Destroyed Femoral Heads
Christopher G. Anton, MD
DIFFERENTIAL DIAGNOSIS
Less Common
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Legg-Calvé-Perthes (LCP) Disease
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Avascular Necrosis
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Septic Arthritis
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Juvenile Idiopathic Arthritis (JIA)
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Slipped Capital Femoral Epiphysis (SCFE)
Rare but Important
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Meyer Dysplasia
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Idiopathic Chondrolysis
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Epiphyseal Bone Tumors
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Epiphyseal Dysplasias
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
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Age and clinical presentation
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Need to exclude infection in child with hip pain and femoral head destruction
Helpful Clues for Less Common Diagnoses
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Legg-Calvé-Perthes (LCP) Disease
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Avascular necrosis of femoral head of unknown etiology
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Age: 3-12 years old, peak 6-8 years old
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Bilateral (10-20%)
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Radiographs
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Normal
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Flattening, sclerosis, fragmentation of femoral head ± subchondral fracture (best seen on frog leg lateral view)
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Bone scintigraphy: Earlier diagnosis than radiographs with decreased or absent perfusion
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MR: Earlier diagnosis than radiographs with decreased perfusion; loss of fatty marrow signal T1WI within femoral head
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Initial: Necrosis, vascular invasion, cartilage hypertrophy, overgrowth
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Fragmentation: Necrotic/dead bone is resorbed, ± metaphyseal cysts (cartilage) and cartilage hypertrophy
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Reparative: Healing and replacement of necrotic/dead bone
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Key: Prognosis heavily depends on containment of femoral head
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Femoral head grows laterally (extrusion of femoral head) with widening of medial joint space
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Incongruency between femoral head and acetabulum
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Avascular Necrosis
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Most commonly located: Anterolateral weight bearing portion of femoral head but can occur anywhere within femoral head
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T2WI: “Double line” sign
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Many causes, including sickle cell disease, trauma, steroids, vasculitis, Gaucher disease, hemophilia
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Children with acute lymphoblastic leukemia (ALL) and those treated with steroids particularly at risk
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Septic Arthritis
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Staphylococcus aureus most common
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May extend into joint from femoral epiphysis, metaphysis, joint capsule, or acetabulum
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Key: Early diagnosis and treatment
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Ultrasound: Detect joint effusion (cannot distinguish infected vs. aseptic fluid)
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Complications: Cartilage destruction (joint space narrowing), erosions, periosteal reaction, osteonecrosis, and soft tissue abscesses
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Juvenile Idiopathic Arthritis (JIA)
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a.k.a. juvenile rheumatoid arthritis (JRA)
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< 16 years old and symptoms > 6 weeks in duration
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Joint space narrowing is a late finding
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Slipped Capital Femoral Epiphysis (SCFE)
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Femoral head or joint destruction as complication in treatment
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Acute or chronic presentations
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Salter-Harris 1 femoral physeal fracture
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More common in boys
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Bilateral in up to 36%
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When bilateral, contralateral SCFE usually occurs within 18 months
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Age
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Girls: 8-15 years old
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Boys: 10-17 years old
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Predisposition
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Complications
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Chondrolysis (10%)
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Avascular necrosis (1%), increase in open reduction with fixation or pins across superolateral quadrant of femoral head ossification center
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Pin penetration
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Helpful Clues for Rare Diagnoses
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Meyer Dysplasia
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Age: 2-4 years old
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Mostly boys
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Bilateral (60%)
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Asymptomatic
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When clinical sign or symptoms present, consider early LCP disease
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Idiopathic Chondrolysis
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Destruction of articular cartilage of femoral head and acetabulum
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Stiffness, limp, and pain around hip
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Radiographs: Concentrically joint space narrowing, < 3 mm with osteopenia, pelvic tilt
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MR: Rectangular hypointense T1 and hyperintense T2 signal abnormality of center 1/3 of femoral head, ± ill defined within acetabulum
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Epiphyseal Bone Tumors
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Chondroblastoma
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1% of primary bone tumors
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2nd decade of life, > 90% are seen in patients < 30 years old
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M:F = 2:1
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Well-defined, eccentric, lucent, sclerotic borders
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Calcified matrix (50%)
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Giant cell tumor
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4-5% of primary bone tumors
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Considered benign, but malignant in up to 10% (can metastasize to lungs)
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Slight female predominance
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After growth plate closure
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Epiphyseal Dysplasias
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Diastrophic dysplasia
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Characteristic: “Hitchhiker thumb”
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Cervical platyspondyly and kyphosis, clubfoot
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Multiple epiphyseal dysplasia
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Ribbing (milder form) or Fairbank forms
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Should differentiate from LCP
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Bilateral and symmetric changes, short limbs
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Spondyloepiphyseal dysplasia
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Congenita: Evident at birth; short trunk, mildly short limbs, pear-shaped vertebral body, atlantoaxial instability
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Tarda: Presents at age 5-10; short trunks, disc spaces widened anteriorly and narrowed posteriorly, flattening vertebral bodies, dysplastic epiphyses
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Image Gallery
![]() Anteroposterior radiograph shows fragmented, flattened, femoral head ossification centers
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