Pediatric Case Challenge: A 7-Year-Old Boy With a Limp and Obesity Who Fell in the Street

Derik L. Davis, MD; Ogechukwu R. Menkiti, MD; Brighita Weinberg, MD

Disclosures

June 15, 2022

Important priorities in the treatment of Legg-Calvé-Perthes disease include maintaining the spherical shape of the femoral head and containing its presence within the acetabulum. Alleviation of symptoms and restoration of range of motion of the lower extremity are desired clinical outcomes. Various therapeutic strategies are used for patient management, but there is still controversy over which methods of intervention are optimal for each patient and how best to grade the severity of disease. The general philosophy of the surgeon on these matters typically dictates the treatment plan. Management is directed by the patient's symptoms and the severity of the disease, as determined by imaging studies.

The bone age of the child is another important consideration for treatment.[4,6,7] Patients younger than 6 years or older children whose condition is classified in Catterall Group I may require only conservative management, without surgery. These children may receive range-of-motion exercises, traction, avoidance of weight bearing, and/or bracing as the only therapy. In certain children, only bedrest and anti-inflammatory medications may be indicated. In older children or in those with advanced disease (Catterall Groups III and IV), surgical intervention may be necessary. Because the outcome in adulthood is usually good, surgery is now performed less often than in the past, as it is effective only in patients with lateral pillar group B or B/C disease with onset after age 8 years.[8] Age at onset and the lateral pillar classification are the two main outcome predictors and serve to guide the surgical indications.

Various procedures are used, depending on the clinical situation and surgeon's preference, to avoid long-term disability. Femoral varus osteotomy and Salter's innominate osteotomy provide good outcomes. In severe forms, combining these two techniques or performing a triple pelvic osteotomy appears preferable. For less severe anatomic alterations, surgical intervention is not recommended. Because risk factors cannot be altered, preventive strategies are not available.

The patient in this case was placed on crutches and given instructions not to bear weight on the left lower extremity. Following discharge from the ED, he received follow-up evaluation by the pediatric orthopedics service of an affiliated institution, and he subsequently received surgical management 4 months later.

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