Legg-calve’perthes Disease Done by : Almaza Al-bakri

objectives: ⁃ patholophysiology ⁃ Risk factors ⁃ symptoms ⁃ prognosis ⁃ diagnosis ⁃ prognostic classification systems ⁃ treatment ⁃ differential diagnosis

pathophysiology • referred to as idiopathic avascular osteonecrosis of the capital femoral epiphysis of the femoral head since the cause of the interruption of the blood supply of the head of the femur in the hip joint is unknown. • Its a childhood hip disorder • initiated by a disruption of blood flow (due to unknown cause) to the femoral head,that leads to death or avascular necrosis. Over time, healing occurs by new blood vessels infiltrating the dead bone and removing the necrotic bone by macrophages which leads to a loss of bone mass and a weakening of the femoral head.The bone loss will lead to mis-shapen the femoral head and can no longer rotate smoothly inside the acetabulum , reducing the range of motion. • Idiopathic Self limiting: Over time, the body removes the dead bone, and the blood supply to the head of the femur returns, and the bone begins to grow back. • The pathological process takes 2–4 years to complete, passing through three stages: ⁃ Stage 1: bone death ⁃ Stage 2: revascularization and repair ⁃ Stage 3: distortion and re-modelling

Risk factors. - Age 4-8years. - Sex: boys affected 4 times than females. - Family history. - Second hand smoking. - More in active children.

Symptoms ⁃ Hip pain …sometimes reffered to the knees . ⁃ Diminished movements (abduction is nearly always limited and usually internal rotation also) … often not seen in child till later when most movements are full….(first symptom). ⁃ Hip limping. ⁃ Change in the way of walking/running. → Antalgic gait (antalgic = anti- + alge, "against pain”……is a gait that develops as a way to avoid pain while walking ). ⁃ The muscle may atrophy ….the leg looks smaller.

prognosis -Age, bad prognosis if >6years. - Sex, worse prognosis in females. - Range of movement (worse with decreased ROM) - Sphericity of femoral head. - Skeletal maturity

Diagnosis (x-ray) • early changes: ⁃ widening of the joint ‘space’. ⁃ Joint effusion ⁃ increased radiographic density in the bony epiphysis (classic feature ). ⁃ Metaphyseal demineralization. • later change: ⁃ Flattening, false ‘fragmentation’ ⁃ lateral displacement of the epiphysis with rarefaction and broadening of the metaphysis (Reduction in density of metaphyseal bony tissue). ⁃ Varus deformity of the femoral neck? angle between the neck and the shaft of the femur is reduced to less than 120 degrees(normal femoral neck–shaft angle is 160 degrees at birth, decreasing to 125 degrees in adults)…..occurs when the bone tissue in the neck of the femur is softer than normal, causing it to bend under the weight of the body

prognostic classification systems • Various prognostic grading systems are employed, based mainly on x-ray appearances. • Herring classification is based on the severity of structural disintegration of the lateral pillar of the femoral epiphysis.

Treatment • To relieve painful symptoms, protect the shape of the femoral head, and restore normal hip movement. If it’s not treated early, hip problems in adulthood and early onset osteoarthritis. This is done by :- Orthotic devices (bracing) - Surgery (Osteotomy), indications: ⁃ >8 years ⁃ Damaged femoral head ⁃ Femoral head not contained within the acetabulum ⁃ Failure of nonsurgical treatment. • Note: The main long-term problem with this condition is that it can produce a permanent deformity of the femoral head, which increases the risk of developing osteoarthritis in adults.

differential diagnosis • The commonest cause of hip pain in children is a non-specifc transient synovitis – the so-called irritable hip . • Diagnosis: Ultrasound may show a joint effusion, but the x-rays are always normal. • Symptoms: last for 1–2 weeks and clear up completely. • The child should be kept in bed until pain disappears and the effusion resolves.

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