Hand SGD

Pedia SGDGeneral InformationPatient is Lucy Raz, a 10 year old female, left-handed, grade 5 student from Caloocan.

CC: shortened left leg

History of Present Illness8months PTA: Patient fell on her hip while walking down the stairs. Patient reported she can still walk and run normally. No consult was done and there is no note of LOM, gross deformity and pain. Patient had fever , lysed by Paracetamol

7 months PTA: Patient was noted to be limping while walking paika-ika. And had pain in the Left inguinal area.

History of Present Illness6 months PTA: Parents noted that the patients left leg shortened. There was also persistence of pain in the left inguinal area and developed left knee pain.

3 months PTA: Consulted at POC and was referred to PGH for further management.

Past Medical History: (-)BA, allergy, previous hospitalizations

Family Medical History: (-) DM,CA (+) HPN - mother

Personal/Social History: (-) smoker (-) alcohol intake. Grade 5 student, iglesia ni cristo member, L-handed

Immunization: Completed EPI c/o LHC

Physical ExaminationGeneral Survey alert, coherent, bed ridden, on traction of bilateral lower extremites, not in cardiorespiratory distressVital SignsBP 100/70PR 100RR 28Temp afebrileHEENT:anicteric sclerae, pink conjunctivae, (-) NVE, (-) CLAD Chest/Lungs:equal chest expansion, clear breath sounds, (-) crackles/wheezesCVS: adynamic precordium, distinct S1 and S2, normal rate, regular rhythm, (-) murmurs, (-) heaves/thrillsAbdomen: flabby, soft abdomen, normoactive bowel sounds, (-) masses, (-) tendernessPhysical ExaminationSkin/Extremities: UPPER EXT: full ROM, muscle strength 5/5, intact sensation on bilateral upper extremities

LOWER EXTInspection: patient left leg is on tibial traction. The right leg was splinted and was also on traction. Apparent leg length = 27cm on both left and right leg. True leg length = 24 cm on both left and right leg

Palpation: intact sensation on bilateral exteremities. (+) warmth and tenderness in the left inguinal area

Motor exam/ ROM: deferredNeurological Findings:oriented to place, person and time, (-) neurological deficitsXRAY Plates

Hips AP, flattening or collapse of the left femoral head, superolateral displacement of the left femoral head

Shentons line, asmooth continuation of an imaginary line drawn along the femoral neck and superior margin ofthe obturator foramen

Perkins line, aline drawn from the lateral margin of the acetabulum perpendicular to Hilgenreiners line

8XRAY Plates

Hips frog leg9DifferentialsDifferentialsRule InRule OutLeggs- carves- perthes diseaselimp, leg length disrepancy, aged 4-10 years old, unilateral, radiograph shows flattening and fragmentation of the femoral headSlipped capital femoral epiphysisHistory of trauma, painful limp, pain in thigh radiating to the kneeUsually obese patient, peak of onset is 11-13 years old, radiograph findings not suggestive(For scfe:Radiograph diagnosis of left slipped capital femoral epiphysis. A: Anteroposterior film shows subtle medial displacement of left epiphysis, best appreciated by drawing a line (Klein line) along the lateral side of the normal and abnormal femoral neck. The slipped epiphysis does not protrude lateral to this line. B: Frog-leg lateral radiograph clearly demonstrates posterior displacement10DifferentialsDifferentialsRule InRule OutDevelopmental dysplasia of the hipLeg length disrepancy, limpingUsually occurs in younger ageTransient synovitis of the hipPain and tenderness in the inguinal area, unilateral, limpUsually boys aged 3-10 years, radiographs typically shows only capsular swellingFor DPH:

A: Hilgenreiner line is a horizontal line of the pelvis, drawn between the triradiate cartilages. The proximal femoral ossification center should be below this line. B:Perkins line is a vertical line (perpendicular to Hilgenreiner line) drawn down from the lateral edge of the acetabulum. The femoral head ossification center, as well as the medial beak of the proximal metaphysis, should fall medial to this line. C: The acetabular index is the angle between Hilgenreiner line and a line joining the acetabular center (triradiate) with the acetabular edge as it intersects Perkins line. It measures acetabular depth and should be below 30 degrees by 1 year of age and below 25 degrees by 2 years of age. D: The center-edge angle is the angle between Perkins line and a line joining the lateral edge of the acetabulum with the center of the femoral head. It is a measure of lateral subluxation that becomes smaller as the hip subluxates laterally. Normal is 20 degrees or greater.11AssessmentLeggs-calves-perthes diseaseClassification SystemsCaterral Classification

Salter-Thomson Classification

Herring Classification

Modified WaldenstromsCaterral ClassificationStage I Histologic and clinical diagnosis without radiographic findingsStage II Sclerosis with or without cystic changes with preservation of the contour and surface of femoral headStage III Loss of structural integrity of the femoral headStage IV Loss of structural integrity of the acetabulum in addition

Salter-Thomson ClassificationGroup A- includes Caterral I and II50% femoral head

Herring ClassificationLateral pillar group A,there is no loss of height in the lateral one third of the head, and there is little density change.lateral pillar group B,there is a lucency and less than 50% loss of lateral height. Sometimes, the head is beginning to extrude from the socket.lateral pillar group C,there is a more than 50% loss of lateral height. Modified Waldenstroms ClassificationInitialFragmentationReossificationHealedTreatment Goalsto reduce hip irritability

restore and maintain hip mobility

to prevent the ball from extruding or collapsing

to regain a spherical femoral head

Nonsurgical ApproachCrutches are used for non-weight bearing treatment for pain. Casts, traction, and braces help return range of motion and mobility. Range of motion exercises may be given to you by your physical therapist to do with your child in the homeSurgicalFemoral Osteotomy

Innominate Osteotomy

Treatment Choice

Patients aged 8 years), indicating the need to develop more effective treatments based on the pathobiology of the disease.

In children over six years at diagnosis with more than 50% of femoral head necrosis, proximal femoral varus osteotomy gave a significantly better outcome than orthosis (p = 0.001) or physiotherapy (p = 0.001). There was no significant difference between the physiotherapy and orthosis groups (p = 0.36), and we found no difference in outcome after any of the treatments in children under six years (p = 0.73).We recommend proximal femoral varus osteotomy in children aged six years and over at the time of diagnosis with hips having more than 50% femoral head necrosis. The abduction orthosis should be abandoned in Perthes' disease.Role of tibial traction

For hips with limited abduction, traction does not appear to be warranted. Conversely, traction could be useful if the aim is to modify the natural course of the disease in precise situations, for example for Herring group B and or B/C patients with bone age above 6 years with a stiff hip. In this case, skin traction should not last more than two weeks and, to be considered useful, should achieve 30 degrees abduction documented on the ap view.

Short DiscussionLegg-Calve-Perthes disease (LCPD) is avascular necrosis of the proximal femoral head resulting from compromise of the tenuous blood supply to this area.

LCPD usually occurs in children aged 4-10 years. The disease has an insidious onset and may occur after an injury to the hip.

It occurs more commonly in boys than in girls, with a male-to-female ratio of 4:1. The condition is rare, occurring in approximately 4 of 100,000 children.

PathophysiologyRapid growth occurs in relation to development of the blood supply of the secondary ossification centers in the epiphyses, creating an interruption of adequate blood flow and making these areas prone to avascular necrosis.

Interruption of the blood supply to the bone results in necrosis, removal of the necrotic tissue, and its replacement with new bone.

Bone replacement may be so complete and perfect that completely normal bone may result.

The adequacy of bone replacement depends on the age of the patient, the presence of associated infection, congruity of the involved joint, and other mechanical and physiologic factors.

Necrosis may occur after trauma or infection, but idiopathic lesions can develop during periods of rapid growth of the epiphyses. PrognosisOverall, the prognosis for recovery and sports participation after treatment is very good for most individuals.

Short term prognosisThe patient's short-term prognosis is related to femoral head deformity at the completion of the healing stage. Risk factors include a clinical onset at an older age, extensive femoral epiphyseal involvement, femoral head containment, reduced range of motion in the hip, and premature closure of the growth plateLong term prognosisThe long-term prognosis is related to the potential for osteoarthritis of the hip as an adult. In patients with metaphyseal defects, in those in whom the disease develops late in childhood (age 10 y or older), and in those who have more complex involvement of the femoral head with residual deformity, the prognosis is worse, and degenerative arthritis occurs in nearly 100% of these patients. This rate is in comparison to those patients who are younger than 5 years when the problem develops. The incidence of degenerative arthritis is negligible in this younger population.