|
Year |
2007 |
|---|---|
|
Question Number |
36 |
|
Category |
Pediatric Orthopaedics |
Question
A 4-year-old boy has mild hip pain, minimal loss of hip range of motion of the affected hip, and a limp. Radiographs are shown in Figures l0a and 10b. What is the next most appropriate step in management?
1- Hip abduction orthosis
2- Observation
3- Intraoperative proximal femoral bone aspiration and culture
4- Proximal femoral varus osteotomy
5- Flexion-extension radiographs of the cervical spine
Figures
Answer (click for answer)
Answer- 2- Observation
Radiographs demonstrate evidence of Legg-Calve-Perthes disease of the left hip. Perthes can be classified by the Lateral Pillar Classification, based on the lateral pillar of the capital femoral epiphysis during the fragmentation stage, which can help determine prognosis in addition to bone age.
Herring et al conducted a multicenter, controlled prospective study of treatment and other risk factors associated with outcome in Perthes patients. In children younger than 8 years of age (and those with bone age <6) at onset of disease, those with class B disease have very good outcomes with operative or nonoperative treatment. Those with class C disease, regardless of age >8 or <8 yrs (or bone age <6yrs, >6yrs), had no significant difference in outcome between operative and nonoperative treatment and good results were uncommon. Therefore, in this question the patient’s age is insignificant and poor outcome is likely regardless of operative or nonoperative intervention. Important to note, no clinically important differences were found among the various nonoperative methods (bracing, casting) or between surgical methods (innominate, femoral osteotomies. Additionally, poor prognosis is associated with older children (bone age>6), female sex, and decreased ROM (Abduction). Catterall’s "head at risk" signs are also associated with poor prognosis (although bone age and Pillar classification are most telling) and include 1) lateral calcification 2) Gage’s sign (V-shaped defect at lateral physis) 3) lateral subluxation 4) metaphyseal cyst formation 5) horizontal growth plate.
Reference:
