What is the workup and management for suspected Legg-Perthes (Legg-Calve-Perthes) disease in pediatrics?

From the Guidelines

The workup for suspected Legg-Calve-Perthes disease in pediatrics should begin with referral to a pediatric orthopedic surgeon, as they are best equipped to manage this condition. According to the guidelines for referral to pediatric surgical specialists 1, children with Perthes disease (ie, osteochondritis of the femoral head) may be best cared for by a pediatric orthopedic surgeon.

Initial Evaluation

The initial evaluation should include a thorough history and physical examination, focusing on hip pain, limping, and limited range of motion in affected children.

• Key points to consider in the history include:
  • Age of onset
  • Duration of symptoms
  • Presence of pain or limping
• Physical examination should assess:
  • Range of motion of the hip
  • Presence of pain or tenderness
  • Gait abnormalities

Imaging Studies

Initial imaging should include anteroposterior and frog-leg lateral radiographs of both hips, which may show femoral head flattening, increased joint space, or sclerosis.

• If radiographs are inconclusive but clinical suspicion remains high, MRI is recommended as it can detect early changes before they appear on X-rays.
• Bone scans may occasionally be used to assess blood flow to the femoral head.

Management

Management depends on the child's age and disease severity, with the goal of containing the femoral head within the acetabulum to maintain sphericity.

• For mild cases in younger children (under 6 years), observation with activity modification and regular follow-up may be sufficient.
• Physical therapy to maintain hip range of motion is important throughout treatment.
• Non-surgical containment methods include abduction braces or casts.
• For more severe cases or older children, surgical intervention may be necessary, including femoral or pelvic osteotomies to improve femoral head coverage.
• Pain management typically involves NSAIDs like ibuprofen (10mg/kg/dose every 6-8 hours) as needed. The rationale for treatment is to prevent femoral head deformity during the healing process, as the avascular necrosis will eventually revascularize over 2-4 years. Prognosis is generally better for younger children and those with less femoral head involvement.

From the Research

Workup for Suspected Legg-Perthes Disease in Pediatrics

• The workup for suspected Legg-Perthes disease in pediatrics involves a combination of clinical evaluation, radiographic imaging, and advanced imaging techniques such as MRI and bone scintigraphy 2, 3.
• MRI is particularly useful in the early diagnosis of Legg-Perthes disease, as it can show proximal femoral abnormalities before they are visible on radiographs 2.
• Bone scintigraphy is also useful in determining the onset of revascularization in the affected femoral head 3.

Imaging Findings

• MRI can assess the extent of the necrotic area within the epiphysis, as well as the position and contour of the femoral head, including the femoral and acetabular cartilage 3.
• Conventional radiography can be used to assess the severity of the disease and monitor its progression, but it may not be as sensitive as MRI in the early stages of the disease 3.
• Multipositional MR imaging can be used to evaluate femoral head containment, articular congruency, and femoral head deformity in Legg-Perthes disease, and has been shown to correlate well with conventional arthrography 4.

Management

• The management of Legg-Perthes disease in pediatrics typically involves a combination of non-surgical and surgical interventions, depending on the severity of the disease and the age of the child 5, 6.
• Non-surgical interventions may include bed rest, physical therapy, and the use of assistive devices such as crutches or a wheelchair.
• Surgical interventions may include osteotomies, such as innominate osteotomy or femoral varus osteotomy, to improve the alignment of the hip joint and promote healing of the affected femoral head 5, 6.
• The outcome of treatment for Legg-Perthes disease can vary depending on the severity of the disease and the age of the child at diagnosis, with younger children tend to have better outcomes 5.