Legg calve perthes disease

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Legg calve perthes disease

  1. 1. Synonyms – Perthes Disease – Osteochondritis Deformans Juvenilis– Childhood Aseptic Necrosis of Femoral Head Dr. P. Ratan khuman (PT) M.P.T., (Ortho & Sports)
  2. 2. Definition Perthes‟ disease is a self-limiting form of osteochondrosis of the capital femoral epiphysis of unknown aetiology that develops in children commonly between the ages of 5 – 12 years. It is a condition of immature hip caused by necrosis of the femoral epiphysis; the femoral head subsequently deforms as necrotic bone is replaced by living bone. It is Hip disease occurring during early childhood and caused by impaired circulation in the femoral head.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 2
  3. 3. Historical background The disease was described almost simultaneously, in 1910, by – – G. C. Perthes in Germany, – J. Calve in France – A.T. Legg in America. – Hence name – “Legg Calve Perthes Disease” The newly discovered x-ray technique allowed doctors to differentiate it from inflammatory forms of hip disease.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 3
  4. 4. Etiological Factors that play a role in development of illness Vascular supply Increased intra-articular pressure Intraosseous pressure Coagulation disorder Growth hormones Growth Social conditions Genetic factors22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 4
  5. 5. Vascular supply: – Angiograms & laser Doppler flow measurements • Medial circumflex artery is missing or obliterated in many cases • Obturator artery or the lateral epiphyseal artery are also affected in some cases.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 5
  6. 6. Increased intra-articular pressure: – Animal experiments have shown that an ischemia similar to that in Perthes disease can be generated by increasing the intra-articular pressure. – However, the condition of transient synovitis of the hip does not appear to be a precursor stage of Perthes disease as the increased pressure resulting from the effusion in transient synovitis does not lead to vessel closure.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 6
  7. 7. Intraosseous pressure: – The measurement of intraosseous pressure in Perthes patients has shown that the venous drainage in the femoral head is impaired, causing an increase in intraosseous pressure. – In animal studies, the intraosseous injection of fluid, and the associated increase in pressure, produced a condition similar to Perthes disease22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 7
  8. 8. Coagulation disorder : – Study have found a coagulation disorder in 75% children with Perthes disease. – In most cases the disorder was thrombophilia. – Rarely the disorder involved elevated serum levels of lipoprotein, a thrombogenic substance. – Recent studies have questioned the significance of clotting factors as an etiological component22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 8
  9. 9. Growth hormones : – While earlier studies found reduced levels of the growth hormone. – Recent studies have not shown any difference from control groups in respect of hormone status22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 9
  10. 10. Growth: – Children with Perthes disease are shorter, on average, than their peers of the same age & show a retarded skeletal age (cartilaginous dysplasia). – The maturation disorder occurs between the ages of 3 and 5 years. – Both the trunk and extremities lag behind in terms of growth.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 10
  11. 11. Growth cont… – The shortening of the extremities is also accompanied by small feet. – Since this shortening is offset by excessive growth at a later age, patients who suffered from Perthes disease as children are no shorter, as adults, than the population average. – More recent experimental studies have shown that the metaphyseal changes are based on a growth disorder.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 11
  12. 12. Social conditions: – Studies in the UK have shown that Perthes disease is more common in the lower social status. – The authors suggest a poorer diet during pregnancy as one possible explanation for this phenomenon. – A recent study did not confirm this theory22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 12
  13. 13. Genetic factors: – Studies have shown that first degree relatives of children with Perthes disease are 35 times more likely to suffer from the condition than the normal population. – Even second- and third-degree relatives show a fourfold increased risk.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 13
  14. 14. To sum up – – Genetic factors play an important role in the etiology of Perthes disease. – The illness develops as a result of impaired circulation in the medial circumflex artery in association with a skeletal maturation disorder with delayed growth in children aged from 3–5 years.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 14
  15. 15. Occurrence In white population is 10.8 per 1,00,000 children & adolescents aged from 0–15 year In Asians is 3.8 per 1,00,000 In Mixed-race populations is 1.7 per 1,00,000 In Blacks is 0.45 per 1,00,000 The highest reported incidence was in city of Liverpool (UK) early 1980‟s, with 15.6 per 1,00,000 individuals under 15 years of age.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 15
  16. 16. A decline was subsequently observed in the 1990‟s – possibly as a result of the improved social conditions. Similarly high incidence 15.4 per 1,00,000 was recently reported in a rural area of Southwest Scotland. In Sweden an annual incidence of 8.6 per 100,000 people under 15 yrs was Determined.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 16
  17. 17. Epidemiology Disorder of hip in young children Usually ages 4-8yr As early as 2yr, as late as teenager Boys: Girls – 4/5:1 Bilateral – 10-12% No evidence of inheritance22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 17
  18. 18. Classification All known classifications of Legg-Calvé- Perthes disease are based on the morphological findings on x-rays.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 18
  19. 19. Morphological classifications ofthe extent of the lesion Classification according to Catterall (Common) Classification according to Salter & Thompson Classification according to Herring22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 19
  20. 20. Classification of extent of lesion - (Acc to Catterall)Grade Characteristics I Only anterolateral quadrant affected II Anterior third or half of the femoral head Up to 3/4 of the femoral head affected, III only the most dorsal section is intact IV Whole femoral head affected22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 20
  21. 21. Grade – I Only anterolateral quadrant affected22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 21
  22. 22. Grade - II Anterior third or half of the femoral head22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 22
  23. 23. Grade – III Up to 3/4 of the femoral head affected, only the most dorsal section is intact22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 23
  24. 24. Grade – IV Whole femoral head affected22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 24
  25. 25. Classification according to Salter& Thompson Group Characteristics A Subchondral # involving <50% of the femoral dome B Subchondral # involving >50% of the femoral dome22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 25
  26. 26. 8-year old boy with subchondral fracture and incipient Legg-Calve- Perthes disease22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 26
  27. 27. Classification according to HerringGroup Characteristics A Lateral pillar not affected >50% of height of lateral B pillar preserved <50% of height of lateral C pillar preserved22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 27
  28. 28. Classification according to Herring “A” Lateral pillar not affected22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 28
  29. 29. Classification according to Herring “B” >50% of height of lateral pillar preserved22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 29
  30. 30. Classification according to Herring “C” <50% of height of lateral pillar preserved22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 30
  31. 31. Deformation of the femoral head Children femoral head becomes deformed during revascularization of the epiphysis. There is evidence to suggest that irreversible deformation occurs either in the latter part of the stage of fragmentation or very early in the stage of regeneration.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 31
  32. 32. Enlargement of the femoral head – – The femoral head becomes enlarged as the disease progresses. – The extent of enlargement is proportional to the degree of its deformation.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 32
  33. 33. Capital physeal growth impairment – – The avascularity of the epiphysis impairs normal growth at the capital femoral physis and, as a result of this, in some older children the femoral neck is foreshortened. – The trochanter continues to grow normally and as a consequence the GT outgrows the femoral head and neck. – This results in altered mechanics of the hip and a Trendelenburg gait.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 33
  34. 34. Secondary degenerative arthritis of the hip – – All 3 morphological changes in the proximal femur listed above can contribute independently or collectively to the development of secondary degenerative arthritis. – However, the most important factor that predisposes to the development of degenerative arthritis is deformation of the shape of the femoral head.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 34
  35. 35. Stages of Perthe‟s Disease(Waldenström Staging) 1. Avascular stage 2. Fragmentation stage 3. Re-ossification stage 4. Healed stage22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 35
  36. 36. Stage and Characteristics Avascular stage. – The femoral head appears slightly flattened & denser than normal on the x-ray. – The joint space is widened (Waldenström sign). – Lateralisation of the femoral head.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 36
  37. 37. Stage and Characteristics cont… Stage of resorption (Fragmentation) - Femoral head breaks up into fragments - Lucent areas appear in the femoral head - Increased density resolves - Acetabular contour is more irregular22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 37
  38. 38. Stage and Characteristics cont… Stage of Re-ossification – The femoral head is rebuilt – New bone formation occurs in the femoral head22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 38
  39. 39. Stage and Characteristics cont… Healing stage – End stage with or without defect healing (normal hip, coxa magna, flattened head etc.)22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 39
  40. 40. CLINICAL FEATURES EARLY (Necrosis, Fragmentation) – – Synovitis – There is pain & limp of insidious onset. – Pain usually in groin, radiating to thigh or knee. – Limp is typically antalgic gait. LATE (Re-ossification – Remodeling) – – There is limp (antalgic, short-leg or stiff hip). – Pain is mild and usually in the hip area.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 40
  41. 41. Stages of radiological changes in Perthes disease: Early Stage – – Joint space widening (waldenstroms sign) – Increased density of femoral epiphysis – Subchondral fracture, or “crescent sign,” seen on lateral radiograph Mid Stage – – Fragmentation and flattening of head (Coxa magna) – Widening of the physis (waldenstroms sign) – Femoral neck cysts – Extrusion of the femoral head22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 41
  42. 42. Stages of radiological changes in Perthes disease: cont… Late Stage– Coxa magna High-riding trochanter Flattened femoral head Irregular articular surface22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 42
  43. 43. Physical Therapy Assessment & Diagnosis22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 43
  44. 44. Clinical Assessment A thorough history and examination be completed to establish an impairment based physical therapy diagnosis and individualized plan of care (APTA). It is recommended initial evaluation, on a monthly basis or sooner if the pt demonstrates a change in status, and at discharge: – Pain and symptoms – Lower extremity PROM & AROM – Lower extremity strength – Gait – Balance – Outcome measures22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 44
  45. 45. Pain and symptoms It is recommended to assessed using – – Oucher pain scale – Numerical Rating Scale (NRS)22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 45
  46. 46. Lower Limb PROM & AROM Fluid filled or linear goniometer is recommended to measure ROM. Hip motions to assess include – – Hip flexion, abduction, extension, internal rotation, external rotation. The knee & ankle ROM be assessed at the initial evaluation and thereafter if they are significantly limited.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 46
  47. 47. Lower Extremity Strength Quantitative muscle testing is recommended using a hand held dynamometer due to its high intra- & inter-rater reliability. MMT also can be used but less reliable. Muscle groups to assess include – – Hip – Flexors, Abductors, Extensors, Internal Rotators, External Rotators – Knee – Extensors, Flexors, – Any Other Muscle Group that is Significantly Limited22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 47
  48. 48. Gait Qualitatively gait assessment is recommended for common LCP deviations. – Note 1: Based on limited accessibility and feasibility, the gold standard for gait analysis of 3-D gait kinematics and kinetics is not recommended to be used in the clinic. – Note 2: There is insufficient evidence & lack of reliability & validity to support use of observational gait assessment tools with this population.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 48
  49. 49. Gait cont… Commonly observed gait characteristics in LCP include, but are not limited to: – Increased hip adduction on stance leg – Trunk lean outside the normal range – Trendelenburg (hip drop on unaffected limb while in swing) – Compensated trendelenburg/reverse trendelenburg/duchenne (trunk lean to the affected side while in stance on the affected limb) – Toe in or toe out22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 49
  50. 50. Balance Balance be assessed on weight bearing status. The desired outcome is that the patient maintain balance for age appropriate times for safe ambulation and stair negotiation. – Note: In pts 7 y or older, balance is to be assessed using the Pediatric Balance Scale. – If the pt is younger than 7 y old, the test is unavailable22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 50
  51. 51. Outcome measure scores The age appropriate Pediatric Quality of Life Inventory Version 4.0 is recommended. Physical Functioning section is administered at the initial evaluation, on a monthly basis for reassessment of patient‟s reported functional status, and at discharge.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 51
  52. 52. Imaging – Radiographic Feature Widening of the joint space and minor subluxation Sclerosis Fragmentation and focal resorption Loss of height Metaphyseal cyst formation Widening of the femoral neck & head (Coxa Magna) Lateral uncovering of the femoral head Sagging rope sign Acetabular remodelling22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 52
  53. 53. Frog-lateral View Of The Hips22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 53
  54. 54. Caffey‟s sign As the disease progresses, a subchondral # may occur in the anterolateral aspect of the femoral capital epiphysis. Is an early radiographic feature best seen on the frog-lateral projection. This produces a crescentic radiolucency known as the crescent, Salter‟s or Caffey‟s sign22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 54
  55. 55. Fragmentation of the femoral capital epiphysis22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 55
  56. 56. Sclerosis of epiphysis & wideningof joint space in the early stages22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 56
  57. 57. Metaphyseal cyst formation within the femoral neck22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 57
  58. 58. „Sagging Rope Sign‟ This a curvilinear sclerotic line running horizontally across the femoral neck. It is confirmed by 3D CT studies. It is a finding in AP radiograph in a mature hip with Perthes‟ disease.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 58
  59. 59. Ultrasound features Effusion, especially if persistent Synovial thickening Cartilaginous thickening Atrophy of the ipsilateral quadriceps muscle Flattening, fragmentation, irregularity of the femoral head New bone formation Revascularisation with contrast enhanced power Doppler22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 59
  60. 60. Differential Diagnosis It is important to rule out infectious etiology (septic arthritis, toxic synovitis) Others: – Chondrolysis -Neoplasm – JRA -Sickle Cell – Osteomyelitis -Traumatic AVN – Lymphoma -Medication22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 60
  61. 61. Differential Diagnosis D/D unilateral Perthes‟ D/D bilateral Perthes‟ disease: disease: – Transient synovitis – Hypothyroidism – Septic arthritis – Multiple epiphyseal – Sickle cell disease dysplasia – Sickle cell disease22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 61
  62. 62. Diagnosis Children with Perthes disease limp and complain of mild to moderate hip pain. This situation can persist for several weeks. Clinical examination usually reveals a slight stiff, protective limp. The ROM of the affected hip is usually restricted, in particular with reduced abduction and internal rotation.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 62
  63. 63. Classification of Phases of Rehab It is recommended that the Classification Instrument in Perthes (CLIPer) be used to place the patient into a rehabilitation classification phase upon examination. The patient should be re-examined using the CLIPer on a monthly basis to determine the appropriate progression through the rehab classification stages It is recommended the patient is referred back to the orthopaedic surgeon if the patient‟s status worsens over two consecutive PT sessions22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 63
  64. 64. Classification Instrument in Perthes (CLIPer)Domains Description Score 7 to10/10 4 Pain with 4 to 6/10 2 ADL 0 to 3/10 0 Less than 50% of uninvolved side for the majority of directions 6 Hip ROM 50 to 75% of uninvolved side for the majority of directions 3 76 to 100% of uninvolved side for the majority of directions 0 Less than 50% of uninvolved side for the majority of muscle groups 6Hip Strength 50 to 75% of uninvolved side for the majority of muscle groups 3 76 to 100% of uninvolved side for the majority of muscle groups 0 Pediatric balance score less than 50% of best score (best score=56) 4 OR SLS with eyes open less than 50% of time on uninvolved side Pediatric balance score 50 to 75% of best score (best score=56) Balance 2 OR SLS with EO of uninvolved side 50 to 75% length of time Pediatric balance score 76 to 100% of best score (best score=56) 0 OR SLS with EO 76 to 100% of uninvolved side NWB and uses an assistive device and without AD, displays excessive gait 4 deficits with decreased efficiency Gait No assistive device & displays excessive deficits without a decrease in 2 efficiency. Uses step to pattern on stairs Non-painful limp Able to perform reciprocal pattern on stairs 0 Total:22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 64
  65. 65. Rehabilitation Classification Phase Score total 14 to 24: Severe Involvement Score total 6 to 13: Moderate Involvement Score total 0 to 5: Mild Involvement22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 65
  66. 66. Instructions for use Upon examination, assess pain with ADL‟s, hip range of motion, hip strength, balance, and gait. Assign a correlating score for each domain of assessment based on examination results and total the sum. Place the patient in a rehabilitation classification phase based on the total score to guide physical therapy treatment.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 66
  67. 67. Physical Therapy Management Supervised PT with a customized written home ex program in all phases of rehab. It is recommended that the PT engage in ongoing communication with the patient, family, and referring physician regarding the disease process & plan of care. It is recommended to progress through the phases of rehabilitation follow a goal based rather than a time based progression.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 67
  68. 68. Phases of Rehabilitation Severe Involvement Phase (CLIPer score 14 to 24) Moderate Involvement Phase (CLIPer score 6 to 13) Mild Involvement Phase (CLIPer score 0 to 5)22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 68
  69. 69. Goals for ManagementCLIPer score 14 to 24 CLIPer score 6 to 13 CLIPer score 0 to 5• Reduce pain to < 7/10 • Reduce pain to < 4/10 • Reduce pain to 1/10 or• Increase ROM to >50% • Increase ROM to > 75% of the less of the uninvolved side uninvolved side • Increase ROM to• Increase strength to • Increase strength to > 75% of >90% of the >50% of the the uninvolved side uninvolved side uninvolved side • Progress from use of an • Increase strength to >• Patient to be assistive device if approved by 90% of the uninvolved independent with the physician and without adverse side appropriate assistive effects • Improve balance to device and weight • Independence with a step to >90% of the maximum bearing precautions pattern on stairs without UE Pediatric Balance Scale• Improve balance to support score or single limb >50% of the maximum • Improved efficiency in walking stance of the uninvolved Pediatric Balance Scale • Improved balance to > 75% of side score or single limb the maximum Pediatric Balance • Ambulation with a non- stance of the uninvolved Scale score or single limb stance painful limp with side. of the uninvolved side normal efficiency 22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 69
  70. 70. Pain ManagementCLIPer • Hot pack with stretching score • Cryotherapy14 to 24 • Medications as prescribed by the referring physician for painCLIPer • Hot pack with stretching score • Cryotherapy6 to 13 • Medications as prescribed by the referring physician for painCLIPer • Hot pack with stretching score • Cryotherapy0 to 5 • Medications as prescribed by the referring physician for pain 22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 70
  71. 71. ROM Management • Static stretch for LE musculature with or without hot pack • Dynamic ROM & AAROM if muscle guarding due to painCLIPer and is unable to achieve end ROM with static stretch. score • Perform AROM and AAROM following passive stretching to14 to 24 maintain newly gained ROM . • Stretching for hip – IR, ER, Abd, Extensor, & any other lower extremity motion that is significantly limitedCLIPer score • Same as above6 to 13 • Dosage of may differ based on patient preference & comfort.CLIPer score • Same as above0 to 5 • Dosage of may differ based on patient preference & comfort. 22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 71
  72. 72. ROM cont… Static Stretching Parameters – – 2 minutes of stretching/day/muscle group – 30 second hold time – 4 repetitions per muscle group – If not tolerated, may do 10 to 30 second hold time with repetitions adjusted to meet 2 minute requirement • e.g. if holding 15 seconds, would do 8 stretches22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 72
  73. 73. ROM cont… Dynamic Stretch Parameters – – 5 second hold – 24 repetitions per muscle group per day to meet 2 minute stretching time required Done if patient does not tolerate static stretch22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 73
  74. 74. Strengthening Ex (CLIPer score 14 to 24) Isometric Ex -> Isotonic Ex in gravity lessened -> Isotonic Ex against gravity. It is appropriate to include concentric and eccentric contractions. Begin with 2 sets of 10 to 15 rep of each ex, progression to 3 sets of each exs. – Note: If the patient is unable to perform 2 sets of 10 rep, the difficulty of the ex is to be decreased either through weight or type of ex.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 74
  75. 75. Strengthening Ex (CLIPer score 14 to 24) Focus on strengthening of HIP (Abd + Flexors + ER + IR + Extensors + or any other LE muscle group that displays significant strength deficits). Special attention to gluteus medius to min intra- articular pain & for pelvic control during single leg activities and ambulation . Weight bearing Vs Non-weight bearing ex is based on patient‟s tolerance to weight bearing positions, and safety.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 75
  76. 76. Strengthening Ex (CLIPer score 14 to 24) Closed chain double limb exercises with light resistance (less than full body weight) It is not recommended to perform single limb closed chain ex on the involved side due to increased intra-articular pressure in the hip joint.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 76
  77. 77. Strengthening Ex (CLIPer score 6 to 13) Isotonic Ex in gravity lessened -> Isotonic Ex against gravity. Include concentric & eccentric contractions. Weight bearing and non-weight bearing activities can be used in combination based on the patient‟s ability and goals of the treatment session.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 77
  78. 78. Strengthening Ex (CLIPer score 6 to 13) Upper extremity supported functional dynamic single limb activities may be performed. – e.g. step ups, side steps Double limb closed chain ex may be used with light resistance if weight bearing allows. – e.g. mini-squats22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 78
  79. 79. Strengthening Ex (CLIPer score 0 to 5) Isotonic Ex in gravity lessened -> Isotonic Ex against gravity. Include concentric & eccentric contractions. Functional dynamic single limb activities with UE support as needed for patient safety may be performed. – e.g. step ups, sidesteps Closed kinetic chain single limb exercises with light resistance may be performed. – E.g. leg press22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 79
  80. 80. Strengthening Ex Prescription Special attention should be given to: – Hip abductors (especially gluteus medius) – Hip internal rotators – Hip external rotators – Hip flexors – Hip extensors22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 80
  81. 81. Isometric Strengthening Parameters – – 10 sec hold + 10 rep/muscle gr, total = 100 sec. – Can adjust hold time to 5 sec + 20 rep to meet 100 sec requirement Intensity – – Performed at approx. 75% maximal contraction Performed with hip in neutral position22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 81
  82. 82. Isotonic Strengthening Parameters – – High repetitions (10 to 15 reps) and 2 to 3 sets – Perform both concentric & eccentric contraction – Low resistance • Rest 1 to 3 minutes between sets • Rest can include exercise of a different muscle group or cessation of activity If pt is unable to perform 2 sets of 10 rep, exercise intensity should be decreased either through weight or type of exercise22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 82
  83. 83. Balance training (CLIPer score 14 – 24) If weight bearing status & symptoms allow – – Activities that include double limb stance and a narrowed base of support on stable surfaces may be performed. It is not recommended to perform single limb activities due to increased intra-articular pressure in the hip joint.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 83
  84. 84. Balance training(CLIPer score 6 – 13 & 0 – 5) Same as previous stage Limit prolonged single limb activities due to excessive joint compressive forces22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 84
  85. 85. Gait training (CLIPer Score 14 – 24) Follow the referring physician‟s guidelines for weight bearing status. Begin gait training with – – Appropriate assistive device – Weight bearing status as determined by the referring physician or – Based on the patient‟s tolerance to full weight bearing due to pain or safety22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 85
  86. 86. Gait training (CLIPer Score 6 – 13) Continue to follow the referring physician‟s guidelines for weight bearing status. Progress to gait training without use of an assistive device as appropriate, focusing on minimizing deficits and improving efficiency of walking. Stair negotiation and other functional mobility.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 86
  87. 87. Gait training (CLIPer Score 0 – 5) Continue to follow the referring physician‟s guidelines for weight bearing status Progress to gait training without the use of an assistive device as appropriate, focusing on minimizing deficits and improving the efficiency of walking. Stair negotiation & other functional mobility. Progress to walking on uneven surfaces with an emphasis on safety.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 87
  88. 88. Weight Relief The load on the hip can basically be relieved by the following methods: – Bed rest – Wheelchair – Walking with crutches, – Bracing devices (Thomas splint , Mainz orthosis, etc.).22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 88
  89. 89. Petrie Cast22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 89
  90. 90. Broomstick Cast22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 90
  91. 91. Bracing22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 91
  92. 92. Discharge Criteria Children may be discharged when 4 of the 5 following criteria have been met: – Pain rating 0 to 1/10 – ROM 90 to 100% of the uninvolved side – Strength 90 to 100% of the uninvolved side – Balance 90 to 100% of the max score on the Pediatric Balance Scale or maintaining balance with SLS 90 to 100% of the uninvolved side – Gait presents with a non-painful limp and uses a reciprocal pattern on the stairs.22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 92
  93. 93. Prognosis 60% of kids do well without Rx AGE is key prognostic factor: – <6y – good outcome regardless of Rx – 6-8y – not always good results with just containment – >9y – containment option is questionable, poorer prognosis, significant residual defect22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 93
  94. 94. Operative Tx If non-op Rx cannot maintain containment Surgically ideal pt: – 6-9yo – Catterral II-III – Good ROM – <12mos sx – In collapsing phase22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 94
  95. 95. Surgical Tx Surgical options: – Excise lateral extruding head portion to stop hinging abduction – Acetabular osteotomy to cover head – Varus femoral osteotomy – Arthrodesis22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 95
  96. 96. Varus Osteotomy22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 96
  97. 97. Head at risk signs Clinical features: Radiological features: – Progressive loss of – Lateral subluxation of the movement femoral head (head partially – Adduction contractures uncovered) – Flexion in abduction – Entire femoral head – Heavy child involved – Calcification lateral to the epiphysis – Metaphyseal cysts – Gages sign22 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 97
  98. 98. References: Lee J, Allen M, Hugentobler K, Kovacs C, Monfreda J, Nolte B, Woeste E; Evidence-Based Care Guideline Conservative Management of Legg-Calve-Perthes Disease In children aged 3 to 12 years, Cincinnati children‟s hospital medical center, 2011 Benjamin Joseph, Paediatric Orthopaedics, A System Of Decision-making, 2009 Fritz Hefti, Pediatric Orthopedics in Practice, 2007 David Wilson (Ed.), Paediatric Musculoskeletal Disease With an Emphasis on Ultrasound, 200522 June 2012 Dr.Ratan M.P.T.,(Ortho & Sports) 98

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