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Coxa Plana

I. Definition
Legg-Calve-Perthes disease is when the head of the thighbone (femur) in
the hip deteriorates due to insufficient blood supply to the area.

II. AKA (also known as)


Legg-Calve-Perthes disease; Perthes disease

III. Incidences
• United States
One in 1200 children younger than 15 years is affected by LCPD.

• Race
Caucasians are affected more frequently than persons of other
races.
• Sex
Males are affected 4-5 times more often than females.

• Age
LCPD most commonly is seen in persons aged 3-12 years, with a
median age of 7 years.

IV. Risk/ Predisposing Factors

• Legg-Calve-Perthes disease occurs most frequently in boys 4 to 10 years


old. Recent research shows that this disorder may reflect subtle disorders
of blood clotting.

• Risk group also includes those who have abnormalities in genetics,


hormonal changes, trauma, infection and metabolic abnormalities
V. Manifestations

• Knee pain (may be the only symptom, initially)


• Persistent thigh or groin pain
• Atrophy (wasting) of muscles in the upper thigh
• Slight shortening of the leg, or legs of unequal length
• Hip stiffness restricting movement in the hip
• Difficulty walking, walking with a limp (which is often painless)
• Limited range of motion
• Decreased range of motion (ROM), particularly with internal rotation and
abduction
• Painful gait
• Muscle spasm
• Leg length inequality due to collapse
• Thigh atrophy: Thigh circumference on the involved side will be smaller
than on the unaffected side secondary to disuse.
• Short stature: Children with LCPD often have delayed bone age.

VI. Type/Stage/Classifications of the Disease

• Stage I (avascularity)

The blood supply to the upper femoral epiphysis is halted


spontaneously and bone growth is halted (lasts a few weeks)

• Stage II (revascularization)

New blood vessels arise to supply the necrotic area, and bone
resorption and deposition take place (lasts everal months to 1 year)
However the new bone lacks strength and pathologic fractures may occur;
the weakened epiphysis may be progressively deformed

• Stage III (reossification)

The head of the femur gradually reforms as dead bone is replaced


with new bone, which gradually spreads to heal the lesion (lasts 2 to
years)

• Stage IV (postrecovery)

The femoral head becomes permanently distorted, with resultant


joint misalignment
VII. Pathophysiology

Idiopathic avascular necrosis of femoral head

Goes through 5 phases:

(1) Initial - histological evidence of dead bone with disappearance of osteocytes from
empty lacunae

(2) Early - incipient revascularization

(3) early intermediate - active resorption of dead bone along with new bone deposits

(4) late intermediate- decreased bone resorption and increasing immature bone
formation

(5) formation of mature haversian systems.

The newly healed epiphysis may be left with residual deformity and never regain a
totally normal shape and appearance. Residual deformity can lead to serious disability
later in life.Some flattening of the epiphysis, referred to as “coxa plana,” can occur. In
more severe disease, complete collapse can occur, with the femoral head mushrooming
around the femoral neck. Because younger patients have more growth potential for
reformation and remodeling of bone, they tend to have better outcomes.

VIII. Diagnostic Studies

• Laboratory Studies
Laboratory studies for Legg-Calv é -Perthes disease include the
following:
 CBC
 Erythrocyte sedimentation rate - May be elevated if infection
present
• Imaging Studies
 Plain x-rays of the hip are extremely useful in establishing the
diagnosis.
 Frog leg views of the affected hip are very helpful.
 Multiple radiographic classification systems exist, based on the
extent of abnormality of the capital femoral epiphysis.
o Waldenstrom, Catterall, Salter and Thompson, and
Herring are the 4 most common classification systems.
o No agreement has been reached as to the best
classification system.
 Five radiographic stages can be seen by plain x-ray. In
sequence, they are as follows:
o Cessation of growth at the capital femoral epiphysis;
smaller femoral head epiphysis and widening of articular
space on affected side
o Subchondral fracture; linear radiolucency within the
femoral head epiphysis
o Resorption of bone
o Re-ossification of new bone
o Healed stage
 Technetium 99 bone scan - Helpful in delineating the extent of
avascular changes before they are evident on plain radiographs
 Dynamic arthrography - Assesses sphericity of the head of the
femur
• Procedures
 Hip aspiration if a septic joint is suspected

IX. Management

• Medical

Monitoring

1. Monitor and assess pain level ising age-appropriate pain measurement


tool.
2. Assess for gait, spasm, or presence of contractures.

Supportive care and education


1. Instruct child and parents to maintain activities that promote range of
motion, such as swimming and bicycling, but to avoid contact sports
and high impact-running.
2. Limitation of activities, bed rest with or without skin traction
3. Provide equipment to assist with mobility (e.g wheelchair, walker) if
needed
4. Teach parents and siblings to assist only as needed.
5. Allow child to care for self and participate as able.
6. Reinforce to child that he or she is only temporarily restrited. Stress
positive aspects of activity.
7. Encourage follow up.
8. Salicylates or anti-inflammatory agents are given to relieve synovitis,
muscle spasm, and pain in the joint and help restore motion.

• Surgical

1. Inominate osteotomy; varus osteotomy; osteotomy of the proximal


femur, acetabulum (Salter innominate), or a combination of these may
be required

X. Nursing Diagnosis

• Top 5 Priorities includes:

1. Acute Pain
2. Bathing or Self-Care Deficit
3. Impaired Physical Mobility
4. Disturbed Body Image
5. Ineffective Therapeutic Regimen Management

XI. Nursing Responsibilities

Preoperative Management

1. Assess nutritional status; hydration, protein and caloric intake. Maximize healing
and reduce risk of complications by providing I.V. fluids, vitamins and nutritional
supplements as indicated.

2. Determine if the patient has had previous corticosteroid therapy – could


contribute to current orthopedic condition (aseptic necrosis of the femoral head;
osteoporosis), as well as affect his or her response to anesthesia and the stress
of surgery. The patient may need corticotrophin post-operatively.

3. Determine if the patient has an infection (cold, dental, skin, UTI); it could
contribute to development of osteomyelitis after surgery. Administer preoperative
antibiotics as ordered.

4. Prepare patient for postoperative routines, w/c include coughing and deep
breathing, frequent v/s and wound checks and repositioning.

5. Have the patient practice voiding on bed pan or urinal in recumbent position
before surgery. This helps reduce the need for post operative catheterization.

6. Acquaint the patient with traction apparatus and the need for splint or cast, as
indicated by the type of surgery.

Post operative Management

1. Monitor for hemorrhage and shock, which may result from significant bleeding
and poor hemostasis of muscles that occur with orthopedic surgery.

a. Evaluate the blood pressure and pulse rates frequently – report rising
pulse rate or slowly decreasing blood pressure.

b. Watch for increased oozing of wounds.

c. Measure suction drainage if used. Anticipate up to 7 to 17 oz (200 – 500


mL) drainage in the first 2 hours, decreasing to less than 1 oz (30 mL) per
8 hours within 48 hours, depending on surgical procedure.

d. Report increased wound drainage or steady increase in pain of operative


area.

2. Administer I.V fluids or blood products as ordered.

3. Monitor neurovascular status.

a. Watch circulation distal to the part where cast, bandage, or splint has been
applied; check pulses, color, warmth, and capillary refill.

b. Prevent constriction leading to interference with blood or nerve supply;


check for swelling.

c. Note movement, and ask about sensation of distal extremities.


4. Elevate affected extremity and apply ice packs as directed to reduce swelling and
bleeding into tissues.

5. Monitor pain level and response to analgesia; administer patient-controlled


analgesia or other method of pain relief as directed; notify health care provider if
not effective or if the patient cannot tolerate adverse effects.

6. Immobilize the affected area and limit activity to protect the operative site and
stabilize musculoskeletal structures.

7. Give analgesics that may cause respiratory depression cautiously. Monitor


respiration depth and rate frequently. Opioid analgesic effects may be
cumulative.

8. Change position and encourage use of incentive spirometer and coughing and
deep-breathing exercises every 2 hours to mobilize secretions and prevent
atelectasis. Auscultate lungs frequently.

9. Monitor v/s for fever, tachycardia, or increased respiratory rate, which may
indicate infection.

10. Maintain aseptic technique for dressing changes and wound care.

11. Encourage the patient to move joints that are not fixed by traction or appliance
through their range of motion as fully as possible. Suggest muscle-setting
exercises (quadriceps setting) if active motion is contraindicated.

12. Apply antiembolism stockings, sequential compression, or give prophylactic


anticoagulants, if prescribed, to prevent thromboembolism.

13. Encourage early resumption of activity.

14. Monitor for anemia, especially after fracture of long bones.

15. Avoid giving calcium supplements patients on bed rest, and encourage other
fluids to prevent other fluids to prevent urinary calculi.
XII. Illustrations