PERTHES DISEASE

QUESTIONS AND ANSWERS

Symptoms

The most recognizable symptom of Perthes disease occurs when observing the child walking or running.  For instance, a child who walks or runs in an awkward way should get evaluated for Perthes disease. Thus, the change in the child’s way of walking or running becomes obvious while participating in sports activities.  Other symptoms that might be present:

• Pain in the hip
• Pain in the knee
• Limping
• Pain in the leg
• Pain in the thigh
• Limited Motion
• Pain in the groin
• Awkward style of walking
• Awkward style of running
• Painful muscle spasms in the hip or leg
• Change in a child’s walking
• Change in a child’s running
• Pain that worsens with activity and goes away with rest

In most cases, these symptoms come and go over the course of several weeks before caregivers decide to seek medical attention.

Doctor’s Consultation

At your child’s initial exam with your Orthopedic Specialist, the doctor will evaluate your child’s gait and make a list of the current symptoms your child displays. Coupling it with a thorough history of your child’s health, a physical examination, and possibly order several diagnostic tests. These additional tests will help complete an accurate diagnosis for your child. Your doctor will want to know the child’s age when symptoms started, and how they progress. The doctor will ask for a list of any treatments received. Finally, your doctor will want to know about any presence of family history. He will also ask if there are any similar orthopedic conditions among other details about your child.

Your doctor will also examine the child, paying close attention to any limitations in range of movement. Perthes disease restricts the child’s ability to move the leg outwards (abduction) or inwards (rotation). In addition, your doctor might order and review x-rays of your child. The X-rays will help your doctor confirm the diagnosis. The X-rays will also help identify the stage of the disease. And lastly, all of these items help in devising a successful plan for treatment.

Over the course of treatment, children struggling with Perthes disease will need occasional X-ray exams to monitor their progress.

Perthes Disease Treatment

The goals of treatment for Perthes’ disease are threefold:

1.  Stop pain
2.  Protect the femoral head shape
3.  Restore the normal range of hip movements

Without treatment, the head of the femur becomes permanently deformed. The child becomes more likely to develop hip problems like arthritis as they age into adulthood.

There are many treatment options for Perthes disease. The option chosen for your child will rely on several different indicators, for instance:

• Child’s age: The younger the child, the better. Diagnosing and treating younger children provides a much better chance of healing. Children who are six and below are usually able to grow new healthy bones to replace the injured ones.
• The stage of the disease: The treatment options when diagnosed earlier can utilize non-surgical treatments, hopefully without surgery. When the disease is diagnosed later in life, it is more likely that the child will require a surgical intervention.
• The degree of damage to the femoral head: If the femoral head appears more than 50% damaged, it will likely require surgery. Without intervention the likelihood of the bone healing without a deformity is low. This means that the doctor may consider surgical measures to resize the bone. This resizing will help reshape the bone to the intended size and reposition it.

There is a range of surgical and nonsurgical procedures for treating Perthes’ disease depending on your diagnosis.

Perthes Disease Non-Surgical Treatments

Normally, non-surgical treatments are commonly used for younger children with early disease and minimal damage to the femoral head. Depending on your doctor’s assessment and diagnosis, your child will receive a treatment plan. Below are some non-surgical treatments your doctor might adopt in the treatment of Perthes disease.

Observation

For this reason, with young children, early-stage disease, and minimal damage to the femoral head, observation is the treatment. One of the non-surgical treatments is simply to observe the bones and the child’s symptoms. During this process, your doctor will order a series of X-rays to monitor the progress of the condition of the bones. As the disease runs its course and as long as the bone is healing properly and the symptoms are relieved, no further treatments will be required, except for periodic checkups.

Medication

Medicine offers another treatment and relieves pain. Pain in Perthes disease occurs from inflammation of the hip joint. To relieve this pain, your doctor can prescribe anti-inflammatory, pain-relieving medication. One of the drugs commonly prescribed for this condition is Ibuprofen. Your doctor can place your child on ibuprofen for many weeks while monitoring their progress. Changing the dose or stopping the drug can be decided based on the condition.

Protecting the joint 

In order to facilitate healing and prevent the condition from getting worse, your doctor will want to protect the joint. Protecting the joint involves two main activities:

1. Limiting activity
2. The use of walking aids.

Your doctor may advise your child to avoid running, jumping, vigorous walking, or any other activities that can strain the joint. Your doctor may also recommend walking aids. These may include crutches or a walker to reduce load bearing on the affected hip and facilitate healing.

Physiotherapy (Physical therapy)

Perthes disease causes stiffness and a reduced range of movement around the hip joint. For doctors, one of the main treatment goals is to restore the range of motion to normal. Physical therapy can do this. The physical therapist will help you and your child learn a range of exercises to improve the child’s ability to move his or her hip outwards and inwards. These exercises will help strengthen the muscles that move the hip and help facilitate normal moments for your child.

Casting and bracing

Casting and bracing are other non-surgical treatment options that can help your child. This option is usually adopted if the X-rays show the formation of a deformity or the range of motion is limited. Using special casts known as Petrie casts, your doctor will immobilize the hip in the best position for healing. Petrie casts are specialized casts shaped like the letter “A”.

Petrie casts are usually applied in the operating room. This allows your doctor to conduct several special x-rays called Anagrams which help to visualize the head of the femur in the correct position. It also allows him to carry out any minor procedures required, such as a Tenotomy where a small incision in the muscle will relieve tightness. Doctors will implement casts for up to six weeks at a time. Based on the progression of the disease, doctors will apply intermittent casting. After casting, your child will require physical therapy to regain their range of movement.

Surgical Treatments

In older children with advanced Perthes disease and more than 50% damage of the femoral head, the treatment option includes surgery.  So, surgery is recommended when the non-surgical methods fail. The most common type of surgery is an osteotomy. During an osteotomy, your doctor will cut the bone and reposition it to make sure the femoral head fits within the socket. Then the bone will then get held in place with screws and plates until it heals. Following the surgery, the patient gets a cast to aid proper healing. Physical therapy gets scheduled when the cast is removed to build your child’s muscles and help with walking correctly.

Prognosis/Outcome

Finally, the prognosis for Perthes disease remains good. Children who are younger than six years old have the best prognosis because their bones have enough time to easily revascularize and remodel. With proper treatment, most children are able to grow into adulthood without any further concerns. Also, the prognosis depends on how well the head of the femur fits into the acetabulum. This in turn depends on the shape of the femoral head and the congruence of the hip. If the femoral head fits well then doctors expect a full recovery. If it does not then the child might develop problems such as arthritis and Coxa Magna as they age.