Updated: 6/3/2019

Legg-Calve-Perthes

Topic
Review Topic
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Questions
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Evidence
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Snapshot
  • A 9-year-old boy presents to his pediatrician with a limp and hip pain. He denies any inciting trauma or event. On exam, he is noted to have atrophy in his upper thigh, asymmetry in leg lengths, and decreased range of motion in his left hip. Radiograph shows sclerosis in the femoral head. His physician recommends conservative management.

 

 

Introduction
  • Clinical definition
    • an idiopathic hip disorder characterized by avascular necrosis of the femoral head 
  • Epidemiology
    • demographics
      • male > female
      • affects children ages 3-12 but most commonly between ages 4-8
      • most commonly unilateral
    • risk factors
      • obesity
      • thrombophilia
        • factor V Leiden mutation
      • South Asian heritage
  • Etiology
    • unknown but thought to be related to factors that can disrupt bone formation or blood supply to the femoral head, including coagulation abnormalities or trauma
  • Pathogenesis
    • blood flow to the femoral head is disrupted causing ischemic necrosis
    • femoral head begins healing after ~1 year and new subchondral bone develops
    • new bone replaces the old bone in 2-3 years
  • Associated conditions
    • acetabular retroversion
    • inguinal hernia
    • Down syndrome
    • cryptorchidism
  • Prognosis
    • over half heal without surgical intervention
Presentation
  • Symptoms 
    • limping
    • pain in the hip that is worse with activity 
    • referred knee pain
  • Physical exam
    • small for age
    • thigh and calf muscle atrophy
    • shortening of the leg (asymmetry) 
    • hip stiffness and limited range of motion
      • reduced abduction and internal rotation
    • gait disturbance
      • may have Trendelenburg sign 
    • no erythema or swelling
Imaging
  • Radiography
    • indication
      • for evaluation of femoral head involvement
    • findings
      • femoral head sclerosis
      • increased width of the femoral neck
  • Magnetic resonance imaging
    • indications
      • for evaluation during early stages of the disease when radiography is unrevealing
      • if the diagnosis is uncertain after radiography
    • findings
      • decreased signal intensity in the femoral head due to sclerosis
  • Technetium bone scan
    • decreased uptake at the epiphysis
Studies
  • Labs
    • typically normal erythrocyte sedimentation rate and C-reactive protein
  • Making the diagnosis
    • based on clinical presentation and imaging studies
Differential
  • Sickle cell disease
    • distinguishing factors
      • anemia
      • sickle cells on peripheral blood smear
  • Slipped capital femoral epiphysis
    • distinguishing factors
      • in obese adolescents
      • displacement of femoral head relative to the femoral neck on radiography
Treatment
  • Management approach
    • treatment is usually conservative but may be treated with surgery
  • Conservative
    • observation and bed rest
      • indication
        • children who were less than 6 years of age at disease onset
    • physical therapy or brace/cast
      • indication
        • for all patients
  • Medical
    • nonsteroidal anti-inflammatory drugs
      • indication
        • pain management
  • Operative
    • surgical treatment
      • indication
        • older children (6 years of age or older) or with more advanced disease
      • surgeries
        • pelvic osteotomy (Salter osteotomy)
        • trochanteric advancement surgery
Complications
  • Permanent femoral head deformity and limp
  • Osteoarthritis
    • due to deformity of the femoral head
 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M2.OR.206) An 8-year-old boy presents to the general pediatrics clinic with hip pain. The pain started several weeks ago on his left side and has worsened over the past several days. His right hip is painless. His temperature is 98.0°F (36.7°C), blood pressure is 107/68 mm Hg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 98% on room air. Physical exam reveals an antalgic gait, decreased range of motion in the left hip, and mild thigh muscle atrophy. A radiograph is shown in Figure A. Which of the following is the most likely diagnosis? Review Topic

QID: 105604
FIGURES:
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Congenital talipes equinovarus

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Legg-Calve-Perthes disease

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Septic arthritis

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4

Slipped capital femoral epiphysis

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5

Trochanteric bursitis

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M2

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