Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Ankush Bansal
M.S.(Orthopaedics)
Kasturba Medical College, Mangalore
A self limiting, non-inflammatory condition, affecting the capital femoral epiphysis with stages of degeneration and regeneration, leading to a restoration of the bone nucleus.
Perthes 1913
Schwarz 1914
Suggested that primary epiphyseal necrosis was due to multiple infarcts as a result of thrombosis or embolism
Usually occurs age 3 -12 years y Most common age 5 - 7 years y Bilateral in 10% - 20 % y Boy 3-5 : 1 Girl y Familial in 8%-12%*
y
Delayed bone age Retarded growth soon after diagnosis with later catch up growth
Undersized at diagnosis
(Wynne-Davies et al JBJS 1978;60B:6-14)
Limp Pain in groin radiating to knee Limited abduction Limited internal rotation Flexion with abduction and external rotation Trendelenberg
Transient synovitis Septic arthritis Slipped femoral epiphysis MED/SED Systemic Steroids Abnormal Coagulation
y y y
Bloods FBC, ESR, CRP, Blood Culture Radiographs Ultrasound Scan Bone Scan
MRI
Earlier diagnosis than plain radiography More information regarding extent of necrosis than bone scanning
Sclerosis
Fragmentation
Re-ossification
Healing
I III
II IV
Groups I & II Good Prognosis Groups III & IV Poor Prognosis
Lateral epiphyseal calcification Lateral subluxation Gages sign Metaphyseal cysts Horizontal growth plate
Salter A B
Group A
Normal Height of lateral pillar maintained
Group B
> 50% of lateral pillar height maintained
Group C
< 50% of lateral pillar height maintained
Significantly better predictor of outcome than Catterall* Stronger determinant of final outcome than age** Inter observer variability better than Catterall grading or head at risk signs**
* Ritterbusch et al.JPO 1993; 13: 200-202 **Herring et al JPO 1992; 12: 143-150
Spherical congruency
Arthritis does not develop
Aspherical congruency
Mild to moderate arthritis mid -late adulthood
Aspherical incongruency
Severe arthritis before age fifty years.
Early Disease
While the femoral head is still plastic
Late Disease
When the femoral head is no longer plastic
1966
Harrison & Menon reported results of Broomstick Plaster (Petrie Cast)
Harrison & Menon JBJS1966;48A:1301-1318
1962
Salter osteotomy first used for Perthes
Pre requisites
Containable hip
Arthrogram
Normal Neutral
Containable
Hinging
Abduction
Femoral epiphysis deformed and no longer plastic Principle complication is hinge abduction Short leg Short femoral neck with high trochanter Limited abduction Gluteal insufficiency symptoms
Objective - maintenance of full pain free ROM Clinical indications that patient doing badly
Increasing symptoms Short limb Abduction limited to < 10o - 20o Limited rotations Flexion with external rotation & abduction
50% - 70% do well without treatment No evidence that treatment alters outcome Treat symptomatically to regain ROM Regular outpatient assessment
Consider containment for : Persistent loss of ROM with Herring C (Catterall III IV at risk) (Salter Thompson B)
Observe: Patients maintaining ROM with Herring A (Catterall I & II not at risk) (Salter Thompson A) Consider containment for : Persistent loss of ROM with Herring B (Catterall III IV at risk) (Salter Thompson B)
Observe: Patients maintaining ROM with Herring A (Catterall I not at risk) (Salter Thompson A) Most patients have: Persistent loss of ROM with Herring B/C (Catterall III IV at risk) (Salter Thompson B)
Principle complication is hinge abduction Short femoral neck with high trochanter Gluteal insufficiency symptoms Limited abduction/Short leg
Neutral
Abduction
Pre requisites Hinging Good range of adduction Arthrogram Congruent hip in adduction