Legg Calve Perthes (LCPD)

Is a degenerative disease of the hip joint, where growth/loss

of bone mass leads to some degree of collapse of the hip joint and
to deformity of the ball of the femur and the surface of the hip
socket. The disease is characterized by idiopathic avascular
osteonecrosis of the capital femoral epiphysis of the femoral head
leading to an interruption of the blood supply of the head of the
femur close to the hip joint. The disease is typically found in young
children, and it can lead to osteoarthritis in adults. The effects of
the disease can sometimes continue into adulthood.

Also known as:

 Perthes disease
 Ischemic necrosis of the hip
 Coxa plana
 Osteochondritis
 Vascular necrosis of the femoral head

Causes:

 The exact cause is unknown

 Reduction in blood flow to the joint
 It is thought that the artery of the ligamentum teres femoris
closes too early, not allowing time for the medical circumflex
femoral artery to take over
 Abnormal blood clotting
 Infection
 Malnourishment
 Genetic
 Trauma

Incidence

Perthes is rare, occurring in approximately 5.5 of 100,000 children.

Signs & Symptoms:

First Signs:
 complaint of sourness from the child (often dismissed
as growing pain)
 limping
 guarding of the joint
Other Symptoms:
  hip, knee (reffered pain), or groin pain, exacerbated
by hip/leg movement.
 Reduce ROM at the hip joint and a painful or antalgic
gait
 Atrophy of thigh muscles from disuse
 Inequality of the leg length.

Pathophysiology

Predisposing/ Risk factors:

 Obesity
 Family history
 Low birth weight
 Abnormal presentation at birth
 Race- Asians, Eskimos, whites

Genetic, Infection, Trauma, Malnutrition, Abnormal Blood Clotting,

Idiopathic.

Rapid Growth > Development of the Supply of the Secondary Ossification

Centers in the Epiphysis.

Interrupted of adequate blood flow

Prone to avascular necrosis

Result in necrosis

Deformity of the ball of the hip, knee or groin

pain
femur and the surface of the
hip socket
Limping, guarding of
the joint
inequality of leg length

antalgic gait

Disuse
 Atrophy thigh muscles

Four Stages of LCPD

1. Femoral head becomes more dense with possible fracture

of supporting bone;
2. Fragmentation and reabsorption of bone;
3. Reossification when new bone has regrown; and
4. Healing, when new bone reshapes.

Phase I takes about 6-2 months, Phase 2 takes one year or

more, and Phase 3 and 4 may go on for many years.

Diagnosis:
 X-Ray
 Magnetic Resonance Imaging (MRI)
 bone scan

Treatment

The goal of treatment is four-fold:

I) to reduce hip irritability
2) restore and maintain hip mobility
3) to prevent the ball from extruding or collapsing
4) to regain a spherical femoral head

Medical MGT:

 NSAID (Motrin) – for pain

 Zoledponic Acid (under investigation)

Surgical MGT:

Surgery is indicated for children greater that age 6 years.

 Excision of extruded portion of the head for hinge abduction

 Acetabular osteotomy
 Lateral shelf osteotomy
 Chiari osteotomy
 Valgus osteotomy
 Arthrodesis

Non-surgical treatment:

 cast
 traction
 braces
Prevention

There is no known effective preventative measure

Nursing MGT:

 Distraction method – for pain

 Advice refrains from contacts sports or game/activities which
impact the pain.

General Interventions:

1. Instruct patient to report pain as soon as it begins

2. Provide quite environment, calm activities.
3. Encourage use of diversional activity (TV, Radio,
socializing)
4. Encourage adequate rest periods to prevent fatigue
evaluate in pain behavior

Nursing Dx:

 Acute pain related to inflammation of joint secondary to legg

calve perthes disease.
 Impaired physical mobility related to abnormal gait secondary
to legg calve perthes disease.
 Risk for injury related to altered mobility secondary to
unsteady gait.
 Avascular Necrosis

Is a disease resulting from the temporary or permanent loss

of the blood supply to the bone. Without blood, the bone tissue dies
and causes the bone to collapse. If the process involves the bones
near a joint, it often leads to collapse of the joint surface.

Also known as:

 Osteonecrosis
 Aseptic necrosis
 Ischemic bone necrosis

Etiologies:

 Alcohol abuse
 Caisson (decompression) disease
 Cigarette smoking
 Fat emboli
 Gout
 Radiation therapy
 Raynauld phenomenon
 Sickle cell disease with increase blood viscosity
 Systemic steroids
 Trauma, such as fracture, disruption circulation in the bone
 Unknown cause, known as idiopathic AVN

Causes:

Following is a list of causes or underlying conditions (see also

Misdiagnosis of underlying causes of Avascular necrosis) that could
possibly cause Avascular necrosis includes:

 Traumatic injury
 Fracture
 Dislocation
 Dislocated hip (see Hip symptoms)
 Alcoholism
 Excessive alcohol
Pathophysiology

Risk factors:

 injury
 steroid use
 Gaucher disease
 alcohol use
 blood disorders, such as sickle cell anemia
 radiation treatments
 chemotherapy
 pancreatitis
 decompression disease

Traumatic causes non-traumatic causes

Temporary or permanent loss of blood supply to the bone

When blood supply is cut off, the bone tissue dies

 minimal early joint pain

Bone collapses
 increased joint pain as bone and joint begin to collapse

If it occurs near a joint, collapse of the joint surface may occur

 limited range of motion due to pain

Diagnostic Tests

The list of diagnostic tests mentioned in various sources as used

in the diagnosis of Avascular necrosis includes:

 X-rays
 MRI - good for diagnosis in the early stages
 Bone scintigraphy (bone scan)
 CT scan
  Bone biopsy

Treatments for Avascular necrosis

The list of treatments mentioned in various sources for Avascular

necrosis includes the following list. Always seek professional medical
advice about any treatment or change in treatment plans.
 NSAIDs - for pain
 Avoid weight bearing - take pressure off the joint (e.g.
crutches); in some cases this allows the body to self-heal.
 Range-of-motion exercises
 Electrical stimulation - to stimulate natural growth of the
bone.
 Avoid alcohol
 Treat alcoholism - if the problem is caused by alcoholism.
 Discontinue corticosteroid use - slowly under medical advice,
since stopping quickly causes problems.
 Surgical treatments
o Core decompression
o Osteotomy
o Bone graft
o Joint replacement (arthroplasty)

Nursing Dx:

 Impair physical mobility related to AVN of femoral head or

tarsal navicular bone.
 Acute pain related to ischemic changes and degeneration of
involved bone.