showed manipulatiomi spica. the The 3, the head of the epiphysis. showed upper humeral fracture diaphysis to the skull the of the humeral disappeared.

I is the

epiphysis; triangular

2, the fragment (Fig. l)atieflt time all

acromion, of the 3). was

humerus,

open

epiphy-

4,
right

the

in the
(Fig. yet in

acetabulum a roentgenogram (Fig. by

A roentgenogram normal treatei in arm by

a normal humeral fracture united

pituitary epipiiysis under had

fossa not general

4), closed

and

of the

that

5). The
which

anesthesia six weeks,

amid immobilization

in a plaster-of-Paris disability

satisfactorily

hip

had

also

DISCUSSION
Ill

discussing it is seen
injury years. does

this
not

type
occur

of fracture, eight
after

Blount fourteen
the age of

suggested years.
eighteen

that Bonnin
years.

the
In

usual
Smiths

age
series,

at said

which
that

is between the The older than


report the normal

and

categorically age of the

this fifteen no It

which
was found disease. closure

described

largest patient any


in that

number here patient


which the alloved

of patients, described, previously


the pituitary this fracture fracture

the at the

average age

patients years, we have


pituitary

of twenty-three Furthermore,
with delaying at such

is significantly
previous is

reported.
w-as to disturbance,

associated by occur

considered

epiphyseal a relatively

beyond

age,

late For
epiphyses

age. example, believe


of from

Several the

signs iliac

of

skeletal until
years.

immaturity are still widely

are

seen open

on (Fig.

the 3).

roentgenograms. Although these years a skeletal


6,

epiphyses

we
age

do not normally fuse that the roentgenographic


sixteen to eighteen

the age of from twenty to twenty-five appearance is more consistent vith


Furthermore,

process
basis of

and the slipping are


an

acromion of the either an


hormone

are not fused upper femoral excess


relative of

the epiphyses (Fig. 6). Harris, in discussing epiphysis, suggested that hormone
normal a

of the coracoid the endocrine


the
necessary

conditions
a deficiency there
hormone.

of

growth
to

of sex
apparent

relative to growth hormone. the

sex
In

hormone
our patient

or of sex lesion

was within

excess in

However,

slipping
plate;

growth of the
whereas

hormone femoral
in the

in addition epiphysis,
so-called

to a deficiency pathological
of
.

lies

the

epiphyseal

separation

the

upper

humeral original
the epiphyseal
a

epiphysis, roentgenogram
classic triangular fragment;

the

lesion of the
fragment

is really injured
of that

a juxta-epiphyseal humerus, it can the diaphysis


in this case

fracture be seen attached


also, the

From

the

that

there to the
was,

is present displaced
in fact,

this

suggests

lesion

juxta-epiphyseal
44.A,

fracture.
1, JANUARY 1962

It

is not

therefore

considered

that

the

hormonal

VOL.

NO.

192
abnormality has been acted suggested directly in hip

G.

C.

ROBIN

AND

S.

S.

KEDAR

on

the

epiphyseal It

plate is

in simply

causing postulated

the

separation, that delayed

as

epiphyseolysis.

skeletal maturity, secondary to the endocrinal lesion, seen in mid-adolescence to take place at a much later
SUMMARY

allowed age.

a fracture

normally

A
twenty-three

case

of

separation
of age

of

the

upper
The

humeral
patient

epiphysis
is significantly

in

a pituitary
older than

giant
any

years

is reported.

previously factors are

reported discussed.

with

a fracture

of this

type.

The

probable

endocrinological

REFERENCES 1. A1TKEN,

A. P. : End
18: 1036-1041,

Results
Oct.

of Fractures
1936.

of the Proximal

Humeral

Epiphysis.

J. Bone

and

Joint

Surg., 2. BLOUNT, 3. BONNIN,


4.

W. P. : Fractures J. G. : A Complete

in Children, p. 13. Baltimore, Outline of Fractures. Ed.

The Williams and Wilkins 2, p. 306. London, William

Co., 1954. Heinemann.

Ltd., 1946. BOURDILLON,

5. 6. 7.

8.

J. F. : Fracture-Separation of the Proximal Epiphysis of the Humerus. J. Bone Surg., 32-B: 35-37, Feb. 1950. BURROWS, H. J. : Slipped Upper Femoral Epiphysis. Characteristics of a Hundred Cases. J. Bone and Joint Surg., 39-B: 641-658, Nov. 1957. GRAY, HENRY: Anatomy. Descriptive and Applied. Edited by T. B. Johnson and J. Whillis. Ed. 27, p. 347. London, Longmans, Green and Co., 1938. 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. SMITH, F.M. : Fracture-Separation of the Proximal ftumeral Epiphysis. A Study of Cases Seen and Joint
at the Presbyterian Hospital from 1929-1953. Am. J. Surg., 91 : 627-635, 1956.

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

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