Left Atrial Ball Thrombus in Man with Rheumatic Heart Disease

A 10-year-old boy presented with a limp and occasional pain in the right knee of 2 years' duration. A roentgenogram of the pelvis revealed fragmentation of the right capital femoral epiphysis with an irregular acetabulum.

Drs Edmond K. H. Liu and Alexander K. C. Leung of Calgary, Alberta, made the diagnosis of Legg-Calv-Perthes disease. The condition is characterized by ischemic necrosis of the proximal femoral epiphysis with later resorption. About 75% of affected youngsters are male; 80% of cases are unilateral.

The onset of Legg-Calv-Perthes disease usually occurs between ages 4 and 8 years. Most children present with occasional mild pain in the anterior thigh or knee and a limp. The classic presentation has been described as a “painless limp.”

Children younger than 6 years with involvement of less than half of the femoral head need to be followed closely for likely disease progression. Nonsurgical or surgical containment of the femoral head is indicated if more than half the femoral head is involved or if the child is older than 6 years at clinical onset.

Abduction casts (Petrie) or orthoses commonly are used to contain the femoral head within the acetabulum. The Scottish Rite orthosis, which does not extend below the knee, is frequently used. Surgical treatment-either femoral osteotomy or pelvic osteotomy-is an option for patients in whom conservative treatment is undesirable or unacceptable.

This patient used a Scottish Rite orthosis for 12 months. His condition improved.