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Pedia SGD

Pedia SGD. General Information. Patient is Lucy Raz , a 10 year old female, left-handed, grade 5 student from Caloocan. CC: shortened left leg. History of Present Illness.

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Pedia SGD

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  1. Pedia SGD

  2. General Information • Patient is Lucy Raz, a 10 year old female, left-handed, grade 5 student from Caloocan. • CC: shortened left leg

  3. History of Present Illness • 8months PTA: Patient fell on her hip while walking down the stairs. Patient reported she can still walk and run normally. No consult was done and there is no note of LOM, gross deformity and pain. Patient had fever , lysed by Paracetamol • 7 months PTA: Patient was noted to be limping while walking “paika-ika”. And had pain in the Left inguinal area.

  4. History of Present Illness • 6 months PTA: Parents noted that the patient’s left leg shortened. There was also persistence of pain in the left inguinal area and developed left knee pain. • 3 months PTA: Consulted at POC and was referred to PGH for further management.

  5. Past Medical History: (-)BA, allergy, previous hospitalizations • Family Medical History: (-) DM,CA (+) HPN - mother • Personal/Social History: (-) smoker (-) alcohol intake. Grade 5 student, iglesianicristo member, L-handed • Immunization: Completed EPI c/o LHC

  6. Physical Examination

  7. Physical Examination

  8. XRAY Plates

  9. XRAY Plates

  10. Differentials

  11. Differentials

  12. Assessment Leggs-calves-perthes disease

  13. Classification Systems • Caterral Classification • Salter-Thomson Classification • Herring Classification • Modified Waldenstroms

  14. Caterral Classification • Stage I — Histologic and clinical diagnosis without radiographic findings • Stage II — Sclerosis with or without cystic changes with preservation of the contour and surface of femoral head • Stage III — Loss of structural integrity of the femoral head • Stage IV — Loss of structural integrity of the acetabulum in addition

  15. Salter-Thomson Classification • Group A- includes Caterral I and II • <50% femoral head • Group B- includes Caterral III and IV • >50% femoral head

  16. Herring Classification • Lateral pillar group A,there is no loss of height in the lateral one third of the head, and there is little density change. • lateral pillar group B,there is a lucency and less than 50% loss of lateral height. Sometimes, the head is beginning to extrude from the socket. • lateral pillar group C,there is a more than 50% loss of lateral height.

  17. Modified Waldenstrom’s Classification • Initial • Fragmentation • Reossification • Healed

  18. Treatment Goals • to reduce hip irritability • restore and maintain hip mobility • to prevent the ball from extruding or collapsing • to regain a spherical femoral head

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

  20. Surgical • Femoral Osteotomy • InnominateOsteotomy

  21. Treatment Choice Patients aged <6 years at onset are best managed nonsurgically, whereas older patients may benefit from surgical treatment. Good surgical results have been reported in 40% to 60% of older patients (>8 years), indicating the need to develop more effective treatments based on the pathobiology of the disease.

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

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

  24. Short Discussion • Legg-Calve-Perthes disease (LCPD) is avascular necrosis of the proximal femoral head resulting from compromise of the tenuous blood supply to this area. • LCPD usually occurs in children aged 4-10 years. The disease has an insidious onset and may occur after an injury to the hip.

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

  26. Pathophysiology • Rapid growth occurs in relation to development of the blood supply of the secondary ossification centers in the epiphyses, creating an interruption of adequate blood flow and making these areas prone to avascular necrosis. • Interruption of the blood supply to the bone results in necrosis, removal of the necrotic tissue, and its replacement with new bone.

  27. Bone replacement may be so complete and perfect that completely normal bone may result. • The adequacy of bone replacement depends on the age of the patient, the presence of associated infection, congruity of the involved joint, and other mechanical and physiologic factors. • Necrosis may occur after trauma or infection, but idiopathic lesions can develop during periods of rapid growth of the epiphyses.

  28. Prognosis • Overall, the prognosis for recovery and sports participation after treatment is very good for most individuals.

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