Legg-Calvé-Perthes

• Legg-Calvé-Perthes disease


  Idiopathic avascular necrosis (AVN) of the proximal femoral head due to compromised tenuous blood supply
• Legg-Calvé-Perthes disease is a rare condition
• Legg-Calvé-Perthes disease has a bilateral occurrence 10% to 20% of the time—happens successively, not simultaneously
• Legg-Calvé-Perthes disease

  May lead to premature osteoarthritis later in life from misalignment of the acetabulum and flattening of the femoral head
• Legg-Calvé-Perthes disease

  Also called coxa plana, osteochondritis deformans juvenilis, and LCPD
• Phases of Legg-Calvé-Perthes disease

  1. Necrosis

  2. Fragmentation

  3. Reossification

  4. Remodeling
• Necrosis phase

  • Disruption of blood supply occurs, causing infarction of the femoral capital epiphysis and leading to cessation of growth of the ossific nucleus
  • The infarcted bone softens and dies
• Fragmentation phase

  • The body reabsorbs infarcted bone
• Reossification phase

  • Osteoblastic activity takes over, reestablishing the femoral epiphysis
• Remodeling phase

  • The new femoral head reshapes during growth, becoming enlarged or flattened
• The cause of Legg-Calvé-Perthes disease is not completely understood
• Ischemia

  Caused by various coagulopathies that can decrease arterial blood flow or slow venous drainage
• Legg-Calvé-Perthes disease may have a hereditary aspect, as small familial subsets have been found to have type-2 collagen gene defects
• Causes of Legg-Calvé-Perthes disease

  • Slipped capital femoral epiphysis
  • Trauma
  • Steroid use
  • Sickle cell crisis
  • Toxic synovitis
  • Congenital dislocation of the hip
• Risk factors for Legg-Calvé-Perthes disease

  • Male sex
  • White ethnicity
  • Family history of the disease
  • Low socioeconomic class
  • Low birth weight
  • Abnormal presentation at birth
  • Exposure to secondhand smoke
• The incidence of Legg-Calvé-Perthes disease is variable, ranging from 0.4 to 29 per 100,000 children
• Legg-Calvé-Perthes disease occurs between ages 3 and 12 years, peaking at ages 5 to 7 years
• Legg-Calvé-Perthes disease affects males three to five times more often than females
• Complications of Legg-Calvé-Perthes disease

  • Permanent disability
  • Premature osteoarthritis in the distorted hip
  • Limb length discrepancy
  • Iatrogenic AVN
  • Hip problems later in life (diagnosis after age 6 years)
• History


  • Family history of the disease
  • Limp that becomes progressively worse
  • Persistent pain in the hip, groin, anterior thigh, or knee that's aggravated by activity and relieved by rest
  • Previous injury to hip
  • Attention deficit hyperactivity disorder
• Physical Findings

  • Muscle atrophy
  • Slight shortening of the affected leg
  • Restricted hip abduction and internal rotation
  • Adductor muscle spasm in the affected hip
  • Limp during walking
  • Pain or stiffness in the hip
  • Thrombophilia (50% of children)
  • Coagulopathy (70% of children)
• Prognosis


  • The overall prognosis is good but depends on the degree of epiphyseal center involvement
  • Short-term prognosis is related to completion of healing of the femoral head deformity
  • Long-term prognosis is related to the potential for osteoarthritis of the hip as an adult
  • Patients younger than age 6 years generally have a good prognosis
  • The prognosis is poor for children older than age 8 years
• Diagnostic Tests


  • Complete blood count (CBC) and erythrocyte sedimentation rate (ESR) help rule out infection
  • Serial hip radiography every 3 to 4 months confirms the diagnosis
  • Magnetic resonance imaging (most sensitive test) provides early diagnosis and determines the extent of loss of perfusion to the femoral epiphysis
  • Bone scan may reveal the site of AVN
• Treatment


  1. Protection of the femoral head from further stress and damage by containing it within the acetabulum

  2. Splints or abduction bracing (most common, can remain in place for 6 to 18 months)

  3. Traction, if indicated

  4. Possibly Petrie casts

  5. Surgery not usually required for children younger than age 6 years
• Diet

  Well-balanced diet
• Activity

  1. Restricted weight-bearing

  2. Avoidance of high-impact activities

  3. Physical therapy focused on hip range of motion (ROM), specifically abduction, as well as crutch or walker training
• Medications


  • Ibuprofen to help manage pain and decrease inflammation
  • Acetaminophen for pain
• Surgery


  1. Adductor tenotomy to restore ROM secondary to adductor contracture

  2. Femoral or pelvic osteotomy to contain the femoral epiphysis within the acetabulum (for older children and those with hip subluxation)
• Nursing Interventions

  • Provide splint or brace care, as indicated
  • Administer prescribed medications and monitor their effect
  • Complete a pediatric fall risk assessment using an approved screening tool, and implement necessary precautions
  • Assess the child's pain level using an age-appropriate assessment tool, and reassess pain after each intervention
  • Encourage the child and family (as appropriate) to verbalize questions, feelings, and concerns
  • Offer support and encouragement to the child and family, and assist with the use of positive coping strategies
  • Provide a well-balanced diet, with appropriate food choices and snacks
  • Monitor intake and output, and document them in the child's medical record
  • Weigh the child daily, using the same scale, at the same time of day, with the child wearing the same amount of clothing
  • Encourage the child and family (as appropriate) to participate in care activities and decision making about care activities to promote feelings of self-esteem and control
  • Collaborate with physical therapy to provide or assist with ROM exercises and measures to reduce weight bearing, as appropriate
  • Collaborate with occupational therapy to assist with activities of daily living and splint application
  • Perform routine skin assessments and care, keeping the skin dry and clean
  • Turn the child every 2 hours and pad bony prominences to protect the skin from breakdown
  • Cluster nursing activities to minimize energy expenditure and provide frequent uninterrupted rest periods
  • Encourage the use of energy-conservation measures
  • Ensure a safe environment for crutch or walker training
  • Prepare the child and family for surgery, if indicated
  • Consult with a child life specialist to provide age-appropriate distractions and support
  • Collaborate with social services to provide counseling, community resources, and support
  • Collaborate with care management to ensure that all home-going needs are met prior to discharge
• Monitoring


  • Pain level and relief
  • Intake and output
  • Neurovascular status of the affected extremity
  • Skin integrity
  • Nutrition
  • ROM
  • Blood pressure
  • Weight
• Associated Nursing Procedures

  • Ambulation, progressive
  • Blood pressure measurement, pediatric
  • Cast assessment and management, pediatric
  • Fall prevention, pediatric
  • Intake and output measurement, pediatric
  • Nutritional screening, pediatric
  • Oral drug administration, older child
  • Oral drug administration, toddler
  • Pain assessment, pediatric
  • Pain management
  • Passive range-of-motion exercises, pediatric
  • Patient teaching
  • Preoperative care, pediatric
  • Pressure injury prevention, pediatric
  • Postoperative care
  • Skin assessment
  • Weight measurement, pediatric
• age-appropriate distractions and support


  Collaborate with social services to provide counseling, community resources, and support
• Collaborate with care management

  Ensure that all home-going needs are met prior to discharge
• Monitoring


  • Pain level and relief
  • Intake and output
  • Neurovascular status of the affected extremity
  • Skin integrity
  • Nutrition
  • ROM
  • Blood pressure
  • Weight
• Associated Nursing Procedures


  • Ambulation, progressive
  • Blood pressure measurement, pediatric
  • Cast assessment and management, pediatric
  • Fall prevention, pediatric
  • Intake and output measurement, pediatric
  • Nutritional screening, pediatric
  • Oral drug administration, older child
  • Oral drug administration, toddler
  • Pain assessment, pediatric
  • Pain management
  • Passive range-of-motion exercises, pediatric
  • Patient teaching
  • Preoperative care, pediatric
  • Pressure injury prevention, pediatric
  • Postoperative care
  • Skin assessment
  • Weight measurement, pediatric
• Patient and Family Teaching - General


  • Include the child's family or caregiver in your teaching, when appropriate
  • Provide information according to their individual communication and learning needs
  • disease, diagnosis, underlying cause, treatment, and prognosis
  • prescribed medications, including drug names; dosages; indications for use; frequency, route, and duration of administration; expected results; potential adverse effects; and signs and symptoms of toxicity
  • proper splint, brace, or cast care, including the importance of never putting anything into the split, brace, or cast
  • ways to identify decreased blood flow to the affected extremity and the importance of immediately notifying the practitioner if any occur
  • importance of follow-up visits and the need for repeated X-rays to monitor progress
  • management of discomfort
  • activity restrictions, including weight-bearing restrictions
  • home structure and ways to make the home environment safe for crutch or walker use
  • measures to maintain skin integrity and reduce the risk of skin breakdown
  • ROM exercises, including type and frequency
• Discharge Planning


  1. Participate in discharge planning with other members of the multidisciplinary team

  2. Assess the child's (if appropriate) and the parents' or caregiver's understanding of the diagnosis, treatment regimen, need for follow-up care, and warning signs or potential problems that require medical attention

  3. Use the teach-back method, when possible

  4. Explain the importance of scheduling and attending all follow-up appointments

  5. Confirm transportation arrangements for initial follow-up appointments

  6. Ensure that the parents or caregivers understand the treatment regimen, including the purpose and desired effect of each medication, the dosage and how to administer it, and potential adverse effects

  7. Ensure that the parents or caregivers are able to obtain the prescribed medications

  8. Ensure that the child (if appropriate) and the parents or caregivers have the name and contact information of someone to call if they encounter a problem

  9. Document the discharge planning evaluation in the child's medical record
• Related Patient Teaching Handouts

  • Legg-Calve-Perthes Disease
  • Legg-Calve-Perthes Disease Discharge Instructions
• Resources


  • American Academy of Orthopaedic Surgeons: www.aaos.org
  • American Orthopaedic Association: www.aoassn.org
  • OrthoInfo: www.orthoinfo.aaos.org