Race: Caucasians are affected
more frequently than persons of
Sex: Males are affected 4-5 times
more often than females.
Age: LCPD most commonly is seen in
persons aged 3-12 years, with a
median age of 7 years.
The capital femoral epiphysis always is involved. In 1520% of patients with LCPD, involvement is bilateral.
The blood supply to the capital femoral epiphysis is
Bone infarction occurs, especially in the subchondral
cortical bone, while articular cartilage continues to
grow. (Articular cartilage grows because its nutrients
come from the synovial fluid.)
Revascularization occurs, and new bone ossification
At this point, a percentage of patients develop
LCPD, while other patients have normal bone
growth and development.
LCPD is present when a subchondral fracture
occurs. This is usually the result of normal
physical activity, not direct trauma to the area
Changes to the epiphyseal growth plate occur
secondary to the subchondral fracture.
Temporary cessation of growth
Revascularization from periphery
Resumption of ossification and trauma
Resorption of underlying bone
Replacement of biologically plastic bone
History: Symptoms usually have been
present for weeks.
Hip or groin pain, which may be
referred to the thigh
Mild or intermittent pain in anterior
thigh or knee
Usually no history of trauma
Decreased range of motion
(ROM), particularly with internal
rotation and abduction
Atrophy of thigh muscles secondary
Leg length inequality due to collapse
Short stature: Children with LCPD
often have delayed bone age.
With patient lying in the supine
position, the examiner rolls the hip of the
affected extremity into external and
This test should invoke guarding or
spasm, especially with internal rotation.
Listed are some other disorders that should be included
in the differential diagnosis for LCPD:
Septic arthritis-This is an infection in the joint
Sickle cell-Osteonecrosis of the hip can be a result of
Spondyloepiphyseal Dysplasia Tarda-This disease
typically affects the spine and the larger more
Gaucher’s Disease- This is a genetic disorder that
often times includes bone pathology
Transient Synovitis-This is an acute inflammatory
process and is the most common cause of hip pain in
Erythrocyte sedimentation rate - May
be elevated if infection present
Plain x-rays of the hip are extremely useful in
establishing the diagnosis.
Frog leg views of the affected hip are very helpful.
Plain radiographs have a sensitivity of 97% and a
specificity of 78% in the detection of LCPD
Multiple radiographic classification systems
exist, based on the extent of abnormality of the
capital femoral epiphysis.
Waldenstrom, Catterall, Salter and Thompson, and
Herring are the 4 most common classification
No agreement has been reached as to the best
Five radiographic stages can be seen
by plain x-ray. In sequence, they are
1. Cessation of growth at
the capital femoral
femoral head epiphysis
and widening of
articular space on
the femoral head
Catterall Group I: Involvement only of the anterior
epiphysis (therefore seen only on the frog lateral film)
Catterall Group II: Central segment fragmentation
and collapse. However the lateral rim is intact and thus
protects the central involved area.
Catterall Group III: The lateral head is also involved
or fragmented and only the medial portion is spared.
The loss of lateral support worsens the prognosis.
Catterall Group IV: The entire head is involved.
Catterall's classification has a significant inter and intra
I – anterior epiphysis
II – up to 50% with collapse
III – only small posterior
portion not involved
IV – whole head involvement
Groups I and II had a good
prognosis (in 90%) and required no
Groups III and IV had a poor
prognosis (in 90 %) and required
The classification is applied to the
frog lateral and AP film during the
Salter and Thompson Classification
Salter and Thompson recognized that
Catterall's first two groups and second two
groups were distinct and therefore
proposed a two part classification.
Salter & Thompson Group A: Less than
1/2 head involved.
Salter & Thompson Group B: More than
1/2 head involved.
Again the main difference between these
two groups is the integrity of the lateral
(Herring) Lateral Pillar
Lateral Pillar Group A: There is no loss in height of
the lateral 1/3 of the head and minimal density
change. Fragmentation occurs in the central segment
of the head.
Lateral Pillar Group B: There is lucency and loss of
height in the lateral pillar but not more that 50% of
the original (contralateral) pillar height. there may be
some lateral extrusion of the head.
Lateral Pillar Group C: There is greater than 50%
loss in the height of the lateral pillar. The lateral pillar
is lower than the central segment early on.
And now there is “B/C Border” since
the ability to differentiate B / C
Unilateral Perthes with entire head involvement and fragmentation. The
reossification phase has not yet begun.
Unilateral Perthes disease with widening of the medial joint space, blurring of
the physis, increased density of the head and lucency between the medial and
central 1/3's of the head corresponding to early fragmentation phase.
Unilateral Perthes in the
reossification phase with
a visible subchondral line
similar to Waldenstrom's
subchondral fracture is
seen very early in the
disease process, before
fragmentation. In this
case the lateral pillar has
“Head at risk signs”
1. Gage's sign. a V shaped lucency in
the lateral epiphysis.
2. lateral calcification (lateral to the
epiphysis) (implies loss of lateral
3. lateral subluxation of the
head.(implies loss of lateral support)
4. A horizontal growth plate.(implies
a growth arrest phenomenon and
Technetium 99 bone
scan - Helpful in
delineating the extent
of avascular changes
before they are
evident on plain
The sensitivity of
in the diagnosis of
LPD is 98%, and the
specificity is 95%.
- Assesses sphericity
of the head of the
Ultrasonography in transient
synovitis and early Perthes' disease
Ultrasonography may provide significant
diagnostic clues to differentiate early
Perthes' from transient synovitis.
T Futami, Y Kasahara, S Suzuki, S Ushikubo, and T Tsuchiya
Journal of Bone and Joint Surgery - British Volume, Vol 73-B, Issue 4, 635639
by using plain
is upgraded in 30%
Not as sensitive as
nuclear medicine or
CT may be used for
follow-up imaging in
patients with LPD.
It allows more precise
MRI is preferred for
position, form, and
size of the femoral
head and surrounding
MRI is as sensitive as
Extent of involvement
Premature physeal closure
Type of treatment
Stage of disease at treatment.
Goals of treatment
Achieve and maintain ROM
Relieve weight bearing
Containment of the femoral epiphysis
within the confines of the acetabulum
Rational behind "containment"
Containment of the head within the acetabulum
is reported to encourage spherical remodelling
during the reossification and subsequent phases.
However if there is total head involvement and
the lateral pillar collapses then the effect of
containment is probably less.
Therefore it seems that the extent of
involvement of the head is the critical factor and
containment simply optimizes the situation.
Medical treatment does not stop or reverse
the bony changes.
Appropriate analgesic medication should be
Nonsteroidal anti-inflammatory drugs
200-400 mg PO q4-6h; not to exceed 3.2 g/d.
6 months to 12 years: 20-40 mg/kg/d PO divided
tid or qid; start at lower end of dosing range and
titrate upward; not to exceed 2.4 g/d
>12 years: Administer as in adults.
The trochanteric overgrowth can be dramatic on
radiographs but several studies have shown that
a Trendelenberg gait does not always occur.
If it does occur, and is significant, then
trochanteric advancement may improve the gait.
An alternative is to perform a trochanteric arrest
at an earlier date but this assumes that the first
statement will not apply to the particular child.
Malformed femoral head
in late group III or residual
A large malformed
femoral head with lateral
Capital femoral physeal
advancement or arrest.
For patients less that 6 years old the
prognosis is good for the majority.
If they are stiff or painful they respond to
bed rest, traction and pain relieving antiinflammatory medication.
There is no evidence that abduction splints
or surgical intervention is warranted in the
majority of these younger patients.
For patients between 6 and 8 years but with a
bone age less than 6 and an intact lateral pillar
(Herring A and B) the prognosis is similar to that
for the first group and observation is as good as
surgical intervention for the majority.
If they have bone ages greater than 6 years and
Herring lateral pillar classification B then
"containment" of the head within the acetabulum
seems to be warranted.
This may be done by abduction bracing, femoral
varus osteotomy or a pelvic osteotomy.
If they are between 6 and 8 and are in lateral
pillar group C then the result of intervention
Children presenting with Perthes disease at age
9 or older often have lateral pillar B or C and a
The trend is towards early containment of
these hips although stiffness can be a problem
following early pelvic (Salter's) osteotomy.
Initially, close follow-up is required to
determine the extent of necrosis.
Once the healing phase has been
entered, follow-up can be every 6
Long-term follow-up is necessary to
determine the final outcome.
The younger the age of onset of LCPD, the
better the prognosis.
Children older than 10 years have a very high
risk of developing osteoarthritis.
Most patients have a favorable outcome.
Prognosis is proportional to the degree of
The Lower Extremity Functional Scale is one that
measures how this disease is affecting the child in a
functional way. Since this questionnaire does ask about
certain activities the child may not be allowed to perform
(i.e. running, hopping, etc), it may not be the outcome
measure of choice.
The Harris Hip score is another questionnaire that has
more to do with a lower level of functional activities such
as walking, stair climbing, donning/doffing shoes, sitting,
Questionnaires that test the patient on a functional level
are useful to provide a baseline and monitor functional
progress in the patient’s activities.
1. The limp:
The limp is usually antalgic.
It is possible that the child has
a Trendelenburg gait (a positive Trendelenburg
test on the affected side) which is marked by a
pelvic drop on the unloaded side during single
The child can also have a Duchenne gait, which
is marked by a trunk lean toward the stance
limb with the pelvis level or elevated on the
unloaded side. 
2. Range of motion: 
The restriction of hip motion is variable in the early stages of the
Many patients, may only have a minimal loss of motion at the
extremes of internal rotation and abduction.
At this stage there usually is no flexion contracture.
Loss of hip ROM in patients with early Perthes’ disease without
intra-articular incongruity is due to pain and muscle spasm. 
This is why, if the child is examined for instance after a night of bed
rest, the range will be much better then later in the day.
Further into the disease process;
Children with mild disease may maintain a minimal loss of motion
at the extremes only and thereafter regain full mobility.
Those with more severe disease will progressively lose motion, in
particular abduction and internal rotation.
Late cases may have adduction contractures and very limited
rotation, but the range of flexion and extension is only seldom
3. Pain: 
Pain occurs during the acute disease. The
pain may be located in the groin, anterior hip
area, or around the greater trochanter.
Referral of pain to the knee is common.
4. Atrophy: 
In most cases there is atrophy of the gluteus,
quadriceps and hamstring muscles,
depending upon the severity and duration of
There is no consensus concerning the possible
benefits of physiotherapy in LCP disease, or in
which phase of the development of the health
problem it should be used.
Some studies mention physiotherapy as a preand/or postoperative intervention, while others
consider it a form of conservative treatment
associated with other treatments, such as
skeletal traction, orthesis, and plaster cast.
In studies comparing different treatments,
physiotherapy was applied in children with a
mild course of the disease.
The characteristics of the patients were:
Children with less than 50% femoral head necrosis
(Catterall groups 1 or 2) 
Children with more than 50% femoral head necrosis,
under six years, whose femoral head cover is good
Herring type A or B
Salter Thompson type A
For patients with a mild course, physiotherapy can
produce improvement in articular range of motion,
muscular strength and articular dysfunction.
The physiotherapeutic treatment included:
Passive mobilisations for musculature stretching of the involved
Straight leg raise exercises, to strengthen the musculature of the
hip involved for the flexion, extension, abduction, and adduction of
muscles of the hip.
They started with isometric exercises and after eight session,
A balance training initially on stable terrain, and later on unstable
For children over 6 years at diagnosis
with more than 50% of femoral head
osteomy gave a significantly better
Goals of PT Rx
management of LCPD are to promote
and optimize range of motion, strength,
and joint preservation to minimize
impairments and maximize function.
Containment of the femoral head in the
acetabulum is the most important focus
during each stage of LCPD.
• Hot Pack for pain management with
• Cryotherapy for 20min at a time2
• Hip abductors
• Hip flexors
• Hip extensors
• Hip internal & external rotators
• Gluteus medius
**Avoid single limb stance activities due to increased force
through hip joint during severe involvement stage
Improving Range of Motion
**ROM is typically lost in this population due to
muscle guarding secondary to pain from
incongruent joint surfaces
• Static Stretching of LE musculature
• Dynamic ROM and AAROM for muscle
guarding due to pain and if unable to achieve
through static stretching
• AROM & AAROM following passive stretching
to maintain newly gained ROM
• Stretching should include the following
muscle groups: hip internal and external
rotators, hip abductors, hip extensors, and any
other LE motion that is significantly limited.
• Single leg dynamic function activities such as
side steps and step ups, according to WB
status and involvement phase
Home Exercise/Modality Use
• Cryotherapy for 20min at a time may be used
to decrease pain and inflammation
• The HEP should be based on orthopedist
recommendations due to the staging of the
disease, age of onset of the disease,
radiographic data, and patient presentation
Post-Surgical Physical Therapy - There is
no evidence on the best post-op physical
therapy interventions following femoral
osteotomy in children with LCPD
• The child will most likely be non-weight
bearing approximately 6-8 weeks3
• During the non-weight bearing phase AROM
of the joints above and below the surgical site
should be done to prevent stiffness and undue
• Once the cast is removed, AAROM, AROM,
and resistive exercises should be done to
restore strength lost from immobility3
• Static stretches held for 30 sec+ and
contract-relax stretches should be done every
day followed by AROM exercises to restore and
maintain full ROM
Conservative Management of Legg-CalvePerthes Disease-pdf
Post-Operative Management of Legg-CalvePerthes Disease-pdf
Evidence based guideline for LCPD from NGC