Perthes disease, or Legg-Calvet-Perthes disease, is a disease in which blood supply to the bone tissue in the region of the femoral head is broken, followed by necrosis( necrosis).This pathology is one of the most common diseases of the hip joint in children from three to fourteen years old. Boys are more often ill, but in girls the osteochondropathy of Legga-Perthes has a heavy course.
The disease has several stages and in the beginning it is practically asymptomatic, which considerably complicates its diagnosis. In 5% of cases, Perthes' disease is bilateral. If treatment is not started on time, the consequences can be very severe. Secondary coxarthrosis, deformity of the limb, its shortening, ankylosis, various abnormalities of the gait may develop, which often becomes the cause of disability even in childhood or in adults.
Juvenile osteochondropathy of the femoral head can cause disability
The diagnosis of Calve-Perthes disease is established based on the patient's age, typical complaints and symptoms, and X-ray diagnosis data. Treatment is long, conservative. In especially severe cases or in the presence of complications resort to reconstructive and restorative operations on the hip joint.
According to the International Classification of Diseases 10 revision( ICD 10), juvenile osteochondropathy of the femoral head is located under the M91.1 code.
Causes and mechanism of development of
At the moment there is no single theory of the development of Perthes' disease. It is believed that this ailment has a polyethological origin, that is, it is associated with a congenital predisposition of the organism and the impact of negative environmental factors.
According to the most common hypothesis of the origin of the pathology, it is caused by such a defect in prenatal development as myelodysplasia of mild degree. This is an underdevelopment of the lumbar segments of the spinal cord, which in most cases is not manifested throughout life, but is associated with a variety of orthopedic ailments, including the youthful osteochondropathy of the femoral head.
With Perthes' disease, the blood vessels of the femoral head are underdeveloped.
. What is the connection between the spinal cord and the hip joint? The fact is that this part of the nervous system controls the growth and development of blood vessels that feed the head of the femur. Under normal conditions( in people without myelodysplasia), these vessels are 10-12, they have a relatively large caliber and manage their task well, providing the bone with all the necessary substances.
Children with myelodysplasia of such arteries are only 2-4, their caliber is shallow. Therefore, the head of the thigh is constantly in a state of deficiency of nutrients and oxygen.
Important! In order to develop Perthes' disease in children, one myelodysplasia and hypoplasia of the hip joints is not enough. To do this, the blood flow in the joint should completely stop, which is facilitated by certain environmental factors.
Factors that contribute to the development of Perthes' disease:
- mechanical trauma of the hip area, even insignificant( jump, light bruise, somersault, fall, clumsy and abrupt movement, etc.);
- inflammatory lesions of the hip joint( viral, bacterial, allergic nature);
- hormonal imbalance in the child's body, for example, during the period of hormonal adjustment in the transition years;
- a violation of the mineral metabolism in the body.
Most parents associate the appearance of symptoms of hip injury with a previous acute respiratory infection. Some children manage to trace and hereditary predisposition to ailment.
Even a regular jump can trigger Perthes' disease in susceptible children
Stages and symptoms of
Five consecutive stages are recognized throughout the course of the disease.
Stage of osteonecrosis
It is at this point in the development of the termination of the blood supply to the head of the femur and its focal necrosis develops. The affected area rarely reaches 10% of the entire bone mass of the femoral head. This stage is asymptomatic. Very rarely there can be a minimum disruption of the child's gait by the type of foot dragging, hitting on one limb. Also, sometimes, low-intensity pain develops in the hip area.
The stage of impression fracture of the femur head
Under the influence of usual loads, a part of the bone tissue is gradually destroyed - a depressed fracture develops and the deformation of the femoral head is formed. The area of structural changes reaches 10-30%.At this stage, pain and discomfort develops in the hip and knee area during movements, the baby begins to limp.
femoral head impression is noticeable in the image.
fragmentation stage During this period, part of the broken bone begins to fragment and disintegrate. The amount of damage increases to 30-50%.The pain is pronounced, does not pass and at rest. The restriction of movements in the hip, swelling of soft tissues develops. Gait changes, limping becomes distinct, sometimes the supporting function of the limb is broken. Some children have fever and other symptoms of intoxication.
repair stage Gradually, the processes of healing and recovery begin to predominate over the processes of destruction. Between the separate fragments of bone tissue connective tissue develops, blood vessels grow, a new cat tissue is formed. The structure of the newly formed bone is close to normal, but, unfortunately, its mechanical strength is much lower.
Also at this stage, the growth of the femoral head resumes. Sometimes, in the absence of adequate treatment of Perthes disease, head growth causes further deformities, as it often does not acquire a normal spherical shape, but, for example, a mushroom shape. Such changes lead to subluxation and secondary coxarthrosis.
Stage of outcome of
At this stage, the effects of Perthes' disease develop, if they occur. Perhaps complete recovery without any residual effects.
An important point is the integrity of the cartilaginous growth zone. In children, it provides the growth of the femur in length. In the case of extensive necrosis, this zone can be completely or partially destroyed. As a result, the formation of the upper end of the femur is impaired, the true shortening of the leg, the violation of gait and the supporting function of the limb develop.
Perthes disease may cause shortening of the limb, which subsequently requires a complex surgical correction of
. In the case of forming a deformation of the femoral head at the 4 th stage, a clinical picture of progressive deforming arthrosis of the hip develops.
The main diagnostic method that allows you to confirm or refute the diagnosis is the radiography of the hip joints. Apply two projections:
- projection of Lauenstein.
This is the required minimum of studies that are needed for diagnosis. It allows you to recognize the disease with high probability even in the first stage. In case of doubt, the specialist may additionally be assigned to the child a joint ultrasound and magnetic resonance imaging.
Differential diagnostics in children is necessary with such diseases as neurodysplastic coke and infectious-allergic arthritis of the hip joint.
Radiography of the hip joints - the main diagnostic method for the osteochondropathy of the femoral head
Treatment of Perthes 'disease
Treatment of Perthes' disease in children is mostly conservative and prolonged. The minimum period is one year. On average, the therapy takes 2.5 years, and in some cases increases to four. The operation is prescribed only in the presence of severe complications to children after 6 years.
Conservative treatment, as a rule, begins in specialized orthopedic centers with the subsequent supervision at the children's orthopedist in an out-patient department on a residence.
- complete unloading of the hip joint for the required time;
- application of stretching, plaster casts, special orthopedic structures and beds to prevent deformation of the femoral head;
- improvement of blood flow in the hip joint area with the help of medicines and non-medicamentous methods;
- stimulation of restoration of normal structure of bone tissue;
- formation and strengthening of the muscular corset of the thigh with the help of therapeutic gymnastics and exercise therapy.
When establishing the diagnosis, the support to the injured leg is partially or completely eliminated. To do this, the child is prescribed a strict bed rest, and the older children are given a semi-bed with walking on crutches during wakefulness. The main treatment is physiotherapy, massage, special medical exercises.
In case of Perthes' disease, the child is given a long-term immobilization with special spacer strips
If there is a need for skeletal traction or immobilization with gypsum bandages, struts, tires, then electromyostimulation is used to maintain the tone of skeletal muscles.
Medical treatment includes the appointment of angioprotectors, chondroprotectors, microelements, vitamins. The motor mode is expanded at the 4th stage of the disease. All exercises are selected only by a specialist and monitor their implementation.
Reconstructive reconstructive surgery is applied only from the age of 6 in patients with an extensive osteonecrosis zone, development of severe deformation of the femoral head, dislocation.
Most often, such interventions as rotational transposition of the acetabulum according to Salter, correcting medializing osteotomy of the femur. After surgical treatment it is necessary to undergo a long rehabilitation period.
Adult people who have suffered Perthes disease, it is necessary throughout life to limit the load on the hip, because they have an increased risk of deforming arthrosis. It is also desirable to regularly undergo therapeutic and preventive courses of therapy and sanatorium treatment.
- Causes and mechanism of development
- Stages and symptoms
- Treatment of Perthes disease