Legg-Calvé-Perthe’s Disease

You are the orthopaedic CT1. The paediatric ST5 asks you to see an overweight 6-year old boy on the paediatric assessment unit who attended with groin pain and limping. He is afebrile. On closer questioning this has been going on for the past 4 months but today the pain has worsened after playing outside with his friends. How would you proceed?

Example answer introduction

I would perform an initial assessment and stabilisation of the child, take a focused history and examine the child. My main differential includes Perthe’s disease, slipped upper femoral epiphysis, septic arthritis and transient synovitis. In a male child of this age with a shorter duration, over hours, I would also be mindful of a testicular torsion. 

Initial Assessment and Simultaneous Resuscitation:
​On arrival, manage the patient using the A to E approach according to the Advanced Paediatric Life Support algorithm.
  • Airway
  • Breathing - O2 saturations, work of breathing - intercostal recession, use of accessory muscles - if any concerns give oxygen
  • Circulation - pulse, blood pressure, central and peripheral capillary refill time, urine output - consider catheterisation, IV access and bloods as above. 
    • Fluid bolus - Paediatrics give 20ml/kg of crystalloid solution (not dextrose)
  • Disability - AVPU, pupillary response, blood glucose
  • Exposure - look for signs of shock, evidence of meningism e.g. rash, nuchal rigidity GCS, pupils, BM, temperature
During the acute phase state remember to provide constant reassessment. 
 
Bloods that are vital to this case include: CRP and ESR. Others including and FBC and U/E would also be useful. 
Focused history
A focussed history and collateral history is important once the patient has been fully stabilised. 
  • Allergies

  • Medications – anticoagulants, consider reversal

  • Past medical history including previous surgery – 

    • Birth method, birth weight, maternal smoking during pregnancy, Caucasian origin, low socioeconomic groups, positive family history

  • Last meal

  • Events leading up to this point

Examination
A full paediatric examination needs to be taken. Specifically as specialty input one must assess the following:
  • Gait – limping

  • Pain on internal rotation and abduction of the hip

  • Muscle atrophy

  • Leg length discrepancy

Example questions to progress the station
Q1 - An A-P pelvic film has been requested. Please take us through it
Q1 - Answer:
"This is an AP plain film of the pelvis. There a no demographic details, date or time stamp. The most obvious abnormality is flattening of the right femoral head suggestive of Perthe’s disease. I would like frog leg lateral views of both hips for more information, as disease can be bilateral in 10-15% of cases."
Q2 - What is your initial management?
Initial management

  • Analgesia according to WHO pain ladder

  • Bloods including inflammatory markers

  • X-ray hip 

  • Keep nil by mouth

  • Maintenance IV fluids

  • Escalate to Orthopaedic Registrar 

  • Keep patient and any relatives informed

  • Document, document, document!!!

Remember to document your findings and management plan and inform the patient/parents.​
Escalation
This question tests your knowledge of paediatric orthopaedic conditions. You will not be expected to understand the intricacies of managing the disease but they will be looking for a safe and systematic approach to the questions posed. 
You must discuss with the orthopaedic Regestrar. 
It may be worth also discussing with the radiologist on call also. 
Useful Resources

​NICE CKS Acute childhood limp 

Pathophysiology and new strategies for the treatment of Legg-Calvé-Perthes disease

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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