Osteochondropathy of the head of the humerus. Surgical and conservative therapy

Perthes disease (or osteochondropathy of the femoral head) is one of the most common diseases of the hip joint in children aged 3 to 14 years and is the most common in childhood a type of aseptic necrosis of the femoral head.
The term “aseptic necrosis” in this case means necrosis bone tissue epiphysis (that is, the upper hemisphere) of the femoral head non-infectious nature(Fig. 1).

Rice. 1. Anatomical structure of the hip joint (R.D. Sinelnikov. “Atlas of normal human anatomy.” 1967):

1. Epiphysis of the femoral head.

2. Femoral neck.

3. Acetabular cavity.

4. Greater trochanter.

5. Lesser trochanter.

6. Joint capsule.

Boys aged 5-12 years are more susceptible to the disease, but in girls it is more severe. The pathological process has several stages and can last for many months, in approximately 5% of cases both hip joints are affected.
The views of different researchers on the etiology and pathogenesis (that is, the origin and development) of Perthes disease still differ. The most common pathogenetic theory of the disease in a “compact” and simplified form is presented below.
A prerequisite for the development of Perthes disease is the presence in the child of certain predisposing (congenital) and producing (acquired) factors. The predisposing factor for Perthes disease (or the background for its appearance) is the so-called myelodysplasia lumbar region spinal cord, responsible for the innervation of the hip joints.
The term “myelodysplasia” means a developmental disorder (in this case, underdevelopment) of the spinal cord. Underdevelopment of the spinal cord is congenital - hereditary in nature; it occurs in a significant proportion of children and varies in severity. Mild myelodysplasia may go undetected throughout life, while more significant disorders of spinal cord development manifest themselves in a variety of ways. orthopedic diseases, which includes Perthes disease.
The anatomical structure of the hip joint area in children with myelodysplasia differs, in particular, in that the number and caliber of vessels and nerves that innervate and supply the joints is less than in a healthy child (Fig. 2).

Rice. 2. Blood supply to the head and neck of the femur (G.H. Thompson, R.B. Salter. “Legg-Calve-Perthes Disease.” 1986):

1. External and internal arteries that bend around the femur.

2. Ascending branches of the circumflex arteries entering the neck and head of the femur.

3. Cartilaginous growth zone of the femoral head.

In an extremely simplified way, this situation can be represented as follows - instead of 10-12 relatively large arteries and veins entering and exiting the femoral head, the patient has 2-4 small (congenitally underdeveloped) arteries and veins, therefore the blood flow in the joint tissues is chronically reduced, and they are nutritionally deficient. The presence of myelodysplasia also negatively affects the tone of the vascular wall.
Meanwhile, Perthes disease develops only when the blood supply to the femoral head completely stops, which occurs under the influence of the so-called producing factors. The producing factors of Perthes disease are most often inflammation of the hip joint or minor trauma, leading to compression (squeezing) of the above-described small and underdeveloped vessels from the outside. Inflammation of the hip joint (in this case, transient synovitis) occurs under the influence of an infection entering the joint, for example, from the nasopharynx during colds. That is why the latter often precede the onset of Perthes disease, as noted by the parents themselves. A minor injury, such as a result of jumping from a chair, or simply an awkward movement may go unnoticed by both parents and children. As a result, there is a complete blockage of blood flow (or a heart attack) of the femoral head, leading to its partial or complete necrosis, that is, the formation of a focus of necrosis (Fig. 3).

Rice. 3. X-ray of the hip joint of a child with Perthes disease:

1. A focus of necrosis in the head of the right femur.

Clinical manifestations of the disease at this stage are very scarce or absent altogether. Most often, children periodically complain of minor painful sensations in the hip, knee or hip area. Parents may notice some gait disturbances in the form of “falling” on one leg or “dragging” of the leg. Severe pain is observed much less frequently, severe lameness, as a rule, does not occur - therefore, visiting a doctor in the first stage of the disease (osteonecrosis stage) is quite rare.
Subsequently, the dead bone tissue of the upper hemisphere of the femoral head loses its normal mechanical strength, as a result of which, under the influence of normal everyday load - walking, jumping, etc. or even in the absence of it, deformation of the femoral head gradually develops, which is the main and most complex problem in the treatment of a child (Fig. 4).

Rice. 4. Saddle deformity of the femoral head in a child with Perthes disease:

A. Diagram of the hip joint.

B. Arthropneumogram of the hip joint.

At the time of completion of Perthes disease, the deformation of the femoral head can have varying degrees of severity - from insignificant and barely noticeable on an x-ray to a rough “mushroom-shaped” or “saddle-shaped” one. The degree of deformation of the femoral head is determined by the size and localization (location) of the necrosis focus in the epiphysis and, in turn, directly determines the outcome of the disease - favorable or unfavorable. An unfavorable outcome of the disease is the appearance clinical signs so-called deforming coxarthrosis (steadily progressing degenerative changes joint) in the form of severe pain and gait disturbance at an age when it is necessary to arrange a personal life and receive an education. A favorable outcome means a situation where the joint functions for many years into old age without making itself felt.
However, according to modern research, the first stage of the disease is reversible, which means that under favorable circumstances (small volume of necrosis and rapid restoration of blood flow in the epiphysis), the disease can be completed before the development of deformation of the femoral head, without moving into the second stage. The appearance of radiological signs of the onset of deformation of the femoral head indicates the transition of the disease to the stage of impression fracture and the beginning of an irreversible and long-term multi-stage pathological process.
During the course of the disease, the structure of the femoral head undergoes significant changes - after flattening in the second stage, it undergoes fragmentation (third stage), that is, the existing focus of necrosis “breaks up” into several separate parts as a result of the ingrowth of connective tissue containing vessels and nerves into it ( Fig. 5).

Rice. 5. Picture of Perthes disease in the fragmentation stage (G.H. Thompson, R.B. Salter. “Legg-Calve-Perthes Disease.” 1986):

1. Fragments of the epiphysis of the femoral head.

Gradually, the processes of “destruction” begin to be dominated by the processes of repair (healing), which consist in the new formation of bone tissue in the focus of necrosis - the stage of fragmentation is replaced by the stage of restoration. Newly formed bone tissue, as a result of ongoing restructuring, over time acquires a beam structure and architectonics approaching normal (outcome stage), however, the mechanical strength of the bone remains reduced.
In addition to the new formation of bone tissue in the area of necrosis, the recovery stage is characterized by the resumption of growth of the femoral head. With a large volume of necrosis and the absence of adequate treatment, the growth of the femoral head is the cause of progression of the deformity. The femoral head, being spherical (convex) before the onset of the disease, becomes flat or concave, its anterior-outer quadrant can significantly stand out from the glenoid cavity, so subluxation in the hip joint often occurs (Fig. 6).

Rice. 6. Scheme of the formation of deformity and subluxation of the femoral head as a result of continued growth in the absence of treatment (K.-P. Schulitz, H.-O. Dustmann. "Morbus Perthes". 1998).

There is a discrepancy between the shape of the articular surfaces of the acetabulum, which maintains sphericity, and the femoral head, which plays a decisive role in the fate of the affected joint.
The femoral head of a child contains a cartilaginous growth zone - this is the part of the femur due to which the latter grows in length (Fig. 2). With extensive foci of necrosis in the epiphysis, the growth zone is involved in pathological process, completely or partially collapsing. As a result, over the years, deformation of the entire upper end of the femur is formed, characterized by shortening of the femoral neck and high standing of the greater trochanter, and shortening of the lower limb, which are the causes of gait disturbance (Fig. 7).

Rice. 7. Typical deformity of the proximal end of the femur in Perthes disease.

Fortunately, in the majority of children with Perthes disease (at least two-thirds of cases), the focus of necrosis in the femoral head is small and does not include outer section epiphysis and its growth zone, therefore the development of severe deformation of the femoral head and significant discrepancy in the shape of the articular surfaces is excluded. In this case, the deformation of the upper end of the femur as a whole and the shortening of the limb are also slightly expressed.
The appearance of pain in the hip, knee or hip joint, as well as gait disturbances, is a reason to contact an orthopedic doctor, who, after ascertaining the history (history of the onset and development) of the disease and a clinical examination of the child, prescribes radiographs of the hip joints in the direct projection and Lauenstein projection (Fig. . 8).

Rice. 8. Minimum required x-ray examination for suspected Perthes disease:

A. X-ray of the hip joint in the anteroposterior projection.

B. X-ray of the hip joint in the Lauenstein projection.

This is the necessary minimum examination, which allows high accuracy confirm the presence of Perthes disease even in the first stage or exclude this disease. In such cases, magnetic resonance imaging may also be recommended and ultrasound examination hip joints, however, the latter are carried out only as additional research methods, since they are not decisive in making the diagnosis of Perthes disease.
There are some pathological conditions that, in their clinical manifestations, resemble the onset of Perthes disease, but are much more favorable in terms of prognosis and less burdensome in terms of treatment. Such diseases include, in particular, neurodysplastic coxopathy and infectious-allergic arthritis of the hip joint. Treatment for these diseases does not require surgical intervention, long-term exclusion of leg support and walking, or the use of orthopedic devices.
Neurodysplastic coxopathy, as in the case of Perthes disease, is based on dysplasia of the lumbosacral spine and spinal cord, which causes a decrease in the influx of arterial and outflow of venous blood in the hip joint and disruption of its innervation. X-rays show signs of degeneration (malnutrition) of the bone tissue of the pelvic and, predominantly, femoral components. The fundamental difference from Perthes disease is the absence of complete blockage of blood flow (infarction) and, consequently, the formation of a focus of necrosis in the femoral head.
Infectious-allergic arthritis (or transient synovitis) is an inflammation of the inner (synovial) membrane of the hip joint, associated with the appearance and short-term residence in the joint of an infectious agent brought from other organs (foci of infection) with the bloodstream, and characterized by impaired blood flow of varying degrees , but also without complete blocking and formation of a necrosis focus.
When diagnosing Perthes disease, the doctor must completely exclude reliance on the “sick” leg - depending on the child’s age and development, strict bed rest or semi-bed rest with the possibility of limited walking on crutches is prescribed. The same measures are taken if Perthes disease is suspected during the examination before diagnosis. final diagnosis. It is necessary to maintain a certain position in bed - on the back and on the stomach with moderate separation of the legs; a position on the side (both on the “sick” and on the “healthy”) is not advisable. The child is allowed to sit up in bed with support for his back and sit to a limited extent. In the presence of inflammatory phenomena in the joint, often accompanying Perthes disease, and the associated limitation of the range of motion of the hip, the patient must be prescribed anti-inflammatory therapy as the first stage of treatment.
The main goal of treating children with Perthes disease is to bring the anatomical structure of the affected hip joint closer to normal (initial), only in this case can we hope that during the next years of life the patient will not experience pronounced gait disturbances and pain. In this case, the most important is the restoration of the shape of the femoral head (round head), which should correspond to the shape of the acetabulum and the prevention of the formation (or elimination) of subluxation in the affected joint.
The treatment of children with Perthes disease is traditionally based on conservative measures - therapeutic exercises, massage, physiotherapeutic procedures, as well as drug therapy which are carried out after ensuring the centration of the femoral head (that is, its complete “immersion” in the acetabulum) through the use of one of the orthopedic devices. Such devices include functional splints (Mirzoeva splint or Vilensky splint), plaster bandages (Lange spacer bandage or coxite bandage) and various types of traction for the thigh or lower leg (adhesive plaster, skeletal or cuff) and other devices (Fig. 9).

Rice. 9. Orthopedic devices used to treat children with Perthes disease:

A. Plaster bandage-spacer according to Lange.

B. Shina Doctor of Medical Sciences Professor I.I. Mirzoeva.

All these devices should give the “sick” leg a constant (during the entire period of treatment) position of abduction and internal rotation, or at least only abduction, which ensures centering in the affected joint.
Constantly maintaining the position of centration (or complete “immersion”) of the femoral head in the acetabulum is a prerequisite for treatment for Perthes disease with a large focus of necrosis, because in this case only with the help of centration can the progression of the deformity and the development of subluxation of the femoral head be stopped. In addition, complete “immersion” of the femoral head into the glenoid cavity ensures optimal conditions to correct a deformity that already existed at the start of treatment. The use of conservative treatment methods that do not involve centering the femoral head is permissible only when the focus of necrosis is small and includes only the anterior or anterior central departments epiphysis, and the child belongs to the younger age group. At the same time, the doctor, when prescribing control radiographs, constantly makes sure that the size of the necrosis focus has not increased.
Therapeutic gymnastics is carried out with the aim of stimulating the reparative process (healing) in the femoral head and increasing the range of motion in the affected joint; it is possible only with the use of removable centering devices, while in conditions of skeletal traction or plaster casts, exercises are performed in to a large extent limited. Toning massage and electrical stimulation of the muscles surrounding the hip joint allows you to maintain their functional activity and prevent the progression of malnutrition (decreased muscle volume), which is one of the integral clinical manifestations of Perthes disease and characteristic of long-term bed rest.
An important component complex conservative treatment is the use medications and physiotherapeutic devices with angioprotective action against which osteoprotectors and chondroprotectors are prescribed. Such devices and drugs (angioprotectors) improve the flow of arterial and outflow of venous blood in the area of the hip joint, while drugs with osteo- and chondroprotective effects stimulate new bone formation in the area of necrosis and have a positive effect on the structure of the cartilage tissue that forms the articular surfaces. These drugs are usually prescribed in the form of electrophoresis to the area of the lumbosacral spine and the affected joint, as well as in oral forms (capsules, tablets, powders) and intramuscular injections. In particular, trace elements have a pronounced osteoprotective effect - calcium, phosphorus and sulfur, which are prescribed, as a rule, in the form of electrophoresis using a three- or two-pole method, in combination with each other or with ascorbic acid. Microelements can also be prescribed in the form of warm (mineral) mud or baths, most often available in a sanatorium. Among the physiotherapeutic devices that help normalize blood flow deep in tissues, widespread received a “Vitafon”, which has a vibroacoustic effect on the vascular wall.
The listed therapeutic measures are prescribed in courses lasting from two to four weeks with breaks of at least one month - usually four or five courses of massage and physiotherapy are carried out per year. An exception is therapeutic exercises, which are performed daily (usually twice a day) throughout the entire period of treatment and, if necessary, combined with hip adjustments. In addition, it is advisable to include swimming in the pool in the treatment plan - no more than twice a week, and during the recovery stage - an exercise bike. Thermal procedures (paraffin, ozokerite and hot mud), the temperature of which is more than 40°C, are considered contraindicated, as they contribute to the obstruction of the outflow of venous blood and the associated increase in intraosseous pressure, which slows down the course of the reparative process. Children receiving treatment for Perthes disease are advised to Spa treatment. There are orthopedic resorts in many regions of Russia - in the Novgorod region (“Old Russia”), in Kaliningrad region(“Pionersk”), in the Ryazan region (“Kiritsy”), as well as on the Black Sea coast (Gelendzhik, Anapa, Evpatoria).
The duration of the conservative treatment under consideration, carried out in conditions of complete and then partial exclusion of support on the “sick” leg, averages two and a half years - from one to four years. It depends mainly on the age of the child at the time of onset of the disease, the stage of the pathological process at the time of treatment and the volume of the necrosis focus in the femoral head. Therefore, such treatment is most often indicated for younger children. age group(up to 6 years) with a small focus of necrosis. The timing of the beginning of dosed weight bearing on the sore leg, and then walking without improvised means, is determined by an orthopedic doctor based on X-ray data of the hip joints, carried out no more than once every three or four months, or magnetic resonance imaging.
In addition to the long duration and associated isolation of the child from peers and lag in physical development, the negative side of conservative treatment is the appearance in many children of excess weight, which subsequently becomes the cause of constant overload of the affected joint. In this regard, treatment is carried out against the background of a special diet and necessarily includes acceptable physical activity. But the main disadvantage of conservative treatment is, perhaps, the need for constant maintenance correct position in bed and the use of the above-mentioned centering devices, causing significant inconvenience to children and their parents. Meanwhile, the use of orthopedic splints, various types traction or plaster casts in many cases are mandatory and absolutely necessary conditions carrying out treatment.
The advantage of conservative treatment is the absence of the need for surgical intervention and related activities, which include general anesthesia(anesthesia), dressings surgical wound and removal of sutures, intramuscular injections of analgesics and antibiotics, and in some cases blood transfusions. Waiting for surgery can be a serious stress for the child, and the early postoperative period is associated with pain.
However, in some of the most severe cases of Perthes disease, instead of using centering orthopedic devices, it is preferable to perform reconstructive surgery on the hip joint. The latter ensures complete “immersion” of the femoral head into the acetabulum not by giving the lower limb a certain position, but by instantly changing the spatial position of the pelvic or femoral component of the joint after crossing the corresponding (pelvic or femoral) bone. Therefore in postoperative period the child is spared from wearing orthopedic splints for many months or being in traction. Important positive effect Such operations also stimulate the reparative process in the focus of necrosis and, consequently, reduce the time of treatment for the patient.
Surgical intervention is included in the treatment plan only in cases of Perthes disease in children aged at least 6 years with a large focus of necrosis, which is the cause of the development of severe deformity, and, often, subluxation of the femoral head. The cases under consideration are also characterized by long periods of the disease - without surgery, a child can be treated for three years and even up to five years. Unfortunately, the incidence of severe cases of Perthes disease has increased significantly in recent years.
Typical reconstructive surgical interventions used to treat children with Perthes disease in world practice are corrective medializing osteotomy of the femur and rotational transposition of the acetabulum according to Salter, which are characterized by relatively low trauma and lasting no more than one hour (Fig. 10).

Rice. 10. Anatomical structure of the hip joint in a child with Perthes disease (candidate of medical sciences D.B. Barsukov, candidate of medical sciences I.Yu. Pozdnikin “Surgical treatment of children with Legg-Calvé-Perthes disease):

A. Before surgical treatment.

B. After performing corrective (varius) medializing osteotomy of the thigh.

B. After performing rotational transposition of the acetabulum according to Salter.

1. Metal structures.

2. Lines of osteotomy (intersection) of the pelvic and femoral bones.

Larger interventions are used much less frequently. When performing these operations, bone fragments are fixed in the correction position with special metal structures, which are usually removed after a few months. On operating table The child is given a plaster cast of one type or another - depending on the nature of the intervention performed, the period of stay in it is four or five weeks.
In addition to reducing the time required to exclude support from the “affected” leg, which averages 12 months (from 9 to 15 months), a serious advantage of surgical treatment is a more complete restoration of the height of the affected femoral head and, consequently, its shape as a whole.
The quality of the surgical intervention certainly has a great influence on the prognosis of the disease. The likelihood of successful completion of the operation increases significantly if the patient is operated on by surgeons who specialize in the pathology of the pediatric hip joint and who frequently perform such operations. Most likely, such specialists can be found in specialized hip pathology departments of research institutes or in children's orthopedic departments of regional, republican and regional hospitals.
No less influence on the prognosis of the disease is exerted by the conscientiousness of the child himself and his parents following the recommendations for further (postoperative) treatment of the data by the orthopedic doctor. The main ones are the elimination of excessive physical activity (jumping, running, lifting weights) and excess body weight throughout subsequent life. In this regard, the child is prohibited from playing almost all types of sports and physical education at school - at best, he is allowed to attend a special group without passing the standards. The physical activity of such children should manifest itself in the form of some acceptable types of exercise - regular swimming in the pool, therapeutic exercises to maintain a normal range of motion in the joint, exercise on an exercise bike and a sports bike. Otherwise, developing physical inactivity almost always leads to excess weight, which becomes a serious additional problem for the patient. For supporting normal weight Often a special diet is required, and sometimes drug treatment in consultation with an endocrinologist.
It is difficult to overestimate the correctness of employment for people who have suffered Perthes disease - the chosen profession should not be associated with heavy physical activity and even constant (during the entire working day) standing on their feet. It is important to regularly conduct maintenance courses of rehabilitation treatment (physical and drug therapy), including in sanatoriums.
Neglect of the listed recommendations, even with the best immediate treatment results, leads to the appearance of clinical signs of deforming coxarthrosis in the form of pain and gait disturbance. Typically, with Perthes disease, the clinical symptoms of coxarthrosis appear relatively late in comparison with other, more severe diseases of the hip joint or do not appear at all. However, in cases where the patient forgets that the joint must be protected, they can develop into at a young age, then, depending on the severity of the pain syndrome, a decision is made about hip replacement (replacing an organ that is unfit for function with an artificial one). Endoprosthesis replacement surgery at a young age is extremely undesirable - it should be performed as late as possible. Fortunately, not all people treated for Perthes disease require endoprosthetics. The same can be said about surgical interventions, aimed at equalizing the length of the lower extremities - a large difference in the length of the legs is not common.
Thus, the determining factors in the prognosis of Perthes disease are the age of the child at the time of the onset of the pathological process, the size and location of the necrosis focus in the femoral head, early diagnosis of the disease and the adequacy of the therapeutic measures. Therefore, the appearance of even minor leg pain or gait disturbances in a child is a reason to consult an orthopedic doctor. Right choice places of treatment and conscientious implementation of medical recommendations ensure favorable outcome Perthes disease even in the most severe cases of the disease.

As for the reasons for the appearance of this disease, then a number of possible causes for pathology have not yet been fully studied, but at the same time there is a certain set of preceding factors.

A hereditary factor, the disease can occur in the womb of the fetus.
Problems with activities endocrine glands or the endocrine system as a whole.
Metabolic disease.
The body's inability to absorb calcium and other vitamins.
Various injuries.
After exhausting physical activity. First, the vessels are compressed, and then they narrow in the spongy bones.

Symptoms

The disease osteochondropathy can affect certain parts of the body:

calcaneus (Haglund-Schinz syndrome) - observed in teenage girls up to about 16 years of age. The manifestations are known for sharp pain in the heel area that appears after exercise. In addition to pain, there is slight swelling. Those suffering from this type of disease cannot step on the entire foot, they begin to walk on their toes, running and jumping become excruciating and painful;
spine (Scheuermann-Mau disease) - affects young people under 18 years of age. Several stages are known. In the first case, the spine is bent in upper section, the second is severe pain. The patient gets tired quickly, the back muscles are weak and ache at the slightest exertion. Last stage characterized by the final fusion of the vertebrae with the apophyses, with progressive pain syndrome;
femur (Legg-Calvé-Perthes syndrome) occurs in boys from preschool age to 12 years. At first it is asymptomatic. Later, the patient feels pain in the hip, which radiates to the knee. As a rule, children do not always complain of such pain, since the discomfort periodically passes and then appears again. Over time, atrophy of the muscle of the sore hip occurs, and it loses a lot of weight;
tibial tuberosity (Schlatter's disease) - boys also suffer from this pathology. The disease can occur from 12 to 16 years of age and is associated with certain activities, so those who are interested in sports dancing, ballet get sick. The patient experiences pain when bending his knees or climbing stairs. The knee area suffers.

Diagnosis of osteochondropathy in a child

The method for identifying a pathological process is closely related to the localization of the pathological process.

Although there is one thing that unites all clinical cases.

The specialist first conducts an x-ray examination of the part of the body that interests him. He looks at all the changes that the X-ray machine can show in detail, and based on the picture he sees, he makes treatment recommendations.

In case of a disease of the heel region, the study shows compaction of the apophysis. In the pictures of a disease of the spine, it is noticeable how much the structure of the vertebrae is changed. As for the femoral part, here we consider the possible five stages of deformation of the femoral head. If we are talking about tibial tuberosity, the diagnosis is also made on the basis clinical picture course of the disease and x-ray images.

Complications

Severe consequences And Negative consequences really avoidable. At adequate therapy Experts give a favorable prognosis for this disease. In general, the prognosis is very favorable. The most important thing is not to delay treatment. To forget about this problem forever, you should treat the problem as soon as possible. An experienced, qualified doctor will help parents here.

Treatment

What can you do

Parents should pay more attention to the child’s problem and follow all the doctor’s recommendations.

The specialist will explain in detail what needs to be done for a certain form of the disease. Parents will only have to comply with all the instructions of the treating specialist.

What does a doctor do

Elimination of inflammation of the heel bone consists of prescribing the use of non-steroidal anti-inflammatory drugs for severe pain, physical procedures, and limiting physical activity. To relieve the load on the sore foot, the doctor recommends special insoles-instep supports.
Osteochondropathy of the vertebrae is eliminated with the help of special massage, swimming, exercise therapy, and underwater exercises. In difficult situations it is indicated surgery.
Therapy for an abnormal process in the femur can be medicinal and surgical. Plastic surgery on bones are carried out depending on the severity of the pathology. Conservative therapy for the pathology consists of prescribing bed rest (the child needs to lie down), foot massage, and physiotherapy. Skeletal hip traction is also shown.
To eliminate problems with tibial tuberosity, physiotherapy and the application of warm compresses are recommended. When the pain is unbearable, a plaster cast is applied. It happens that doctors perform an operation to eliminate the area of the tuberosity. Loads are eliminated.

Prevention

Preventive measures are related to the part of the body that has been affected by the pathological process.

So, to prevent pathology it is necessary:

Always wear comfortable and spacious shoes - if you experience pain in the heel.
Engage in physical therapy and strengthen the back muscles if you have problems with the spine, and at the same time do not bother yourself with excessive loads.
If knees hurt during training, athletes are recommended to sew foam pads into their uniforms.
Massage and swimming are indicated for the prevention of hip disease.

reading information

Osteochondropathy is necrosis (death) of a section of bone due to various reasons. The area adjacent to the bone also suffers cartilage tissue. The disease is chronic, gradually causing deformation of bones and joints; with age, arthrosis and limited mobility (contracture) develop. Most often, children and adolescents aged 5-14 years are affected, but osteochondropathy also occurs in adults. In the structure of orthopedic morbidity, it accounts for 2.5-3% of the total number of visits.

Impaired blood flow through the arteries leading to the epiphysis of the bone leads to the development of osteochondropathy

The cause of osteochondropathy is a violation of blood circulation in the area of the bone near the joint (epiphysis), leading to its necrosis and associated complications - deformation, fractures. The following factors can lead to circulatory disorders: :

Injuries: bruises, hematomas, damage to soft tissue, bone, cartilage.
Hormonal and metabolic disorders, mainly during puberty (adolescence), lack of phosphorus and calcium salts.
Lack of protein in the diet (for example, vegetarians).
Increased bone growth when it outstrips vascular development.
Excessive functional load on joints, especially in childhood and adolescence.
A sedentary lifestyle (hypodynamia), leading to blood stagnation.
Congenital anomalies of the development of the osteoarticular system.
Excess weight, which increases stress on bones and joints.
Hereditary predisposition (feature of bone structure).

Important! Persons at risk for osteochondropathy should pay special attention to the skeletal system, and consult a doctor at the slightest complaint.

Classification of osteochondropathy, its types

Osteochondropathy varies according to the location of the disease, which has 3 main “favorite” places:

epiphyses (articular ends) of tubular bones;
bone apophyses (protrusions, tuberosities);
short bones (vertebrae, tarsal bones of the foot).

In the area of the epiphyses of bones they develop the following types osteochondropathy:

femoral head;
heads of metatarsal bones of the foot;
upper epiphysis of the leg;
fingers;
sternal epiphysis of the clavicle.

Apophyseal osteochondropathy:

tibia of the leg;
vertebral apophyses;
calcaneus;
knee joint;
pubic bone.

Study in more detail on our portal.

Osteochondropathies of short bones:

vertebral bodies;
navicular bone of the foot;
lunate carpal bone;
sesamoid (accessory) bone at the base of the 1st toe.

Stages of development and clinical manifestations of osteochondropathy

The disease develops gradually over 2-3 years, going through the following 3 phases:

First stage- initial, when necrosis (necrosis) of a section of bone occurs due to circulatory problems. Manifested by aching pain in the bones, joints or spine (depending on location), increased fatigue, movement disorders.
Second stage- destruction, fragmentation of bone (separation into fragments). Characterized by increased pain, bone deformation, and pathological fractures(without visible injury). The function is significantly impaired.
Third stage- bone restoration. The destroyed bone is gradually restored, the defects are filled with bone tissue, but sclerotic phenomena and arthrosis of nearby joints develop. Pain syndrome decreases, but deformation and limited function may remain.

Phases of development of osteochondropathy: a - circulatory disorders, b - development of necrosis, c - formation of bone fragments, d, e - restoration, bone healing

Diagnostic methods

The following methods are used to diagnose osteochondropathy:

radiography;
computed tomography (CT);
magnetic resonance imaging (MRI);
radioisotope study of the entire skeleton (scintigraphy);
ultrasound scanning (ultrasound);
densitometry (determination of bone density).

Information. When examining children, preference is given to non-radiation methods - ultrasound, MRI.

Certain types of osteochondropathy, treatment

Each type of osteochondropathy has its own characteristics of manifestation; the treatment program is also compiled individually, taking into account the age and stage of the disease.

Legg-Calvé-Perthes disease

This is osteochondropathy of the hip joint. Most patients are boys from 5 to 14 years old, the lesion is often unilateral. Necrosis develops in the head of the femur. The disease manifests itself as pain in the joint, difficulty walking, lameness, and later the muscles of the thigh and buttocks atrophy, and the limb shortens.

Treatment of the disease requires a long time (2-4 years). The joint is immobilized, the limb is isolated from the load (splint, crutches or traction). Prescribed calcium and phosphorus supplements, vitamins, vasodilators, local iontophoresis with calcium, massage, exercise therapy. Treatment in a specialized sanatorium gives a good effect. The disease usually responds well to treatment, and only if it is ineffective is surgery indicated (osteotomy, removal of necrotic areas of bone, joint plastic surgery or endoprosthetics).

Important. Perthes disease can lead to irreversible changes joint when prosthetics are needed. Therefore, its treatment must be timely and qualified.

Schlatter's disease (Osgood-Schlatter)

This is osteochondropathy of the tibia, or more precisely, its tuberosity, located on the front surface of the tibia, immediately below the knee joint. Both boys and girls aged 10 to 17 years old, mostly those who actively engage in sports, are affected. A painful swelling appears below the knee; walking and movements in the knee are painful.

To treat osteochondropathy of the tibia, the limb is fixed with a splint, physiotherapy, massage, and calcium supplements are prescribed. The disease usually responds well to treatment, although the “bump” on the bone remains.

Osteochondropathy of the foot in children

The navicular, calcaneal, and metatarsal bones are most often affected. Necrosis in the navicular bone, located on the inside of the foot, is called Keller disease I. Mostly boys from 3 to 7 years old are affected; the lesion is one-sided. When walking, the child begins to limp and leans on the outer part of the foot (crooks the leg). Usually the disease does not cause severe symptoms, may remain undiagnosed, and goes away on its own within a year. If detected, they are prescribed to wear arch supports, special shoes, physiotherapy, and exercise therapy.

Osteochondropathy of the heads of the II-III metatarsal bones (Keller's disease II) more common in girls adolescence, both feet are affected. When walking, pain appears in the foot, which then becomes permanent and can bother you even during sleep. Swelling of the foot and shortening of the toe appear. The disease lasts 2-3 years until the increased bone growth stops. The treatment regimen also includes calcium supplements, vitamins, physiotherapy, massage and exercise therapy.

Osteochondropathy of the calcaneus (Schinz disease) can develop in both boys and girls aged 7-12 years, most often both limbs are affected. There is pain, swelling on the back of the heel, lameness, and difficulty wearing shoes. The child begins to walk, relying more on his toes. Over time, atrophy of the calf muscle may develop.

Osteochondropathy of the calcaneus in children is a fairly common phenomenon that lasts quite a long time, until the end of bone growth, and compaction in the area of the tuberosity of the heels can remain for life. Treatment of osteochondropathy of the calcaneus in children consists of immobilizing the foot with a splint, prescribing physiotherapy, vitamin and anti-inflammatory drugs, and means to improve blood circulation and microcirculation.

Spinal osteochondropathy

Osteochondropathy of the thoracic spine is more common; there are 2 types:

Scheuermann-Mau disease, in which the destructive process occurs in the epiphyses of the vertebrae, that is, near the discs;
Calve's disease is a lesion of the vertebral bodies themselves.

Mostly teenagers and young adults (11-19 years old) get sick. The disease is common, especially in recent decades. Symptoms include spinal deformity (flat or round back), concavity of the sternum (“cobbler’s chest”), back pain, muscle atrophy chest, increased fatigue. The patient cannot remain in the vertical position, perform physical activity. A wedge-shaped deformity of the vertebrae gradually develops, they take on the appearance of a trapezoid (the height of the bodies in the anterior sections decreases). Later, these changes are joined by osteochondrosis and spondylosis deformans.

Changes in the vertebral bodies during osteochondropathy: on the left - their wedge-shaped deformation, on the right - its result (kyphosis of the back)

Long-term treatment of spinal osteochondropathy: physiotherapy, exercise therapy, massage, wearing a corrective corset, vitamin therapy, chondroprotectors, sanatorium treatment. IN in rare cases When spinal deformity is pronounced or disc herniations or vertebral displacement have occurred, operations are performed (correction and fixation of vertebrae, plastic arches and discs).

Osteochondropathy is an age-related disease that can be treated. If it is started on time, carried out comprehensively and skillfully, in most cases recovery occurs.

Perthes disease (synonym: osteochondropathy of the femoral head, juvenile deforming arthritis, Legg-Calvé-Perthes disease) - aseptic necrosis of the femoral head, most often observed in boys 4-16 years old. The disease is based on malnutrition of the femoral epiphysis; Trauma (including repeated microtrauma), congenital factors, and endocrine disorders play a role.

Usually one limb is affected. Perthes disease begins gradually, with limited abduction and external rotation of the hip while maintaining other movements. A slight lameness appears. pain, crunching in the hip joint when walking. The limb becomes somewhat thinner. When tapping the trochanter of the thigh, there is pain. Radiographs initially show a thinning of the bone tissue pattern, widening of the joint space and areas of necrosis of the femoral head (this stage lasts 6-8 months); Then, when loaded, the femoral head is crushed like eggshells; dead tissue is absorbed and replaced by connective tissue, which leads to the division of the head into segments. After 10-12 months, the fusion of the head segments begins, and after 2-3 years it is restored, but its shape is deformed. The contours of the floor of the acetabulum are also deformed.

With proper early treatment - restorative therapy, bed rest, immobilizing bandages, unloading devices (see Orthopedic devices) - the function of the limb is completely restored. Sometimes there are indications for surgery aimed at improving blood supply to the femoral head. Children with Perthes disease are best treated in specialized sanatoriums. See also Osteochondropathy.

Perthes disease (G. C. Perthes; synonymous with Legg-Calvé-Perthes disease) - aseptic necrosis of the femoral head. Trophic disorders in the form of primary aseptic necrosis of the femoral head lead to serious changes in the shape and function of the hip joint. The disease belongs to the group of osteochondropathy (see). The disease mainly affects children aged 5-12 years. Boys get sick about 4-5 times more often than girls. In Perthes disease, the femoral head is affected predominantly on one side, but bilateral lesions have also been described in the literature.

The etiology of the disease still remains unclear. Of all the theories proposed to explain the reasons for the development of P. b. (infection, rickets, disorder endocrine system, congenital predisposition to circulatory disorders, trauma, etc.), the most common and justified traumatic theory. Naturally, not every patient has a bruise that can lead to P. b.

The pathoanatomical observations and experimental data that have accumulated to date more or less confirm the traumatic theory, but do not allow us to draw final conclusions on the etiology of P. b.

Clinical picture. Perthes disease has a hidden onset and is asymptomatic. Initially, children complain of fatigue and moderate and intermittent pain in the hip and sometimes knee joints. The pain intensifies towards the end of the day and subsides at night.

On examination, a slight limitation of hip abduction, mild lameness and subtle atrophy of the limb are noted. Loading along the axis of the limb is painless. From time to time the pain disappears for a certain period. Over time, there is a limitation of rotation and abduction in the hip joint, a Trendelenburg symptom appears, and when measured, a slight shortening of the limb and a high position of the greater trochanter are detected.

IN general condition body noticeable changes not happening. Children are reluctant to go to bed, despite their lameness, they continue to run around. There are no abnormalities in the blood. X-ray examination is decisive in the differential diagnosis of diseases of the hip joint.

The prognosis of Perthes disease is always favorable for life, however, the functional prognosis largely depends on the stage at which the disease is diagnosed and how early treatment is started.

Transferred in childhood P. b. in the absence of necessary treatment, it can leave the patient disabled for life.

Treatment. With P. b. timely complete unloading of the limb is necessary (prevents deformation of the soft femoral head) and general strengthening therapy (promotes rapid regeneration of bone tissue of the femoral head).

Along with the main, conservative method of treating P. b. There are surgical methods that stimulate the ossification of rarefied bone lesions (tunnelization and introduction of a frozen homograft into the femoral neck). Best conditions for children sick with P. b. created in specialized sanatoriums. Conservative treatment P. b. in the sanatorium consists of bed rest, vitamin therapy, good nutrition. Among physiotherapeutic procedures, transverse ionogalvanization with calcium chloride on the hip joint area (during the recovery period).

Rest can be achieved either by applying a coxite plaster cast or by using orthopedic devices(see) with emphasis on the ischial tuberosity, reducing the load on the limb.

The most rational option is bed rest for 6-8 months with adhesive traction on the affected leg. With the latter, the load is eliminated, and flexion and rotation movements are even advisable. They are elements of therapeutic exercises for this disease.

X-ray diagnostics. X-ray data for P. b. play important role in establishing a diagnosis, conducting differential diagnosis, comparative observations of the development of changes occurring in the osteoarticular apparatus of the hip joint, and recognition long-term consequences past illness. X-ray picture P. b. characterized a certain sequence development of ongoing changes. In the normal course of the disease, this sequence is expressed in five stages, naturally replacing one another (S. A. Reinberg).

I. Initial stage of development of aseptic necrosis of the femoral head; macroscopically not accompanied by changes in the shape and structure of the epiphysis; X-ray picture of the hip joint is normal. Its duration is several months.

Rice. 1. Perthes disease, stage II. Flattening of the epiphysis of the left femur, compaction of its structure, expansion of the strip of metaepiphyseal cartilage and expansion of the X-ray gap of the left hip joint.

II. Stage of impression fracture of the femoral epiphysis. X-ray signs of the disease at this stage, lasting 6-8 months. are flattening of the epiphysis of the femur, compaction of its structure and expansion of the x-ray joint space. The strip of metaepiphyseal cartilage acquires some tortuosity, indicating a violation of enchondral bone growth. These signs gradually increase over the specified period (Fig. 1).

III. Stages of sequestration-like shadows, which are especially indicative in the X-ray display of the disease. In the deformed and compacted epiphysis of the femoral head, areas of rarefaction appear, which indicate the resorption of necrotic bone tissue. In the most pronounced process, against the background of rarefaction of the structure of the epiphysis, areas of still unresolved necrotic bone remain, creating some external resemblance to bone sequestra. The deformation of the head intensifies: in addition to its flattening, it increases in transverse size. The previously appeared and intensified symptoms are accompanied by thickening of the femoral neck (due to periosteal bone formation), which also turns out to be shortened in comparison with the healthy one due to inhibition of enchondral bone growth. The strip of metaepiphyseal cartilage undergoes significant changes; it becomes expanded, even more tortuous and ill-defined. The joint space widens even more. Cervical - diaphyseal angle the femur decreases.

Rice. 2. Perthes disease, stage III, the same Solnoy as in Fig. 1, after 1 year and 4 months. Uneven depression of the deformed and compacted epiphysis of the head of the left femur - a picture of sequestration-like shadows, thickening of the head and neck of the femur, widening of the X-ray joint space, subluxation of the femur outward.

According to the changed shape of the femoral head, the shape of the acetabulum also changes. There are signs of outward subluxation of the femur (Fig. 2). At this stage, mild osteoporosis may appear. Its duration is approximately two years.

IV. Reparation stage. Lasts about a year. X-ray shows a picture of gradual restoration of the structure of the bone substance of the femur while maintaining the resulting deformation of the hip joint.

There are no clear boundaries between these stages. Therefore, when diagnosing Perthes disease, the X-ray picture is sometimes defined as II-III or III-IV stages of its development.

V. Stage of consequences of aseptic necrosis, when characteristic deformities of the hip joint remain (Fig. 3). Many years after clinical recovery and with the patient’s condition satisfactory (only a slight limitation of rotation and abduction of the limb in the hip joint remains), already in mature age a picture of deforming osteoarthritis develops in the joint (see).

In addition to the described course of development of morphological changes in the osteoarticular apparatus, with timely recognition and proper treatment, a different outcome of the disease is possible - restoration of the completely correct shape of the femoral head and acetabulum (Fig. 4).

Rice. 3. Perthes disease, stage V. Primary bone deforming osteoarthritis.

Rice. 4. Preservation of the correct shape of the head of the left femur during clinical cure of Perthes disease - transition from stage IV to V (after immobilization for 3 years).

Source: www.medical-enc.ru

Perthes disease

Perthes disease is a pathological process characterized by impaired blood supply and subsequent necrosis of the femoral head. It is a fairly common disease and accounts for about 17% of the total number of osteochondropathy. Children aged 3 to 14 years are affected. Boys get sick 5-6 times more often than girls, but girls tend to have a more severe course. Both unilateral and bilateral damage is possible, with the second joint usually suffering less and recovering better.

Causes and predisposing factors for the development of Perthes disease

At present, no single cause of Perthes disease has been identified. It is believed that this is a polyetiological disease, in the development of which both the initial predisposition and metabolic disorders, as well as environmental influences, play a certain role. According to the most common theory, Perthes disease is observed in children with myelodysplasia, a congenital underdevelopment of the lumbar spinal cord, a common pathology that may not manifest itself or cause various orthopedic disorders.

With myelodysplasia, the innervation of the hip joints is disrupted, and the number of vessels delivering blood to the tissues of the joint decreases. Simplified, it looks like this: instead of 10-12 large arteries and veins in the area of the femoral head, the patient has only 2-4 underdeveloped vessels of smaller diameter. Because of this, the tissues constantly suffer from insufficient blood supply. Yours Negative influence It also has a change in vascular tone due to disruption of innervation.

Under relatively unfavorable conditions (with partial compression of arteries and veins due to inflammation, trauma, etc.) in a child with normal amount blood vessels, the blood supply to the bone deteriorates, but remains sufficient. In a child with myelodysplasia under similar circumstances, blood completely stops flowing to the femoral head. Due to the lack of oxygen and nutrients, part of the tissue dies - an area of aseptic necrosis is formed, that is, necrosis that develops without microbes and signs of inflammation.

It is assumed that the following factors may be the triggering factors in the occurrence of Perthes disease:

Minor mechanical injury (for example, a bruise or sprain when jumping from a small height). In some cases, the injury is so minor that it may go unnoticed. Sometimes an awkward movement is enough.
Inflammation of the hip joint (transient synovitis) with microbial and viral infections (influenza, sore throat, sinusitis).
Changes in hormonal levels during adolescence.
Disorders of the metabolism of calcium, phosphorus and other minerals that are involved in bone formation.

In some cases it is revealed hereditary predisposition to the development of Perthes disease, which may be due to a tendency to myelodysplasia and genetically determined structural features of the hip joint.

Stages and outcome of Perthes disease

There are five stages of Perthes disease:

Termination of blood supply, formation of a focus of aseptic necrosis.
Secondary depressed (impression) fracture of the femoral head in the destroyed area.
Resorption of necrotic tissue, accompanied by shortening of the femoral neck.
Overgrowth of connective tissue at the site of necrosis.
Replacement of connective tissue with new bone, fracture healing.

The outcome of Perthes disease depends on the size and location of the area of necrosis. With a small lesion it is possible full recovery. With extensive destruction, the head breaks up into several separate fragments and, after fusion, can acquire irregular shape: flatten, protrude beyond the edge of the articular cavity, etc. Violation of the normal anatomical relationships between the head and the acetabulum in such cases causes further aggravation pathological changes: formation of contractures. support restrictions and rapid development severe coxarthrosis.

Symptoms of Perthes disease

On early stages non-intense ones appear dull pain when walking. Usually the pain is localized in the hip joint, but in some cases pain may occur in the knee joint or throughout the leg. The child begins to limp slightly, falls on the sore leg or drags it. As a rule, during this period, clinical manifestations are so mild that parents do not even think of contacting an orthopedist. and explain the symptoms of the disease as a bruise, increased load, a consequence of an infectious disease, etc.

With further destruction of the head and the occurrence of an impression fracture, the pain sharply intensifies, and lameness becomes pronounced. Soft fabrics the joint area swells. A limitation of movements is detected: the patient cannot turn the leg outward, rotation, flexion and extension in the hip joint are limited. Walking is difficult. Autonomic disorders are noted in the distal parts of the diseased limb - the foot is cold, pale, and sweating is increased. Body temperature may rise to subfebrile levels. Subsequently, the pain becomes less intense, support on the leg is restored, but lameness and limited movement may persist. In some cases, shortening of the limb is detected. Over time, a clinical picture of progressive arthrosis appears.

Diagnosis of Perthes disease

The most important research that has crucial When diagnosing Perthes disease, an x-ray of the hip joint is performed. If this disease is suspected, not only images in standard projections are taken, but also radiographs in the Lauenstein projection. The X-ray picture depends on the stage and severity of the disease. There are various radiological classifications, the most popular of which are the Catterall and Salter-Thomson classifications.

Catterall classification:

1 group. X-ray signs Perthes disease is mild. A small defect is detected in the central or subchondral zone. The femoral head has a normal configuration. There are no changes in the metaphysis, the fracture line is not determined.
2nd group. The contours of the head are not disturbed; destructive and sclerotic changes are visible on the radiograph. There are signs of fragmentation of the head, and a forming sequestration is detected.
3 group. The head is almost completely damaged and deformed. The fracture line is identified.
4th group. The head is completely damaged. The fracture line and changes in the acetabulum are identified.

Salter-Thomson classification:

1 group. A subchondral fracture is determined only on a radiograph in the Lauenstein projection.
2nd group. The subchondral fracture is visible on all images, the outer border of the head is not changed.
3 group. A subchondral fracture “captures” the outer part of the epiphysis.
4th group. A subchondral fracture extends to the entire epiphysis.

In doubtful cases, at the first stage of the disease, an MRI of the hip joint is sometimes prescribed for a more accurate assessment of the condition of the bone and soft tissues.

Treatment of Perthes disease

Children aged 2-6 years with mild symptoms and minimal changes on radiographs should be seen by pediatric orthopedist; special therapy not required. In other cases, patients are referred for treatment to the orthopedic department, followed by outpatient follow-up treatment. Conservative therapy is long-term, lasting at least a year (on average 2.5 years, in severe cases up to 4 years). Treatment includes:

Complete unloading of the limb.
Application of skeletal traction. use of plaster casts. orthopedic structures and functional beds to prevent deformation of the femoral head.
Improving blood supply to the joint using medicinal and non-medicinal methods.
Stimulation of the processes of resorption of destroyed tissues and bone restoration.
Maintaining muscle tone.

Children with Perthes disease remain inactive for a long time, which often provokes excess weight and a subsequent increase in the load on the joint. Therefore, all patients are prescribed special diet to prevent obesity. In this case, nutrition should be complete, rich in proteins, fat-soluble vitamins and calcium. During the entire treatment period, massage and special complexes Exercise therapy. When using skeletal traction and plaster casts, which exclude the possibility of active movements, electrical stimulation of the muscles is performed.

Children are prescribed angioprotectors and chondroprotectors in the form of oral and intramuscular injections. Starting from the second stage, patients are referred to UHF. diathermy, electrophoresis with phosphorus and calcium, mud therapy and ozokerite. Weight-bearing on the leg is permissible only after radiographically confirmed healing of the fracture. At the fourth stage, patients are allowed to perform active exercises, at the fifth stage they use exercise therapy complex to restore muscles and range of motion in the joint.

Surgical interventions for Perthes disease are indicated in severe cases (severe deformity, hip subluxation) and only in children over 6 years of age.

Usually, rotational transposition of the acetabulum according to Salter or corrective medialization osteotomy of the femur is performed. In the postoperative period, physiotherapy, exercise therapy, massage, chondroprotectors and angioprotectors are prescribed.

People who have suffered Perthes disease, regardless of the severity of the disease, are recommended to avoid excessive stress on the hip joint throughout their lives. Jumping, running and heavy lifting are contraindicated. Swimming and cycling are permitted. You need to do therapeutic exercises regularly. You should not choose a job that involves heavy physical activity or standing for a long time. It is necessary to periodically undergo rehabilitation treatment in outpatient and sanatorium conditions.

Perthes disease - treatment in Moscow

Perthes disease is a rare pathology characterized by death of the head of the femur due to impaired blood supply to the bone. The lack of blood flow to the bones of the upper leg leads to gradual tissue death, which is accompanied by severe inflammation.

Most often, children are susceptible to pathology age category 4-12 years, and girls get sick five times less often, and their course of the disease is much more severe.

In 90%, there is a lesion on one side, but it happens that the femurs of both legs are susceptible to pathology.

Perthes disease does not pose a threat to the patient's life, but cases of the development of physical defects and disability are not uncommon.

Causes

The main reason why Perthes disease appears has not yet been identified.

Experts put forward several theories of origin and cause:

lower limb injuries;
exposure to microorganisms, viruses or toxins on the joint;
hormonal dysfunctions, especially during puberty;
violations metabolic processes, taking part in the formation of bones;
heredity.

One of the important conditions for the development of pathology, which can lead to disability, is considered to be congenital myelodysplasia in the sacrolumbar region, which is responsible for supplying the joints with blood.

Symptoms

Symptoms of the anomaly develop gradually. The main symptom of the disease is lameness, the peak of which occurs at the age of 6-8 years, namely during the period of greatest physical activity child.

Other manifestations of pathology include:

painful sensations when walking, which are localized both in the hip joint and in the knee;
change in gait with dragging of the affected limb or falling on it.

With significant violations of bone anatomy, the disease has inherent symptoms:

intense pain when moving;
obvious lameness;
swelling of the joint and nearby tissues;
muscle weakness in the buttocks;
inability to turn the leg outward;
limited ability to flex/extend the joint;

slight increase in temperature;
changes in indicators general analysis blood (high ESR, leukocytosis, lymphocytosis);
formation of wrinkles on the foot of the injured limb;
weak pulse in the toes on the affected side.

Stages

Legg Calve Perthes disease has the following stages:

Stage I - the damage is minor and difficult to diagnose. This stage is characterized by the development of osteonecrosis.

Stage II - painful symptoms appear in the knee and/or hip joint. A depressed fracture occurs, in which small cracks form on the surface of the head of the bone.

Stage III - intense pain is present both during movement and at rest. Dead tissue is reabsorbed and the femoral neck is shortened.

Stage IV - there is a lack of joint function, acute pain symptoms in any body position. Subluxation or dislocation develops. The head of the bone is completely destroyed, the edges of the acetabulum are displaced. The space between the joint and the socket is significantly narrowed or absent. Connective tissue is growing rapidly.

Stage V - at this stage bone fusion occurs, but the shape of the femoral head often, especially with delayed therapy, remains with significant changes. This condition provokes irreversible joint changes and, sometimes, disability.

According to some reports, each stage of the disease takes 5-7 months to form.

Diagnostics

The main way to diagnose this disease is radiography. The study is used in standard projections and Lauenstein projection. The study helps determine the degree of destruction and condition of the joint, as well as determine the stage of the pathology.

Rarely, an MRI scan is used to confirm the diagnosis, which helps determine the presence of bone marrow edema.

In this article we talk about the types of postural disorders and the reasons that cause them.
What prevention is necessary to avoid postural disorders can be found here.

Treatment

In other cases, mandatory therapy is carried out. Treatment of the disease should be carried out as soon as possible after confirmation of the diagnosis, otherwise the pathology may result in disability. With timely treatment, complications of the disease are minimal, and the child is not at risk of disability.

The main principles of conservative therapy are:

absolute unloading of the legs;
applying traction, using plaster casts, special devices and structures that help prevent deformation of the bone head;
restoration of blood supply to the damaged joint;
elimination of inflammation;
stimulation of tissue regeneration;
maintaining muscle tone.

Drug treatment

In order to reduce the inflammatory process in the joint and periarticular membrane, non-steroidal anti-inflammatory drugs, such as Ibuprofen, are used. It happens that NSAID treatment lasts long time. The treatment regimen is determined by a specialist and changes it in accordance with the dynamics of restoration of damaged tissue.

Physiotherapeutic treatment

UHF therapy;
diathermy;
electrophoresis;
mud treatment;
ozokerite.

Physiotherapy

Weight-bearing on the affected leg is allowed only after the healing of the fracture has been confirmed by radiography. Starting from stage IV, patients are allowed to perform active physical exercise, and at the fifth stage, exercise therapy is used, the exercises of which are developed individually for each patient. Therapeutic exercises are aimed at restoring and further maintaining muscle tone and motor functions of the diseased joint.

Nutrition

Children with Perthes disease remain inactive for a long time, which can provoke overweight and correspondingly, additional load on the joint. To prevent such complications, patients are recommended to adhere to a certain diet that excludes fatty, fried and salty foods, dishes rich in carbohydrates and fats.

Orthopedic devices

Treatment of the pathology with conservative methods is carried out after the head of the bone is completely “immersed” in the acetabulum.

functional splints (Mirzoeva splint, Vilensky splint);
plaster casts (coxite, Lange spacer bandage);
traction for the lower leg or thigh (cuff, adhesive, skeletal), etc.

Surgical treatment

In severe cases of pathology in children over 6 years of age, surgery is used instead of using orthopedic devices. During the operation, the “immersion” of the bone head into the acetabulum is performed by simultaneously changing the position of the bone head. Bolts and plates are used to fix the position. Sometimes, due to an increase in the size of the head due to necrosis, surgical deepening of the cavity is performed.

Disability

In severe cases of the disease, doctors may advise that the sick child be granted disability status. Whether or not to register a disability is the choice of each parent. If there are any doubts, you can study the discussion of this problem on the Internet. There are many forums on the Internet where parents share their experiences, help with advice and simply show moral support.

Does it happen to adults?

Perthes disease can also occur in adult patients aged 30-50 years and, again, predominantly in the male population. Due to age-related decline in the ability to regenerate bone tissue, the disease is treated surgically. At the very beginning of the development of pathology, tunnels are drilled into the hip bone, which help increase the inflow of arterial and outflow of venous blood, which reduces intraosseous pressure. If this method does not bring the desired effect, or the disease is very advanced, the joint is replaced with an endoprosthesis.

How long can treatment take?

Statistically, the earlier Legg Perthes disease is diagnosed, the shorter the treatment will be. As a rule, treatment for the disease lasts from 3 to 5 years.

Possible complications
If treatment is not started in the early stages of the disease, the child may face disability. The formation of deforming arthrosis, limited mobility of the lower limb, and lameness are possible. The disease is completely curable with timely diagnosis and adequate treatment.

Causes of the disease
Types of disease
Diagnostics
Treatment

The question often arises: what is it and who does it manifest itself in? WITH Greek language osteochondropathia means: osteo – bone, chondro – cartilage, pathia – disease, suffering. Osteochondropathy is a series of painful manifestations that are more common in the younger generation (children, adolescents). Changes occur in bone tissue musculoskeletal system(for example, in the apophysis of short tubular bones), the bone is deformed (it loses its strength), disruption and changes in the joints. A person with such a predisposition, standing on his hands, can easily break them. Bones can crumble under their own weight, even from muscle tension.

Why does this disease appear?

Transmitted genetically.
Hormonal balance is disrupted (especially in the functioning of the endocrine glands).
Poor metabolism (difficult to absorb calcium and vitamins).
No interactions vascular network with bone tissue.
Changes in the regulation of blood flow and nerve trophism.
Very often the body is subjected to microtrauma.
The limbs and spine are not in their natural position (most often in professional athletes).

Types of disease

This disease can be divided conditionally into IV groups, each type of manifestation has its own characteristics and individuality.
How is it distributed?

1. In tubular bones (in the epiphysis):

in the femur (head) – Legg-Calvé-Perthes disease;
in I-III metatarsal(head), collarbone (its sternal end), fingers (their phalanges) - b. Koehler II.

2. In short tubular bones:

in the foot (scaphoid) - Köhler disease I;
in the hand (lunate) – b. Kinbeka;
in the wrist (scaphoid) – b. Praiser;
in the vertebral body – b. Calvet.

3. In the apophyses:

in the tibia (its tuberosity) – b. Osgood-Schlatter;
in the calcaneus (its tubercle) – b. Haglund - Schintz;
in the apophyseal rings of the vertebrae – b. Scheuermann – May.

4. In the surfaces of the joints - Koenig's disease.

Osteochondropathy of the femoral head (Legg-Calvé-Perthes b.) is a lesion of the hip joint, most often its right side. It appears more in boys (5-10 years old). May have different stages diseases (I-V). This disease first manifests itself as unpleasant sensations in the lower extremities, then in the pelvic area. The pain may not be at the site of the outbreak, but in the knee joint, and lameness begins. With a complex form of manifestation of this disease, the function of the hip joint is impaired, accompanied by severe pain, changes occur in the head of the femur.

Osteochondropathy of the tibial tuberosity (Osgood-Schlatter b.) is a kind of bone necrosis in the knee area (necrosis). It often occurs after numerous injuries and damage in this area (more often in boys who play sports professionally, aged 10-15 years). Knee pain and swelling appear. It takes a long time to treat and goes away after growth has completely stopped.

Spinal osteochondropathy (b. Scheuermann - May) is the destruction of the spine (discs, vertebrae, endplates). The thoracic region most often suffers from this disease (age 11-18 years). First, unpleasant sensations appear in the back area, then they intensify and with progressive development, kyphosis (curvature of the spine) and intervertebral neuralgia appear.

Osteochondropathy of the calcaneus (B. Haglund-Shintz) - this disease manifests itself as unpleasant pain in the area of the Achilles foot, heel, and swelling forms. It usually appears in girls after prolonged exercise (aged 12-16 years).

If your children complain of unpleasant pain in the foot, knee, spine, pelvis, then you should pay attention to this. Especially when the pain intensifies, you should consult a doctor. The disease is difficult to detect in the early stages; it is better to avoid complications. This disease takes a very long time to be treated and goes away completely when the body’s growth has stopped. It is better not to self-medicate. The doctor will make a diagnosis and prescribe treatment.

How can this disease be detected?

Assign X-ray examination: radiography, tomography, angiography. Thanks to this, we can distinguish 5 stages of this disease. At the initial stage, only cartilaginous necrosis appears; at the latter stage, a method of regeneration (complete recovery) or further destruction, arthrosis, can occur.

How is it treated?

Treatment takes place in the constant presence of doctors. Each manifestation of osteochondropathy has its own therapeutic purpose. For example, with osteochondropathy of the knee joint (Osgood-Schlatter b.), the load on the lower extremities is eliminated (a splint is installed), electrophoresis with P (phosphorus) and Ca (calcium), paraffin, and a good supply of the body with vitamins are prescribed. This disease goes away within a year and a half.