Legg-Calvé-Perthes Disease

Definition: a self-limiting condition of the proximal femur characterized by

avascular necrosis of the femoral head.

Cause: UNKNOWN

Classifications:

1. Stage I: Avascular stage – aseptic necrosis or infarction of the femoral capital

epiphysis with generative changes producing flattening of upper surface of
the femoral head.

2. Stage II: Fragmentation or revascularization stage – capital bone absorption

and revascularization with fragmentation that gives a mottled appearance on
radiographs

3. Stage III: Reparative stage – newborn formation, which is represented on

radiographs as calcification on ossification or increased density in the areas
of radiolucency; this filling in process appears to take place from the
periphery of the head centrally.

4. Stage IV: Regenerative stage – gradual reformation of the head of the femur
without radiolucency and it is hoped, to a spherical form

Manifestations:

• Hip soreness, ache or stiffness (constant or intermittent)

• Pain experienced on hip, along the entire thigh or in the vicinity of the knee
joint

• Limp on the affected side

• Joint dysfunction

• Limited ROM

• Unequal leg length

• Muscle spasm

• Short stature

Risk factors:

1. Male (Boys 3-12 years old)

2. Short stature

3. More common in whites than in blacks

Pathophysiology:
 The cause of the disease is unknown, but there is a disturbance of circulation
to the femoral capital epiphysis that produces an ischemic aseptic necrosis of the
femoral head. During middle childhood, circulation to the femoral epiphysis is more
tenuous than at other ages and can become obstructed by trauma, inflammation,
coagulation defects, and a variety of other causes. The pathologic events seem to
take place in four stages. The entire process may encompass as little as 18 months
or continue for several years. The reformed femoral head may be severely altered
of appear entirely normal.

Complications:

1. Permanent hip deformity - Legg-Calve-Perthes disease may cause a

permanently deformed hip joint – especially if the condition develops after
ages 6 to 8.

Nursing Responsibility – Explain the importance of compliance to treatment

to the patient and to the parents.

2. Increased chance of osteoarthritis - Severe cases of Legg-Calve-Perthes

disease may increase the risk of osteoarthritis as an adult.

Nursing Responsibility – explain the techniques on how to prevent further

complications to patient and family

Diagnostic Tests:

 X-rays (anteroposterior [AP] and frog leg lateral) allow assessment of the
extent of epiphyseal involvement and stage of disease.

 Explain procedure to the patient

 Inform patient that the procedure is not painful and will take only a few
minutes
 Assist patient in going to the x-ray room

 MRI has been useful in detecting infarction but is not accurate in showing
the stages of healing.

 Obtain health history

 Sign consent
 Ensure that patient is removed of any metal objects and does not have
any metal implants.
 Have patient void before the procedure

 Bone scan is used to help diagnose LCP in the early stage of the disease,
where the diagnosis is questionable.

 Obtain health history

 Sign consent
 Remove all jewelry and/or metal objects
  Have patient void before the procedure

Nursing Management:

1. Acute pain related to inadequate blood supply to the epiphysis and

acetabulum
Rationale: Impaired circulation of blood to the epiphysis making bone collapse
resulting to pain
Goal: Patient will be relieved of pain
Objectives:
 After 1 hour of nursing intervention, the patient will enumerate techniques
to prevent or decrease pain.
 After 20 minutes of nursing intervention, the patient will enumerate
techniques to prevent or decrease pain.
Nursing intervention:
• Assess pain. Provide information as a basis for pain management.
• Promote rest, sleep and comfort techniques. Reduces or prevents pain.
• Move extremity with smoothness and care. Prevents pain caused by
careless handling or abrupt movement of the affected part.
• Provide diversional activities. Diverts attention from the pain.
• Explain to parents and patient the importance of maintaining
immobilization of the extremity and avoiding weight bearing activities.
Prevent undue pain caused by movement of affected area.
• Dependent: Administer pain medication per doctor’s order. Relieves pain.

2. Impaired physical mobility related to musculoskeletal impairment

(femoral head)
Rationale: Medical protocol of corrective device impose restrictions in movement
 Goal: Patient will gain improved physical mobility
Objectives:
 After 1 hour of nursing intervention, the patient will report measurable
increase in mobility.
 After 30 minutes, the patient will participate willingly in necessary
activities.
 After 30 minutes, the patient will identify techniques to enhance mobility.
Nursing intervention:
• Assess motor function. Provides information about musculoskeletal
condition of the patient and may indicate decline or progression of
condition.
• Assist in ROM strengthening exercises. May prevent further complications
related to disease. Maintains muscle and joint function.
• Provide and apply corrective devices. Prevent deformity.
• Teach parents and patient proper use and care of devices and aids.
Promote safe use of aids and apparatus.
• Reposition patient according to schedule and provide skin care regularly.
Prevent impaired skin integrity.
3. Risk for impaired skin integrity related to immobilization and usage of
corrective devices
Rationale: Pressure from cast or appliance may cause damage to skin and
underlying tissues.
Goal: Patient will demonstrate absence of signs of impaired skin integrity.
Objectives:
 After the intervention, the patient will demonstrate techniques to prevent
skin integrity
Nursing intervention:
• Assess skin. Inspect bony prominences. Check for skin damage.
• Reposition patient according to schedule. Prevent too much tissue
pressure on particular body part.
• Gently massage bony prominences. Avoid friction.
• Provide skin care regularly. Helps maintain skin integrity.
• Encourage fluid intake and adequate nutrition. Maximize skin integrity.

4. Delayed growth and development related to immobilization

Rationale: Chronic illness or disability delay or unable patient to perform
developmental task typical for age group.
 Goal: Patient will exhibit age appropriate growth and development
Objectives:
 After the intervention, the patient will increase social interaction.
 After the intervention, the patient will participate in activities appropriate
to his age and abilities.
Nursing intervention:
• Assess patient’s growth and developmental level. Help to assist in plan of
care or therapy.
• Provide developmentally appropriate activities based on age related
abilities. Enhance patients maximum growth and development abilities.
• Encourage socialization. Develop and maintain peer relationship and
reduces boredom.
• Provide age appropriate toys. Promote social and developmental activities
and reduces boredom.
• Encourage parents to allow as much independence in self care by child as
possible. Promote independence and allows some control over the
situation.
• Dependent: Refer to child development expert if appropriate. Provide
source of assistance to ensure proper age related development.

5. Deficient knowledge related to lack of information about the disease

Rationale: Patient and family might not have knowledge about the illness, its
treatment, management of the therapy and modification of activities.
Goal: Clients will obtain knowledge about the illness
Objectives:
 After 30 minutes, the parents will verbalize understanding of importance
and proper use of corrective devices.
 After 30 minutes, the parents and patient will demonstrate return
demonstration of application of corrective devices.
Nursing intervention:
• Provide information about the disease. Ensure compliance of medical
regimen for correction.
• Teach parent and patient about use and purpose of corrective devices.
Provides containment of position of the femur.
• Teach parents about the care of corrective devices including tightness and
alignment with joints. Promotes proper function of appliance used and
prevents complication associated with its use.
 • Teach child the importance of rest and avoiding weight bearing (except as
prescribed by the physician). Prevents degeneration of the hip joint
caused by femoral damage.

Medical and Surgical Management:

1. Abduction Traction – used to increase the range of motion in a child who has
developed limited hip motion from pain and spasm. Abduction traction is
gradually incrased on a daily basis to a point comfortably tolerated by the
child.
o Explain the purpose of the traction
o Check and monitor for complications
2. Serial casting – casting in the hips in an abducted position with weekly cast
changes using a progressively longer bar until full range of abduction in
achieved.
o Assist physician in putting the cast
o Explain the purpose of the procedure to the parent and patient
o Check for complications
o Encourage client to report any unusual sensation in the casted
extremity
3. Pavlik harness – by flexing up the legs, and allowing the knees to fall
outwards, the hips are held in proper position.
o Check the skin 2-3 times a day
o Massage the skin under straps to stimulate circulation
o Avoid putting on lotion or powder
4. Tetonomy – surgery performed to release atrophied muscle that has
shortened due to limping.
o Verify doctors order
o Secure consent
o Provide information about the procedure
o Prepare patient physically and psychologically before the operation
5. Osteotomy – surgical realignment of the femur so that the head of the femur
is securely contained within the acetabulum.
o Secure consent
o Provide information about the procedure
o Prepare patient physically and psychologically before the operation
References:
Hockenberry, Marilyn J. Wong’s Essentials of Pediatric Nursing, 7th ed. USA: Mosby,
2005
Lexner, Karla L. Delmar’s Pediatric Nursing Care Plan, 3rd ed. USA:Thomson, 2005
Porth, Carol M. Pathophysiology. USA: Lippincott Company, 1996
Skinner, Harry B. Current Diagnosis and Treatment in Orthopedics, 4th ed. USA:
McGraw-Hill, 2006