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Legg- Calve – Perthes disease

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Dr. Le Giang

Dr. Le Giang

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    • 1. Case StudyMay 25th, 2012Reported by Dr. Giang
    • 2.  Name: Tran Thi Thu Phuong Sex: Female Age: 10 years old Dept: Outpatient
    • 3. Clinical Right hip pain Limp No fever History: no trauma
    • 4. MRI Findings(T2WI, Coronal, Pre C+) Right femoral head : Flattening ( 7mm) Left femoral head: normal ( 13mm) No hip joint dislocated
    • 5. MRI Findings(T2WI, Axial, Pre C+) Right hip joint effusion: hyperintensity Right articular cartilage: irregular thickness Epiphyseal marrow: hypointensity.
    • 6. MRI Findings(T1WI, Coronal, Pre C+) Right intraarticular effusion: hypointense Irregular articular border. Epiphyseal marrow center: hypointense(necrosis)
    • 7. MRI Findings(T2FS, Coronal, Pre C+) Right femoral neck: Hyperintense
    • 8. MRI DiagnosisAvascular necrosis of right femoral epiphysis Grade II(Legg- Calve – Perthes disease)
    • 9. Legg Calve DiseaseBackground Definition: Necrosis of osseous epiphysis offemoral head classified as an osteochondrosis Location: Proximal femoral epiphysis15 to 20% with bilateral involvement Age:o 3-12 yearso Median = 7 years Gender: M:F = 4-5: 1
    • 10. Legg Calve DiseaseBackground Clinical symptom:- No history of trauma- Limp + hip, thigh or knee pain .- Leg length inequality.- Thigh atrophy.- Decrease range of motion (internal rotation& abduction)
    • 11. Legg Calve DiseaseBackground Prognosis:- Younger age of presentation = better prognosis- > 8 years old = poor prognosis Treatment:1. Conservative:- 50% improve with no treatment- Bed rest + abduction stretching & bracing2. Surgical:Femoral/pelvic osteotomies to contain hip
    • 12. ClassificationCatterall classification: Based on extent of epiphysealinvolvement Group I : < 1/4 epiphysis involved Group II : < 1/2 epiphysis involved Group III : Most of epiphysis involved Group IV : All epiphysis involved
    • 13. ClassificationSalter - Thompson: Extent + location ofsubchondral fractureo A = fracture < 50% span of epiphysiso B = fracture> 50% span of epiphysis
    • 14. Imaging Diagnosis Method1. X ray2. CT scanner3. Bone scintigraphy4. MRI
    • 15. X-RAY FINDINGS Effusion, fragmentation + flattening of sclerotic capitalepiphysis Metaphyseal irregularity (rarefaction of lateral + medialmetaphysis + cystic changes) Joint space (inferomedial) widening + intact subchondralplate Catterall classification (group I-IV) estimates amount offemoral head involvement
    • 16. Perthes bilateral.
    • 17. X-RAY FINDINGSWaldenstroms radiographic staging1.• Initial stage = increased head-socket distance,subchondral plate thinning + dense epiphysis2.• Fragmentation stage = subchondral fracture,inhomogeneous dense epiphysis + porous appearance +metaphyseal cysts3.• Reparative stage = normal bone in areas of resorption +removal of sclerotic bone + more homogeneous epiphysis4.• Growth stage = approaches normal femoral shape5.• Definite stage = final shape (joint congruency vs.incongruency)
    • 18. MRI FINDINGSProtocol: T1WI, T2WI, STIR, T1 C+ (coronal & axial)1. T1WIo Hypointense intraarticular effusiono Hypointense irregularity along periphery ofossific nucleus (diem cot hoa)o Linear hypointensity traversing femoralossification center (trung tam cot hoa) in earlystageso Revascularization of necrotic epiphysis =replacement of hypointense focus with marrow fatsignal intensity
    • 19. MRI FINDINGS2. T2WI- FS PD or T2 FSEimages to assess articular cartilage thickness+ chondral irregularities- Physeal cartilage ± hyperintense on T2WI - in early stagedisease- Loss of femoral head containment in acetabulum• Intermediate signal hypertrophied synovium in iliopsoasrecess• Thickening of intermediate signal epiphyseal cartilage-Hyperintense joint effusionSagittal T1 + T2WI also useful to display acetabular + femoralhead cartilage
    • 20. MRI FINDINGS3. STIR± Hyperintense femoral head + hyperintense neckedema /& effusion
    • 21. MRI FINDINGS4. T1 C+Decreased enhancement with gadolinium in earlyavascular necrosisNo enhancement
    • 22. MRI FINDINGSSagittal T1 + T2WI also useful to display acetabular +femoral head cartilage
    • 23. Different Diagnosis1. Toxic synovitis: Self-limiting acute synovitis (3 to 10 days) •Boys < 4 years Minimal thigh atrophy Improves in < 5 days with bedrest + anti-inflammatory medications Significant effusion + capsular distension
    • 24. Different Diagnosis2. Septic HipAcute ill& feverJoint effusion +/- joint debris +/- reactivemarrow 7 Increased white blood cell count +sedimentation rate Hips held in flexion, abduction (dang) +external rotation vs. hip adduction (khep) inPerthes edema
    • 25. Different Diagnosis3. Juvenile Chronic ArthritisLimp + hip painChronicity + thigh atrophyFever + rash + positive antinuclear antibodyEpiphyseal erosions (an mon)
    • 26. Different Diagnosis4. Slipped Capital Femoral Epiphysis Posterior-inferior displacement of proximalfemoral epiphysis Pain + limp Limitation of internal rotation + abduction
    • 27. Different Diagnosis5. Osteoid Osteoma (u xuong dangxuong)Local pain worse at night, decreased bysalicylates Local swelling + point tendernessExtensive marrow edema on FS PD FSE orSTIR
    • 28. Thank you for attention!