Perthes disease
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Perthes disease






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Perthes disease Perthes disease Presentation Transcript

  • What is Legg calve perthes disease?  It is a degenerative disorder that affects the hip joint. It occurs when there is an insufficiency in the volume of blood reaching the ball of the thighbone, causing death of the bone.  the condition is also known as Ischemic Necrosis of the Hip or Avascular Necrosis of the Hip.
  •  Legg-Calvé-Perthes (LCPD) disease is a childhood hip disorder that results in infarction of the bony epiphysis of the femoral head. LCPD represents idiopathic avascular necrosis of the femoral head.
  •  The disease is bilateral in 10-20% of patients  Children aged 4-8 years  A family history is present in 6% of patients  In adults, the corresponding condition is termed Chandler disease.
  • ETIOLOGY  Male sex (3to 5 times more common).  Common in low socioeconomic group.  Low birth weight babies.  Presence of an inguinal hernia and  Genitourinary tract anomalies.
  • Legg calve perthes disease Symptoms  Patients usually limp while walking  Knee pain  Constant pain in groin or thigh  Limited range of movement  Hip stiffness, which limits motion in the hip  Reduction of muscles in the upper thigh  Shortening of the leg or unequal length of legs
  • STAGING  Several staging schema are used to determine severity of disease and prognosis; these include the Catterall, Salter-Thomson, and Herring systems.  The Catterall classification is based on radiographic appearances and specifies 4 groups during the period of greatest bone loss.
  • Catterall staging is as follows:  Stage I — Histologic and clinical diagnosis without radiographic findings  Stage II — Sclerosis with or without cystic changes with preservation of the contour and surface of femoral head  Stage III — Loss of structural integrity of the femoral head  Stage IV — Loss of structural integrity of the acetabulum in addition
  • Same disease but different names (synonyms)  Calve-Perthes disease  Legg-Perthes disease  Avascular necrosis of the femoral head  Coxa plana  Osteochondritis juvenilis
  • RADIOGRAPHY Early radiographic signs of LCPD  Small femoral epiphysis (96%)  Sclerosis of the femoral head with sequestration and collapse (82%)  Slight widening of the joint space caused by thickening of the cartilage, failure of epiphyseal growth, the presence of joint fluid, or joint laxity (60%)
  • the flattened appearance on the affected side, compared to the smooth curve of the femoral head on the normal side.
  • Late signs of LCPD on radiographs  Delayed osseous maturation of a mild degree, a radiolucent crescent line representing a subchondral fracture  Femoral head fragmentation and femoral neck cysts from intramedullary hemorrhage or loose bodies, and coxa plana
  •  Coxa magna, or remodeling of the femoral head, which becomes wider and flatter, similar in appearance to a mushroom
  • COMPUTED TOMOGRAPHY Early signs of LCPD on CT scans include the following:  Bone collapse  Curvilinear zones of sclerosis  Subtle changes in bone trabecular pattern
  •  Late signs of the disease on CT scans include :  Central or peripheral areas of decreased attenuation  Intraosseous cysts  Coronal reconstructions can show subchondral fractures, or collapse of the articular surface.
  •  Legg-Calvé-Perthes disease. Axial nonenhanced CT scan through the hip joints shows the loss of structural integrity of the right femoral head.
  •  Legg-Calvé-Perthes disease. Nonenhanced axial CT section through the hip joints obtained at a different level in the same patient as in the previous images. Once again, the scan shows the loss of structural integrity of the right femoral head. Note the acetabular subchondral sclerosis
  •  Legg-Calvé-Perthes disease. Coronal reconstruction shows flattening, sclerosis, and early fragmentation of the right femoral head
  • Magnetic Resonance Imaging  Early in the course of LCPD, irregular foci of low signal intensity or linear segments replace the normal high signal intensity of bone marrow in the femoral epiphysis on T1- and T2-weighted images.
  •  Other findings include an intra-articular effusion and a small, laterally displaced ossification nucleus, and femoral head deformity.
  •  Legg-Calvé-Perthes disease. Coronal T2-weighted MRIs show irregularity and flattening of cortical margins of the left femoral epiphysis. Also note a mild joint effusion
  •  Legg-Calvé-Perthes disease. Coronal T1-weighted MRIs show the loss of normal high signal intensity in the left femoral epiphysis, which now has low signal intensity.
  •  Legg-Calvé-Perthes disease. Axial T1-weighted MRIs through the femoral heads show low signal intensity in the left femoral head.
  • ULTRASONOGRAPHY  Ultrasonography is useful in establishing the diagnosis of transient synovitis of the hip and the onset of LCPD.  Hip effusion  Assessment of epiphyseal cortex.  Articular cartilage assesment.
  •  Normal anatomy of the anterior hip joint capsule. fce = femoral capital epiphysis; fm = femoral metaphysis; between cursors = both layers of joint capsule (hyperechoeic to muscle); I = iliopsoas muscle; small arrows = echogenic interface between joint capsule layers.
  •  Normal right hip compared to the left hip with an effusion. Hyperaemia of the soft tissues is evident on the left side. The machine settings are kept the same for comparison.
  •  Transverse image of both hips at the level of the neck of femur. Fluid distends the joint capsule on the left side (as marked by calipers).
  •  Normal hip
  •  Perthes disease with joint effusion but normal cartilage
  •  Perthes disease in a 4 year old boy with fragmentation of the femur epiphysis
  •  Perthes disease with irregular flattened epiphysis and joint effusion
  • Nuclear Imaging  Technetium-99m diphosphonate uptake depends on the stage of the disease, but it does play a role in the diagnosis. Characteristic features include a photopenic void in proximal femoral epiphyses as compared with the contralateral side.
  •  Legg-Calvé-Perthes disease. Magnified pinhole views from a bone scan show decreased accumulation of radiopharmaceutical in the lateral aspect of the left femoral head (arrow), caused by disruption of the blood supply to the femoral head. The normal right femoral head is shown for comparison.
  • Legg calve perthes disease Differential Diagnosis  The differential diagnosis of LCPD includes ruling out the possibility of the symptoms being caused by other disorders, such as:  Juvenile idiopathic arthritis  Sickle cell disease  Septic arthritis  Transient synovitis of the hip