Perther Disease Ppt-1 Hetvi

PERTHER 'S
DISEASE
SYNONYMS:COXA PLANA, LEGG-CLAVE-
PERTHES'DISEASE PSEUDOCOXALGIA,
OSTEOCHONDRITIS DEFORMITIS
JUVENILE.
INTRODUCTION
• Perther's disease is disease of childhood

characterized by avascular necrosis of femoral
head
• .The exact cause is unknown
• How ever, a local disturbance of blood supply
thought to be the main causative factor.
EPIDEMIOLOGY
1. There is profound geographical variation

incidence of the disease.
2. The incidence is higher in the southwest

costal area but it is much less elsewhere in
india.
PATHOGENESIS OF FEMORAL HEAD
DEFORMITY
• During the first stage of the disease, synovitis occur.

Synovitis leads to hypertrophy of the articular cartilage,
which is most marked on the medial aspect of the hip.
• This causes the Lateral part of the femoral head to
extrude beyond the roof of the acetabulum. This is
reffered to as extrusion/loss of containtment /Lateral
subluxation.
• • Various activity including standing and Walking cause
the acetabular margin to compress on the extruded
part of the avascular epiphysis. This leads to the
deformation of the femoral head.
• • The epiphysis of the femoral head becomes necrotic
and soft. In this state It is suceptable to get deformed if
subjected to the stresses of weight bearing.
• ALTHOUGH, THE HEAD REVASCULSRIZES AND HARDENS AGAIN
AFTER SOMETIME, IT NEVER REGAINS THE NORMAL SHAPE IF
DEFORMED. THE WHOLE PROCESS TAKES ABOUT 2-4YEARS.
CLINICAL FEATURE
• 1. Age at onset of the disease is between

5and12 years. In the western countries, it is
more common around 6 years of age while in
india, it is seen around 8-9years and after the
age of 12years.
USUALLY, THE CHILD PRESENTS WITH A LYMP OF INCIDIOUS ONSET. THE CHILD HAS PAIN IN THE GROIN,
HIP THIGH, AND/OR KNEE.
PAIN AGGRAVATES BY PHYSICAL ACTIVITY AND IS USUALLY WORSE IN THE LATTER PART OF THE DAY.
RARELY, THE CHILD MAY PRESENT WITH ACUTE ONSET OF PAIN AND LIMP, WHILE VERY FEW CHILDREN
REMAINS ASTMPTOMATIC THROUGHOUT THE DISEASE.
SYMPTOMS
• Painless limp (classical presentation)

• Mild pain in the hip or Anterior thigh or knee
• History of trauma may be present or absent
• Onset of pain may be acute or incidious.
SIGNS
• The child walk with combination of antalgic

gait and trendlenberg gait.
• Varying degrees of atrophy of the gluteus,
quadriceps, and hamstring muscle may be
present
•Muscle spasm(detected by roll test)
• Limitation of Abduction and internal rotation.
RADIOLOGICAL FEATURE
• • The Pathology of perthers' disease is described

in four stage.
• • The radiological feature change with the stage of
disease.
• • Avascular necrosis may involve either a part or
the entier epiphysis.
STAGE I:
Stage of avascular necrosis:

- The capital femoral epiphysis
is sclerotic (dense and white on X-ray),and the
height of the epiphysis is reduced
STAGE II :
• Stage of fragementation:
-The sclerotic and flattend
epiphysis breakups in to several fragements.
STAGE III :
• Stage of revasculsrization :
-New bone formation is visible
at the periphery of the avascular fragemented
epiphysis. The new bone gradually replaces the
dead bone.
STAGE
IV :
• Healed Stage :
There is no evidence of avascular
bone.
OTHER RADIOLOGICAL INVESTIGATION
• Magnatic resonance imaging (MRI) and bone

scintigraphy are effective means used for
diagnosis in the early Stages before classical
radiofinding are apparent.
TREATMENT
• Goals of Treatment:
1. Elimination of hip irritability can be done by
1-2 weeks period of bed rest, sling,
suspension, traction, etc.
2. Restoration and maintenance of hip motion
this can be done by physical therapy active
and passive.
•
3 . Prevention of extrusion and collapse by bed
rest, abduction splint, etc.
4. Attaintment of spherical femoral head to
prevent femoral head deformity and can be
done by containtment methods,which may be
nonsurgical or surgical.
• The following are the four currently accepted
forms of management.
• A. Observation is indicated for children less
than 6 years and for more than 6 years in
catterall I and II.
• B.Intermittent symptomatic treatment consist
of Observation, bed rest and abduction
exercised.
• C. Definitive early treatment consist of nonsurgical or
surgical containtment of the femoral head (see
chart) early in the course of the disease is indicated
when:
1. Age at onset is more than 6 year older.
2.caterall III and IV grade .

PHYSIOTHERAPY MANAGEMENT IN PERTHES’
DISEASE
1. Measure to control pain, inflammation and

spasm:
A.cryotherapy:in the Later stages.
B. Thermotherapy – In initial stages.
• 2. Isometric Painless Contractions should be taught for
the hip extensors, abductors, and quadriceps with leg
in traction.
• 3.Intermittent compression of the joint: It can be
achieved by early slow relaxed passive movements.
• this helps in improving nourishment of the joint
cartilage, moulding the joint surfaces and maintainig of
the soft tissue.
• 3. Improve ROM:
A.Passive range of motion (ROM) exercise to the
I.Flexion
II. Extension
III.Abduction
Of the hip joint, knee joint.
Ankle planter and dorsi flexion.
• 4. Measure to prevent contractures: A patient with
perthes ‘disease tends to develop flexion contracture of
the hip. This can be prevented by:
• a. Repeted Prone lying positions.
• b. Repeted slow passive stretching of the hip joint.
• C. Gentle Stretching of hip joint.
• 5. Measures for ambulation :
a. Non- weight-bearing Walking: Patient is taught NWB standing and
Walking initially in a parallel bar. Later he is permitted to use a walker
and then axillary crutches for Walking.
b. Walking by weight bearing:
i. Initially the patient is allowed weight bearing Walking with the help
of specially designed braces and splints like the scottise rise brace
and petric cast.
• These devices help in containtment of the femoral head within the
acetabular during weight-bearing by maintainig a position of flexion,
• ii. After removal of the brace or splint, patient is
encouraged by proper assistance and support both at
home by the parents and at the clinic by the therapist to
stand bear-weight and walk independently.
PHYSIOTHERAPY MANAGEMENT
FOLLOWING SURGERY
• Varus derotation osteotomy of the femur is the usual

Surgical procedure which allows better containment
of the femoral head within the acetabulum.
• After surgery the limb is immobilized in a hip spica
for a period of 6 weeks and the Physiotherapy is
limited to:
• 1. Resistive toe movements and isometric for the hip
and knee muscles inside plaster cast to the affected
side.
2. Resistive full range movements to the contralateral
knee, ankle and toes with isometric to the hip abductors
and extensors.
MOBILIZATION
• After removed of hip spica gradualy

mobilization of the hip and knee is initiated with
relaxed passive movements.
• Continuous passive motion (CPM) equipment is
very useful to initiate the relaxe passive ROM
exercise.
• Mobilization, Strengthening and ambulation are
progressed as described for conservative
treatment.
LATE SURGICAL MANAGEMENT FOR
DEFORMITY
• For a significant femoral head deformity ,which

prevents reduction into the acetabulum or
remodeling after treatment with standard
Containtment method,an alternative must be
considered and may consist of one of the following
techniques:
Muscle release and abduction casts, partial
exicision of the femoral head or cheliectomy,
proximal Femoral valgus osteotomy and greater
trochenter advancement.
REFFERENCE
• 3rd edition John Ebnezar

• 2nd edition Jayant Joshi
• Physiotherapy in orthopedic condition and
rheumatology. ( Neeta .j. Vyas. )

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PERTHER 'S

• Perther's disease is disease of childhood

1. There is profound geographical variation

2. The incidence is higher in the southwest

• During the first stage of the disease, synovitis occur.

• 1. Age at onset of the disease is between

• Painless limp (classical presentation)

• The child walk with combination of antalgic

• • The Pathology of perthers' disease is described

Stage of avascular necrosis:

• Magnatic resonance imaging (MRI) and bone

1. Age at onset is more than 6 year older.

2.caterall III and IV grade .

1. Measure to control pain, inflammation and

• Varus derotation osteotomy of the femur is the usual

• After removed of hip spica gradualy

• For a significant femoral head deformity ,which

• 3rd edition John Ebnezar

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