Separation of the proximal humeral epiphysis.

Accepted 23 April 1998 A 42-month-old girl presented with a history of sudden onset swelling of the left shoulder of 4-5 days duration with no preceding history of significant trauma or fall. The child was irritable and mildly febrile on examination. A tense globular swelling measuring 6 x 5 x 5 cm was present in the left shoulder region which was tender and fluctuant on palpation (figure 1). There was an increase in the local temperature and the skin overlying the swelling was stretched and glossy. Shoulder movements were painful and restricted. There was no regional lymphadenopathy nor any distal neurovascular compromise. Other joints were normal and no abnormality was detected in other systems. The child had chronic non-pitting oedema of both legs and was reluctant to walk. There was no history of a bleeding disorder nor was any such family history elicitable. An X-ray of the left shoulder revealed a complete separation of the proximal humeral epiphysis with osteopenia and surrounding soft tissue swelling (figure 2). Haemogram revealed anaemia (haemoglobin 5.3 g/dl) but a normal leucocyte count of 7.2 x 109/l (polymorphs 44%, lymphocytes 48%, and eosinophils 8%). Reticulocyte count was 1%, platelet count was adequate, and the erythrocyte sedimentation rate was 10 mm at one hour. Bleeding time, clotting time and other tests for bleeding profile were within normal limits. Serum calcium and phosphorus levels were normal but alkaline phosphatase level was elevated to 306 IU/l (normal range 80-180 IU/l). Needle biopsy of the swelling resulted in the evacuation of approximately 20 ml of altered blood and a few soft tissue and bony fragments which on microscopic examination revealed the presence of proliferating fibroblasts, spicules of necrotic bone and abundant vascular proliferation. A single X-ray of the knee (figure 3), however, showed typical changes which aided in the diagnosis of this condition.