CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; WBC, white blood cell.
*Examples: Septic arthritis, osteomyelitis of hip.
Legg-Calve-Perthes disease (LCPD) is idiopathic avascular necrosis (osteonecrosis) of the capital epiphysis of the femoral head. The etiology is unclear, but it is likely caused by an interruption of the blood supply to the capital femoral epiphysis. There may be an associated hypercoagulability state (factor V Leiden).
LCPD commonly presents in patients 3 to 12 years of age, with a mean age of 7 years. It is four to five times more common in boys.
Patients may not present for several weeks because of minimaldiscomfort; the classic presentation is a child with an atraumatic, painless limp. There may be mild or intermittent hip/groin, anterior thigh, or knee pain. Decreased internal rotationand abduction with some discomfort, thigh muscle spasm, andanterior thigh muscular atrophy may be present. Patients havedelayed bone age.
Anteroposterior and frog-leg radiographs of both hips are usually adequate for diagnosis and management. It is necessary to document the extent of the disease and follow its progression. MRI and bone scan are helpful to diagnose early LCPD.
LCPD is usually a self-limited disorder that should be followed by a pediatric orthopedist. Initial treatment focuses on pain control and restoration of hip range of motion. The goal of treatment is prevention of complications, such as femoral head deformity and secondary osteoarthritis.
Containment is important in treating LCPD; the femoral head is contained inside the acetabulum, which acts like a mold for the capital femoral epiphysis as it reossifies. Nonsurgical containment uses abduction casts and orthoses, whereas surgical containment is accomplished with osteotomies of the proximal femur and pelvis.
The short-term prognosis is determined by the magnitude of the femoral head deformity after healing has completed. It is improved by early diagnosis, good follow-up, and compliance with the treatment plan. Older children and children with a residual femoral head deformity are more likely to develop osteoarthritis (OA). The incidence of OA in patients who developed LCPD after 10 years of age is close to 100%; it is negligible in children with onset before 5 years of age. Patients between 6 and 9 years of age have a risk of OA of less than 40%.
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Slipped capital femoral epiphysis (SCFE) is a common adolescent hip disorder that is an orthopedic emergency. The incidence is 10.8 per 100,000, and it is slightly higher in males. African-American and Hispanic populations are at higher risk. Approximately 20% of patients with SCFE will have bilateral involvement at presentation, and another 20% to 40% may progress to bilateral involvement. The average age is 10 to 16 years, with a mean of 12 years in boys and 11 years in girls. Additional risk factors for SCFE include obesity, trisomy 21, and endocrine disorders (hypothyroid, pituitary tumor, growth hormone deficiency).
SCFE is classified as stable or unstable. Unstable patients refuse to ambulate even with crutches. Stable patients have an antalgic gait. SCFE can also be characterized as acute (symptoms less than 3 weeks) or chronic (symptoms over 3 weeks). Acute-on-chronic SCFE is seen when more than 3 weeks of symptoms are accompanied by an acute exacerbation of pain and difficulty/inability to bear weight.