Perthes disease is a childhood condition characterized by avascular necrosis of the femoral head. It most commonly affects children between the ages of 4-10 years old. The condition is caused by interruption of the blood supply to the femoral head, which leads to bone death. This can result in deformity and distortion of the femoral head over time if not properly contained. Treatment depends on the stage and severity, and may involve symptomatic care, bracing, or corrective osteotomies to contain the femoral head within the acetabulum and prevent further deformity. Prognosis is generally better in younger children with less involvement of the femoral head.

1. Perthes Disease
Presented By Siti Nur Rifhan Kamaruddin

2. OVERVIEW
• Although the incidence is only 1 in 10,000 – it
should always be considered in differential dx of
hip pain in young children.
• Pts usually 4-10 years old and often show
delayed maturity
• Boys affected 4x than girls
DEFINITION: A disorder of childhood characterized by
avascular necrosis of the femoral head

3. PATHOGENESIS
Infants: femoral head is supplied by
- Metaphyseal vessels which penetrate the
growth disc
- Lateral Epiphyseal vessels in retinacula
- Scanty vessels in Ligamentum Teres
The metaphyseal supply (MS) gradually declines.
4 years old: MS has disappeared
7 years old: The vessels in Ligamentum Teres developed
Between 4-7 years, Femoral
Head depends entirely on the
lateral epiphyseal vessels

4. • Between 4-7 years old : Femoral head depends
almost entirely on lateral epiphyseal vessels 
whose situation in retinacula makes them
susceptible to stretching & pressure from an
effusion
• Precipitating cause : An effusion into hip joint
following
- Trauma
- Synovitis

5. PATHOLOGY
Stage 1: Bone Death
• Episodes of ischemia leads to part of bony
femoral head dies.
• X-ray looks normal but it stops enlarging
Stage 2: Revascularization and Repair
• New blood vessels enter the necrotic area and
new bone is laid down on dead necrotic area.
• X-ray - increase In density
• If only part of epiphysis is involved, rapid bony
architecture is completely restored.

6. Stage 3: Distortion and Re-modelling.
• If large part of bony epiphysis is damaged & the repair
process is slow- Epiphysis may collapse and growth of the
head and neck will be distorted.
• Epiphysis ends up as
- Flattened (Coxa Plana)
- Flat and enlarged ( Coxa Magna)
- Femoral head will be incompletely covered
by the acetabulum.

8. CLINICAL FEATURES
• Age 4-8 years old
• Complaint of pain and starts limping
• Symptoms complaint for weeks or recur
intermittently
• Hip may looks normal although there is little
wasting
• All Range of Movement are limited
• Pt may have an antalgic gait with limited hip motion
• Passive ROM are limited, esp. internal rotation and
abduction

9. INVESTIGATION
Plain Radiograph
• To establish diagnosis : Do Hip radiographs,
anteropoesterior and frog-leg lateral views of the
pelvis
• Initial radiographs can be normal.
X-Ray Changes
• Early Changes : Increased density of Body Epiphysis
and Widening of joint space
• Late Changes : Flattening , Fragmentation and lateral
displacement of the epiphysis with rare fraction at
metaphysis.

10. Herring Classification
The Herring Classification addresses the
Integrity of the lateral pillar of the femoral head.
Group A: Normal height of lateral pillar
Group B : There is collapse of lateral pillar (less than
50%)
Group C : There is more than 50% loss of the lateral
Lateral pillar height. – These pt usually end up with
significant distortion of the femoral head.

12. CT Scan
• Allow early diagnosis of bone collapse
• Demonstrates subtle changes in the bone
trabecular pattern
Ultrasonography
• Preliminary diagnosis of transient synovitis of
the hip and the onset of CP. Hip effusion with
capsular distension is well depicted on
sonographic images
MRI
• Allows more precise localization of the femoral
head

13. GENERAL MANAGEMENT
• Skin traction as long as the hip is
painful (usually takes 3 weeks)
• Encourage movement once pain is
subsided.
• Further treatment is taken by
assessment of clinical and
radiographic features.
• Choice of further treatment :
- Symptomatic treatment
- Containment

14. Good Prognosis
• Onset under Age 6
• Partial involvement
of femoral head
• Absence of
metaphyseal
involvement
• Normal femoral
head shape
No Active treatment
needed
Poor Prognosis
• Age over 6 years old
• Involve the whole
femoral head
• Severe metaphyseal
rarefraction
• Lateral displacement of
femoral head
Mgmt: Containment

15. Symptomatic Treatment
• Pain control if necessary
• Gentle exercise – to maintain movement
• Regular assessment
Containment
• Containment means keeping the femoral head
well seated as fully as possible within the
acetabulum
• Can be achieved by :
- Holding the hips widely abducted in plaster of
removable splint ( will take at least a year)
- Varus Osteotomy of femur or innominate
osteotomy of the pelvis.

16. TREATMENT GUIDELINE
Under 6 years
• Symptomatic
Treatment
- Activity modification

17. Children Aged 6-8 years
# Here the bone age is more important than
the chronological age
Bone Age at or below 6 years:
• Lateral pillar Group A, B : Symptomatic
• Lateral Pillar Group C : Abduction brace
Bone Age over 6 years :
• Lateral Pillar Group A & B : Brace or Varus
osteotomy
• Lateral Pillar Group C : Outcome not
affected by treatment

18. REFERENCES
• Apley and Solomon’s Concise System of
Orthopedics and Trauma 4th Edition. CRC Press

19. Thank you..