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Perthes disease (osteochondropathy of the hip joint) in children: causes and symptoms of the disease, treatment principles

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What is Legg’s Calvet Perthes disease?

Legg's Calvet Perthes disease affects the hip joint and the hip bone. Due to the fact that the head and cartilage of the thigh are insufficiently supplied with blood, they become soft and deformed. As a consequence, the development of aseptic necrosis occurs - the process of necrosis of the upper hemisphere of the femoral head, which is dystrophic and not bacterial or purulent.

The disease affects one bone, and the other remains healthy. The right thigh usually suffers. Bilateral lesion occurs in 5% of cases. Despite the fact that the disease is more common in boys (there are 1 girl for 5 children), if a girl falls ill, the illness is more severe and is fraught with disability.

Causes of the disease

A specific cause leading to the development of pathology has not yet been established in medicine. The most likely factors that can trigger Perthes disease in children include:

  • inherited genetic predisposition
  • high load on leg joints,
  • congenital abnormalities of the endocrine system of the body,
  • getting injured
  • hormonal changes that occur in adolescence,
  • infectious diseases developing on the background of a weakened immunity.

One of the latest theories explaining the mechanism of progression of Perthes disease is myelodysplasia. This is a congenital underdevelopment of the spinal cord in the section that is responsible for the neural connections of the femoral head.

Underdevelopment, smaller size and insufficient number of nerve endings and vessels, through which the hip joint is powered, leads to its chronic insufficiency. To give rise to the development of necrosis is capable of injury or inflammation.

Babies are at risk:

  • born with a small weight (less than 2.1 kg),
  • had rickets at an early age,
  • malnourished with severe nutrient deficiencies,
  • susceptible to infectious and allergic diseases,
  • guys who often and long have viral and infectious diseases,
  • suffering from hypotrophy,
  • with allergic problems.
Often ill children fall into the risk group for developing Perthes disease

Stages of the disease and associated symptoms

Symptoms of Perthes disease does not appear immediately, at the initial stage, sometimes it may be completely absent. Children usually begin to complain of knee pain. Gradually, the following symptoms join the pain:

  • dull pain while walking, which affects the hip joint or spreads over the entire length of the affected limb,
  • the appearance of weakness of the gluteal muscles,
  • lameness,
  • change of gait, which is reduced to a characteristic crouching on the aching leg,
  • the inability to completely twist the leg out,
  • limited rotational capabilities of the hip joint,
  • poor flexion or extension of the joint,
  • swelling in the area of ​​disease,
  • reduced ripple in the toes,
  • high temperature reaching 37.5 degrees,
  • pallor, coldness, heavy sweating of the foot.
At the initial stage of the development of the child's illness, there may be worrisome periodic pain in the knee joint.

In modern medicine, there are 5 stages in the development of Legg Calvet Perthes disease. The table shows the characteristics of each of them:

general information

Perthes disease in children - photo:

Perthes-Legg-Calvet disease is type of non-infectious necrosis the upper part of the femoral head, which has arisen due to circulatory failure.

The disease progresses slowly, so both the patient and the parents may not immediately notice the symptoms.

Perthes disease may develop for the following reasons:

  • the presence of myelodysplasia (malformation of the spinal cord),
  • the presence of failures in metabolic processes,
  • injuries of the hip joint,
  • weak immunity (the disease can manifest itself as a complication of some infectious disease),
  • hormonal disruptions in adolescence,

  • unbalanced diet, lack of vitamins and minerals,
  • pinching of the spinal nerves,
  • the presence of prolonged high load on the joint due to spinal deformity,
  • hereditary reasons (if one of the parents had this pathology, it can also manifest itself in a child).
  • Increased development risks certain categories of children have diseases:

    1. Floor: in boys this pathology is diagnosed several times more often than in girls.
    2. Age: most often pathology is diagnosed in children aged 3 to 10 years.
    3. Growth: children of low (for their age) height, having regular high physical exertion, are at risk.

    Also increased risks are children who are regularly exposed to cigarette smoke.

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    Stage of the disease

    There are the following stages of the disease:

    1. Interruption of blood supply, the development of primary aseptic necrosis.
    2. Occurrence of secondary depressed fracture.

  • Necrotic tissue dissolves, and the femoral neck becomes shorter.
  • Gradual proliferation of connective tissue restoration of bone beams thereby.
  • The connective tissue is replaced by bone, the fracture grows together.
  • Recommendations for treating Schlätter’s disease in adolescents can be found on our website.

    Complications and consequences

    The most common complications of Perthes disease are the following:

      Osteoarthritis of the femoral head - due to the deformity of the femoral head, the acetabulum area can be injured, so the cartilage tissue begins to thin, and the joint is no longer able to properly perform its functions.

    The person who received such a complication needs surgery: the damaged joint is replaced by an implant.

  • Children whose Perthes disease has arisen at the age of over seven years have high risks of residual constant deformation of the femoral head. In such a situation, an operation is also shown to replace the joint.
  • to content ↑

    Clinical picture

    The first stages of the disease are hidden, the parents and the child often overlook symptoms either do not give them attention.

    At the very beginning there is only a feeling of heaviness in the pelvic zone, and the child begins to avoid vigorous activity, it is harder for him to run, he gets tired faster. Gradually, the disease progresses, lameness and other symptoms occur.

    First signs Perthes disease:

    1. There is a weak joint painin rare cases extending to the whole leg or localized in the zone of the knee. Since it occurs mainly after considerable physical exertion and then disappears, this symptom may not alert the parents.
    2. Gait changes, appears lameness, sometimes imperceptible even to the child himself.

    Further, if treatment has not been started, develop more severe symptomswhich do not subside after rest:

    1. The pain becomes stronger and occurs even after a minor load (for example, daily walking).
    2. Child lagging behind in physical development compared to peers.
    3. The limp becomes more noticeable, like other changes in gait.
    4. Joint area swells up.
    5. The joint does not perform its functions correctly: many movements are limited, difficulties may arise even with normal walking.
    6. In some cases limb shortens.
    7. Toes become less sensitive.
    8. The skin on the legs is wrinkled.
    9. Availability is possible subfebrile temperatureespecially during periods of exacerbation of pain.

    After a while, the symptoms subside, but some of them remain, and later arthrosis develops.

    Diagnostics

    The basis of diagnostic measures is X-ray of the joint, with its help, specialists determine at what stage the disease is and choose the optimal therapy.

    In medical practice there are several classifications, most often used by the classification of Salter Thomson and Ketterol.

    X-ray Catterola classification:

    1. First Group. Weak severity of the disease. There are minor destructive changes, but the bone head is normal. Fracture lines are not observed, metaphysical changes are also absent.
    2. The second Group. There are no violations in the contours of the head, X-rays show the proliferation of connective tissue and other destructive changes. The initial stage of fragmentation of the head.
    3. Third Group. Revealed a significant lesion of the head and its deformation. The fracture line is clearly visible.
    4. Fourth Group. Complete defeat of the bone head, acetabulum also changed.

    X-ray Salter Thomson classification:

    1. First Group. In the anterior zone of the epiphysis, a fracture line is noticeable, but it is visible only in pictures taken in positions according to the Lauenstein method.
    2. The second Group. The presence of a subchondral fracture is clearly visible in the anterior zone of the epiphysis, the lateral border of the bony head remains.
    3. Third Group. A fracture is visible in the lateral zone of the epiphysis.
    4. Fourth Group. Fracture covers the entire zone of the epiphysis.

    In some cases, MRI is used to clarify the diagnosis, but usually X-rays are sufficient.

    Treatment methods

    Children under six years of age who have the initial signs of the disease do not receive treatment and should be monitored by the attending physician.

    Older children are most often treated conservatively, surgical intervention is necessary only for severe disease or when conservative therapy is ineffective.

    Conservative methods of treatment of this pathology usually show high efficiency.

    The following treatment methods are used:

    1. Full refusal of any physical activityaffecting the affected limb for a long period, which is determined by the doctor individually.
    2. Application medication to improve blood circulation (Pentoxifylline and similar drugs).
    3. Reception of vitamins (especially group B) and minerals (mainly calcium).
    4. Purpose chondroprotectors - drugs that eliminate the symptoms and slow down the progression of the disease: Teraflex, Movex, Rumalon and others.
    5. Various treatments are widely used during treatment. orthopedic constructions. Often used Petri bandage, which is a plaster bandage, superimposed on both legs and having a crossbar, which secures the child's legs in the desired position: widely spread to the sides. The dressing is applied for 4-6 weeks, after it there is a recovery period, which includes physical therapy.
    6. Physiotherapy it is used during the entire treatment, except for periods of use of orthopedic structures that impede movement (instead of physical therapy, in such cases electrical stimulation of the muscles is prescribed). Physical therapy includes simple movements: dilution of the hips, rotation of the hips.

  • Compliance special diet, preventing the appearance of excess weight due to prolonged low mobility.
  • Massage in Perthes disease, it stimulates muscles, improves blood supply and reduces pain, is carried out strictly according to instructions, includes stroking, grinding, kneading, squeezing muscles, circular and dotted movements. The massage course has up to thirty procedures and repeats after a while.
  • Are held physiotherapy: electrophoresis, ozokeritotherapy, UHF-therapy, diathermy, mud therapy.
  • Therapy is long, takes at least one year, and in severe cases - at least four years.

    You can learn about signs of systemic lupus erythematosus in a child from our article.

    Surgery

    Surgery for this pathology is performed only in case of severe disease (severe deformity of the head, subluxations) to children who have reached the age of six.

    Most often, the acetabular transposition or corrective osteotomy of the femur is performed.

    After surgery should be long recovery period, including physiotherapy, the implementation of physical therapy complexes, massage and taking medication.

    Prognosis and disability

    If the disease is detected in the early stages, the treatment was carried out qualitatively and in a timely manner, and the parents and the child carefully followed all the recommendations. Positive outlook: the child will be able to live fully, but he will have to limit the physical stress on the joint.

    Severe disease and the absence of long-term treatment entail the development of complications that able to lead a child to disability. Therefore, it is most important to go to the hospital with the first symptoms, even if they are almost invisible.

    Prevention of this disease does not exist, but risks can be reduced: the child’s nutrition should be correct and varied, physical exertion should be sufficient, but not excessive, and any serious injury should be treated under the control of a traumatologist. Also very important is the timely passage of preventive examinations.

    How is funnel chest treated in a child? Find out the answer right now.

    You can learn about non-surgical treatment of Perthes disease in children from the video:

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    Content

    The etiology of the disease is unknown: there are various theories about the causes of the development of the disease - trauma, excessive stress on the joint in weakened children, recently transferred infectious diseases, metabolic disorders, congenital anomalies of the hip joints. The most common cause may be the displacement of the fourth lumbar vertebra L4, often one-sided, causing the infringement of the nearby nerve roots that control the vessels, sclera of the femoral head.

    Perthes disease often affects boys (3-5 times more often) between the ages of 3 and 14 years. The right joint is more often affected, sometimes bilateral lesions occur, although the second joint is usually less affected.

    Perthes disease accounts for about 17% of all osteochondropathies.

    Blood circulation disturbances, dystrophy of bone and cartilage tissue (mainly femoral epiphysis, to a much lesser extent of acetabular structures), dystrophy and necrosis of bone and cartilage structures, changes in the anatomy and biomechanics of the joint develop. In the pathogenesis of Perthes disease, there are five stages: I - necrosis of the nucleus of ossification of the femoral head, II - secondary compression / impression fracture of the femoral head, III - resorption of necrotic bone tissue and its fragmentation, shortening of the femoral neck, IV - proliferation of connective tissue instead of the affected bone and cartilage structures, V - ossification of the replacing connective tissue structures due to the deposition of calcium with the formation of bone tissue.

    As a result of these processes, the anatomy and biomechanics of the joint are disrupted, the femoral neck is shortened, the cervical-diaphysial angle is reduced, and the structure of the acetabulum is disturbed.

    The disease most often begins gradually.

    The initial manifestations of the disease are pain in both the hip and knee joints, and more often the disease begins with pain in the latter. A change in gait — the child begins to limp.

    The defeat of the hip joint in Perthes disease is most often unilateral.

    In the later stages of contractures, hypotrophy of the gluteal muscles are observed.

    Clinical and radiological classifications Edit

    Catterol Classification [1]

    Group 1 - initial radiological manifestations. Small subchondral or central defect with preserved normal configuration of the femoral head. Metaphysal changes, sequestration or fracture lines are not detected.

    Group 2 - sclerotic and destructive changes in the head of the femur while maintaining its contour, signs of fragmentation and sequestration.

    Group 3 - Subtotal lesion of the femoral head with its deformation and the presence of a fracture line.

    Group 4 - total lesion of the femoral head, as well as the presence of changes in the acetabulum.

    Salter - Thomson Classification (Salter - Thomson) [2]

    Group I - subchondral fracture line only in the picture in the position of the Lauenstein in the anterior part of the epiphysis.

    Group II - subchondral fracture in the anterior part of the epiphysis, the lateral border of the head is preserved.

    Group III - subchondral fracture in the lateral part of the epiphysis.

    Group IV - subchondral fracture in the entire region of the epiphysis.

    Therapy of the disease is complex and depends on the stage.

    In the early stages - unloading of the affected joint (wearing orthopedic devices, unloading the hip joint, crutches), immobilization (abduction and derotation), periodic daily stretching, drug treatment, aimed at improving the blood supply to the bone and cartilage structures of the hip joint. In the later stages - surgery, elimination of biomechanical disorders in the joint.

    Also in the process of treatment are applied physiotherapy methods, massage (by various methods), physical therapy, electrophoresis, hyperbaric oxygen therapy, sanatorium-resort treatment.

    The best results of treatment can be achieved, as a rule, in children with an age of less than 4 years, which is associated with less development and differentiation of the tissues that make up the structures of the hip joint.

    The treatment is long, for 2 to 5 years, and requires constant follow-up with a doctor.

    In the case of the displacement of the vertebrae of the lumbar spine L4-L5, the removal of displacement allows you to restore the rate much faster. The use of chondroprotectors proved to be inexpedient.

    Causes of disease

    A single reason for the occurrence of this pathology to date has not yet been formulated. It is considered that a combination of several factors leads to its occurrence. Some children still at birth have a certain predisposition to the occurrence of Perthes disease, which is triggered by myelodysplasia - congenital hypoplasia of the spinal cord in the lumbar region. With such a deviation of blood supply to the femoral head is limited, and in some cases even completely stops. As a result of the cessation of oxygen supply, the tissues die off, which leads to the development of aseptic necrosis - the death of tissues without exposure to bacteria or inflammation. Myelodysplasia can absolutely not manifest itself in the course of a lifetime, but if combined with other factors (infectious diseases, injuries), it can lead to the development of various orthopedic pathologies.

    Also, a hereditary factor, which affects the very structure of the hip joint at the genetic level, also has a certain value.

    Other factors that increase the risk of developing Perthes disease:

    general infectious diseases and complications, for example, inflammation of the hip joint in the presence of influenza, tonsillitis, sinusitis,

    small baby weight at birth,

    metabolic disorders, especially phosphorus and calcium, which are actively involved in the formation of bone tissue,

    postponed hypotrophy, rickets,

    hormonal disorders in children in puberty,

    increased stress on the joints with a weakened body during the development of acute infections, it is for this reason that bed restraint is recommended in case of inflammatory diseases,

    chronic exposure of a child to tobacco smoke (passive smoking),

    hip injury and adjacent joints, for example, during falls, jumps.

    Stages of Perthes disease

    There are five stages of Perthes disease in children:

    the first is the cessation of the blood supply to the femoral head and the onset of necrosis of the tissues of the femur,

    the second is a secondary fracture of the femoral head,

    the third - shortening of the femoral neck, resorption of dead tissue,

    the fourth - the connective tissue grows in the place of the bone released from the dying off of the tissues,

    fifth, the connective tissue begins to stiffen, the fracture fusion process takes place, as a result, the natural structure of the joint is disrupted.

    The consequences of osteochondropathy of the femoral head depend on the size and localization of the site of necrosis. With a small focus of tissue necrosis, a full recovery is possible. If there are significant deformities of the femoral head, it breaks up into several separate fragments and already at the fifth stage (with ossification of the connective tissue and fusion) has an irregular shape (acquires a convex, thin or flat shape). As a result, complications begin to form: contractures, difficulty in walking, and severe coxarthrosis, or arthrosis of the hip joint, also appears.

    Perthes disease treatment

    Treatment of the disease depends on the stage of development of the pathology, the age of the child and some individual characteristics. In the early stages of the pathology, conservative treatment is applied, the later stages are treated only surgically.

    Children aged 2 to 7 years with a predisposition to osteochondropathy of the femoral head should undergo a full examination (with the obligatory X-ray examination) and be registered with the district orthopedist. Moreover, in the event of early (minor) symptoms, special treatment may not always be prescribed: if, when performing additional images in dynamics, the progression of the disease is not confirmed, the orthopedist may prescribe simple control over the dynamics of the pathology without pharmaceutical correction. If the pathology is exacerbated, go to the conduct of conservative treatment.

    Such a conservative therapy of pathology is very long and rarely can last less than two years, usually it takes from 2.5 to 4 years to eliminate the pathology. Treatment involves the following set of measures:

    Reducing the load on the joints - wearing special gypsum dressings, orthopedic insoles, massage, a special complex of physical therapy, walking on crutches.

    Fighting overweight - as a result of reducing the mobility of the child, problems with excessive body weight often appear, which gives an additional load to an already damaged hip joint. Therefore, doctors prescribe a special diet for children to normalize weight. Parents should ensure that the child receives a normal diet, which is saturated with calcium, proteins and vitamins.

    Appointment of vasoconstrictor drugs, drugs for resorption of necrotic tissue, improve blood supply to the joint, maintain muscle tone.

    To reduce the inflammatory process in the hip joint, anti-inflammatory drugs can be prescribed, for example, Ibuprofen. In some cases, there is a need for several months for this therapy.

    Hondoprotectors and angioprotectors are also prescribed intramuscularly and orally.

    Physical therapy - massage, ozokerite, therapeutic mud, electrophoresis with phosphorus and calcium, electrical muscle stimulation, UHF.

    In the late stages of the development of Perthes disease in the event of significant deformities of the joint, there is no benefit from conservative treatment, therefore, surgery is required - correction of the damaged joint.

    Surgical treatment of Perthes disease is recommended for children after 6 years of age. The main methods of correction are pelvic osteotomy according to Salter, medializing osteotomy of the femur. The head of the femur is placed deep in the acetabulum and fixed with plates, which are then removed. After surgery, there is a need to apply a plaster corset from the chest to the feet for 1.5-2 months. Physical exercises to restore mobility begin immediately after removal of the plaster cast and are carried out only under strict radiological control. Also, the rehabilitation period includes hondoprotectors, physiotherapy, massage.

    After successful treatment of Perthes disease, patients are recommended to limit the load on the hip joint for the rest of their lives: weight lifting, running loads, jumps from a height are prohibited. Work activities should not be associated with prolonged standing on their feet. It is mandatory recommended to engage in medical gymnastics, allowed cycling and swimming. It is necessary to regularly undergo examinations at the orthopedist, to perform X-rays to monitor the dynamics and condition of the joint.

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