Legg-Calve-Perthes disease

Question 1

A 5-year-old Caucasian boy is brought in to the orthopaedic clinic by his mother with complaints of a limp favouring the right side with no associated pain. This painless limp had started insidiously 3 weeks earlier and was first noticed by the school physical education teacher.

Answer 1

Impression
Several considerations in this presentation. Notably, want to rule out infective causes such as septic arthritis/osteomyelitis. otherwise, more likely MSK

DDx

• MSK: perthes disease, transient synovitis of the hip, SUFE
• Autoimmune: idiopathic juvenile arthritis (Systemic illness)

Perthes disease;

• idiopathic avascular necrosis of the femoral head
• peak age of incidence is 5-7, higher in males
• mismatch between rapid growth of epiphyseal plate and slower/inadequate development of blood supply to match

Question 2

Perthe’s disease - History

Answer 2

History

• age
• sx: pain (SOCRATES - hip located, may have referred knee pain), worsens as disease progresses, limp stiffness, reduced ROM, leg length discrepancy.
• other: infective sx
• meds: steroid use (is an A/E)
• Risks: male, fam history
• paeds history

Question 3

Perthes disease - examiantion

Answer 3

Examiantion

• general appearance + vitals (infective)
• inspection: position, muscle wasting, trendelenburg gait (?SUFE), swelling, erythema. ROM, etc. leg length discrepancy, FABER elicits pain.

Question 4

Perthes disease - Investigations

Answer 4

Investigations
Diagnostic;
- Xray: may not be changes early, but looking for reducing in epiphysis size and fragmentation of femoral head.
- bone scan: reduced perfusion through femoral head
- MRI - allows for earlier diagnosis. would go straight to this then in consideration of differentials.

Question 5

Perthes disease - Management

Answer 5

Management
- usually has good long-term progress, altho increased predisposition to OA of the hip

DEfinitive

• if ROM affected then can utilise bracing to keep abducted to ensure appropriate moulding of the femoral head
• surgical: osteotomy. referral to paeds ortho

Supportive

• physio for rehab and ROM
• avoid high-impact activities
• regular monitoring including physical examination and x-rays
• analgesia