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 type of aseptic necrosis of the femoral head in childhood.
The term "aseptic necrosis" in this case means the necrosis of the bone tissue of the epiphysis (that is, the upper hemisphere) of the femoral head of a 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. Hip neck.

3. Acetabular cavity.

4. Large skewer.

5. Small skewer.

6. Joint capsule.

Boys aged 5-12 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 about 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 in the following.
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 of the lumbar spinal cord, which is 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 unnoticed throughout life, while more significant developmental disorders of the spinal cord manifest themselves in the form of a number of orthopedic diseases, which include 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 circulate the joints are 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 envelop 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.

Extremely simplified, this situation can be represented as follows - instead of 10-12 relatively large arteries and veins entering and leaving the femoral head, the patient has 2-4 small (congenital underdeveloped) arteries and veins, so the blood flow in the tissues of the joint is chronically reduced, and they are undernourished. 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 is completely stopped, 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 a minor injury, leading to compression (clamping) 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 that enters the joint, for example, from the nasopharynx with colds. That is why the latter often precede the onset of Perthes' disease, which is noted by the parents themselves. A minor injury, such as jumping from a chair, or just an awkward movement, can go unnoticed by both parents and children. As a result, there is a complete blockage of blood flow (or infarction) 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 poor or absent. Most often, children periodically complain of minor pain in the hip, knee or hip joint. Parents may notice some gait disturbances in the form of "slumping" on one leg or "dragging" the leg. Severe pain is noted much less frequently, as a rule, there is no gross lameness - therefore, going to the doctor in the first stage of the disease (the stage of osteonecrosis) is quite rare.
In the future, the dead bone tissue of the upper hemisphere of the femoral head loses its normal mechanical strength, as a result, under the influence of the usual daily load - walking, jumping, etc. or even in the absence of such, deformity of the femoral head gradually develops, which is the main and most difficult problem in the treatment of the 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 deformity of the femoral head can have a different degree of severity - from slight and barely noticeable on the radiograph to a rough "mushroom" or "saddle". The degree of deformation of the femoral head is determined by the size and localization (location) of the focus of necrosis 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 of clinical signs of the so-called deforming coxarthrosis (steadily progressive degenerative changes in the joint) in the form of a pronounced pain syndrome and gait disturbance at an age when it is necessary to arrange a personal life and receive education. By a favorable outcome is meant a situation where the joint functions for many years until old age, without making itself felt.
However, according to modern studies, the first stage of the disease is reversible, which means that under favorable circumstances (a small volume of necrosis and rapid restoration of blood flow in the epiphysis), the disease can end before the development of deformity of the femoral head, without passing into the second stage. The appearance of radiological signs of the onset of deformity of the femoral head indicates the transition of the disease to the stage of an impression fracture and the beginning of an irreversible and prolonged 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 dominate the processes of reparation (healing), which consist in the neoformation of bone tissue in the focus of necrosis - the stage of restoration comes to replace the stage of fragmentation. As a result of ongoing restructuring, the newly formed bone tissue eventually 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 focus of necrosis, the recovery stage is characterized by the resumption of growth of the femoral head. With a large volume of the focus of necrosis and the absence of adequate treatment, the growth of the femoral head is the cause of the 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 protrude from the articular 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 retains sphericity, and the femoral head, which plays a decisive role in the fate of the affected joint.
The head of the child's femur 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 the pathological process, completely or partially collapsing. As a result, over the years, a deformity of the entire upper end of the femur is formed, characterized by a shortening of the femoral neck and a high standing of the greater trochanter, and a 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 most children with Perthes disease (at least two-thirds of cases), the necrosis foci in the femoral head are small and do not include the outer section of the epiphysis and its growth zone, so the development of severe deformity of the femoral head and a significant discrepancy in shape articular surfaces are excluded. At the same time, the deformity of the upper end of the femur as a whole and the shortening of the limb were also insignificantly expressed.
The appearance of pain in the hip, knee or hip joint, as well as gait disturbance are the reason for contacting an orthopedist, who, after clarifying the anamnesis (history of occurrence and development) of the disease and clinical examination of the child, prescribes radiographs of the hip joints in the direct projection and the Lauenstein projection (Fig. . eight).

Rice. 8. Required minimum x-ray examination for suspected Perthes disease:

A. X-ray of the hip joint in the anterior-posterior projection.

B. Radiograph of the hip joint in the Lauenstein projection.

This is a necessary minimum examination, which allows you to confirm with high accuracy the presence of Perthes disease, even in the first stage, or to exclude this disease. In such cases, magnetic resonance imaging and ultrasound examination of the hip joints may also be recommended, however, the latter are carried out only as additional research methods, since they are not decisive in 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. The treatment of these diseases does not require surgical intervention, prolonged exclusion of support on the legs and walking, as well as the use of orthopedic devices.
At the heart of neurodysplastic coxopathy, as in the case of Perthes disease, is dysplasia of the lumbosacral spine and spinal cord, which causes a decrease in arterial and venous blood outflow in the hip joint and a violation of its innervation. On radiographs, there are signs of dystrophy (malnutrition) of the bone tissue of the pelvic and, predominantly, femoral components. The fundamental difference from Perthes disease is the absence of a 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) - inflammation of the inner (synovial) membrane of the hip joint, associated with the appearance and short stay in the joint of an infectious agent brought from other organs (foci of infection) with the blood flow, and characterized by impaired blood flow of varying degrees , but also without complete blocking and formation of a focus of necrosis.
When diagnosing Perthes' disease, the doctor must completely exclude reliance on the "sick" leg - depending on the age of the child and its development, strict bed rest or half-bed rest is prescribed with the possibility of limited walking on crutches. The same measures are taken if Perthes disease is suspected at the time of the examination until the final diagnosis is made. It is necessary to maintain a certain position in bed - on the back and on the stomach with a moderate spread of the legs, the position on the side (both on the "sick" and on the "healthy") is not desirable. The child is allowed to sit down in bed with support under the back and sit limitedly. In the presence of inflammatory phenomena in the joint, often associated with Perthes disease, and the associated limitation of the amplitude of hip movements, anti-inflammatory therapy is prescribed as the first stage of treatment for the patient.
The main goal of treating children with Perthes disease is to bring the anatomical structure of the affected hip joint closer to the normal (initial) one, only in this case it can be hoped that over the next years of life the patient will not have 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.
Traditionally, the treatment of children with Perthes disease is based on conservative measures - therapeutic exercises, massage, physiotherapy, as well as drug therapy, which are carried out after ensuring the centering of the femoral head (that is, its complete "immersion" in the acetabulum) through the use of one of the orthopedic fixtures. Such devices include functional splints (Mirzoeva's splint or Vilensky's 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-strut according to Lange.

B. Sheena MD professor I.I. Mirzoeva.

All these devices should give the “sick” leg a permanent (throughout the entire treatment period) position of abduction and internal rotation, or at least only abduction, which ensures centering in the affected joint.
The constant maintenance of the position of centration (or complete "immersion") of the femoral head in the acetabulum is a prerequisite in the treatment of Perthes disease with a large focus of necrosis, because in this case only with the help of centration it is possible to stop the progression of deformity and the development of subluxation of the femoral head. In addition, the complete "immersion" of the femoral head into the articular cavity provides optimal conditions for correcting the deformity that was already present at the time of treatment. The use of conservative methods of treatment that do not involve the centering of the femoral head is permissible only if the necrosis focus is small and includes only the anterior or anterior and central sections of the epiphysis, and the child belongs to the younger age group. At the same time, the doctor, prescribing control radiographs, constantly makes sure that the size of the necrosis focus has not increased.
Therapeutic exercises are carried out in order to stimulate the reparative process (healing) in the femoral head and increase the range of motion in the affected joint, it is possible only with the use of removable centering devices, while under conditions of skeletal traction or plaster casts, exercises are largely limited. Tonic massage and electrical stimulation of the muscles surrounding the hip joint allows you to maintain their functional activity and prevent the progression of malnutrition (decrease in muscle volume), which is one of the integral clinical manifestations of Perthes' disease and is characteristic of prolonged bed rest.
An important component of complex conservative treatment is the use of medications and physiotherapeutic devices of angioprotective action against which osteoprotectors and chondroprotectors are prescribed. Such devices and preparations (angioprotectors) provide an improvement in arterial and venous blood outflow in the area of the hip joint, while osteo- and chondroprotective drugs stimulate new formation of bone tissue in the focus of necrosis and have a positive effect on the structure of the cartilaginous tissue that forms the articular surfaces. These drugs are usually prescribed in the form of electrophoresis on the area of the lumbosacral spine and the affected joint, as well as in the form of oral forms (capsules, tablets, powders) and intramuscular injections. In particular, microelements - calcium, phosphorus and sulfur, which are prescribed, as a rule, in the form of electrophoresis according to a three- or two-pole method, in combination with each other or with ascorbic acid, have a pronounced osteoprotective effect. Trace elements can also be prescribed in the form of warm (mineral) mud or baths, which are most often found in a sanatorium. Among the physiotherapeutic devices that contribute to the normalization of blood flow in the depths of tissues, the Vitafon, which has a vibroacoustic effect on the vascular wall, is widely used.
The listed therapeutic measures are prescribed in courses lasting from two to four weeks with interruptions of at least one month - usually four or five courses of massage and physiotherapy are performed 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 styling. In addition, it is desirable to include in the treatment plan swimming in the pool - no more than twice a week, and in the recovery stage - an exercise bike. Thermal procedures (paraffin, ozocerite and hot mud), the temperature of which is more than 40 ° C, are considered contraindicated, as they contribute to the difficulty of 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 shown sanatorium-and-spa treatment. Orthopedic resorts are available in many regions of Russia - in the Novgorod region ("Staraya Russa"), in the Kaliningrad region ("Pionersk"), in the Ryazan region ("Kiritsy"), as well as on the Black Sea coast (Gelendzhik, Anapa, Evpatoria).
The duration of the considered conservative treatment, which is carried out under conditions of complete and then partial exclusion of reliance 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 the onset of the disease, the stage of the pathological process at the time of the start of treatment, and the volume of the focus of necrosis in the femoral head. Therefore, such treatment is indicated most often for children of the younger age group (up to 6 years old) with a small focus of necrosis. The timing of the start of a dosed support load on the sore leg, and then walking without improvised means, is determined by an orthopedist based on radiography of the hip joints, which is carried out no more than once every three or four months, or magnetic resonance imaging.
In addition to the long duration and the isolation of the child from peers and physical development associated with it, the negative side of conservative treatment is the appearance of excess weight in many children, which subsequently becomes the cause of constant overload of the affected joint. In this regard, the treatment is carried out against the background of a special diet and necessarily includes a permissible physical activity. But the main disadvantage of conservative treatment is, perhaps, the need to constantly maintain the correct position in bed and the use of the aforementioned centering devices, which cause significant inconvenience to children and their parents. Meanwhile, the use of orthopedic splints, various types of traction or plaster casts in many cases are among the mandatory and absolutely necessary conditions for the treatment.
The advantage of conservative treatment is the absence of the need for surgical intervention and related measures, which include general anesthesia (anesthesia), bandaging of the surgical wound and removal of sutures, intramuscular injections of analgesics and antibiotics, and in some cases blood transfusion. 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 more severe cases of Perthes disease, reconstructive hip surgery is preferred over the use of centering prosthetic devices. The latter provides complete "immersion" of the femoral head into the acetabulum not by giving the lower limb a certain position, but by a simultaneous change in the spatial position of the pelvic or femoral joint component after crossing the corresponding (pelvic or femoral) bone. Therefore, in the postoperative period, the child is spared from wearing orthopedic splints for many months or staying in traction. An important positive effect of such operations is also the stimulation of the reparative process in the focus of necrosis and, consequently, the reduction of the patient's treatment time.
Surgical intervention is included in the treatment plan only in cases of Perthes disease in children aged at least 6 years with a large foci 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 course 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 for the treatment of children with Perthes disease in the 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 duration of no more than one hour (Fig. 10).

Rice. 10. Anatomical structure of the hip joint in a child with Perthes disease (Ph.D. D.B. Barsukov, Ph.D. I.Yu. Pozdnikin "Surgical treatment of children with Legg-Calve-Perthes disease):

A. Before surgical treatment.

B. After performing a corrective (varus) medial osteotomy of the thigh.

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

1. Metal structures.

2. Lines of osteotomies (crossings) of the pelvic and femoral bones.

Interventions of a larger volume are used much less often. 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 the operating table, a plaster cast of one variety or another is applied to the child - depending on the nature of the intervention, the period of stay in it is four or five weeks.
In addition to reducing the period of exclusion of support on the “sore” 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, of course, has a great influence on the prognosis of the disease. The probability 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 perform such operations frequently. Most likely, such specialists can be found in specialized departments of hip joint pathology of research institutes or in children's orthopedic departments of regional, republican and regional hospitals.
No less influence on the prognosis of the disease has the conscientiousness of the implementation by the child and his parents of recommendations for further (postoperative) treatment of these data by an orthopedic doctor. The main ones are the exclusion of excessive physical activity (jumping, running, lifting weights) and excess body weight throughout the rest of life. In this regard, the child is prohibited from practicing almost all sports and physical education at school - at best, a visit to a special group is allowed without passing the standards. The physical activity of such children should be manifested in the form of some permissible types of load - 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 overweight, which becomes a serious additional problem for the patient. To maintain a normal weight, it is often necessary to follow a special diet, and sometimes medication in consultation with an endocrinologist.
It is difficult to overestimate the correctness of the employment of people who have had Perthes disease - the chosen profession should not be associated with heavy physical exertion and even constant (during the whole working day) being on their feet. Important is the regularity of maintenance courses of rehabilitation treatment (physio- and drug therapy), including in the conditions of sanatoriums.
Neglect of the above recommendations, even with the best immediate results of treatment, leads to the appearance of clinical signs of deforming coxarthrosis in the form of pain and gait disturbance. Usually, in Perthes disease, the clinical symptoms of coxarthrosis appear relatively late compared to 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 also develop at a young age, then, depending on the severity of the pain syndrome, a decision is made on hip arthroplasty (replacement of an unsuitable for the function of one's own organ with an artificial one). Endoprosthesis surgery at a young age is extremely undesirable - it should be carried out as late as possible. Fortunately, not all people treated for Perthes disease need arthroplasty. The same can be said about surgical interventions aimed at equalizing the length of the lower limbs - a large difference in the length of the legs is not common.
Thus, the determining factors in the prognosis of Perthes' disease are the child's age at the onset of the pathological process, the size and location of the focus of necrosis in the femoral head, early diagnosis of the disease, and the adequacy of the ongoing therapeutic measures. Therefore, the appearance of even minor pain in the legs or gait disturbance in a child is a reason for contacting an orthopedic doctor. The correct choice of the place of treatment and conscientiousness in the implementation of medical recommendations provide a favorable outcome of Perthes disease even in the most severe cases of the disease.

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

A hereditary factor, the disease can occur even in the womb of the fetus.
Problems with the activity of the endocrine glands or the endocrine system as a whole.
Metabolic disease.
The inability of the body to absorb calcium and other vitamins.
Various injuries.
After exhausting exercise. First, there is compression of the vessels, and then their narrowing in the spongy bones.

Symptoms

Osteochondropathy disease can affect certain parts of the body:

calcaneus (Haglund-Shinz syndrome) - observed in adolescent girls up to about 16 years of age. Manifestations are known for sharp pain in the heel area, which appear after exercise. In addition to pain, there is a 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) - young people under 18 years of age are ill. Several stages are known. With the first - the spine is bent in the upper section, the second - severe pain. The patient gets tired quickly, the back muscles are weak, aching at the slightest exertion. The last stage is characterized by the final fusion of the vertebrae with apophyses, with a progressive pain syndrome;
femur (Legg-Calve-Perthes syndrome) occurs in boys from preschool age to 12 years. At first it is asymptomatic. Later, the patient feels pain in the thigh, which radiates to the knee. As a rule, children do not always complain of such pains, since the discomfort periodically disappears, then reappears. Over time, atrophy of the muscle of the diseased thigh occurs, and it becomes very thin;
tibial tuberosity (Schlatter's disease) - boys also suffer from pathology. The disease can occur from 12 to 16 years old, is associated with certain activities, so those who are fond of: sports dancing, ballet get sick. The patient experiences pain when bending the legs at the knees, climbing up the stairs. The knee area is affected.

Diagnosis of osteochondropathy in a child

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

Although there is something that unites all clinical cases.

The specialist first of all conducts an x-ray examination of the part of the body of interest to 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 recommendations for treatment.

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

Complications

Severe consequences and negative consequences can really be avoided. With adequate therapy, experts give a favorable prognosis for such a 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, follow all the doctor's recommendations.

The specialist will explain in detail what needs to be done with a certain form of the disease. Parents will only have to fulfill all the indications of the attending specialist.

What does a doctor do

Elimination of inflammation of the calcaneus consists in prescribing non-steroidal anti-inflammatory drugs for severe pain, physiotherapy, and limiting physical activity. To relieve the load on the sore foot, the doctor recommends special arch support insoles.
Osteochondropathy of the vertebrae is eliminated with the help of a special massage, swimming, exercise therapy, underwater exercises. In severe situations, surgical intervention is indicated.
Therapy of an abnormal process in the femur can be medical and surgical. Plastic surgery on the bones is carried out depending on the severity of the pathology. Conservative therapy of pathology consists in prescribing bed rest (the child needs to lie down), massaging the legs, and physiotherapy. A skeletal hip extension is also shown.
To eliminate problems with tibial tuberosity, physiotherapy is indicated, the application of warm compresses. When pain is unbearable, plaster is applied. It happens that doctors perform an operation - they eliminate the site of tuberosity. Loads are excluded.

Prevention

Preventive measures are associated with that part of the body that has been exposed to the pathological process.

So, to prevent pathology it is necessary:

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

information to read

Osteochondropathy - necrosis (necrosis) of a bone area due to various reasons. The cartilaginous tissue adjacent to the bone also suffers. The disease proceeds chronically, gradually causing deformation of bones and joints, arthrosis, limitation of mobility (contracture) joins with age. Most often, children and adolescents aged 5-14 years are sick, but osteochondropathy in adults also occurs. In the structure of orthopedic morbidity, it is 2.5-3% of the total number of visits.

Violation of blood flow through the arteries going 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 \u200b\u200bthe bone near the joint (epiphysis), leading to its necrosis and associated complications - deformities, fractures. The following factors can lead to circulatory disorders :

Injuries: bruises, hematomas, damage to soft tissues, bone, cartilage.
Hormonal and metabolic disorders, mainly in the pubertal (adolescent) period, lack of phosphorus and calcium salts.
Lack of protein in the diet (for example, in vegetarians).
Increased bone growth when it outpaces vascular development.
Excessive functional load on the joints, especially in childhood and adolescence.
A sedentary lifestyle (physical inactivity), leading to stagnation of blood.
Congenital anomalies in the development of the osteoarticular system.
Being overweight puts more stress on the 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;
apophyses of bones (protrusions, tuberosities);
short bones (vertebrae, tarsal bones of the foot).

In the region of the epiphyses of bones, the following types of osteochondropathy develop:

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

Apophyseal osteochondropathy:

tibia of the lower leg;
apophyses of the vertebrae;
calcaneus;
knee joint;
pubic (pubic) bone.

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Osteochondropathy of short bones:

vertebral bodies;
navicular bone of the foot;
semilunar bone of the wrist;
sesamoid (additional) bone at the base of the 1st toe.

Stages of development and clinical manifestations of osteochondropathy

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

First stage- initial, when there is necrosis (necrosis) of the bone area due to circulatory disorders. It is manifested by aching pains in the bones, joints or spine (depending on location), increased fatigue, impaired movement.
Second stage- destruction, fragmentation of the bone (separation into fragments). Characterized by increased pain, bone deformity, the appearance of 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. The pain syndrome decreases, but deformity and limitation of function may remain.

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

Diagnostic methods

The following methods are used to diagnose osteochondropathy:

radiography;
computed tomography (CT);
magnetic resonance imaging (MRI);
radioisotope examination of the entire skeleton (scintigraphy);
ultrasonic 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-Calve-Perthes disease

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

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). Assign calcium and phosphorus preparations, vitamins, vasodilators, locally - calcium iontophoresis, massage, exercise therapy. A good effect gives treatment in a specialized sanatorium. The disease usually responds well to treatment, and only if it is ineffective, surgery is indicated (osteotomy, removal of necrotic bone, joint plasty or arthroplasty).

Important. Perthes disease can lead to irreversible changes in the joint when a prosthesis is needed. Therefore, its treatment should be timely and qualified.

Schlatter's disease (Osgood-Schlatter)

This is osteochondropathy of the tibia, or rather, its tuberosity, located on the anterior surface of the lower leg, immediately below the knee joint. Both boys and girls from 10 to 17 years old are ill, mostly strenuously involved in sports. Painful swelling appears below the knee, walking and movements in the knee are painful.

For the treatment of osteochondropathy of the tibia, the limb is fixed with a splint, physiotherapy, massage, and calcium preparations are prescribed. The disease usually responds well to treatment, although the "bump" on the bone remains.

Osteochondropathy of the foot in children

The navicular, calcaneus, and metatarsal bones are most commonly affected. Necrosis in the navicular bone located on the inside of the foot is called Keller's disease I. Boys from 3 to 7 years old get sick in the majority, the lesion is unilateral. When walking, the child begins to limp, leans on the outer part of the foot (curves the leg). Usually the disease does not give sharp symptoms, it may remain undiagnosed, it goes away on its own within a year. When detected, the wearing of arch supports, special shoes, physiotherapy, exercise therapy is prescribed.

Osteochondropathy of the heads of the II-III metatarsal bones (Keller's disease II) more common in adolescent girls, both feet are affected. When walking, pain in the foot appears, which then becomes permanent, can disturb even during sleep. There is swelling of the foot, shortening of the toe. 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 (Shinz's disease) can develop in both boys and girls aged 7-12 years, both limbs are more often affected. There is pain, swelling on the back of the heel, lameness, difficulty wearing shoes. The child begins to walk, relying more on the toes. Over time, atrophy of the calf muscle may develop.

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

Osteochondropathy of the spine

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

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 people (11-19 years old) get sick. The disease is widespread, especially in recent decades. Symptoms are expressed in spinal deformity (flat or round back), concavity of the sternum ("cobbler's chest"), back pain, atrophy of the chest muscles, and increased fatigue. The patient cannot stay upright for a long time, perform physical activity. A wedge-shaped deformity of the vertebrae gradually develops, they take on the form of a trapezoid (the height of the bodies in the anterior sections decreases). In the future, osteochondrosis and deforming spondylosis join these changes.

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

Long-term treatment of osteochondropathy of the spine: physiotherapy, exercise therapy, massage, wearing a corrective corset, vitamin therapy, chondroprotectors, sanatorium treatment. In rare cases, when the spinal deformity is pronounced or disc herniations, displacement of the vertebrae have formed, operations are performed (correction and fixation of the vertebrae, plasty of the arches and discs).

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

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

Usually one limb is affected. Perthes' disease begins gradually, with limited abduction and external rotation of the hip while other movements are preserved. Mild lameness appears. pain, crunch in the hip joint when walking. The limb is somewhat thinner. When tapping on the trochanter of the thigh - soreness. On radiographs, at first, rarefaction of the bone tissue pattern, expansion of the joint space and areas of necrosis of the femoral head are noted (this stage lasts 6-8 months); further, under load, the head of the femur is crushed like an eggshell; 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 segments of the head begins, and after 2-3 years it is restored, but its shape is deformed. The contours of the bottom of the acetabulum are also deformed.

With the right early treatment - restorative therapy, bed rest, immobilizing dressings, unloading devices (see Orthopedic devices) - the function of the limb is restored completely. Sometimes there are indications for surgery aimed at improving the 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-Calve-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 predominantly affected on one side, but bilateral lesions have also been described in the literature.

The etiology of the disease is still not clear enough. Of all the theories proposed to explain the reasons for the development of P. b. (infection, rickets, endocrine system disorders, congenital predisposition to circulatory disorders, trauma, etc.), the traumatic theory is the most common and justified. It is natural that not at each patient the bruise can lead to P. b.

The pathoanatomical observations and experimental data accumulated to date to some extent confirm the traumatic theory, but do not allow us to draw final conclusions on the issue of P.'s etiology 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 in the knee joints. The pain intensifies towards the end of the day, subsides at night.

On examination, a slight limitation of hip abduction, mild lameness, and subtle atrophy of the limb are noted. The load 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, Trendelenburg's symptom appears, and when measured, a slight shortening of the limb and a high standing of the greater trochanter are found.

There are no noticeable changes in the general state of the body. Children are reluctant to go to bed, despite the lameness, continue to run. 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, how early treatment is started.

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

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

Along with the main, conservative, method of treatment P. b. there are surgical methods that stimulate the ossification of rarefied bone foci (tunnelization and the introduction of a frozen homotransplant into the femoral neck). The best conditions for children sick with P. would. created in specialized sanatoriums. Conservative treatment P. b. in a sanatorium consists in observing bed rest, vitamin therapy, good nutrition. Of the physiotherapy procedures, transverse ionogalvanization with calcium chloride can be applied to the area of the hip joint (in the recovery period).

Rest is achieved either by applying a coxite plaster bandage, or by using orthopedic devices (see) with an emphasis on the ischial tuberosity, which reduce the load on the limb.

The most rational is bed rest for 6-8 months with sticky plaster traction of the diseased leg. With the latter, the load is excluded, and flexion and rotational movements are even advisable. They are elements of therapeutic exercises for this disease.

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

I. The 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 epiphysis of the femur. X-ray signs of the disease in this stage, lasting 6-8 months. are the flattening of the epiphysis of the femur, the compaction of its structure and the expansion of the x-ray joint space. The strip of metaepiphyseal cartilage acquires some tortuosity, which indicates a violation of endochondral bone growth. These signs gradually increase over the specified period (Fig. 1).

III. Stages of sequester-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 unresorbed necrotic bone remain, creating some external resemblance to bone sequesters. The deformation of the head increases: in addition to its flattening, it increases in transverse size. The thickening of the neck of the femur (due to periosteal bone formation), which also turns out to be shortened in comparison with the healthy one due to inhibition of endochondral bone growth, joins the previously arisen and intensified signs. A strip of metaepiphyseal cartilage undergoes significant changes; it becomes extended, even more tortuous and indistinctly defined. The joint space is further expanded. The cervical-diaphyseal angle of the femur decreases.

Rice. 2. Perthes' disease, stage III, the same Salt as in fig. 1, after 1 year and 4 months. Uneven rarefaction of the deformed and compacted epiphysis of the head of the left femur - a picture of sequester-like shadows, thickening of the head and neck of the femur, expansion 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 subluxation of the femur outward (Fig. 2). Mild osteoporosis may appear at this stage. Its duration is approximately two years.

IV. reparation stage. It goes on for about a year. Radiographically, there is a picture of a gradual restoration of the structure of the bone substance of the femur while maintaining the resulting deformity of the hip joint.

There are no clear boundaries between these stages. Therefore, when diagnosing Perthes' disease, sometimes they give such definitions of the x-ray picture as II-III or III-IV stages of its development.

V. The stage of the consequences of aseptic necrosis, when characteristic deformities of the hip joint remain (Fig. 3). Many years after clinical recovery and with a satisfactory condition of the patient (there is only a slight limitation of rotation and abduction of the limb in the hip joint), already in adulthood, 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 - the restoration of a 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 form of the head of the left femur in the clinical cure of Perthes disease - the transition from IV to V stage (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 between the ages of 3 and 14 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 lesions are possible, while the second joint usually suffers less and recovers better.

Causes and predisposing factors for the development of Perthes disease

Currently, there is no single cause of Perthes disease. 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 in any way or cause various orthopedic disorders.

With myelodysplasia, the innervation of the hip joints is disturbed, and the number of vessels that supply 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 a smaller diameter. Because of this, tissues constantly suffer from insufficient blood supply. Changes in vascular tone due to impaired innervation also have a negative effect.

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

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

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 move is enough.
Inflammation of the hip joint (transient synovitis) with microbial and viral infections (flu, tonsillitis, sinusitis).
Changes in hormonal levels during adolescence.
Metabolic disorders of calcium, phosphorus and other minerals that are involved in bone formation.

In some cases, a hereditary predisposition to the development of Perthes disease is revealed, 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.
Growth of connective tissue at the site of necrosis.
Replacement of connective tissue with new bone, fracture union.

The outcome of Perthes disease depends on the size and location of the area of necrosis. With a small focus, a full recovery is possible. With extensive destruction, the head breaks up into several separate fragments and, after fusion, may acquire an 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 of pathological changes: the formation of contractures . limitation of support and rapid development of severe coxarthrosis.

Symptoms of Perthes disease

In the early stages, non-intense dull pains appear when walking. Usually the pain is localized in the area of the hip joint, but in some cases pain is possible in the area of the knee joint or throughout the leg. The child begins to slightly noticeably limp, falls on a sore leg or drags it. As a rule, during this period, the 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 increases sharply, lameness becomes pronounced. The soft tissues in the joint area swell. Restriction of movements is revealed: the patient cannot turn the leg outward, rotation, flexion and extension in the hip joint are limited. Walking is difficult. Vegetative disorders are noted in the distal parts of the diseased limb - the foot is cold, pale, its sweating is increased. An increase in body temperature to subfebrile numbers is possible. Subsequently, the pain becomes less intense, support on the leg is restored, however, lameness and limitation of movement may persist. In some cases shortening of a limb comes to light. Over time, there is a clinic of progressive arthrosis.

Diagnosis of Perthes disease

The most important study, which is decisive in the diagnosis of Perthes disease, is the radiography of the hip joint. If this disease is suspected, not only images in standard projections are performed, but also an X-ray in the Lauenstein projection. The X-ray picture depends on the stage and severity of the disease. There are various radiographic classifications, the most popular of which are the Catterall and Salter-Thomson classifications.

Catterall classification:

1 group. X-ray signs of Perthes disease are mild. A small defect is revealed 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 defined.
2 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, the emerging sequester is determined.
3 group. The head is affected almost completely, deformed. A fracture line appears.
4 group. The head is completely damaged. The line of fracture and changes in the acetabulum are revealed.

Salter-Thomson classification:

1 group. A subchondral fracture is determined only on a radiograph in the Lauenstein projection.
2 group. The subchondral fracture is visible on all images, the outer border of the head is not changed.
3 group. Subchondral fracture "captures" the outer part of the epiphysis.
4 group. 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 to more accurately assess 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 observed by a pediatric orthopedist; special therapy is not required. In other cases, patients are referred for treatment to the orthopedic department, followed by outpatient aftercare. Conservative therapy is long-term, lasting at least a year (average 2.5 years, in severe cases up to 4 years). Treatment includes:

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

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

Children are prescribed angioprotectors and chondroprotectors in the form of oral and intramuscular injections. Starting from the second stage, patients are sent to UHF. diathermy, electrophoresis with phosphorus and calcium, mud therapy and ozocerite. The load on the leg is permissible only after radiologically confirmed fracture union. At the fourth stage, patients are allowed to perform active exercises, at the fifth stage, a complex of exercise therapy is used to restore muscles and range of motion in the joint.

Surgical interventions for Perthes disease are indicated in severe cases (the occurrence of severe deformity, hip subluxation) and only in children older than 6 years.

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

People who have had Perthes disease, regardless of the severity of the disease, are recommended to exclude excessive loads on the hip joint throughout their lives. Jumping, running and lifting weights are contraindicated. Swimming and cycling are allowed. You need to do physical therapy regularly. You should not choose work associated with heavy physical exertion or prolonged stay on your feet. It is necessary to periodically undergo rehabilitation treatment in polyclinic conditions and conditions of sanatoriums.

Perthes disease - treatment in Moscow

Perthes disease is a rare pathology characterized by the death of the head of the femoral bone 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 of the age category of 4-12 years old are affected by pathology, and girls get sick five times less often, and the course of the disease is much more difficult for them.

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

Perthes disease does not pose a danger to the patient's life, however, there are frequent cases of the development of physical defects, as well as disability.

The reasons

The main reason for the appearance of Perthes disease has not yet been identified.

Experts put forward several theories of origin and causes:

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

One of the important conditions for the development of pathology that can lead to disability is congenital myelodysplasia in the sacro-lumbar 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 the child's greatest physical activity.

Other manifestations of pathology include:

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

With significant violations of bone anatomy for the disease, the 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;

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

stages

Legg Calve-Perthes disease has the following stages:

Stage I - the destruction 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. There is a resorption of dead tissue and a shortening of the femoral neck.

Stage IV - there is a lack of joint function, acute pain symptoms in any position of the body. 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 cavity is significantly narrowed or absent. Connective tissue grows rapidly.

Stage V - at this stage, the bone grows together, but the shape of the femoral head often, especially with delayed therapy, remains with significant changes. This condition provokes an irreversible articular change and, sometimes, disability.

According to some reports, each stage of the disease is formed 5-7 months.

Diagnostics

The main way to diagnose this disease is radiography. Use research in standard projections and Lauenstein projections. The study helps to determine the degree of destruction and the condition of the joint, as well as determine the stage of 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 posture disorders and the reasons that cause them.
What preventive measures should be taken to avoid posture disorders can be found here.

Treatment

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

The main principles of conservative therapy are:

absolute unloading of the legs;
imposition of traction, the use of 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.

Medical treatment

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

Physiotherapy treatment

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

Physiotherapy

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

Food

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

Orthopedic appliances

Treatment of pathology by conservative methods is carried out after complete "immersion" of the head of the bone in the acetabulum.

functional tires (Mirzoyeva's tire, Vilensky's tire);
plaster bandages (coxite, Lange bandage);
traction for the lower leg or thigh (cuff, adhesive plaster, skeletal), etc.

Surgical treatment

In severe cases of pathology in children older than 6 years, surgery is used instead of the use of orthopedic devices. During the operation, “immersion” of the head of the bone into the acetabulum is performed by means of a one-time change in the position of the head of the bone. Bolts and plates are used to fix the position. Sometimes, due to an increase in the size of the head due to necrosis, an operative deepening of the cavity is performed.

Disability

In severe cases of the disease, doctors may advise you to issue a disability to a sick child. To apply for a disability or not is the choice of each parent. If there is any doubt, you can study the discussion of this problem on the Internet. There are many forums on the network 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 the age-related decrease in the ability to regenerate bone tissue, the disease is treated with a surgical method. At the very beginning of the development of pathology, tunnels are drilled in the thigh bone, which help to 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 severely neglected, the joint is replaced with an endoprosthesis.

How long can treatment take?

According to statistics, the sooner Legg-Perthes disease is diagnosed, the shorter the treatment will be. As a rule, the therapy of 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 be at risk of disability. Perhaps the formation of deforming arthrosis, limited mobility of the lower limb, lameness. The disease is completely curable with timely diagnosis and adequate treatment.

Reasons for the development of the disease
Disease types
Diagnostics
Treatment

Often the question arises, what is it and who manifests it? From Greek 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). There is a change in the bone tissue of the musculoskeletal system (for example, in the apophysis of short tubular bones), the bone is deformed (it loses its strength), a violation and a change in the joints. A person, having 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?

It is transmitted genetically.
The hormonal balance is disturbed (especially in the work of the endocrine glands).
Poor metabolism (hard to absorb Ca and vitamins).
Lack of interactions between the vasculature and bone tissue.
Changes in the regulation of blood flow, nervous trophism.
Very often the body is exposed to microtrauma.
The limbs and spine are not in their natural position (most often among professional athletes).

Types of disease

This disease can be conditionally divided into groups IV, each type of manifestation has its own characteristic and individuality.
How are they distributed?

1. In the tubular bones (in the epiphysis):

in the femur (head) - Legg-Calve-Perthes disease;
in the I-III metatarsal bone (head), clavicle (its sternal end), fingers (their phalanges) - b. Kehler II.

2. In short tubular bones:

in the foot (scaphoid) - Koehler's disease I;
in the brush (lunate k.) - b. Kienbek;
in the wrist (navicular k.) - b. Price;
in the vertebral body b. Calve.

3. In apophyses:

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

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

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

Osteochondropathy of the tibial tuberosity (b. Osgood-Schlatter) is a kind of necrosis of the bone in the knee area (necrosis). It often occurs after numerous injuries and injuries in this area (more often in boys who are professionally involved in sports, aged 10-15 years). There are pains in the knee, swelling. It is treated for a long time, disappears after a complete suspension of growth.

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

Osteochondropathy of the calcaneus (b. Haglund-Shinz) - this disease is manifested by unpleasant pain in the region of the Achilles foot, heel, swelling is formed. It usually manifests itself in girls, after prolonged exertion (at the age of 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 need to see a doctor. The disease is difficult to detect in the early stages, it is better to avoid complications. This disease is treated for a very long time and completely disappear when the growth of the body has stopped. Better not to self-medicate. The doctor will diagnose and prescribe treatment.

How can this disease be diagnosed?

An X-ray examination is prescribed: X-ray, tomography, angiography. Thanks to this, 5 stages of this disease can be distinguished. At the initial stage, only cartilage necrosis appears, at the latter, a regeneration method (complete recovery) or further destruction, arthrosis, can occur.

How is it treated?

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