It most often happens in one hip, but can affect both. The hip is the joint where the leg meets the body. The top of the thighbone is ball-shaped. It fits inside a round socket.
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It should not be confused with Perthes lesion of the shoulder. Perthes disease is relatively uncommon and in Western populations has an incidence approaching 5 to , Boys are five times more likely to be affected than girls. Most children present with atraumatic hip pain or limp 3,5,6.
Some children have a coincidental history of trauma. This may precipitate the presentation or the realization of symptoms that in fact had been long-standing.
Blood tests are typically normal in Perthes. It is important to be certain that there is no other cause of osteonecrosis e. Osteonecrosis generally occurs secondary to the abnormal or damaged blood supply to the femoral epiphysis, leading to fragmentation, bone loss, and eventual structural collapse of the femoral head. The best initial test for the diagnosis of Perthes is a pelvic radiograph. In a small number of patients with Perthes, the radiograph will be normal and persistent symptoms will trigger further imaging, e.
The investigation of atraumatic limp will often include a hip ultrasound to look for effusion, but ultrasound is unlikely to pick up osteonecrosis. The radiographic findings are those of osteonecrosis. There are separate systems for staging of Perthes disease:. The radiographic changes to the femoral epiphyses depend on the severity of osteonecrosis and the amount of time that there has been an alteration of blood supply:. As changes progress, the width of the femoral neck increases coxa magna in order to increase weight-bearing support.
Eventually, the femoral head begins to fragment stage 2 , with subchondral lucency crescent sign and redistribution of weight-bearing stresses leading to thickening of some trabeculae which become more prominent.
The typical findings of advanced burnt out stage 4 Perthes disease are:. Additionally, tongues of cartilage sometimes extend inferolaterally into the femoral neck, creating lucencies, which must be distinguished from infection or neoplastic lesions 4. The presence of metaphyseal involvement not only increases the likelihood of femoral neck deformity but also make early physeal closure with resulting leg length disparity more likely.
Traditionally arthrography performed under general anesthesia with conventional fluoroscopy is performed to assess congruence between the femoral head and the acetabulum in a variety of positions 3.
MRI is increasingly replacing this, in an effort to eliminate pelvic irradiation. Treatment in Perthes disease is largely related to symptom control, particularly in the early phase of the disease. As the disease progresses, fragmentation and destruction of the femoral head occur.
In this situation, operative management is sometimes required to either ensure appropriate coverage of the femoral head by the acetabulum, or to replace the femoral head in adult life. The younger the age at the time of presentation, the more benign disease course is expected and also for the same age, the prognosis is better in boys than girls due to less maturity 5,8. Conservative treatment is favourable in children with a skeletal age of 6 years or less at time of disease onset Prognosis is also influenced by the percentage of femoral head involvement and degree of primary deformity of the femoral head and the secondary osteoarthritic changes that ensue.
The aim of therapy is to try and maintain good femoroacetabular contact and a round femoral head. Bracing may be used in milder cases, although femoral neck and acetabular osteotomies may be required to correct more severe abnormal femoroacetabular malalignment. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Updating… Please wait. Unable to process the form.
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Kaplan P. Musculoskeletal MRI. W B Saunders Co. Read it at Google Books - Find it at Amazon. Promoted articles advertising. Edit article Share article View revision history Report problem with Article.
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Case 16 Case Case 17 Case Case 18 Case Case 19 Case Case 20 Case Imaging differential diagnosis. Meyer dysplasia Meyer dysplasia. Developmental dysplasia of hip Developmental dysplasia of hip. Slipped upper femoral epiphysis Slipped upper femoral epiphysis. Loading more images Close Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Loading Stack - 0 images remaining.
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Rev Chir ; 54— Waldenstrom H. On coxa plana. Osteochondritis deformans coxae juvenilis. Acta Chir Scand ; Catterall A. Acta Orthop Belg ; —
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