Legg-Calve-Perthes Disease

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Clinically Relevant Anatomy

This disease involves the femoral head.

Mechanism of Injury / Pathological Process

The origin of this disease is unknown. The pathology of the disease is, however, accepted and is as follows.
First, there is interrupted blood supply to the capital femoral epiphysis. After this, an infarction of the subchondral bone occurs. Next, revascularization of the area occurs and new bone ossification begins. This is the turning point where a percentage of patients will have normal bone growth and development; while others will develop Legg Calve Perthes Disease. (LCPD). This disease is present when a subchondral fracture occurs. Usually, there is no trauma to cause this scenario. LCPD is most commonly the result of normal physical activity. Because of the subchondral fracture, changes occur to the epiphyseal growth plate.

Classification:
Severity and prognosis of the disease is determined by using a variety of classification systems.
Two of the classification systems are listed here.
In the Catteral Classification there are four different groups to define the radiographic appearance during the period of greatest bone loss.
The Catteral Classification specifies four different groups to define radiographic appearance during the period of greatest bone loss.
These four groups are reduced down to two by the Salter-Thomson Classification. The first group, which is Group A (Catteral I,II) shows less than 50% of the ball is involved. Group B (Catteral III, IV) shows that more than 50% of the ball is involved. If there is less than 50% involvement the prognosis is good; if there is more than 50% there is usually a poor prognosis.
The Herring Classification is based on the integrity of the lateral pillar of the ball. Group A of this classification shows no loss of height in the lateral 1/3 of the head and little density change. In Lateral Pillar Group B, there is less than 50% loss of lateral height and lucency is present in the joint. In some cases, the ball is beginning to extrude the socket. In Lateral Pillar Group C, there is more than 50% loss of lateral height.

Clinical Presentation

This disease presents in children 2-13 years of age and there is a four times greater incidence in males compared to females. The average age of occurrence is six years.
A psoatic limp is typically present in these children secondary to weakness of the psoas major.
The child will show a decrease in extension and abduction active ranges of motion.
There is usually no traumatic event to initiate symptoms

Diagnostic Procedures

An MRI is usually obtained to confirm the diagnosis; however x-rays can also be of use to determine femoral head positioning.

Outcome Measures

The Lower Extremity Functional Scale is one that measures how this disease is affecting the child in a functional way. Since this questionnaire does ask about certain activities the child may not be allowed to perform (i.e. running, hopping, etc), it may not be the outcome measure of choice. The Harris Hip score is another questionnaire that has more to do with a lower level of functional activities such as walking, stair climbing, donning/doffing shoes, sitting, etc. Questionnaires that test the patient on a functional level are useful to provide a baseline and monitor functional progress in the patient’s activities.

Management / Interventions

Medications include acetaminophen for pain as well as NSAIDS for pain and/or inflammation.
Physical therapy can help with joint protection strategies, improving joint mechanics, building a safe aerobic endurance component, and regaining functional flexibility, strength, coordination, endurance and gait training.

Differential Diagnosis

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Key Evidence

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