Legg-Calve-Perthes Disease Workup

  • Author: George D Harris, MD, MS; Chief Editor: Carlos J Lavernia, MD, FAAOS   more...
 
Updated: May 4, 2011
 

Laboratory Studies

Determination of the CBC with a differential and the erythrocyte sedimentation rate (ESR) are recommended, but the findings may be normal.

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Imaging Studies

Obtain hip radiographs, including anteroposterior and frog-leg lateral views of the pelvis to establish the diagnosis.[1, 2]

Initial radiographs can be normal, but radiographic changes can be divided into 5 distinct stages representing a continuum of the disease process.

  • Stage 1 reveals cessation of femoral epiphyseal growth.
  • Stage 2 is a subchondral fracture.
  • Stage 3 shows resorption.
  • Stage 4 demonstrates reossification.
  • Stage 5 is the healed or residual stage.Image in an 8-year-old boy with Herring type C LegImage in an 8-year-old boy with Herring type C Legg-Calvé-Perthes disease shows evidence of lateral extrusion. Symptoms began 18 months before this view was obtained. Image courtesy of Dennis P. Grogan, MD. Anteroposterior (AP) radiograph in a 9-year-old boAnteroposterior (AP) radiograph in a 9-year-old boy with Legg-Calvé-Perthes disease. Image courtesy of Dennis P. Grogan, MD. Frog-leg lateral radiograph of same 9-year-old boyFrog-leg lateral radiograph of same 9-year-old boy with Legg-Calvé-Perthes disease as in Image above. Image courtesy of Dennis P. Grogan, MD.

Early radiographic changes may reveal only a nonspecific effusion of the joint associated with slight widening of the joint space, metaphyseal demineralization (decreased bone density around the joint), and periarticular swelling (bulging capsule). This is the acute phase, and it may last 1-2 weeks. Decreasing bone density in and around the joint is noted after a few weeks.

With advancement of the disease, the joint space between the ossified head and acetabulum widens as the necrotic ossification center appears denser than the surrounding structures. Narrowing or collapse of the femoral head causes it to appear widened and flattened (coxa plana). A varus deformity of the femoral neck may occur as a result of damage to the femoral head growth center and overgrowth of the greater trochanteric apophysis.

Eventually, the disease may progress to collapse of the femoral head, increase in the width of the neck, and demineralization of the femoral head. The final shape of this area depends on the extent of necrosis and the degree of collapse. All of the findings are correlated with disease progression and the extent of necrosis. This is the active phase, and it can last 12-40 months.

A bone scan can be used to evaluate the site for avascular necrosis.

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Contributor Information and Disclosures
Author

George D Harris, MD, MS  Professor of Medicine, University of Missouri-Kansas City School of Medicine and Truman Medical Center at Lakewood; Assistant Dean Year 1 and 2 Medicine, University of Missouri-Kansas City School of Medicine

George D Harris, MD, MS, is a member of the following medical societies: American Academy of Family Physicians, American Diabetes Association, American Medical Society for Sports Medicine, and American Society for Colposcopy and Cervical Pathology

Disclosure: Nothing to disclose.

Specialty Editor Board

B Sonny Bal, MD  Associate Professor, Department of Orthopedic Surgery, University of Missouri School of Medicine

B Sonny Bal, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

James J McCarthy, MD, FAAOS, FAAP  Associate Professor, Consulting Orthopedic Surgeon, Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health;

James J McCarthy, MD, FAAOS, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Orthopaedic Association, Limb Lengthening and Reconstruction Society ASAMI-North America, Orthopaedics Overseas, Pediatric Orthopaedic Society of North America, Pennsylvania Medical Society, Pennsylvania Orthopaedic Society, and Philadelphia County Medical Society

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Carlos J Lavernia, MD, FAAOS  Adjunct Clinical Professor, Department of Orthopedic Surgery, University of Miami School of Medicine; Medical Director, Orthopedic Institute at Mercy Hospital

Carlos J Lavernia, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, Arthritis Foundation, Biomedical Engineering Society, Florida Orthopaedic Society, and Orthopaedic Research Society

Disclosure: Zimmer Stock Implant Designer

References

  1. Poul J. Diagnosis of Legg-Calvé-Perthes disease. Ortop Traumatol Rehabil. Oct 30 2004;6(5):604-6. [Medline].

  2. Sales de Gauzy J, Briot J, Swider P. Coxa magna quantification using MRI in Legg-Calve-Perthes disease. Clin Biomech (Bristol, Avon). Jan 2009;24(1):43-6. [Medline].

  3. Wiig O, Terjesen T, Svenningsen S. Prognostic factors and outcome of treatment in Perthes' disease: a prospective study of 368 patients with five-year follow-up. J Bone Joint Surg Br. Oct 2008;90(10):1364-71. [Medline].

  4. Beer Y, Smorgick Y, Oron A, Mirovsky Y, Weigl D, Agar G, et al. Long-term results of proximal femoral osteotomy in Legg-Calvé-Perthes disease. J Pediatr Orthop. Dec 2008;28(8):819-24. [Medline].

  5. Canavese F, Dimeglio A. Perthes' disease: prognosis in children under six years of age. J Bone Joint Surg Br. Jul 2008;90(7):940-5. [Medline].

  6. Myers GJ, Mathur K, O'Hara J. Valgus osteotomy: a solution for late presentation of hinge abduction in Legg-Calvé-Perthes disease. J Pediatr Orthop. Mar 2008;28(2):169-72. [Medline].

  7. Rosenfeld SB, Herring JA, Chao JC. Legg-calve-perthes disease: a review of cases with onset before six years of age. J Bone Joint Surg Am. Dec 2007;89(12):2712-22. [Medline].

  8. Zarzycka M, Zarzycki D, Kacki W, Jasiewicz B, Ridan T. Long-term results of conservative treatment in Perthes' disease. Ortop Traumatol Rehabil. Oct 30 2004;6(5):595-603. [Medline].

  9. Nowacki W, Szymkowiak E, Futyma J, Stencel P. A comparative analysis of conservative and surgical treatment of Perthes' disease. Ortop Traumatol Rehabil. 2004;6(6):748-50. [Medline].

  10. Kim HK, da Cunha AM, Browne R, Kim HT, Herring JA. How much varus is optimal with proximal femoral osteotomy to preserve the femoral head in legg-calve-perthes disease?. J Bone Joint Surg Am. Feb 2011;93(4):341-7. [Medline].

  11. Traina F, De Fine M, Sudanese A, Calderoni PP, Tassinari E, Toni A. Long-term results of total hip replacement in patients with legg-calve-perthes disease. J Bone Joint Surg Am. Apr 2011;93(7):e25. [Medline].

  12. Barkin RM, Rosen P. Emergency Pediatrics, A Guide to Ambulatory Care. 5th ed. St Louis: Mosby-Year Book;1999: 216, 278, 546-7.

  13. Hay WW, Hayward AR, Levin MJ. Current Pediatric Diagnosis and Treatment. 14th ed. Stamford; Appleton and Lange;1999: 710-1.

  14. Lauren M. Simon. Chapter 35. Thigh, Hip, and Pelvis Injuries. In: Richard B. Birrer. Pediatric Sports Medicine for Primary Care. philadelphia, PA.: Lippincott Williams and Wilkins; 2002:pages 393-394.

  15. McMillan JA, DeAngelis CD, Feigin RD. Oski's Pediatrics Principles and Practice. 3rd ed. Philadelphia: Lippincott-Raven;1999: 2105-6.

 
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Image in an 8-year-old boy with Herring type C Legg-Calvé-Perthes disease shows evidence of lateral extrusion. Symptoms began 18 months before this view was obtained. Image courtesy of Dennis P. Grogan, MD.
Anteroposterior (AP) radiograph in a 9-year-old boy with Legg-Calvé-Perthes disease. Image courtesy of Dennis P. Grogan, MD.
Frog-leg lateral radiograph of same 9-year-old boy with Legg-Calvé-Perthes disease as in Image above. Image courtesy of Dennis P. Grogan, MD.
 
 
 
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