Perthes_Disease_Flashcards

Question 1

What is Perthes’ disease?

Answer 1

Perthes’ disease is a degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years. It is due to avascular necrosis of the femoral head, specifically the femoral epiphysis.

Question 2

What causes Perthes’ disease?

Answer 2

Impaired blood supply to the femoral head causes bone infarction.

Question 3

Who is more likely to develop Perthes’ disease?

Answer 3

Perthes’ disease is 5 times more common in boys. Around 10% of cases are bilateral.

Question 4

What are the features of Perthes’ disease?

Answer 4

Hip pain developing progressively over a few weeks, limp, stiffness, and reduced range of hip movement.

Question 5

What are the early and later changes seen on x-ray in Perthes’ disease?

Answer 5

Early changes include widening of joint space. Later changes include decreased femoral head size/flattening.

Question 6

How is Perthes’ disease diagnosed?

Answer 6

Plain x-ray, technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist.

Question 7

What are the complications of Perthes’ disease?

Answer 7

Osteoarthritis, premature fusion of the growth plates.

Question 8

What are the features of Catterall Stage 1?

Answer 8

Clinical and histological features only.

Question 9

What are the features of Catterall Stage 2?

Answer 9

Sclerosis with or without cystic changes and preservation of the articular surface.

Question 10

What are the features of Catterall Stage 3?

Answer 10

Loss of structural integrity of the femoral head.

Question 11

What are the features of Catterall Stage 4?

Answer 11

Loss of acetabular integrity.

Question 12

What is the management for Perthes’ disease?

Answer 12

To keep the femoral head within the acetabulum: cast, braces. If less than 6 years: observation. Older: surgical management with moderate results. Operate on severe deformities.

Question 13

What is the prognosis for Perthes’ disease?

Answer 13

Most cases will resolve with conservative management. Early diagnosis improves outcomes.

Question 14

At what age is Perthes Disease most commonly diagnosed?

Answer 14

4-8 years old.

Question 15

How is Perthes Disease generally characterized in terms of its progression?

Answer 15

It is a benign self-limiting condition.

Question 16

What supportive care measures can be taken for acute pain in Perthes Disease?

Answer 16

Simple analgesia
Ice packs
Protective pad over the tibial tubercle
Physical therapy

Question 17

What should patients and families be educated about regarding Perthes Disease?

Answer 17

Education about exacerbations and management.

Question 18

What is the role of physical therapy in managing Perthes Disease?

Answer 18

Stretching of the quadriceps and hamstring muscles
Strengthening of the quadriceps
Encouraging hip abduction

Question 19

When is surgical treatment considered for Perthes Disease?

Answer 19

Surgical treatment is reserved for patients who fail to respond to conservative measures, typically if they are older than 6 years.

Question 20

summarise perthes disease

Answer 20

Perthes’ disease

Perthes’ disease is a degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years. It is due to avascular necrosis of the femoral head, specifically the femoral epiphysis. Impaired blood supply to the femoral head causes bone infarction.

Perthes’ disease is 5 times more common in boys. Around 10% of cases are bilateral

Features
hip pain: develops progressively over a few weeks
limp
stiffness and reduced range of hip movement
x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening

Diagnosis
plain x-ray
technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist

Complications
osteoarthritis
premature fusion of the growth plates

Catterall staging

Stage Features
Stage 1 Clinical and histological features only
Stage 2 Sclerosis with or without cystic changes and preservation of the articular surface
Stage 3 Loss of structural integrity of the femoral head
Stage 4 Loss of acetabular integrity

Management
To keep the femoral head within the acetabulum: cast, braces
If less than 6 years: observation
Older: surgical management with moderate results
Operate on severe deformities

Prognosis
Most cases will resolve with conservative management. Early diagnosis improves outcomes.

Question 21

summarise perthes disease management

Answer 21

Perthes Disease
 4-8 year olds
Management
 Non-surgical treatment – benign self-limiting condition 
Supportive care for acute pain: simple analgesia, ice packs, protective pad over the tibial
tubercle
Activity continuation
Physical therapy: stretching of the quadriceps and hamstring muscles, strengthening of the
quadriceps, encourage hip abduction
Education about exacerbations and management
Surgical treatment is reserved for patients who fail to respond to conservative measures
(only if >6yrs

Question 22

A 5-year-old boy is brought to the Emergency Department by his parents. He has been complaining of pain around his left hip for the past fortnight and has been limping. He is apyrexial and examination of his left hip joint shows a slight reduction in the range of movement. There are no signs of effusion or swelling. His right hip is unremarkable. Blood tests, including cultures, come back negative.

Which is the most appropriate initial management option for the underlying diagnosis?

Open reduction and internal fixation
Splinting of the limb
Reassurance and follow-up
Pavlik harness
Surgical correction

Answer 22

Reassurance and follow-up

Perthes’ disease presenting under the age of 6 years has a good prognosis requiring only observation

This child is suffering from Perthes’ disease. This is a degenerative condition affecting the hip joints of children, and classically is seen between the ages of 4 and 8. Perthes’ is 5 times more common in boys and presents with hip pain, limping and reduced range of movement of the hip. Perthes’ disease occurring under the age of 6 has a good prognosis and most cases will resolve with conservative management. For this reason, simple observation and follow-up is the preferred management choice, therefore this option is correct.

Open reduction and internal fixation is not the correct answer as this is used in the management of more complicated fractures, which this child does not have. Perthes’ disease does not involve fracture of a bone and therefore does not require this management.

Splinting of the limb is not required in this scenario. Bracing, splinting or casting is not routinely recommended for the treatment of Perthe’s disease, especially in under 6 years of age due to the good prognosis mentioned earlier. Splinting is more appropriate after injuries such as fractures.

A Pavlik harness is incorrect as this is the preferred management for developmental dysplasia of the hip (DDH). This is a separate disease entity that presents with asymmetrical hip creases and leg length discrepancies in babies. Risk factors for this include female sex and breech delivery.

Surgical correction of Perthes’ disease is only indicated for older children (i.e. older than 6) or if there is severe deformity of the joint or limb. Neither of these is the case, therefore this is incorrect.

Question 23

A 4-year-old boy is brought to his GP by his mother. He has a 4-week history of increasing right hip pain. There is no history of trauma and the child appears systemically well.

Clinical examination reveals an antalgic gait, pain upon movement of the right leg, particularly in the hip region, and some discomfort in the right knee. There is stiffness and reduced range of motion in the right hip. The left leg shows no abnormalities.

A pelvic x-ray shows mild osteonecrosis of the right femoral head.

What is the most appropriate initial management for this boy’s likely condition?

In-situ fixation with a single screw
Minimal weight bearing with a splint or brace
Osteotomy of the femoral head
Steroid injection
Total hip replacement in the next year

Answer 23

Minimal weight bearing with a splint or brace

Perthes’ disease presenting under the age of 6 years has a good prognosis requiring only observation

This patient is showing signs of Perthes’ disease, an idiopathic osteonecrosis of the femoral head that occurs in childhood. The condition is characterised by avascular necrosis of the epiphysis, which disrupts the normal process of endochondral ossification in the femoral head. Perthes’ disease typically manifests in children aged between 4 and 8 years and is five times more prevalent in males. Presentation before the age of 6 years is associated with a better prognosis, often requiring observation only. Conservative management is usually sufficient to resolve most cases. In this instance, minimal weight bearing with a splint or brace represents the optimal conservative approach.

In-situ fixation with a single screw would be inappropriate for this diagnosis. This would be the recommended management of a slipped capital femoral epiphysis (SCFE), not Perthes’ disease. SCFE treatment involves a minor surgical procedure where a metal screw is inserted through a small incision near the hip to secure the femoral head and prevent further displacement. SCFE typically arises during peak growth spurts following puberty and predominantly affects individuals between 10-16 years old, especially those who are overweight or obese, making it an unlikely diagnosis for a 4-year-old child.

Osteotomy of the femoral head is an inappropriate choice in this scenario given the patient’s young age and early stage of presentation. Should conservative measures fail or severe disease develops, osteotomy may be considered to promote containment of the femoral head within the acetabulum.

Administering a steroid injection would be an inappropriate course of action as it does not align with recognised treatments for Perthes’ disease and carries a risk of inducing avascular necrosis with prolonged high-dose corticosteroid use.

Lastly, total hip replacement in the next year is not an inappropriate option. Based on current evidence, non-surgical management effectively addresses most cases of Perthes’ disease. Total hip replacement or hemiarthroplasty may be options for patients presenting with a fractured neck of the femur; however, there is no indication of a fracture according to the patient’s radiographic finding.

Question 24

A 5-year-old girl presents to her GP accompanied by her mother. She has a 2-week history of pain in her right hip which has got progressively worse. Upon examination, she has a reduced range of hip movement, and she walks with a limp. A plain x-ray shows a widening of the joint space. She is diagnosed with Perthes’ disease.

What aspect of her history is atypical for this condition?

Her age
Her sex
Unilateral pain
Widening of the joint space
Worsening symptoms

Answer 24

Her sex

Perthes’ disease is around 5 times more common in boys

Her sex is the correct answer. Perthes’ disease is 5 times more common in boys than girls.

Her age is typical of a patient with Perthes’ disease, which typically affects patients between 4 and 8.

Unilateral pain is typical of Perthe’s disease, only around 10% of cases are bilateral.

In Perthe’s disease, a plain x-ray will show widening of the joint space early on, and flattening of the femoral head later.

Worsening symptoms are typical in Perthe’s disease, pain develops over a few weeks.

Question 25

Which one of the following statements regarding Perthes disease is incorrect?

Typically affects children between the ages of 4-8 years
Complications include premature fusion of the growth plates
Due to avascular necrosis of the femoral head
Twice as common in girls
10% of cases are bilateral

Answer 25

Twice as common in girls

The incorrect statement regarding Perthes disease is ‘Twice as common in girls’. Perthes disease, also known as Legg-Calve-Perthes disease, is a childhood condition that affects the hip. It results from a temporary loss of blood supply to the femoral head, leading to avascular necrosis. The condition is more prevalent in boys than girls, with a male-to-female ratio of about 4:1 or 5:1 according to different sources.

Discussing the other options:

The statement ‘Typically affects children between the ages of 4-8 years’ is correct. Although Perthes disease can occur at any age during childhood, it most commonly presents between the ages of 4 and 8 years.

‘Complications include premature fusion of the growth plates’ is also correct. A possible complication of Perthes disease is premature closure or fusion of the growth plates (physeal arrest), which can lead to leg length discrepancy and deformity.

‘Due to avascular necrosis of the femoral head’ is another accurate statement about Perthes disease. This condition occurs when there is a disruption to the blood supply to part of the femoral head (the ‘ball’ part of the ball-and-socket joint that forms the hip). Without sufficient blood flow, this area of bone dies (avascular necrosis) and subsequently collapses.

Finally, ‘10% of cases are bilateral’ is true too. Although most cases affect only one hip (unilateral), approximately 10% -15% of cases involve both hips (bilateral). This can make diagnosis and management more challenging.

Question 26

An 8-year-old boy attends a general practice appointment with his mother with a 1-month history of right-sided hip pain and occasional limp. The patient feels well, is afebrile, and measures in the 90th percentile for weight.

He was born by spontaneous vertex vaginal delivery at term, with an unremarkable newborn physical examination.

On examination, there is a limited range of movement in his right hip.

A frog-leg hip x-ray is requested, showing sclerosis of the right upper femoral epiphysis and moderate of resorption of the femoral head.

Which of the following statements is most accurate regarding the likely diagnosis?

30% of cases are bilateral
The condition is 5 times more common in boys
The condition is associated with obesity
The condition may be managed with a Pavlik harness
The condition’s peak incidence is in children aged over 12

Answer 26

The condition is 5 times more common in boys

Perthes’ disease is around 5 times more common in boys

This patient has many features of Perthes’ disease. Perthes’ disease is an idiopathic avascular necrosis of the femoral head in children. It classically presents in a 4-8-year-old boy with an irritable hip, limp, and reduced range of motion, despite no history of trauma or systemic symptoms. X-ray imaging may demonstrate epiphyseal sclerosis, or in severe cases resorption of the femoral head.

The correct answer is the condition is 5 times more common in boys. Perthes shows significant male predominance, with most patients between the ages of 4-8. Risk factors include.

30% of cases are bilateral is incorrect, as only 10% of patients with Perthes disease have bilateral disease. The majority of patients with Perthes disease have only unilateral disease.

The condition is associated with obesity is incorrect, as obesity is not a risk factor for Perthes disease. Slipped capital femoral epiphysis is another cause of irritable hip in older children, with a close association with obesity.

The condition may be managed with a Pavlik harness is incorrect, as this is the management of developmental dysplasia of the hip rather than Perthes disease. Perthes disease is managed conservatively with a cast or brace in most instances. Older children or children with severe acetabular destruction may require surgical management.

The condition’s peak incidence is in children aged over 12 is incorrect, as the peak incidence of Perthes disease is between the ages of 4 and 8. While rare in older children, the condition is more likely to require surgical management.

Question 27

A five-year-old male walks with a limp due to right hip pain, relieved by rest and made worse by walking or standing. His vital signs are normal. The Trendelenburg sign presents when he stands on his right leg. X-rays reveal periarticular right hip swelling in soft tissue. A bone scan reveals reduced activity in the anterolateral right capital femoral epiphysis.

What is the most likely diagnosis?

A slipped capital femoral epiphysis
Legg-Calvé-Perthes disease
Septic arthritis
Epiphyseal dysplasia
Synovitis

Answer 27

Explanation
B
Legg-Calvé-Perthes disease
Legg–Calvé–Perthes disease is a self-limiting condition caused by compromised blood flow to the femoral head. Its exact cause is unclear but may relate to developmental changes in the hip’s blood supply. The disease typically occurs between ages four and nine when retinacular arteries are crucial for femoral head blood supply. The formation of the epiphyseal plate and ossification at puberty further alters blood flow. The patient also exhibits synovitis and hip joint effusion, indicated by soft tissue swelling around the hip joint.

A
A slipped capital femoral epiphysis
A slipped capital femoral epiphysis would be obvious on hip radiography. The radiological findings, in this case, do not suggest this diagnosis.

C
Septic arthritis
Septic arthritis would cause features of a systemic inflammatory response. The normal vital signs in this scenario indicate no systemic inflammatory process occurring.

D
Epiphyseal dysplasia
Epiphyseal dysplasia, a congenital defect, would most likely present when the child started to walk.

E
Synovitis
There is radiological evidence of synovitis in this scenario. However, synovitis is a non-specific sign and not a specific diagnosis.