Legg-Calve-Perthes Disease in Emergency Medicine Workup
- Author: Jessica Hernandez, MD; Chief Editor: Trevor John Mills, MD, MPH more...
When the diagnosis of Legg-Calvé-Perthes disease is unclear, initial laboratory studies can aid in ruling out other diagnoses. CBC count, erythrocyte sedimentation rate, and C- reactive protein evaluation may be helpful to evaluate for suspected infection.
Plain radiographs of the hip, including anteroposterior and frog-leg views, are the preferred diagnostic tests. These are extremely useful in establishing the diagnosis.
Several radiographs are shown below.
Multiple radiographic classification systems exist, based on the extent of abnormality of the capital femoral epiphysis. Waldenstrom, Catterall, Salter and Thompson, and Herring are the 4 most common classification systems. No agreement has been reached as to the best classification system.
Five radiographic stages can be seen by plain radiography. In sequence, they are as follows:
Cessation of growth at the capital femoral epiphysis; smaller femoral head epiphysis and widening of articular space on affected side
Subchondral fracture; linear radiolucency within the femoral head epiphysis
Resorption of bone
Reossification of new bone
Other imaging studies
Technetium Tc-99m bone scanning can be used to detect early disease or define the extent of ischemia, as well as to predict severity. Currently, this type of study is not in high use owing to radiation exposure and the lack of anatomic detail of the femoral head and its relationship to the acetabular fibrocartilage.
Dynamic arthrography can provide early information by assessing the degree of flattening and amount of cartilaginous extrusion; however, it remains an invasive procedure and is difficult to repeat.
A recent review of the literature has proposed MRI as a valuable modality to evaluate Legg-Calvé-Perthes disease, especially with the use of newer sequences such as delayed gadolinium enhancement (to depict cartilage) and diffusion-weighted sequences (to assess cartilage repair). However, under current American College of Radiology guidelines, MRI evaluation is not the initial test of choice.[13, 14, 15, 16]
An example of an MRI depicting Legg-Calvé-Perthes disease is shown below.
Ultrasonography is less helpful for the diagnosis of Legg-Calvé-Perthes disease because it provides limited evaluation of osseous structures; however, it may be used to evaluate for effusion.
Hip aspiration with fluid analysis can be performed if a septic joint is suspected.
Brand RA. Legg-Calvé-Perthes syndrome (LCPS): an up-to-date critical review Charles W. Goff, MD CORR 1962;22:93-107. Clin Orthop Relat Res. 2012 Sep. 470(9):2628-35. [Medline].
Kim HK. Legg-Calve-Perthes disease. J Am Acad Orthop Surg. 2010 Nov. 18(11):676-86. [Medline].
Kim HK. Pathophysiology and new strategies for the treatment of Legg-Calvé-Perthes disease. J Bone Joint Surg Am. 2012 Apr 4. 94(7):659-69. [Medline].
Marx J, Hockberger R, Walls R. Musculoskeletal Disorders. Marx JA, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th Ed. Philadelphia, Pa: Mosby Elsevier; 2010. 174.
Georgiadis AG, Seeley MA, Yellin JL, Sankar WN. The presentation of Legg-Calvé-Perthes disease in females. J Child Orthop. 2015 Aug. 9 (4):243-7. [Medline].
Nguyen NA, Klein G, Dogbey G, McCourt JB, Mehlman CT. Operative versus nonoperative treatments for Legg-Calvé-Perthes disease: a meta-analysis. J Pediatr Orthop. 2012 Oct-Nov. 32(7):697-705. [Medline].
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. 2003 Jul. 40(4):345-54. [Medline].
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. 2004 Oct. 86-A(10):2103-20. [Medline].
Hyman JE, Trupia EP, Wright ML, Matsumoto H, Jo CH, Mulpuri K, et al. Interobserver and intraobserver reliability of the modified Waldenström classification system for staging of Legg-Calvé-Perthes disease. J Bone Joint Surg Am. 2015 Apr 15. 97 (8):643-50. [Medline].
Heesakkers N, van Kempen R, Feith R, Hendriks J, Schreurs W. The long-term prognosis of Legg-Calvé-Perthes disease: a historical prospective study with a median follow-up of forty one years. Int Orthop. 2015 May. 39 (5):859-63. [Medline].
de Sanctis N. Magnetic resonance imaging in Legg-Calvè-Perthes disease: review of literature. J Pediatr Orthop. 2011 Sep. 31(2 Suppl):S163-7. [Medline].
Kaniklides C, Lonnerholm T, Moberg A. Legg-Calve-Perthes disease. Comparison of conventional radiography, MR imaging, bone scintigraphy and arthrography. Acta Radiol. 1995 Jul. 36(4):434-9. [Medline].
Milla SS, Coley BD, Karmazyn B, Dempsey-Robertson ME, et al. ACR Appropriateness Criteria® limping child--ages 0 to 5 years. J Am Coll Radiol. 2012 Aug. 9(8):545-53. [Medline].
Kim HK, Wiesman KD, Kulkarni V, Burgess J, Chen E, Brabham C, et al. Perfusion MRI in Early Stage of Legg-Calvé-Perthes Disease to Predict Lateral Pillar Involvement: A Preliminary Study. J Bone Joint Surg Am. 2014 Jul 16. 96 (14):1152-1160. [Medline].
Sankar WN, Thomas S, Castañeda P, Hong T, Shore BJ, Kim HK, et al. Feasibility and safety of perfusion MRI for Legg-Calvé-Perthes disease. J Pediatr Orthop. 2014 Oct-Nov. 34 (7):679-82. [Medline].
Milla SS, Coley BD, Karmazyn B, Dempsey-Robertson ME, Dillman JR, Dory CE, et al. ACR Appropriateness Criteria® limping child--ages 0 to 5 years. J Am Coll Radiol. 2012 Aug. 9 (8):545-53. [Medline].
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. 2004 Nov. 86(8):1176-81. [Medline].
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. 2009 Feb. 33(1):231-5. [Medline].
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. 2008 Oct. 90(10):1364-71. [Medline].
Nakamura J, Kamegaya M, Saisu T, Kakizaki J, Hagiwara S, Ohtori S, et al. Outcome of patients with Legg-Calvé-Perthes onset before 6 years of age. J Pediatr Orthop. 2015 Mar. 35 (2):144-50. [Medline].