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. Perthes disease is the name used for a condition which affects the ball-shaped end of the thigh bone (femoral head), where it enters into the formation of the hip joint. In this condition, the femoral head goes through a series of changes in which it softens, may become flattened and then gradually re-forms. It is a self limiting disease and the treatment is aimed at minimizing damage while the disease runs its course, not at 'curing' the disease. It is named after Legg(American) Calve(French) Perthes(German) physicians who simultaneously and separately reported it on 1910 distinguishing it from the TB of the hips. II. Other known name Legg-Calve-Perthes disease; Perthes disease; Idiopathic avascular necrosis of the proximal femoral epiphysis; Childhood Hip Disorder 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 median age of 7 years

IV. Risk factors • • • • • positive family history low birth weight abnormal birth presentation children exposed to second hand smoke occurs most frequently in boys 4 to 10 years old

• • • • hormonal changes trauma infection metabolic abnormalities V. which usually occurs 6 months after the onset of symptoms  Group A outcome . However the new bone lacks strength and pathologic fractures may occur. which gradually spreads to heal the lesion (lasts 2 toyears) Stage IV (postrecovery)The femoral head becomes permanently distorted.maintains 50 to 100% height. with resultant joint misalignment • • Classifications: 1.lateral pillar maintains full height. Herring lateral pillar classification -Determined on AP x-ray at start of fragmentation stage. and bone resorption and deposition take place (lasts several months to 1 year). poor outcome in patients > 6 years . Type/Stage/Classifications of the Disease Stages of Coxa Plana: • • 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. uniformly good   Group B . 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.

Stulberg classification  gold standard for rating residual femoral head deformity and joint congruence  recent studies show poor interobserver and intraobserver reliability . Group C .fragmentation involves > 1/2 of femoral head 3.maintains < 50% height.fragmentation involves < 1/2 of femoral head  Stages III and IV .cresent sign involve less than 1/2 of femoral head  Class B .involves > 1/2 of femoral head 4. poor outcomes in all patients 2. Salter-Thompson classification  Class A . Catterall classification  Stages I and II .

VI. Manifestations • • • • • • • • • • • • • Knee pain (may be the only symptom. Short stature: Children with LCPD often have delayed bone age. 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. initially) Persistent thigh or groin pain Atrophy (wasting) of muscles in the upper thigh Slight shortening of the leg. walking with a limp (which is often painless) Limited range of motion Decreased range of motion (ROM). . or legs of unequal length Hip stiffness restricting movement in the hip Difficulty walking.

low birth weight Phase 1: Initial Absent blood supply in the femoral head Hip joint becomes inflamed. (+) family history Precipitating factors: Metabolic abnormalities. hormonal changes. sex. stiff and painful Portions of the bone turned into dead tissues Phase 2: Fragmentation The body cleans up dead cells and replaces them with new healthier bone cells Femoral head begins to remodel Joint is still irritated and painful Phase 3: Reossification Irregular process starting in subchondral area New formed areas of bone Femoral epiphysis regains strength Normal bone density returns . infection. trauma. Pathophysiology Predisposing factors: Age. children exposed to second hand smoke. abnormal birth presentation.VII.

Resorption of bone 4. linear radiolucency within the femoral head epiphysis 3. • Multiple radiographic classification systems exist.Phase 4: Healed Normal bone cells replace the new bone cell Femoral head is healed Proximal VIII. Catterall. smaller femoral head epiphysis and widening of articular space on affected side 2. Re-ossification of new bone 5. • Five radiographic stages can be seen by plain x-ray. and Herring are the 4 most common classification systems. based on the extent of abnormality of the capital femoral epiphysis. Subchondral fracture.Assesses sphericity of the head of the femur Treatment: 1. Diagnostic studies femur is left with any deformity Laboratory studies: • 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. In sequence. Salter and Thompson. Cessation of growth at the capital femoral epiphysis. • Frog leg views of the affected hip are very helpful. • No agreement has been reached as to the best classification system.Helpful in delineating the extent of avascular changes before they are evident on plain radiographs • Dynamic arthrography . • Waldenstrom. Nonoperative • observation alone . they are as follows: 1. Healed stage • Technetium 99 bone scan .

 Salicylates or anti-inflammatory agents are given to relieve synovitis.  Limitation of activities. or presence of contractures Supportive care and education  Instruct child and parents to maintain activities that promote range of motion. Surgical • .  Encourage follow up. walker) if needed  Teach parents and siblings to assist only as needed. Operative • femoral or pelvic osteotomy o indications  children > 8 years of age. Stress positive aspects of activity. spasm. 2. and pain in the joint and help restore motion. such as swimming and bicycling. Medical Analgesics for pain. bracing. Management 1.o indications  children < 6 years of age activity restriction. muscle spasm. partial weight bearing.g wheelchair. Monitoring:  Monitor and assess pain level rising age-appropriate pain measurement tool  Assess for gait. and physical therapy o indications  children 6-8 years of age with early symptoms (controversial) 2.  Allow child to care for self and participate as able. especially Lateral Pillar B and B/C  children > 6 years of age with late symptoms (controversial) IX. bed rest with or without skin traction  Provide equipment to assist with mobility (e. but to avoid contact sports and high impact-running.  Reinforce to child that he or she is only temporarily restricted.

Bathing or Self-Care Deficit 3.V. hydration. varus osteotomy. which may result from significant bleeding and poor homeostasis of muscles that occur with orthopedic surgery. Acute Pain 2. as well as affect his or her response to anesthesia and the stress of surgery. dental. 6. 5. osteotomy of the proximal femur. Prepare patient for postoperative routines. The patient may need corticotrophin postoperatively. vitamins and nutritional supplements as indicated. Administer preoperative antibiotics as ordered. Disturbed Body Image 5. Assess nutritional status. This helps reduce the need for post operative catheterization. frequent v/s and wound checks and repositioning. Ineffective Therapeutic Regimen Management XI. Impaired Physical Mobility 4. Nursing responsibilities Preoperative Management: 1. .  Inominate osteotomy. Monitor for hemorrhage and shock. 4. it could contribute to development of osteomyelitis after surgery. Acquaint the patient with traction apparatus and the need for splint or cast. Nursing diagnosis Top 5 Priorities includes: 1. Maximize healing and reduce risk of complications by providing I. as indicated by the type of surgery. 2. Osteoporosis). UTI). Determine if the patient has had previous corticosteroid therapy – could contribute to current orthopedic condition (aseptic necrosis of the femoral head. Post operative Management: 1. skin. 3. Determine if the patient has an infection (cold. or a combination of these maybe required Hip replacement X. w/c include coughing and deep breathing. acetabulum (Salter innominate). protein and caloric intake. Have the patient practice voiding on bed pan or urinal in recumbent position before surgery. fluids.

or splint has been applied. d. Evaluate the blood pressure and pulse rates frequently – report rising pulse rate or slowly decreasing blood pressure. Measure suction drainage if used.a. or increased respiratory rate. b. Note movement. 4. Encourage the patient to move joints that are not fixed by traction or appliance through their range of motion as fully as possible. Monitor neurovascular status. Change position and encourage use of incentive spirometer and coughing and deep-breathing exercises every 2 hours to mobilize secretions and prevent atelectasis. and encourage other fluids to prevent other fluids to prevent urinary calculi. Report increased wound drainage or steady increase in pain of operativearea. tachycardia. Monitor v/s for fever. check pulses. and capillary refill. Auscultate lungs frequently. Administer I. 6. . 5. a. which may indicate infection. 8. Suggest muscle-setting exercises (quadriceps setting) if active motion is contraindicated. Give analgesics that may cause respiratory depression cautiously. Monitor respiration depth and rate frequently. 9. 2. Monitor pain level and response to analgesia. 3. c. check for swelling. b.V fluids or blood products as ordered. 11. Avoid giving calcium supplements patients on bed rest. 7. Prevent constriction leading to interference with blood or nerve supply. bandage. and ask about sensation of distal extremities. c. warmth. Watch circulation distal to the part where cast. 12. Immobilize the affected area and limit activity to protect the operative site and stabilize musculoskeletal structures. Maintain aseptic technique for dressing changes and wound care. color. Elevate affected extremity and apply ice packs as directed to reduce swelling and bleeding into tissues. Watch for increased oozing of wounds. 10.