What is your diagnosis?

Legg-Calve-Perthes Disease (LCPD): Typical age of onset is 2-14 years old and is most common between 4-9 years old. More common in males than females (4:1) [1].

• Pearl: Early radiography may be normal, so a high index of suspicion is necessary in these cases. If there is concern for LCPD, a bone scan/MRI may be indicated in the outpatient setting [2]. 

• Pearl: In the early stages of the disease, pain can be minimal or absent. Limp is usually insidious in onset over weeks to months.

What is your management in the ED?

Obtain radiographs of the patient's pelvis and AP and lateral views of the affected hip. Frog-leg views may also be helpful. You must rule out other causes of hip pain such as infection and fracture. Once LCPD is identified, appropriate analgesia with NSAIDs can be administered.  

• Pearl: If a patient presents with knee pain to the emergency department, a full examination of the hip is also warranted as often, knee pain is referred pain from the hip

What is your disposition?

The patient can be discharged home with close follow-up with a pediatric orthopedist. Depending on the classification, severity, and patient's age, the patient may need surgical intervention. Non-operative management consists of avoiding repetitive, high impact activities, and weight bearing as tolerated. Bracing or splinting has not shown a difference in outcomes [3,4]. 

• Pearl: Patients less than 6 years of age have better outcomes. This is thought to be due to greater time for revascularization and remodeling. Conversely, patients over 8 typically will need surgical intervention. About 50% of patients have almost full recovery [4].

Do you consult orthopedics emergently?

There is no need for an emergent ortho consult, though the patient will need close follow-up with an outpatient orthopedic surgeon for close monitoring.

Additional reading about Legg-Calve-Perthes' disease can be found here