Perthes Disease / Legg–Calvé–Perthes Disease
Important: Perthes disease-এ কোনো “curative medicine” নেই। মূল চিকিৎসা হলো hip containment + activity modification + physiotherapy ± surgery। ওষুধ দেওয়া হয় mainly pain/synovitis control এবং supportive purpose-এ।
1) Definition — সংজ্ঞা
Perthes disease হলো শিশুদের hip joint-এর রোগ, যেখানে femoral head / thigh bone-এর মাথার blood supply সাময়িকভাবে কমে যায়, ফলে সেখানে avascular necrosis হয়। পরে bone আবার heal করে, কিন্তু ঠিকমতো containment না হলে femoral head চ্যাপ্টা/বিকৃত হয়ে যেতে পারে। AAOS অনুযায়ী রোগটি কয়েক বছর ধরে stages-এর মাধ্যমে চলে এবং চিকিৎসার লক্ষ্য femoral head-কে যতটা সম্ভব round shape-এ heal করানো।
2) Causes / Etiology — কারণগুলো
Perthes disease-এর exact cause unknown / idiopathic। তবে সম্ভাব্য কারণ ও risk factors:
- Femoral head-এর temporary blood supply interruption → bone cell death / AVN।
- Age: সাধারণত ৪–১০ বছরের শিশুতে বেশি।
- Male predominance: ছেলেদের বেশি হয়।
- Genetic tendency / family history: কিছু ক্ষেত্রে familial association থাকতে পারে।
- Coagulation abnormality / thrombophilia: clotting tendency থাকলে blood flow কমতে পারে—সব রোগীতে থাকে না।
- Repeated minor trauma / microtrauma: hip-এ repeated stress theory হিসেবে ধরা হয়।
- Delayed skeletal maturation: bone age কম থাকলে association থাকতে পারে।
- Second-hand smoke exposure: risk factor হিসেবে উল্লেখযোগ্য।
- Low birth weight / poor nutrition / socioeconomic factors: association থাকতে পারে, direct cause নয়।
Pathophysiology stages — সহজভাবে
- Initial / necrosis: blood supply কমে bone মরে যায়।
- Fragmentation: dead bone ভেঙে/চ্যাপ্টা হতে পারে—এই phase সবচেয়ে risky।
- Reossification: নতুন bone তৈরি হয়।
- Healed stage: final shape তৈরি হয়—round থাকলে outcome ভালো, flat হলে complication বেশি।
3) Symptoms — লক্ষণগুলো
- Limping / খুঁড়িয়ে হাঁটা: সবচেয়ে common early sign।
- Hip pain / groin pain: hip বা কুঁচকিতে ব্যথা।
- Referred knee pain: শিশুর knee pain থাকতে পারে, কিন্তু আসল problem hip-এ।
- Activity-related pain: হাঁটা/দৌড়/খেলার পর ব্যথা বাড়ে, rest করলে কমে।
- Limited hip movement: বিশেষ করে abduction ও internal rotation কমে যায়।
- Trendelenburg gait: hip abductor weakness থাকলে হাঁটার সময় pelvis drop করতে পারে।
- Muscle spasm / stiffness: hip-এর চারপাশে stiffness।
- Thigh/gluteal muscle wasting: chronic হলে muscle ছোট/দুর্বল দেখাতে পারে।
- সাধারণত fever, redness, severe systemic illness থাকে না—এগুলো থাকলে septic arthritis/osteomyelitis ভাবতে হবে।
4) Clinical Diagnosis — clinically কীভাবে ধরবেন
History
- ৪–১০ বছরের শিশু।
- ধীরে ধীরে limp শুরু।
- hip/groin/thigh/knee pain।
- খেলাধুলার পর pain বাড়ে।
- fever usually absent।
Examination
- Gait: antalgic gait বা Trendelenburg gait।
- ROM test: hip abduction ও internal rotation কম।
- Pain at extreme movement: internal rotation/abduction করলে pain।
- Leg length discrepancy: femoral head collapse হলে limb shortening হতে পারে।
- Muscle wasting: thigh/gluteal atrophy chronic case-এ।
5) Investigations — specific investigation
1. X-ray pelvis — first-line
AP pelvis + frog-leg lateral view নিতে হবে। Findings:
- Early: epiphysis dense/small; কখনও X-ray normal।
- Fragmentation: sclerosis, lucency, fragmentation, joint space widening, crescent sign।
- Late: coxa magna, coxa plana, aspherical femoral head।
2. MRI hip — early/unclear case
- X-ray normal কিন্তু suspicion বেশি হলে।
- Early marrow change / perfusion loss detect করতে।
- Necrosis extent ও prognosis বুঝতে।
3. Ultrasound hip
- Joint effusion দেখাতে পারে।
- Perthes confirm করে না।
4. Blood tests
Perthes-এ routine CBC/ESR/CRP usually normal। এগুলো করা হয় infection/inflammatory disease exclude করার জন্য। CBC, ESR, CRP raised হলে septic arthritis/osteomyelitis ভাবতে হবে।
5. Staging / classification
- Waldenström stage: initial, fragmentation, reossification, healed।
- Herring lateral pillar classification: prognosis ও surgery decision-এ useful।
- Catterall classification: femoral head involvement extent।
6) Differential Diagnosis
- Transient synovitis
- Septic arthritis
- Osteomyelitis
- Slipped capital femoral epiphysis — SCFE
- Juvenile idiopathic arthritis
- Trauma/fracture
- Developmental dysplasia of hip
- Bone tumour/leukaemia — persistent night pain/systemic signs থাকলে ভাবতে হবে
StatPearls অনুযায়ী Perthes-এর differential diagnosis-এ SCFE, transient synovitis, septic arthritis, JIA গুরুত্বপূর্ণ।
7) Complications — জটিলতা
- Coxa plana: femoral head চ্যাপ্টা হয়ে যায়।
- Coxa magna: femoral head বড় ও irregular হয়।
- Lateral extrusion/subluxation: femoral head socket থেকে বাইরে সরে যেতে পারে।
- Leg length discrepancy: growth disturbance হলে affected leg ছোট হতে পারে।
- Restricted ROM: hip movement permanent কমে যেতে পারে।
- Trendelenburg gait: abductor weakness থাকলে limp persist করে।
- Femoroacetabular impingement: abnormal head-neck shape থেকে adult life-এ hip impingement।
- Labral tear/cartilage damage: abnormal mechanics এর জন্য।
- Early osteoarthritis: young adult age-এ hip arthritis হতে পারে।
- Later total hip replacement need: severe deformity হলে adulthood-এ THA লাগতে পারে।
8) Treatment / Management
Core management goal
Femoral head-কে acetabulum-এর ভিতরে ভালোভাবে contained রাখা, যাতে healing শেষে head যতটা সম্ভব round থাকে। Management depends on age, stage, femoral head involvement, extrusion, ROM।
A) Non-pharmacological treatment — main treatment
- Activity restriction: running, jumping, football, high-impact sports বন্ধ।
- Protected weight bearing: pain থাকলে crutch/walker।
- Physiotherapy: hip abduction, internal rotation, stretching, abductor/core strengthening।
- Swimming/hydrotherapy: low-impact exercise।
- Brace/cast: abduction brace বা Petrie cast, containment needed হলে।
- Serial X-ray follow-up: disease progression/stage দেখার জন্য।
B) Surgical treatment — selected cases
Surgery বেশি consider করা হয় যদি:
- Child >8 years at diagnosis।
- Femoral head involvement >50%।
- Lateral extrusion/loss of containment।
- ROM therapy দিয়েও improve না করে।
Common surgery:
- Femoral varus osteotomy
- Pelvic osteotomy / Salter osteotomy
- Shelf acetabuloplasty / triple pelvic osteotomy
- Severe residual adult deformity: hip preservation surgery / THA।
9) Bangladesh-এ commonly used prescription medicines — supportive list
খুব গুরুত্বপূর্ণ কথা
Perthes disease-এ antibiotic, steroid, DMARD, uric acid drug routinely indicated নয়। Pain control-এর জন্য নিচের medicines used হয়। NSAID একসাথে দুইটা দেওয়া যাবে না—যেমন ibuprofen + naproxen একসাথে নয়।
1. Generic name: Paracetamol / Acetaminophen
- Therapeutic category: Analgesic, antipyretic
- Pharmacological class: Non-opioid analgesic; para-aminophenol derivative
- Purpose in Perthes: mild–moderate hip/knee pain control; fever থাকলে fever control, তবে fever থাকলে infection exclude করতে হবে।
- Dose: Child: 10–15 mg/kg/dose PO every 4–6 hours PRN, usually 3–4 times/day; max commonly 60 mg/kg/day.
- Duration: pain flare-এ 2–3 দিন; prolonged daily use doctor review ছাড়া নয়।
- Side effects: nausea, rash; overdose হলে severe liver injury।
- Interactions: warfarin দীর্ঘদিন high dose-এ bleeding risk বাড়াতে পারে; alcohol/liver disease/enzyme inducer drugs থাকলে hepatotoxicity risk; একই সাথে multiple paracetamol products avoid।
- Bangladesh available brand examples:
- Napa — Paracetamol 500 mg tablet; 120 mg/5 ml syrup; 80 mg/ml pediatric drop।
- Ace — Paracetamol 500 mg tablet; 120 mg/5 ml suspension/syrup।
- Reset — Paracetamol 500 mg tablet; 120 mg/5 ml formulation available।
- Renova — Paracetamol 500 mg tablet/suppository; 120 mg/5 ml suspension/syrup।
2. Generic name: Ibuprofen
- Therapeutic category: NSAID analgesic
- Pharmacological class: Propionic acid derivative; non-selective COX inhibitor
- Purpose in Perthes: hip synovitis/inflammatory pain কমাতে; painful phase-এ short course।
- Dose: Child: 5–10 mg/kg/dose every 6–8 hours after food PRN; MedEx adult/adolescent >40 kg dose 200–400 mg 3–4 times/day, max 1200 mg/day; child dosing weight-based।
- Duration: usually 3–5 days, then review; chronic continuous NSAID avoid।
- Side effects: gastritis, vomiting, abdominal pain, GI bleeding/ulcer, renal injury, asthma exacerbation, rash। NSAID-associated GI bleeding/ulcer risk documented।
- Interactions: other NSAIDs, aspirin, anticoagulants, steroid, ACE inhibitor/ARB + diuretic, lithium, methotrexate।
- Avoid/caution: dehydration, vomiting/diarrhoea, renal disease, active peptic ulcer, NSAID-induced asthma।
- Bangladesh available brand examples:
- Flamex — Ibuprofen 100 mg/5 ml suspension, 200 mg tablet, 400 mg tablet।
- Reumafen — Ibuprofen 100 mg/5 ml suspension, 200 mg tablet, 400 mg tablet।
- Intaflam — Ibuprofen 400 mg tablet।
- Neurofen — Ibuprofen 400 mg tablet।
3. Generic name: Naproxen / Naproxen Sodium
- Therapeutic category: NSAID analgesic
- Pharmacological class: Propionic acid derivative; long-acting non-selective COX inhibitor
- Purpose in Perthes: persistent inflammatory hip pain/synovitis—usually specialist-guided; ibuprofen ineffective হলে consider।
- Dose: Child specialist dose: 5 mg/kg twice daily or total 10 mg/kg/day in 2 divided doses; MedEx notes juvenile rheumatoid arthritis dose over 2 years 10 mg/kg/day in two divided doses।
- Duration: usually short course 3–7 days for pain flare; long-term হলে renal/GI monitoring।
- Side effects: gastritis, ulcer/GI bleeding, renal impairment, edema, BP increase, rash।
- Interactions: other NSAIDs/aspirin, anticoagulants, steroid, SSRI, ACEi/ARB + diuretic, lithium, methotrexate।
- Bangladesh available brand examples:
- Naprox — 250 mg tablet, 500 mg tablet, 125 mg/5 ml suspension, 10% gel।
- Naprosyn — 250 mg tablet, 500 mg tablet, 125 mg/5 ml suspension।
- Naxin — 250 mg tablet, 500 mg tablet, 10% gel।
- Napro-A — 250 mg tablet, 500 mg tablet।
- Napsod — 275 mg tablet, 550 mg tablet।
4. Generic name: Diclofenac sodium — topical gel only in selected case
- Therapeutic category: NSAID analgesic
- Pharmacological class: Phenylacetic acid derivative; non-selective COX inhibitor
- Purpose in Perthes: deep hip joint pain-এ topical gel-এর benefit limited; superficial thigh/muscle pain হলে short course use করা হতে পারে। Oral diclofenac routinely child Perthes-এ prefer করা উচিত নয় unless specialist advises।
- Dose: topical gel thin layer locally 2–3 times/day for 3–5 days; broken skin-এ নয়।
- Side effects: local irritation, rash; large area/long duration use করলে systemic NSAID adverse effect হতে পারে।
- Interactions: oral NSAID/anticoagulant/steroid সহ caution।
- Bangladesh available brand examples:
- Diclofen — Diclofenac sodium 1% gel।
- Erdon — Diclofenac sodium 1% gel।
- Fastfit — Diclofenac sodium 1% gel।
- Fengel — Diclofenac sodium 1% gel।
5. Generic name: Omeprazole
- Therapeutic category: Anti-ulcerant
- Pharmacological class: Proton pump inhibitor — PPI
- Purpose in Perthes: Perthes treat করে না। NSAID-related gastritis/ulcer risk থাকলে gastroprotection হিসেবে দেওয়া হতে পারে।
- Dose: child dose weight/age-based; commonly 0.7–1 mg/kg once daily or practical whole-capsule dose 10–20 mg once daily depending on age/weight; BNFC lists 1–2 mg/kg once daily for children, max 40 mg per dose।
- Duration: NSAID চলার সময় বা gastritis indication অনুযায়ী usually 5–14 days; long-term doctor follow-up।
- Side effects: headache, abdominal pain, nausea, diarrhoea/constipation; long-term useে hypomagnesemia, B12/iron absorption issue, infection risk।
- Interactions: clopidogrel, warfarin, diazepam, phenytoin; iron/ketoconazole absorption কমতে পারে।
- Bangladesh available brand examples:
- Nuprazol — Omeprazole 20 mg capsule।
- O-20 — Omeprazole 20 mg capsule।
- O-40 — Omeprazole 40 mg capsule।
- Omecap — Omeprazole 20 mg capsule; 40 mg/vial IV।
- Losectil MUPS — Omeprazole 20 mg/40 mg MUPS tablet।
6. Generic name: Calcium + Vitamin D3 / Cholecalciferol
- Therapeutic category: Mineral + vitamin supplement
- Pharmacological class: Calcium salt + vitamin D analogue
- Purpose in Perthes: disease cure করে না। Vitamin D deficiency, rickets, poor calcium intake, low 25-OH vitamin D থাকলে bone health support হিসেবে।
- Dose:
- Calcium 500 mg + Vitamin D3 200 IU: MedEx dose 2 tablets daily or 1 tablet twice daily with/after meal।
- Cholecalciferol deficiency regimen lab-based; MedEx examples include 20,000 IU intermittent regimens; child dose doctor/lab report অনুযায়ী।
- Duration: deficiency থাকলে usually 6–8 weeks, তারপর maintenance; 25-OH vitamin D দেখে adjust।
- Side effects: constipation, nausea, abdominal pain; excess হলে hypercalcemia, kidney stone।
- Interactions: tetracycline/doxycycline/quinolone antibiotics, levothyroxine, digoxin, thiazide diuretic; calcium-containing antacid/other calcium supplement সহ caution। MedEx calcium+D3 interaction list-এ antacids, other calcium/vitamin D, digoxin, tetracyclines উল্লেখ আছে।
- Bangladesh available brand examples:
- A-Cal D, Calcibo D, Oscal-D Forte, Orthocal-D, Protebon-D — Calcium + Vitamin D3 preparations।
- D-Rise — Cholecalciferol 1000 IU chewable, 2000 IU tablet/oral solution, 20000 IU/40000 IU/50000 IU capsule।
- D3 — Cholecalciferol 200 IU/ml pediatric drop, 2000 IU tablet, 20000 IU/40000 IU capsule।
- Osteo-D — Cholecalciferol 200 IU/ml pediatric drop, 1000 IU chewable, 20000 IU capsule।
Bangladesh doctors commonly prescribe — practical list
Perthes disease prescription usually looks like supportive care:
- Paracetamol — pain control; safest first-line analgesic।
- Ibuprofen — painful synovitis/inflammatory pain; short course after food।
- Naproxen — longer-acting NSAID; specialist-guided if pain persists।
- Omeprazole — only if NSAID-induced gastritis risk or abdominal symptoms।
- Calcium + Vitamin D3 / Cholecalciferol — only if deficiency/poor intake/rickets suspicion।
- Diclofenac topical gel — limited role; superficial muscle pain only, deep hip disease treat করে না।
Not routine: antibiotic, steroid, allopurinol/febuxostat, DMARD, long-term opioid, bisphosphonate—unless separate diagnosis/specialist protocol থাকে।
10) Prevention — কীভাবে prevent করবেন?
Primary prevention নিশ্চিতভাবে সম্ভব নয়, কারণ cause incompletely understood। তবে outcome ভালো করার জন্য:
- শিশুর persistent limp >1–2 weeks হলে hip X-ray করুন।
- Knee pain থাকলেও hip examine করুন।
- Running/jumping/football painful phase-এ বন্ধ।
- Second-hand smoke exposure avoid।
- Balanced diet: protein, calcium, vitamin D।
- Obesity থাকলে weight control।
- Physiotherapy follow করুন—hip abduction/internal rotation preserve করা জরুরি।
- Follow-up X-ray miss করবেন না; disease 2–4 বছর পর্যন্ত monitor লাগতে পারে।
- Fever, severe pain, inability to bear weight হলে emergency—septic arthritis exclude করতে হবে। Primary prevention not currently possible, but early recognition and risk modification are recommended.
Overview / Summary
Perthes disease হলো childhood femoral head avascular necrosis। Main problem হলো femoral head collapse/deformity; তাই চিকিৎসার main target হলো containment, ROM preservation, pain control, and long-term monitoring। Medicine শুধু pain/supportive purpose-এ—definitive management orthopedic plan অনুযায়ী।
Actionable Plan / Steps
- Confirm diagnosis: AP pelvis + frog-leg lateral X-ray।
- Early X-ray normal কিন্তু suspicion থাকলে: MRI hip।
- Pain control: Paracetamol first; synovitis হলে short NSAID course।
- Avoid: running, jumping, football, heavy weight bearing।
- Start physiotherapy: abduction/internal rotation ROM + stretching।
- Refer: pediatric orthopedic surgeon—especially age >6–8 years, limited ROM, extrusion, >50% head involvement।
- Follow-up: serial X-ray every 3–4 months or as orthopedic plan।
Reference List
Textbook
- Apley & Solomon’s System of Orthopaedics and Trauma, latest edition — Pediatric hip disorders / osteochondroses chapter.
- Maheshwari & Mhaskar, Essential Orthopaedics, latest edition — Legg–Calvé–Perthes disease section.
- Nelson Textbook of Pediatrics, latest edition — Musculoskeletal disorders / pediatric hip pain section.
Guideline / Clinical reference
- AAOS OrthoInfo. Perthes Disease / Legg–Calvé–Perthes Disease.
- StatPearls / NCBI Bookshelf. Legg-Calvé-Perthes Disease. Updated clinical review.
- NICE BNFC. Paracetamol, ibuprofen/naproxen/omeprazole pediatric dosing references.
- MedEx Bangladesh medicine index — Bangladesh brand and strength verification for paracetamol, ibuprofen, naproxen, diclofenac, omeprazole, calcium/vitamin D.
Peer-reviewed journals with DOI
- Rodríguez-Olivas AO, Hernández-Zamora E, Reyes-Maldonado E. Legg–Calvé–Perthes disease overview. Orphanet Journal of Rare Diseases. 2022;17:125. DOI: 10.1186/s13023-022-02275-z.
- Leroux J, Abu Amara S, Lechevallier J. Legg-Calvé-Perthes disease. Orthopaedics & Traumatology: Surgery & Research. 2018;104:S107–S112. DOI: 10.1016/j.otsr.2017.04.012.
Md.Rafiqul Islam Lipu,Date:-15-06-2026 Monday,Time:-12-29-12 Pm