Legg calve perthes diseaseBy: Ala’a AlGhanem | 211508057 | B1

Learning Objectives: Normal anatomy of hip joint.

Introduction and epidemiology

Aetiology and classifications

Clinical presentation

Investigations

Treatment and prognosis

Complications

Anatomy of hip joint:

Legg calve perthes disease

Idiopathic avascular necrosis of the proximal femoral epiphysis in children

Legg Calve Perthes

Epidemiology:

2-Sex:

1-incidence:affects 1 in 1200 children

>

5 : 1

3-Age

4-8 years is most common age of presentation

4-Population:

more commonly seen in urban populations versus rural

5-Location:bilateral in 12% (never at the same stage of disease)

the exact cause of disruption of blood supply remains unknown.

Etiology:

Associated conditions:

-ADHD (33%)

-delayed bone age (98%)

-Thrombophilia (50%)

how Avascular necrosis (AVN) develops:

Risk Factors:

1-positive family history2-low birth weight3-abnormal birth presentation4-children exposed to second hand smoke

5-Asian, Inuit, and Central European decent

Classifications:Waldenström

Lateral Pillar (Herring ) Classification

Catterall Classification

Salter-Thompson classification

Stulberg classification

Stages of Legg-Calves-Perthes (Waldenström)

Initial stage (infarction)

Fragmentation

Reossification

Healing or remodeling

Lateral Pillar (Herring ) ClassificationDetermined at the beginning of fragmentation stage

lateral pillar maintains full height

Maintains >50% height

Maintains <50% height

Catterall ClassificationBased on degree of head involvement

Salter-Thompson classificationBased on radiographic cresent sign

crescent sign involves < 1/2 of femoral head

crescent sign involves > 1/2 of femoral head

Class A

Class B

Stulberg classification

normalSpherical head

with enlargement, short neck, or

steep acetabulum

Nonspherical head

Flat head Flat head with incongruent hip joint

Gold standard for rating residual femoral head deformity and joint congruence

Clinical presentation:

-insidious onset-may cause

painless limp-intermittent

knee, hip, groin or thigh pain

Physical Exam:

Symptoms:

-Trendelenburg gait-antalgic limp

limb length discrepancy is a late finding

-hip stiffness with loss of internal rotation

and abduction-gait disturbance:

Investigations:Plain radiographs:

AP of pelvis and frog leg laterals

early findings include:

medial joint space widening (earliest)

irregularity of femoral head ossification

cresent sign (represents a subchondral fracture)

MRIcan provide early diagnosis revealing alterations in the

capital femoral epiphysis and physis.

Bone scan:

can confirm suspected case of LCP

decreased uptake (cold lesion) can predate changes on radiographs

Arthrograma dynamic arthrogram can demonstrate coverage and containment

of the femoral head

Differential Diagnosismultiple epiphyseal dysplasia

spondyloepiphyseal dysplasia

sickle cell disease

Gaucher disease

hypothyroidism

Meyers dysplasia

Treatment:The main Goals of treatment:

1-keep the femoral head contained and maintain good motion

2-containment limits deformity and minimizes loss of sphericity and lessen subsequent degenerative changes.

Non-operative:

observation alone, activity restriction, and physical therapy

Indications:

1-children < 8 years of age2-children with lateral pillar A3-consider activity restriction and protected weight-bearing during earlier stages until reossification is complete

techniques:

Cast Brace

Operative:

Femoral or pelvic osteotomy

Indications:1-children > 8 years of age, especially lateral pillar B and B/C

improved outcomes with surgery for lateral pillar B and B/C in children > 8 years  poor outcome for lateral pillar C regardless of treatment.

Pelvic osteotomy:

Dega Osteotomy

Salter (Innominate) Osteotomy

Femoral osteotomy: Varus femoral osteotomy

Prognosis:prognosis worse with:

1-age (bone age) > 6 years at presentation

2-female sex

3-decreased hip range of motion (abduction)

prognosis improved with:

1-age (bone age) < 6 years at presentation

Complications: The head of the femur may lose its normal, spherical

shape and/or collapse.

Also, degenerative joint disease can occur (i.e. as occurs in osteoarthritis).

The affected leg may lose some of its motion and may become shorter than the normal leg.

References:

Johns Hopkins Pediatric Orthopaedics Patient

Thank You