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Orthopedics 5th year, 3rd & 4th/part one lectures (Dr. Bakhtyar)

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The lecture has been given on Dec. 22nd, 2010 & Feb. 5th, 2011 by Dr. Bakhtyar.

Published in: Health & Medicine

Orthopedics 5th year, 3rd & 4th/part one lectures (Dr. Bakhtyar)

  1. 1. <ul><li>Perthes’ Disease (Coxa plana) </li></ul><ul><li>Legg-Calve- Perthes </li></ul>
  2. 2. <ul><li>Perthes’ Disease (Coxa plana) </li></ul><ul><li>Painful disorder of childhood characterized by necrosis of the femoral head. </li></ul><ul><li>Boys: Girls = 4:1 </li></ul><ul><li>Age: 4-8 years </li></ul>
  3. 3. <ul><li>PATHOGENESIS </li></ul><ul><li>3 sourses of blood supply to femoral head </li></ul><ul><li>1- Metaphyseal vessels: Disappear at 4 years age </li></ul><ul><li>2- Ligamentum teres vessels: develop fully at 7 years age </li></ul><ul><li>3- Lateral epiphyseal vessels: All the ages </li></ul><ul><li>Between 4-7 y. the only sourse is lateral epiphyseal </li></ul>
  4. 4. Trauma OR Non-specific synovitis ->effusion -> stretching of retinaculum -> obstruction of vessels -> necrosis
  5. 5. <ul><li>PATHOLOGY </li></ul><ul><li>2-4 years </li></ul><ul><li>3 stages : </li></ul><ul><li>1- Bone Death </li></ul><ul><li>2- Revascularization and repair </li></ul><ul><li>New bone is laid down on the dead trabeculae if: </li></ul><ul><li>(a) Part of the head is involved </li></ul><ul><li>(b)Repair process is rapid </li></ul><ul><li>Restoration of the bony architecture </li></ul><ul><li>3- Distortion and remodeling if: </li></ul><ul><li>(a) A large piece is damaged </li></ul><ul><li>(b) Repair process is slow. </li></ul><ul><li>The head and neck are distorted </li></ul>
  6. 6. <ul><li>XRAY </li></ul><ul><li>(A)Early changes :(1) ↑density of the bony epiphysis </li></ul><ul><li>(2) ↑joint space (apparent) </li></ul><ul><li>(B)Later changes :(1) flattening(coxa plana) </li></ul><ul><li>(2) fragmentation </li></ul><ul><li>(3) coxa magna </li></ul><ul><li>(4) mushroom like head </li></ul><ul><li>(5) lateral displacement of the epiphysis </li></ul><ul><li>(6) sagging rope sign </li></ul><ul><li>(7) rarefaction and broadening of the metaphysis(neck) </li></ul>
  7. 10. <ul><li>CLINICAL FEATURES </li></ul><ul><li>Boys: Girls = 4:1 </li></ul><ul><li>4-8 years </li></ul><ul><li>Pain in the groin ± knee </li></ul><ul><li>Limping </li></ul><ul><li>Little wasting of quadriceps ± </li></ul><ul><li>Early stage: The hip is irritable. i.e.: </li></ul><ul><li>All movements are diminished </li></ul><ul><li>Their extremes are painful </li></ul><ul><li>Later on (after the irritable state): </li></ul><ul><li>All movements are full except Abduction and Internal rotation </li></ul>
  8. 11. <ul><li>TREATMENT </li></ul><ul><li>(A)Irritable state: Skin traction till pain subsides (3 weeks) </li></ul><ul><li>(B) Further treatment depends on the assessment of prognosis </li></ul><ul><li>(a) Favourable prognostic signs </li></ul><ul><li>(1) Onset< 6 years </li></ul><ul><li>(2) Partial involvement of the femoral head </li></ul><ul><li>(3) Normal shape of the femoral head </li></ul><ul><li>(4) Absence of metaphyseal rarefaction </li></ul><ul><li>TREATMENT: Supervised Neglect </li></ul>
  9. 12. <ul><li>(b)Unfavourable prognostic signs </li></ul><ul><li>(1) >6 years age </li></ul><ul><li>(2) Whole femoral head involved </li></ul><ul><li>(3) Lateral displacement of the head </li></ul><ul><li>(4) Severe metaphyseal rarefaction </li></ul><ul><li>TREATMENT: Containment of the femoral head (Keeping the femoral head well seated within the acetabulum to retain its normal shape during the period of healing). This is achieved by 2 methods: </li></ul><ul><li>Conservative: Holding the hips widely abducted in POP or by a removable splint for 1 year. </li></ul><ul><li>. </li></ul>
  10. 13. Surgery(a) Varus osteotomy of the femur (b) Innominate osteotomy of pelvis
  11. 14. <ul><li>NOTE: Those with very worse Xray changes, treatment is useless. </li></ul>

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