Legg-Calve-Perthes Disease in Emergency Medicine Clinical Presentation

  • Author: Geofrey Nochimson, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Apr 14, 2011
 

History

Symptoms of Legg-Calvé-Perthes disease usually have been present for weeks because the child often does not complain.

  • Hip or groin pain, which may be referred to the thigh
  • Mild or intermittent pain in anterior thigh or knee
  • Limp
  • Usually no history of trauma
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Physical

  • Decreased range of motion (ROM), particularly with internal rotation and abduction
  • Painful gait
  • Atrophy of thigh muscles secondary to disuse
  • Muscle spasm
  • Leg length inequality due to collapse
  • Thigh atrophy: Thigh circumference on the involved side will be smaller than on the unaffected side secondary to disuse.
  • Short stature: Children with LCPD often have delayed bone age.
  • Roll test: With patient lying in the supine position, the examiner rolls the hip of the affected extremity into external and internal rotation. This test should invoke guarding or spasm, especially with internal rotation.
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Causes

The etiology of Legg-Calvé-Perthes disease remains unclear; however, the following scenario generally is accepted:

  • The blood supply to the capital femoral epiphysis is interrupted.[1]
  • Bone infarction occurs, especially in the subchondral cortical bone, while articular cartilage continues to grow. (Articular cartilage grows because its nutrients come from the synovial fluid.)
  • Revascularization occurs, and new bone ossification starts.
  • At this point, a percentage of patients develop LCPD, while other patients have normal bone growth and development.
  • LCPD is present when a subchondral fracture occurs. This is usually the result of normal physical activity, not direct trauma to the area
  • Changes to the epiphyseal growth plate occur secondary to the subchondral fracture.
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Contributor Information and Disclosures
Author

Geofrey Nochimson, MD  Consulting Staff, Department of Emergency Medicine, Sentara Careplex Hospital

Geofrey Nochimson, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Eric M Kardon, MD, FACEP  Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center

Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

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

Tom Scaletta, MD  Chair, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine

Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. Kim HK. Legg-Calve-Perthes disease. J Am Acad Orthop Surg. Nov 2010;18(11):676-86. [Medline].

  2. Sharma S, Shewale S, Sibinski M, Sherlock DA. Legg-Calve-Perthes disease affecting children less than eight years of age: a paired outcome study. Int Orthop. Feb 2009;33(1):231-5. [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. Boss JH, Misselevich I. Osteonecrosis of the femoral head of laboratory animals: the lessons learned from a comparative study of osteonecrosis in man and experimental animals. Vet Pathol. Jul 2003;40(4):345-54. [Medline].

  5. Epidemiology of Perthes' disease. Arch Dis Child. May 2000;82(5):385. [Medline].

  6. Erkula G, Bursal A, Okan E. False profile radiography for the evaluation of Legg-Calve-Perthes disease. J Pediatr Orthop B. Jul 2004;13(4):238-43. [Medline].

  7. Frick SL. Evaluation of the child who has hip pain. Orthop Clin North Am. Apr 2006;37(2):133-40, v. [Medline].

  8. Herring JA. The treatment of Legg-Calve-Perthes disease. A critical review of the literature. J Bone Joint Surg Am. Mar 1994;76(3):448-58. [Medline].

  9. Herring JA, Kim HT, Browne R. Legg-Calve-Perthes disease. Part I: Classification of radiographs with use of the modified lateral pillar and Stulberg classifications. J Bone Joint Surg Am. Oct 2004;86-A(10):2103-20. [Medline].

  10. Jacobs R, Moens P, Fabry G. Lateral shelf acetabuloplasty in the early stage of Legg-Calve-Perthes disease with special emphasis on the remaining growth of the acetabulum: a preliminary report. J Pediatr Orthop B. Jan 2004;13(1):21-8. [Medline].

  11. Kamegaya M, Saisu T, Ochiai N, Hisamitsu J, Moriya H. A paired study of Perthes' disease comparing conservative and surgical treatment. J Bone Joint Surg Br. Nov 2004;86(8):1176-81. [Medline].

  12. Kaniklides C. Diagnostic radiology in Legg-Calve-Perthes disease. Acta Radiol Suppl. 1996;406:1-28. [Medline].

  13. Kaniklides C, Lonnerholm T, Moberg A. Legg-Calve-Perthes disease. Comparison of conventional radiography, MR imaging, bone scintigraphy and arthrography. Acta Radiol. Jul 1995;36(4):434-9. [Medline].

  14. Kim HK. Legg-Calve-Perthes disease. J Am Acad Orthop Surg. Nov 2010;18(11):676-86. [Medline].

  15. Molloy MK, MacMahon B. Incidence of Legg-Perthes disease (osteochondritis deformans). N Engl J Med. Nov 3 1966;275(18):988-90. [Medline].

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

  17. Roy DR. Current concepts in Legg-Calve-Perthes disease. Pediatr Ann. Dec 1999;28(12):748-52. [Medline].

  18. Sinigaglia R, Bundy A, Okoro T, Gigante C, Turra S. Is conservative treatment really effective for Legg-Calve-Perthes disease? A critical review of the literature. Chir Narzadow Ruchu Ortop Pol. Nov-Dec 2007;72(6):439-43. [Medline].

  19. Skaggs DL, Tolo VT. Legg-Calve-Perthes Disease. J Am Acad Orthop Surg. Jan 1996;4(1):9-16.

  20. Thompson GH, Salter RB. Legg-Calve-Perthes disease. Clin Symp. 1986;38(1):2-31. [Medline].

 
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Legg-Calvé-Perthes disease. Image shows subchondral sclerosis and radiolucency in the left femoral head (stage II disease). The femoral head is slightly smaller on the left than the right.
Legg-Calvé-Perthes disease. The left subchondral radiolucency is more readily demonstrated on a frog-leg view and represents subchondral fracture.
Legg-Calvé-Perthes disease. Image shows left femoral subchondral sclerosis and radiolucency.
Legg-Calvé-Perthes disease. Image shows left femoral subchondral sclerosis and radiolucency.
Legg-Calvé-Perthes disease. Image shows flattening and early fragmentation of the left femoral head with the presence of femoral neck cysts. The femoral head is obviously smaller on the left than on the right.
Legg-Calvé-Perthes disease. Image shows loss of structural integrity of the right femoral head. Also note lateral extrusion of the right femoral head.
 
 
 
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