Perthes disease

Perthes disease (synonym: osteochondropathy of the femoral head, juvenile arthritis deformans, Legg - calve - Perthes disease)aseptic necrosis of the femoral head is more common in boys 4-16 years. The disease lies malnutrition epiphysis of the femur; play the role of injury (including re-micro), congenital factors, endocrine disorders.
Usually suffers from one extremity. Perthes disease begins gradually with restrictions abduction and external rotation of the hips in - preservation of other movements. Appear easy limp, pain, crackle in the hip while walking. Limb several thinner. Effleurage to spit hip - pain. On radiographs initially marked depression of the picture of the bone tissue, the expansion of the joint space and areas of necrosis of the femoral head (this stage lasts 6-8 months); then when the load is the crushing of the femoral head like an egg-shell; dead tissue is resorbed and replaced by connective that leads to the division head into segments. After 10-12 months starts healing segments of the head, and in 2-3 years it is restored, but the form of its strain. Deformed and bottom contours of the acetabulum.
With proper early treatment - restorative therapy, bed rest, immobilizers bandages, discharge devices (see Orthopedic devices) - function of a limb can be completely recovered. Sometimes there are indications for surgery aimed at improving the blood supply to the femoral head. Children, people with Perthes disease, better treated in specialized sanatoriums. Cm. also Osteochondropathy.

Perthes disease (G. S. Perthes; synonym Legg - calve - Perthes disease) aseptic necrosis of the femoral head. Nutritional disorder in the form of primary aseptic necrosis of the femoral head, lead to serious changes in the shape and function of the hip joint. The disease belongs to the group of osteochondropathy (see). Basically the disease affects children aged 5-12 years. Boys are sick about 4-5 times more often than girls. When of Perthes disease, the head of the femur is affected mainly on the one hand, but are described in literature and bilateral lesion.
The etiology of the disease is still not clear. All of the theories proposed to explain the reasons for development section b. (infection, rickets, a violation of the endocrine system, congenital predisposition to the circulatory disorders, trauma and other), the most widespread and justified traumatic theory. Naturally, not every patient injury can lead to P. B.
Accumulated to date pathological observations and experimental data in one way or another prove traumatic theory, but do not allow to draw final conclusions on the etiology P. B.
The clinical picture. Perthes disease has hidden the beginning and flows asymptomatic. First, children complain of fatigue and on reasonable and non-permanent pain in the hip, and sometimes in the knee joints. The pain intensifies the end of the day, at night subside.
In the survey noted a slight limitation thigh, easy lameness and unobtrusive atrophy limbs. The load on the axis of the limb painless. From time to time of pain for a certain period disappear. Over time there is limited rotation and disposal in the hip joint, you receive a symptom Trendelenburg, and when measuring discover a small LLD and high standing of greater trochanter.
In the General condition of an organism of significant changes occur. Children are reluctant to go to bed, despite the lameness, continue to run. Any abnormalities in the blood is not observed. X-ray examination is crucial for differential diagnosis of diseases of the hip joint region.
Forecast of Perthes disease is always favorable for the life, however, at what stage are diagnosed with the disease, as early treatment depends largely forecast functional.
Childhood P. B. in the absence of appropriate treatment may leave the patient for life in a wheelchair.
Treatment. In P. B. required to timely complete unloading limb (prevents deformation of soft femoral head) and restorative therapy (faster regeneration of bone tissue of the femoral head).
Along with the core, conservative treatment P. B. there are surgical ways that stimulate ossification sparse bone lesions (tonalitatea and introduction to her hip frozen gomotransplantatov). The best conditions for children, the sick, P. b., created in specialized hospitals. Conservative treatment of P. B. in the sanatorium consists in the observance of bed rest, vitamin therapy, nutrition. Of physiotherapeutic procedures can be applied transverse inegalitarian with chloride calcium on the area of the hip joint (reconstruction period).
Peace can be achieved either by imposing Kokshetau bandage, or the use of orthotic devices (see) with emphasis on the sciatic hill, reducing the load on the limb.
The most rational is in bed for 6-8 months lipoplasties by an extension of the patient's legs. When the last load is ruled out, flexion and rotation of the movement even appropriate. They are elements of therapeutic exercises in this disease.
X-ray diagnostics. The data of x-ray studies at the P. B. play an important role in the diagnosis, the conduct differential diagnosis, comparative observations of development changes in the osseous-articular apparatus of the hip joint, and the recognition of remote consequences of an illness. X-ray picture P. B. characterized by a certain sequence of the development of the ongoing changes. In the normal course of the disease this sequence is expressed in five stages, changing one another (C. A. Reinberg).
I. the Initial development stage avascular necrosis of the femoral head; macroscopically not accompanied by changes in the shape and structure of the epiphysis; x-ray picture of the hip joint is normal. A period of several months.

Perthes disease
Fig. 1. Perthes disease, II stage. The flattening of the epiphysis of the left femur, seal its structures, expansion strips metaepiphysis cartilage and extension x-ray cracks of the left hip joint.

II. Stage impressionado fracture epiphysis of the femur. X-ray signs of illness in this stage, lasting 6-8 months, are flattening of the epiphysis of the femur, the seal of its structures and expansion of the x-ray of the joint space. Strip metaepiphysis cartilage gets some crookedness that indicates a violation encontrarnos growth of the bone. These characteristics during the specified period gradually increase (Fig. 1).
III. Stage sequestrating shadows that in the x-ray mapping disease is especially indicative. In deformed and compacted epiphysis of the femur appear sections of depression that indicate the dead bone resorption tissue. When most pronounced process on the background of the vacuum structure of epiphysis are still areas still prisosalsya necrotic bone, creating some external similarity with bone curtailment. Deformation head increases: in addition to its flattening and increase in the transverse size. Previously arisen and increasing signs attached thickening of the neck of the femur (because of the periosteal osteopat-tion), which turns out to be shortened in comparison with healthy as a result of braking encontrarnos growth of the bone. Considerable changes strip metaepiphysis cartilage; it becomes extended, even more tortuous and ill-defined. Even more expanding the articular gap. Cervico - diaphyseal femoral angle bones decreases.


Fig. 2. Perthes disease, stage III, the same Solo as on Fig. 1, after 1 year and 4 months. Uneven depression deformed and compacted epiphysis head of the left femur - picture sequestrating shadows, thickening of the head and neck of the femur, the extension of the x-ray of the joint space, subluxation thigh in outside direction.

Accordingly changed the form of the femoral head is changing and the form of the acetabulum. There are signs of subluxation of the femur outwards (Fig. 2). In this stage can be blurred expressed osteoporosis. A period of approximately two years.
IV. Stage of reparation. Lasts about a year. Radiograph shows a picture of gradual recovery of the structure of bone substance of the femur when saving the resulting deformation of the hip joint.
Clear boundaries between these stages not exist. Therefore, when the diagnosis of Perthes disease sometimes give such definitions of the x-ray pictures, as II-III or III - IV stage of its development.
V. stage consequences transferred aseptic necrosis, when you are characteristic deformation of the hip joint (Fig. 3). Many years after clinical recovery, and in a satisfactory condition of the patient (only a limitation of rotation, and the discharge of limbs in the hip joint), at a Mature age in the joint develops picture deforming osteoarthrosis (see).
In addition to the described progress in the evolution of morphological changes in the osseous-articular apparatus, in case of timely detection and proper treatment are possible depending on the outcome of disease - restore completely the correct form of the femoral head and acetabulum (Fig. 4).


Fig. 3. Perthes disease, V stage. Primary bone deforming osteoarthrosis.

Fig. 4. Maintaining the correct form of the head of the left femur in clinical cure of Perthes disease - the transition from IV to the V stage (after immobilization within 3 years).