Intended for healthcare professionals

Practice Easily Missed?

Perthes’ disease

BMJ 2014; 349 doi: (Published 23 September 2014) Cite this as: BMJ 2014;349:g5584
  1. Peter Kannu, paediatrician1,
  2. Andrew Howard, paediatric orthopaedic surgeon2
  1. 1Paediatrics, Hospital for Sick Children, Toronto, ON, Canada
  2. 2Orthopaedics, Hospital for Sick Children, Toronto, ON, Canada, M5G 1X8
  1. Correspondence to: A Howard andrew.howard{at}
  • Accepted 12 August 2014

A mother took her 8 year old son, who had been limping and complaining of occasional leg pain, to see their general practitioner. The boy was otherwise healthy. He walked with a limp, was afebrile, and had painful, reduced internal rotation and abduction of his right hip. Plain radiographs confirmed the diagnosis of Perthes’ disease, prompting paediatric orthopaedic referral, followed by an osteotomy.

What is Perthes’ disease?

Perthes’ disease is the clinical manifestation of idiopathic femoral capital epiphysis vascular compromise, affecting children aged between 4 and 12 years when the epiphyseal blood supply is solely from the lateral epiphyseal vessels.1 The annual incidence of Perthes’ disease among children under the age of 15 ranges from 0.2 to 19.1 per 100 000.2 Bilateral involvement occurs in approximately 15% of cases and is usually asymmetric. Perthes’ disease affects boys three to four times more frequently than girls and is more common in children of low birth weight, children exposed to maternal smoking during pregnancy, those from lower socioeconomic groups, and children of white ethnicity.2 3 4 5 Affected children tend to be shorter than controls and have delayed bone age.6 Whether Perthes’ disease is a single disease or the result of different pathogenetic mechanisms remains a question. A long term natural history study found that the entire clinical course of Perthes’ disease lasted, on average, approximately 34 months during childhood, with long term sequelae affecting patients later in adult life.7

Why is Perthes’ disease missed?

Musculoskeletal complaints are common in children; most are related to self resolving trauma.8 Most have a benign clinical course requiring no specific treatment. Among many children …

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