LCP Algorithm:

CC:
Key History: 1) Painless limp
Age onset – 5-8 yrs old, males (less than 5yrs – DDH or Meyer’s dysplasia) 2) Decreased hip motion
Progressive? 3) Intermittent knee, hip, groin
Unilateral/Bilateral? – 10-15% bilateral or thigh pain
Pain (OPQRST)? Due to synovitis/acute subchondral fracture
Family Hx (10%)/Perinatal – low birth weight, abnormal birth presentation
Develomental history – assoc with ADHD, delayed bone age Clinical at risk signs:
Neurologic deficits? Mechanical? Constitutional – fever/chills? 1) Age >6 yrs old
2) Female
Key Physical: 3) Marked decrease ROM
1) Gait : Trendelenburg or antalgic (head collapse leads to decreased tension 4) Obesity
on abductors)
2) Inspection:
a) SEADS (thigh/calf atropy of affected side)
3) Palpation
4) Alignment/ROM – decreased hip abduction and IR (check prone), flexion/adduction contracture (in flexion = add longus,
in extension = gracilis)
5) Special tests:
a) LLD – can be due to adduction contracture or shortening femoral neck
b) Neuro exam
c) Spine exam – r/o MED/SED
Xray at risk signs…
Imaging: 1) Gage’s – radiolucent V
Xray – WB AP pelvis and frog leg lateral both sides, skeletal age – hand (Pyle), olecranon laterally
apophysis, skeletal survey if bilateral 2) Calcification lateral to epi
1) Subluxation (Shenton’s line) – due to 1) adduction contracture 2) lateral pillar collapse 3) Lateral subluxation of head
2) Irregularity of femoral head ossification (Bilateral LCP is asymmetric) 4) Horizontal physis
3) Medial joint space widening (first sign) 5) Metaphyseal cysts

Waldenstrom classification:
a) Initial – ischemic insult, smaller radiodense epiphysis (avascular), medial joint space widening (relative cartilage
hypertrophy), Crescent sign – subchondral fracture of resorbing femoral head
b) Fragmentation (1-2yrs) – 6 months after onset symptoms = lateral fragmentation of avascular
epiphysis due to revascularization Catterall
c) Reossification (up to 3 yrs) – new bone formed I/II - <50% head involved
d) Healed – trochanteric overgrowth, coxa magna/breva/vara (remodeling) III/IV >50% involved
Herring: Lateral pillar (lateral 25-30%) during fragmentation phase (on AP pelvis) Salter (frog lateral – extent
- predicts outcome when healed of subchondral #
A - no density change B/C – lateral pillar narrowed, 50% height maintained A - <50% of head
B - < 50% collapse C - >50% collapse B - >50% of head
Stulberg: Predicts OA at followup
I – Normal hip joint III – Nonspherical head V – Flat head + incongruent
II – Spherical head + coxa magna/breva IV – Flat head joint

DDx:
Unilateral
Septic arthritis
Transient Synovitis
JRA
Sickle cell
Acute presentation?
1) R/O infection!
2) Metabolic/endocine workup
3) Bilateral – xray knees and spine
to r/o dysplasia (if symmetric)
Bilateral Herring B/C definition:
SED MED – symmetric dz 1) Narrow lateral pillar (2 to 3
Gaucher’s SED mm wide) >50% of the original
Hypothyroid height or…
Sickle cell 2) Lateral pillar with very little
ossification but > 50% of the
original height or…
3) Lateral pillar with exactly
LC 50% of the original height that
P is depressed relative to the
central pillar
Initial/Fragmentation phase? NO HIP SURGERY DURING ACUTE FLAREUP
 > 8 years old chronological (> 6 yrs < 8 years old (< 6 yrs old
bone age) bone age)

a) Herring A – do well, no difference a) Herring A/B with good

between op/nonop mobility
Acute presentation/Synovitis
= do well, treat
1) Rest
b) Herring B, B/C symptomatically
2) NSAIDs
= proximal femoral varus osteotomy
3) Activity modification
- check congruency (arthrogram/ b) Herring B/C, C – if
abd/IR xray) extrusion do containment
- maximize ROM, need 30 degrees (even more controversial)
abduction

c) Herring C – if extrusion do
containment (controversial)
2) Containment of femoral head (check with arthrogram/xrays)
a) Proximal femoral varus osteotomy
Late complications: 1) Maintain ROM (1st and most important step, want 35-40 degrees
- reduce the laterally subluxated
1) Hinge abduction - hinged abduction occurs portion of the femoral head
abduction) – canto better
do x1 distribute
before surgery
joint forces, Ab/IR xray
when an enlarged femoral head is laterally preop shows potentiala) Physio x 6 weeks, NSA
improvement, goal 110-115
if no improvement then traction
degrees
extruded and impinges against the acetabular b) Traction in abduction frame x 3-5 days, out of traction TID for physio… if
rim when the- hipcauses limb shortening
is abducted (diagnose and residual abductor
with noweakness
improvement then tenotomy.
- supine,of+/-dye
athrogram – pooling addmedially/broken
tenotomy if not previously done, lateral approach,
c) Adductor insert
tenotomy/arthrogram/Petrie cast
guidepin below GT apophysis confirm on AP/lateral
Shenton’s line) – supinefluoro
in frog– insert
lateralusing
position, palpate add longus tendon, cut tendon
triangleosteotomy
a) Femoral valgus guide to indicate
(lateraldegees
closingof correction, insert with
- check chisel, make osteotomy
arthrogram (use 22ga, 3.5 inch spinal needle, using fluoro aim
parallel
wedge) - if ROM ok to first k-wire 10-12mm distal (lateral
needle for superiorjust
opening wedge) above LT
head/neck junction) intraop to determine best position (abd
(have oblique
- lateral approach, kwire above
limb and below osteotomy site and
of osteotomy to control
IR) androtation,
assess forcanhinge
makeabduction, if hips congruent and no hinge
just below LT,second osteotomy
transvere using
cut distal, same
120 starting point but
degree parallel no
abduction, to femoral
casting shaft. Insert
90 degree blade plate.
plate (for 20 degree correction, insert at 100 - if abnormal position in acetabulum, Petrie cast x 6 weeks.
degrees fromPostop:
shaft) +/- spicca cast x 6 weeks, PWB - post-op WBAT with casts, physio after removal
- to add extension chisel posterior to axis of
shaft/flexion b) Salter
insert – Sciatic notch to ASIS, provides anterolateral coverage, rotates
anteriorly
through pubis
b) Shelf – if c) Combined
decreased ROM