Coxa Plana d1u1n

Coxa Plana

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Definition Legg-Calve-Perthes disease is when the head of the thighbone (femur) in the hip deteriorates due to insufficient blood supply to the area.

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AKA (also known as) Legg-Calve-Perthes disease; Perthes disease

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Incidences •

United States One in 1200 children younger than 15 years is affected by LD.

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Race

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races. Sex

Caucasians are affected more frequently than persons of other

Males are affected 4-5 times more often than females. •

Age LD most commonly is seen in persons aged 3-12 years, with a median age of 7 years.

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Risk/ Predisposing Factors •

Legg-Calve-Perthes disease occurs most frequently in boys 4 to 10 years old. Recent research shows that this disorder may reflect subtle disorders of blood clotting.

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Risk group also includes those who have abnormalities in genetics, hormonal changes, trauma, infection and metabolic abnormalities

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Manifestations • • • • • • • • • • • • •

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Knee pain (may be the only symptom, initially) Persistent thigh or groin pain Atrophy (wasting) of muscles in the upper thigh Slight shortening of the leg, or legs of unequal length Hip stiffness restricting movement in the hip Difficulty walking, walking with a limp (which is often painless) Limited range of motion Decreased range of motion (ROM), particularly with internal rotation and abduction Painful gait Muscle spasm Leg length inequality due to collapse Thigh atrophy: Thigh circumference on the involved side will be smaller than on the unaffected side secondary to disuse. Short stature: Children with LD often have delayed bone age.

Type/Stage/Classifications of the Disease •

Stage I (avascularity) The blood supply to the upper femoral epiphysis is halted spontaneously and bone growth is halted (lasts a few weeks)

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Stage II (revascularization) New blood vessels arise to supply the necrotic area, and bone resorption and deposition take place (lasts everal months to 1 year) However the new bone lacks strength and pathologic fractures may occur; the weakened epiphysis may be progressively deformed

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Stage III (reossification) The head of the femur gradually reforms as dead bone is replaced with new bone, which gradually spreads to heal the lesion (lasts 2 to years)

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Stage IV (postrecovery) The femoral head becomes permanently distorted, with resultant t misalignment

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Pathophysiology Idiopathic avascular necrosis of femoral head Goes through 5 phases:

(1) Initial - histological evidence of dead bone with disappearance of osteocytes from empty lacunae

(2) Early - incipient revascularization

(3) early intermediate - active resorption of dead bone along with new bone deposits

(4) late intermediate- decreased bone resorption and increasing immature bone formation

(5) formation of mature haversian systems.

The newly healed epiphysis may be left with residual deformity and never regain a totally normal shape and appearance. Residual deformity can lead to serious disability later in life.Some flattening of the epiphysis, referred to as “coxa plana,” can occur. In more severe disease, complete collapse can occur, with the femoral head mushrooming around the femoral neck. Because younger patients have more growth potential for reformation and remodeling of bone, they tend to have better outcomes.

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Diagnostic Studies

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Laboratory Studies Laboratory studies for Legg-Calv é -Perthes disease include the following:  CBC  Erythrocyte sedimentation rate - May be elevated if infection present

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Imaging Studies

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 Plain x-rays of the hip are extremely useful in establishing the diagnosis.  Frog leg views of the affected hip are very helpful.  Multiple radiographic classification systems exist, based on the extent of abnormality of the capital femoral epiphysis. o Waldenstrom, Catterall, Salter and Thompson, and Herring are the 4 most common classification systems. o No agreement has been reached as to the best classification system.  Five radiographic stages can be seen by plain x-ray. In sequence, they are as follows: o Cessation of growth at the capital femoral epiphysis; smaller femoral head epiphysis and widening of articular space on affected side o Subchondral fracture; linear radiolucency within the femoral head epiphysis o Resorption of bone o Re-ossification of new bone o Healed stage  Technetium 99 bone scan - Helpful in delineating the extent of avascular changes before they are evident on plain radiographs  Dynamic arthrography - Assesses sphericity of the head of the femur Procedures  Hip aspiration if a septic t is suspected

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Management

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Medical Monitoring 1. Monitor and assess pain level ising age-appropriate pain measurement tool. 2. Assess for gait, spasm, or presence of contractures. ive care and education

1. Instruct child and parents to maintain activities that promote range of motion, such as swimming and bicycling, but to avoid sports and high impact-running. 2. Limitation of activities, bed rest with or without skin traction 3. Provide equipment to assist with mobility (e.g wheelchair, walker) if needed 4. Teach parents and siblings to assist only as needed. 5. Allow child to care for self and participate as able. 6. Reinforce to child that he or she is only temporarily restrited. Stress positive aspects of activity. 7. Encourage follow up. 8. Salicylates or anti-inflammatory agents are given to relieve synovitis, muscle spasm, and pain in the t and help restore motion. •

Surgical 1. Inominate osteotomy; varus osteotomy; osteotomy of the proximal femur, acetabulum (Salter innominate), or a combination of these may be required

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Nursing Diagnosis •

Top 5 Priorities includes: 1. Acute Pain 2. Bathing or Self-Care Deficit 3. Impaired Physical Mobility 4. Disturbed Body Image 5. Ineffective Therapeutic Regimen Management

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Nursing Responsibilities

Preoperative Management 1. Assess nutritional status; hydration, protein and caloric intake. Maximize healing and reduce risk of complications by providing I.V. fluids, vitamins and nutritional supplements as indicated. 2. Determine if the patient has had previous corticosteroid therapy – could contribute to current orthopedic condition (aseptic necrosis of the femoral head;

osteoporosis), as well as affect his or her response to anesthesia and the stress of surgery. The patient may need corticotrophin post-operatively. 3. Determine if the patient has an infection (cold, dental, skin, UTI); it could contribute to development of osteomyelitis after surgery. ister preoperative antibiotics as ordered. 4. Prepare patient for postoperative routines, w/c include coughing and deep breathing, frequent v/s and wound checks and repositioning. 5. Have the patient practice voiding on bed pan or urinal in recumbent position before surgery. This helps reduce the need for post operative catheterization. 6. Acquaint the patient with traction apparatus and the need for splint or cast, as indicated by the type of surgery.

Post operative Management 1. Monitor for hemorrhage and shock, which may result from significant bleeding and poor hemostasis of muscles that occur with orthopedic surgery. a. Evaluate the blood pressure and pulse rates frequently – report rising pulse rate or slowly decreasing blood pressure. b. Watch for increased oozing of wounds. c. Measure suction drainage if used. Anticipate up to 7 to 17 oz (200 – 500 mL) drainage in the first 2 hours, decreasing to less than 1 oz (30 mL) per 8 hours within 48 hours, depending on surgical procedure. d. Report increased wound drainage or steady increase in pain of operative area. 2. ister I.V fluids or blood products as ordered. 3. Monitor neurovascular status. a. Watch circulation distal to the part where cast, bandage, or splint has been applied; check pulses, color, warmth, and capillary refill. b. Prevent constriction leading to interference with blood or nerve supply; check for swelling. c. Note movement, and ask about sensation of distal extremities.

4. Elevate affected extremity and apply ice packs as directed to reduce swelling and bleeding into tissues. 5. Monitor pain level and response to analgesia; ister patient-controlled analgesia or other method of pain relief as directed; notify health care provider if not effective or if the patient cannot tolerate adverse effects. 6. Immobilize the affected area and limit activity to protect the operative site and stabilize musculoskeletal structures. 7. Give analgesics that may cause respiratory depression cautiously. Monitor respiration depth and rate frequently. Opioid analgesic effects may be cumulative. 8. Change position and encourage use of incentive spirometer and coughing and deep-breathing exercises every 2 hours to mobilize secretions and prevent atelectasis. Auscultate lungs frequently. 9. Monitor v/s for fever, tachycardia, or increased respiratory rate, which may indicate infection. 10. Maintain aseptic technique for dressing changes and wound care. 11. Encourage the patient to move ts that are not fixed by traction or appliance through their range of motion as fully as possible. Suggest muscle-setting exercises (quadriceps setting) if active motion is contraindicated. 12. Apply antiembolism stockings, sequential compression, or give prophylactic anticoagulants, if prescribed, to prevent thromboembolism. 13. Encourage early resumption of activity. 14. Monitor for anemia, especially after fracture of long bones. 15. Avoid giving calcium supplements patients on bed rest, and encourage other fluids to prevent other fluids to prevent urinary calculi.

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Illustrations