Case: Tommy is a 6yo boy coming in for a sick appointment. His mother states that he has had a limp for “a while.” He is an active kid and she thought he had bruised himself and didn’t think too much of it. Now, 2 weeks later, he has not improved.  After a complete history and physical, an x-ray of the hips is obtained: 

 

 

lcp_2

AP Hip

lcp_1

Frog leg view

Diagnosis: Legg-Calve-Perthes Disease

Radiology Findings (courtesy of Radiopaedia):  The left superior femoral epiphysis is markedly flattened, sclerotic and appear to be undergoing fragmentation. Alignment is unremarkable and the pelvis and acetabulum appear normal. The Right hip appears normal.

Brief Summary:

  • Legg-Cavle-Perthes Disease is an idiopathic avascular necrosis of the femoral head
  • Generally affects children between 2-12 years of age and tends to be more common in boys as opposed to girls  (Hermann et al, 2015)
    • Bilateral in 10-20% of patients (Nigrovic, 2016)
  • Children tend to present with limp and limited range of motion of the hip.
    • Children may also initially present with knee pain or thigh pain
  • Plain films of the hips help make the diagnosis, though tend to normal early in the course [unlike case above, which likely details later stage findings] (Nigrovic, 2016)
    • MRI helpful in diagnosis early in disease process as well as detailing prognosis (Dillman et al, 2009)
      • findings include: proximal femoral necrosis, delayed contrast enhancement, abnormalities in the proximal femoral physis
  • Referral to orthopedic surgeon important for long term management
    • Once diagnosed, children should be made nonweight bearing until seen by orthopedist (Nigrovic, 2016)
  • Ongoing management is symptomatic (anti-inflammatory meds, physical therapy, limited activities), though there is a paucity of evidence to guide recommendations.

Faculty Reviewer: Alison Riese, MD

References

Case courtesy of Dr. Bruno Di Muzio, Radiopaedia.org. From the case rID: 12153

Dillman JR et al. “MRI of Legg-Calve-Perthes Disease.” American Journal of Radiology. 2009;193(5)1394- 1407.

Herman MJ et al. “The Limping Child.” Pediatrics in Review. 2015;36(5)184-197.

Nigrovic PA. “Overview of hip pain and childhood.” https://www.uptodate.com/. Accessed October, 2016.