Docs Tag: bone

Perthes Disease

Perthes Disease


Physiotherapy in Toronto for Pediatric Issues

Welcome to In Balance Physiotherapy’s Guide to Perthes Disease of the Hip.

Perthes disease is a condition that affects the hip in children between the ages of four and eight. The condition is also referred to as Legg-Calve-Perthes disease in honor of the three physicians who each separately described the disease. In this condition, the blood supply to the growth center of the hip (the capital femoral epiphysis) is disturbed, causing the bone in this area to die. The blood supply eventually returns, and the bone heals. How the bone heals determines what problems the condition will cause in later life. Perthes disease may affect both hips. In fact, 10 to 12 percent of the time the condition is bilateral (meaning that it affects both hips). This condition can lead to serious problems in the hip joint later in life.

This guide will help you understand:

  • what part of the hip is involved
  • what causes the condition
  • what treatment options are available
  • what In Balance Physiotherapy’s approach to rehabilitation is


What part of the hip is affected?

The hip joint is where the thighbone (femur) connects to the pelvis. The joint is made up of two parts. The upper end of the femur is shaped like a ball. It is called the femoral head. The femoral head fits into a socket in the pelvis called the acetabulum. This ball and socket joint is what allows us to move our leg in many directions in relation to our body.




In the growing child, there are special structures at the end of most bones called growth plates. The growth plate is sandwiched between two special areas of the bone called the epiphysis and the metaphysis. The growth plate is made of a special type of cartilage that builds bone on top of the end of the metaphysis and lengthens the bone as we grow. In the hip joint, the femoral head is one of the epiphyses of the femur.




The capital femoral epiphysis is somewhat unique. It is one of the few epiphyses in the body that is inside the joint capsule. (The joint capsule is the tissue that surrounds the joint.) The blood vessels that go to the epiphysis run along the side of the femoral neck and are in danger of being torn or pinched off if something happens to the growth plate. This can result in a loss of the blood supply to the epiphysis


How does this problem develop?

Perthes disease results when the blood supply to the capital femoral epiphysis is blocked. There are many theories about what causes this problem with the blood supply, yet none have been proven. There appears to be some relationship to nutrition as children who are malnourished are more likely to develop this condition.

Children who have abnormal blood clotting (a condition called thrombophilia) may also have a higher risk of developing Perthes disease. These children have blood that clots easier and quicker than normal. This may lead to blood clotting that blocks the small arteries going to the femoral head. As a result of new evidence, the certainty of thrombophilia as a cause of Perthes is now under debate. This will remain an area of study until scientists clear up the significance of thrombophilia as a possible cause of Perthes.

There is some new evidence that Perthes disease may be genetic as a result of a mutation (abnormal change) in the type II collagen (fibers that make up soft tissue structures). Previously there was no known increase in risk for children whose parent had Perthes disease as a child, but this belief may no longer be accurate.

Studies among Asian families who have many family members with this disease have been found with this mutation in the type II collagen gene. Scientists think that the mutation results in weakening of the hip joint cartilage that also affects the blood vessels within the cartilage.

Whatever the true cause of ischemia (lack of blood to the area), the result is bone death (called necrosis) of the femoral head. Without a normal blood supply, the bone loses its strength and shape. The loss of bone density and softening of the head result in a femoral head that is misshaped. With the hip supporting the weight of the body, tiny microfractures in the soft, necrotic bone fail to heal. This is another reason why normal wear and tear results in a deformity.


What does this problem feel like?

Most children with Perthes disease develop discomfort in the hip and walk with a limp. Children will not usually complain of pain unless specifically asked. The most common way that the disease is discovered is when someone, usually a parent, notices the limp and consults a physician.

When the doctor examines the hip, the motion of the hip is abnormal and restricted. Turning the leg inward produces pain. This usually indicates that the hip is inflamed and may have inflammatory fluid (called an effusion) present in the hip joint.

Interestingly, problems in the hip sometimes do not cause pain in the hip itself. The knee is where the pain is felt. This can be confusing both to patients and physicians. In general, a child with knee pain (who has no clear-cut reason to have knee pain), or an abnormal gait, should be examined for possible Perthes disease. This usually includes X-rays of the hips to make sure that Perthes disease is not missed.


The main problem with Perthes disease is that it changes the structure of the hip joint. How much it affects the way the hip joint works depends on how much the hip joint is deformed. Muscle weakness and atrophy affecting the thigh and calf muscles may develop over time. The affected leg can shorten as a result of the changes in the hip. The result may be a significant leg length difference. Problems later in life are more likely the greater the deformity after the condition has healed.

In general, the most common problem later in life is the development of arthritis in the hip joint. The type of arthritis that develops in the hip is osteoarthritis (also known as wear and tear arthritis). Just like a machine that is out of balance, the hip joint wears out and becomes painful.


How do health care professionals identify the problem?

The history and physical examination are usually enough to make your health care professional highly suspicious about the diagnosis of Perthes disease. X-rays are usually necessary to confirm the diagnosis. It is usually not necessary to get an MRI scan to make the diagnosis, however, this test may be useful to determine whether the other hip is involved in the disease. A special MRI using a dye called gadolinium may help show changes in blood supply before anything shows up on an X-ray.

In planning treatment another test, called an arthrogram, may be required. In this test, dye is injected into the hip joint to outline the cartilage surface of the joint. Much of the child’s hip joint is made up of cartilage. Cartilage does not usually show up on X-rays. The dye is necessary to see what the hip will actually look like when the cartilage turns to bone.


What treatment options are available?

The primary goal of treatment for Perthes disease is to help the femoral head recover and grow to a normal shape. The closer to normal the femoral head is when growth stops, the better the hip will function in later life. The way that surgeons achieve this goal is using a concept called containment.

Containment is a simple concept. The femoral head can be molded as it heals. This is very similar to molding plastic. Plastic is poured into a mold and held there as it cools. It then holds the shape of the mold. The hip socket, or acetabulum, is not affected when the femoral head loses its blood supply. It can be used as a mold to shape the femoral head as it heals. The trick is that the femoral head must be held in the joint socket (acetabulum) as much as possible, however, it is better if the hip is allowed to move and is not held completely still in the joint socket. Joint motion is necessary for nutrition of the cartilage and for healthy growth of the joint.

All treatment options for Perthes disease try to position and hold the hip in the acetabulum as much as possible. This healing process can take several years.
Many children who are diagnosed with Perthes disease do not require any treatment except careful watching. When the condition is mild, the results of not doing anything are often as good as aggressive treatment. The majority of children who are treated for Perthes disease these days require only a program for maintaining a near-normal range of motion. This may include nighttime splinting, home traction, and physiotherapy (see below.) The surgeon will determine treatment based on the classification of the severity of the disease. The classification is determined by the X-ray findings.

Nonsurgical Treatment

Maintaining or regaining hip motion to as near to normal as possible, is critical to the successful treatment of Perthes disease. The disease causes inflammation in the joint. This leads to loss of motion and contracture (tightening) of the muscles surrounding the hip joint. Treating these problems to restore normal motion is necessary.

When lack of motion has become a problem, the child may be admitted to the hospital and placed in traction. Traction is used to give the joint some space and therefore quiet the inflammation. The rest for the joint while in traction also helps to settle the inflammation. Settling the inflammation usually takes about a week. Home traction may also be an option.

Anti-inflammatory medications may also be prescribed. In addition, antiresorptive agents may also be prescribed. These medications help to slow or block the resorption of bone and help decrease deformity. Studies are being done to fully test the effect of these medications in children with Perthes.

Physiotherapy while in the hospital is used to restore the hip motion as the inflammation comes under control. A physiotherapist will visit your child in their room and assist them with some gentle hip rotation and abduction exercises (taking the leg out to the side.) These exercises will maintain and improve range of motion but will also assist in moving the fluid inside the hip joint, which assists with joint nutrition and is crucial to healing. They will also show you and your child how to continue the exercises independently once your child leaves the hospital if you will be using a home traction unit, and may prescribe further simple exercises that your child should do once they are no longer in traction. Your physiotherapist may even recommend that your child do some exercises in the pool to take advantage of the hydrostatic properties of the water to gain range of motion with less weight bearing impact.

In the past, surgeons have tried to hold the hip in the best position where the femoral head was molded by the acetabulum using many different casts and braces. The most common way of doing this today is the Scottish Rite Orthosis. This brace fits around the waist and thighs and has hinges at the hip joints. The brace allows the child to walk and play while it holds the hip joint in the best position for containment. Your doctor may prescribe this for your child once they leave the hospital. Your physiotherapist will help your child learn to safely use crutches or a walker/frame if they are needed while in the brace.


Sometimes, adequate motion cannot be regained with traction and physiotherapy alone, therefore in some cases, surgery will be required to obtain adequate containment.  If the condition is longstanding, the muscles may have contracted or shrunk and cannot be stretched back out. To help restore motion, the surgeon may recommend a tenotomy of the contracted muscles. When a tenotomy is performed, the tendon of the muscle that is overly tight is cut and lengthened. This is a simple procedure that requires only a small incision. The tendon eventually scars down in the lengthened position, and no functional loss is noticeable.


Surgical treatment for containment may be best in older children who are not compliant with brace treatment or where the psychological effects of wearing braces may outweigh the benefits. Surgical containment does not require long-term braces or casts. Once the procedure has been performed and the bones have healed, the child can pursue normal activities as tolerated.

Surgical treatment for containment usually consists of procedures that realign the femur (thighbone), the acetabulum (hip socket), or both.



Realignment of the femur is called a femoral osteotomy. This procedure changes the angle of the femoral neck so that the femoral head points more towards the socket. To perform this procedure, an incision is made in the side of the thigh. The bone of the femur is cut and realigned in a new position. A large metal plate and screws are then inserted to hold the bones in the new position until the bone has healed. The plate and screws may need to be removed once the bone has healed.


Realignment of the acetabulum is called a pelvic osteotomy. This procedure changes the angle of the acetabulum (socket) so that it better covers, or contains, the femoral head. To perform this procedure, an incision is made in the side of the buttock. The bone of the pelvis is cut and realigned in a new position. Large metal pins or screws are then inserted to hold the bones in the new position until the bone has healed. The pins usually must be removed once the bone has healed.

If there is a serious structural change in the anatomy of the hip, there may need to be further surgery to restore the alignment closer to normal. This is usually not considered until growth stops. As a child grows, there will be some remodeling that occurs in the hip joint. This may improve the situation such that further surgery is unnecessary.

In severe cases, both femoral osteotomy and pelvic osteotomy may be combined to obtain even more containment.

Osteotomy Types




Information taken from https://www.inbalancephysio.ca/Injuries-Conditions/Pediatric/Pediatric-Issues/Perthes-Disease/a~4303/article.html


What is childhood bone cancer?

Childhood bone cancer is a cancerous, or malignant, tumour that starts in bone or cartilage cells. Cancerous means that it can invade, or grow into, and destroy nearby tissue. It can also spread, or metastasize, to other parts of the body. When cancer starts in bone or cartilage cells, it is called primary bone cancer.

Childhood bone cancer is rare. Non-cancerous, or benign, conditions of the bone are more common. Non-cancerous conditions of the bone such as bone cysts, pathological fractures and even infections can have the same symptoms as a childhood bone cancer.

The most common type of bone cancer in children is osteosarcoma. It starts in bone cells and occurs most often during the adolescent growth spurt. It commonly starts in the end of a long bone.

Information taken from https://www.cancer.ca/en/cancer-information/cancer-type/bone-childhood/childhood-bone-cancer/?region=on


Osteosarcoma is the most common type of bone cancer in children. Almost 50% of all childhood bone cancers are osteosarcomas. They occur most often during the second decade of life during the adolescent growth spurt. They most commonly occur at the sites of the most rapid growth in the end (called the metaphysis) of a long bone. This includes the thigh bone (femur) next to the knee, the shin bone (tibia) next to the knee and the upper arm bone (humerus) next to the shoulder.

Information taken from https://www.cancer.ca/en/cancer-information/cancer-type/bone-childhood/childhood-bone-cancer/types-of-bone-cancer/?region=on

Bone Age Test

What is a Bone Age Test?

A Bone Age Test is used to see how your body is growing by looking at your bones in your hand and wrist. To look at the bones in your hand and wrist, an X-Ray is used to take the pictures.

As you grow, your bones grow. Sometimes your bones can grow fast and sometimes they grow slow. The Bone Age gives the doctors information about how fast or slow your bones are growing.

The doctors can even predict how tall you may be when you are an adult by using the information from the Bone age test and how tall you are right now.

Why do I need to have a Bone Age Test?

You are having a bone age test because the doctor needs to check how your bones are growing.

What does a Bone Age machine look like?

An X-Ray machine is used for the Bone Age test. The X-Ray machine is a big
camera. Some X-Ray  machines are portable, that means that they can be
moved and even brought to your room to take the picture. There are special flat square boxes that keep the pictures, just like in a camera. The box is used to help take the pictures with the X-Ray machine. Your left hand and wrist is placed on top of the box. The X-ray machine will then be placed over top of your hand with a light that will shine on your hand. The X-ray machine will never touch you so you should not feel anything.  Only one picture will need to be taken and then you are all done.  Once the picture has been taken, the picture is shown to the radiologist. He is a special doctor who looks at X-Ray pictures.

What happens when I have a Bone Age Test?

A porter will come to bring you to the special room to have the X-Ray. A technologist (the person who will take the pictures) will greet you and explain what will happen. Sometimes the technologist will come to your room with an X-Ray machine on wheels and take the pictures there. The technologist may give you a gown to wear. This looks like a backward housecoat. You may already be wearing one. The X-Ray room is usually a little dark; this helps when the technologist takes the pictures.

The technologists will put on special lead vests that are called aprons. They will also put smaller lead blankets over the parts of your body that will not be in the picture. These blankets sometimes can feel a little heavy. The lead blankets and vests are used to help keep the X-Rays only on the body parts that the doctors want pictures of.

Someone like your mom or dad can stay in the room with you; they will also have to wear a lead vest. The technologist will tell you where to put your hand so that they can get the best picture. The technologist will then move the X-Ray tube over the part of your hand and wrist where they are taking the picture. You will see a light shining on your hand. The technologist will then ask you to stay very still and not move while they go behind a window to press a button to take the picture.

If you are moving when the picture is being taken, the picture will be blurry and they will have to take more pictures. When the picture is done, the technologist takes the film and the lead blankets away. The test is very fast. It only takes a few minutes and then you can go back to your room.

What will the Bone Age Test feel like?

  • The X-Ray will not hurt
  • You cannot see, feel or hear the special rays that come from the X-Ray machine. They are invisible. You might hear noises coming from the machine when it is taking the pictures. You will also see a light shining on your hand
  • Sometimes the special flat square box that stores the pictures can feel a little cold when you touch it
  • The lead blankets that they put on you can feel a little heavy
  • Remember to stay still like a statue so they can get a clear picture

Preparing for the test

There is no preparation for a bone age test. When it is time for the test, remember to relax and stay very still so the picture will be clear. The technologist will remind you to sit very still during the picture.


If you have any questions about the test, always ask!

This content has been reviewed and approved by health care team members at McMaster Children’s Hospital in Hamilton, Ontario. All content is for educational purposes only. For further information, please speak with your health care team.

Bone Scan

What is a Bone Scan?

A bone scan is a test used to take pictures of your bones and joints. The scan?s pictures are taken with the help of a special medicine that makes your bones bright and clear.

Why do I need to have a Bone Scan?

You need a bone scan because the doctor needs to see pictures of your bones. The bone scan will see things in your bones that an X-Ray cannot see.

What does the Bone Scan look like?

The bone scan is a large machine with a special camera that takes pictures of your bones.  There is a bed, sometimes called a table that you lie down on. The camera hangs over you as you lie down on the bed. The camera will not touch you. There is also a computer that helps to take the pictures.

What happens when I have a Bone Scan?

A porter will come and bring you to the area where you will have the bone scan.   A technologist (the person who will take the pictures) will greet you and explain what will happen.  You will be given a gown to wear, this looks like a backward housecoat, you may already be wearing one.

You will go into the room where the bone scan machine is. Before you have the scan you will be given a special medicine called radioisotope. This medicine will act like a highlighter to make your bones bright. This will help the doctor to see your bones better. This medicine has to go into your vein. That means that the technologist will give you a small needle to put the medicine into your vein.

After you get the medicine, you will have to wait about 2 ? 3 hours because it takes that long for the medicine to go into your bones. You will probably go back to your hospital room to wait. When it is time for the test, a porter will bring you back to the bone scan area. The technologist will help you get up onto a bed where you will lie down. It is now time to take the pictures. In the room, there is a camera and a computer. The camera is very big and will come very close to your body but it will not touch you. The camera is a special camera that will see the medicine in your bones; it will take pictures of your bones for the doctor to see. Sometimes the technologist will give you a picture of your bones to take back with you. Sometimes the scan can last for 30-60 minutes. When you are done, you are able to go back to your room.

What will it feel like?

You will feel a quick pinch or poke when the technologist gives you the medicine with the small needle.

The camera used for the test will not hurt you.  It will not touch your body. It is important for you to lie very still and relax so that the pictures are not blurry. It sometimes can help to pass the time faster if you think about some of your favourite things or a favourite place.

Preparing for the test

Your nurse will give you the information you need to help you get ready to have your bone scan. All you have to do for the scan is to remember that you will have to lie still.


If you have any questions about the test, always ask!

This content has been reviewed and approved by health care team members at McMaster Children’s Hospital in Hamilton, Ontario. All content is for educational purposes only. For further information, please speak with your health care team.

Bone Scan

What is a Blood Pressure test?

Throughout your body, your heart pumps blood through blood vessels.  The heart can pump the blood fast and slow.  For example, think about a garden hose.  If the water is just trickling out, the water is moving slow and at a low force, but if you turn on the hose all the way, the water shoots out really fast and at a high force.  This is how your blood vessels work; your heart can pump blood through the vessels slow or fast.  To measure how your blood is moving around your body, the blood pressure test is used.

A blood pressure test (sphygmomanometer) measures the force (how fast or slow) of the blood moving through your blood vessels.  You may remember hearing numbers when nurses and doctors are talking about your blood pressure.  For example you may hear 120 over 80.  The first number 120 means how fast your blood is being pushed out of your heart and into the blood vessels, this is called systolic.  The other number 80 means this is how fast your blood is going back to your heart, this is called diastolic.  A blood pressure test measures both how fast your blood is being pushed out of your heart and how fast your blood is going back to your heart.

Why do I need to have a Blood Pressure test?

Usually when you are in the hospital, your blood pressure is checked everyday, sometimes it can even be checked a few times a day.  This just lets the doctor and nurse know how your blood is moving around your body.

What does a Blood Pressure machine look like?

Blood Pressure Cuff/Machine

The blood pressure machine has a small computer and a blood pressure cuff.  The cuff is made of material with some Velcro on it.  The cuff is attached to the computer by a rubber cord.  It is on a cart or a small pole so that the nurses can move it around from room to room, or sometimes it is attached to the wall in your room.   No picture is taken, just the numbers show up on the small computer screen for the nurses to write down and tell the doctor.

Sometimes the nurse will use a blood pressure cuff that is not attached to a computer.  When the nurse uses this type of blood pressure cuff, they use a pump to pump air into the cuff to fill it with air and read the numbers from the side of the cuff where the pump is.

What happens when I have a Blood Pressure test?

A nurse will come to you with the blood pressure machine.   She may ask you to roll up your sleeve.  She will then place the cuff around your arm, just above your elbow.  Sometimes the nurses may put the cuff on part of your leg.  The nurse will then attach the Velcro to make sure it says in place.  A button will then be pushed on the machine, and the cuff will start to fill with air.  If the blood pressure cuff is not one that connects to a computer, then the nurse will use a pump on the side of the cuff to help the cuff fill with air.  Once it has filled, you will notice that the cuff is very puffy and gives your arm a tight hug/squeeze.  The machine will beep that it is done and the nurse will remove the cuff from your arm.

What will the Blood Pressure test feel like?

The nurse will wrap a small cuff around a part of your arm or your leg.  When the machine is on, the cuff fills with air.  The cuff will get snug (tight) around your arm or leg.  Do not worry, the cuff will stop filling with air when it is done, and the air will be let out of the cuff.  It is important to relax and stay still so that the test will be short.  If you move your arm or leg around, the test will take longer which means the snug cuff will be on your arm or leg longer.  The test should take less then a few minutes and will be done a few times a day, sometimes even at night.  Sometimes it can help to think of something else, like your favourite place or song, while having the blood pressure done.  Other ideas to try to help you lie still are quiet activities like blowing bubbles or watching your favourite movie.

Preparing for the test

There is nothing that you need to do to prepare for a blood pressure test.  You do not have to go anywhere to have the test done; your nurse will come into your room with the machine and check it for you.


If you have any questions about the test, always ask!

This content has been reviewed and approved by health care team members at McMaster Children’s Hospital in Hamilton, Ontario.