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OSTEOCHONDROSES
Chapter 71
MARIA THERESA M. NAVARRO, MD.Department of Medical ImagingQuirino Memorial Medical Center
OSTEOCHONDROSISGENERAL CHARACTERISTICS rapidly ossifying central nucleus of bone within the
cartilage enlage of the epiphysis is vulnerable to mechanical pressures superimposed on hormonal and nutritional changes, explaining the appearance of certain conditions during the “midgrowth” spurt of childhood
become apparent in the 1st decade of life (when the developing bone still contains a cartilaginous model)
boys > girls predominantly single and unilateral trauma (usually an initiating event or common
pathway)
LEGG-CALVE-PERTHES DISEASE
children ages 4 – 8 years old boy > girls bilateral involvement (10% of cases) (+) family history (6% of cases) Clinical signs: limping, pain, and limitation
of joint motion in few days or weeks (+) history of trauma (25% of cases)
LEGG-CALVE-PERTHES DISEASE Radiographic abnormalities:1. soft tissue swelling on the lateral side of the
joint2. smallness of the femoral ossification
nucleus3. lateral displacement of the femoral
ossification nucleus4. fissuring and fracture of the femoral ossific
nucleus (radiographs on frog-leg position)5. flattening and sclerosis of the femoral ossific
nucleus6. intraepiphyseal gas
LEGG-CALVE-PERTHES- DISEASE
soft tissue distortion (arrowheads), sclerotic femoral ossification center that is laterally displaced and contains radiolucent fissures, and metaphyseal irregularity.
LEGG-CALVE-PERTHES DISEASE
Radiographic abnormalities:
further compression, disintegration, fragmentation, and sclerosis of the epiphysis, together with metaphyseal changes, can be seen
1. metaphyseal “cysts” – characteristic
2. widening and shortening of the femoral neck
LEGG-CALVE-PERTHES DISEASE: METAPHYSEAL ABNORMALITIES
A. Metaphyseal “cysts”. Observe the large cystic lesion of the medial metaphysis of the femur (arrow), which is associated with a fragmented, sclerotic, and laterally placed ossific nucleus.
B. In another child, note the broad and short femoral neck containing multiple radiolucent lesions. Most of the epiphyseal ossification center is destroyed.
I II III IV
Site of epiphyseal involvement
anterior part
anterior part
almost whole epiphysis
whole epiphysis
Sequestrum No Yes Yes Yes
Crescent sign No anterior
anterior and extends posteriorly
anterior and posteriorly
Collapse No Yes Yes Yes
Metaphyseal abnormalities
No Localized Diffuse Diffuse
GRADES OF FEMORAL INVOLVEMENT IN LEGG-CALVE-PERTHES DISEASE (CATTERALL CLASSIFICATION)
FREIBERG’S INFRACTION
involvement of the head of the 2nd metatarsal unilateral predominant in women 13 – 18 years of age clinical features: local pain, tenderness, and
swelling and limitation of motion of the corresponding metatarsophalangeal joint
FREIBERG’S INFRACTION
Radiographic Abnormalities subtle flattening, increased radiodensity, and
cystic lucent lesions of the metatarsal head
FRIEBERG’S INFRACTION : EARLY RADIOGRAPHIC ABNORMALITIES
A. Initial radiograph reveals minimal increased radiodensity of the head of the 3rd metatarsal bone (arrow)
B. Two weeks later, the depression of the articular surface of the metatarsal head and the sclerosis are more apparent (arrow)
FRIEBERG’S INFRACTION: LATER RADIOGRAPHIC ABNORMALITIES
Note the flattened metatarsal head with two osteochondral fragments (arrowheads), osteophytosis, joint space narrowing, widening of the phalangeal base
FRIEBERG’S INFRACTION: RESIDUAL DEFORMITIES Residual flattening of the 2nd metatarsal head, narrowing of the
adjacent joint space, intraarticular osseous bodies, expansion of the phalangeal base, widening of the 2nd metatarsal with cortical thickening
KIENBOCK’S DISEASE
Kienbock’s disease of the carpal lunate is most commonly observed in patients between the ages of 20 and 40 years
cause of condition is not clear certain anatomic features may predispose the lunate
to injury and subsequent osteonecrosis: vulnerable blood supply fixed position in the wrist, resulting in forces that may
be greater than those on neighboring carpal bones
KIENBOCK’S DISEASE
A. Magnification radiograph demonstrates patchy increased density of the lunate without alterations in the shape of the bone
B. Collapse of a sclerotic lunate bone
KOHLER’S DISEASE Kohler’s disease of the tarsal navicular is relatively
rare more frequent in boys, ages 3 and 7 years unilateral (75% to 80%) criteria in the diagnosis:
changes are detected in a previously normal navicular bone;
alterations consisting of resorption and reossification must be compatible with those of osteonecrosis
KOHLER’S DISEASEA. Lateral radiograph reveals the small fragmented and slightly
dense tarsal navicular bone. The interosseous spaces of the tarsus are not disturbed.
B. Wafer-like radiodense tarsal navicular bone is identified in a different child. Again, the neigboring joint spaces are not diminished in width
PANNER’S DISEASE
Osteochondrosis of the capitulum of the humerus rare disease that usually appears between the
ages 5 and 10 years boys are affected almost exclusively linked to history of trauma “little-leaguer’s elbow” because of its frequency in
young baseball pitchers
PANNER’S DISEASE Findings include fissuring and fragmentation of the
capitulum (arrow) and deformity of the adjacent radial head in this child with elbow pain and swelling
THIEMANN’S DISEASE
principal clinical manifestations of Thiemann’s disease are an onset in the second decade in life
a predilection for boys painless swelling of proximal interphalangeal joints
of the fingers digital shortening, and deformity
THIEMANN’S DISEASE Radiograph shows physeal closure and shortened
middle phalanges in the 2nd and 5th finger. The opposite side was similarly affected.
OSGOOD-SCHLATTER DISEASE disease of the tibial tuberosity adolescents, ages 11- 15 years boy> girls generally unilateral, bilateral (25%) clinically : local pain and tenderness, soft tissue
swelling, and firm masses on palpation radiographic abnormalities: soft tissue swelling due to edema of skin and soft
tissue margins of patellar tendon are indistinct ossific collection in the avulsed fragment
OSGOOD-SCHLATTER DISEASE. SOFT TISSUE ABNORMALITIES Low KV radiography indicates soft tissue edema over the
tibial tuberosity (solid arrow). Note indistinctness of the infrapatellar tendon (arrowheads) and osseous irregularity of the tuberosity (open arrow)
OSGOOD-SCHLATTER DISEASE : OSSEOUS ABNORMALITIES
Observe soft tissue swelling (arrowhead) and an avulsed osseous fragment of the tibial tuberosity (arrow)
BLOUNT’S DISEASE Blount’s disease, tibia vara, or osteochondrosis
deformans tibiae is a local disturbance of growth of the medial aspect of the proximal tibial epiphysis
Two Types: Infantile Type – 1st few years of life
5-8 X more frequent physiologic bowing persists and worsens radiographic abnormalities : simulate those of
physiologic bowing but are more severealtered alignment occurs in the proximal
portion of the tibia, not between the femur and tibia, as seen in physiologic bowing
BLOUNT’S DISEASE
Infantile Type – 1st few years of lifetibia is in varus position owing to angulation
of the metaphysistibial shaft is adducted without intrinsic
curvaturedepressed medial tibial metaphysis with an
osseous excrescence or spur
I (2 to 3 years) progressive increase in the degree of varus deformity of the tibia is associated with irregularity of the entire growth plate.
Medial part of the metaphysis protrudes with a medial and distal beak
II (2 ½ to 4 years) lateromedial depression of the ossification line of the medial portion of the metaphysis and a wedge-shaped medial end of the epiphysis are observed.
Complete healing of the lesion is possible at this stage
III (4 to 6 years) The cartilage-filled depression in the metaphyseal beak deepens.
The medial part of the bone epiphysis remains wedge-shaped and is less distinct.
Small calcific foci may be evident beneath the medial border
IV (5 to 10 years). With increasing bone maturation, the cartilaginous growth plate is reduced to a narrow plate, and the bone epiphysis occupies an increasing part of the end of the bone.
The medial margin of the epiphysis shows definite irregularity
V (9 to 11 years) The bone epiphysis and the corresponding articular surface are greatly deformed.
The epiphysis is separated in two portions by a clear band, extending medially from the lateral portion of the growth plate to the articular cartilage.
VI (10 to 13 years) The branches of the medially located double growth plate ossify, whereas growth continues in the normal lateral part.
Stages V and VI represent phases of irreparable structural damage
BLOUNT’S DISEASE: INFANTILE TIBIA VARA
A. Stage II, at age 4 years
B. Stage IV, at 8 ½ years
BLOUNT’S DISEASE Adolescent Type – children between ages 8 – 15
years cause is not clear, though arrest of epiphyseal
growth is suspected history of trauma or infection are elicited
occasionally radiographically :
unilateral (90%)leg shortening, mild to moderate varus
deformity (10 -20 degrees)proximal tibial epiphysis reveals medial wedgingmedial tibial growth plate is diminished in height
INFANTILE VERSUS ADOLESCENT TIBIA VARA
INFANTILE ADOLESCENT
Age of Onset 1-3 years 8-15 years
Distribution Bilateral : 50-75% Unilateral : 90%
Clinical Findings:
Obesity, absent pain, tenderness,
prominent derformity, slight leg shortening
Normal body weight, pain and tenderness,
mild deformity, moderate, severe leg
shortening
Etiology or Pathogenesis
Trauma, growth arrest or dysplasia
Trauma
Growth arrest
SCHEUERMANN’S DISEASE disorder of the spine, leading to lower thoracic
kyphosis cartilaginous node formation is fundamental to the
disease process has been suggested that congenital weakness of the
endplates predisposes certain persons to intraosseous discal prolapse during periods of excessive physical stress
combination of kyphosis, cartilaginous nodes, and irregular vertebral outlines (pathognomonic)
SCHEUERMANN’S DISEASE clinical abnormalities: high variable asymptomatic; others fatigue, defective posture,
aching pain aggravated by physical exertion, and tenderness to palpation
kyphotic deformity, which may be associated with mild scoliosis, predominates in the thoracic region (75% of patients)
SCHEUERMANN’S DISEASE The underlying abnormality relates to intraosseous displacement of
disc material (cartilaginous nodes) through the cartilaginous endplates (arrowheads).
This produces radiolucent lesions of the vertebral bodies with surrounding sclerosis;
intervertebral disc space narrowing; irregularity of vertebral contour
SCHEUERMANN’S DISEASEA. Thoracic spine. Findings include irregularity of vertebral contour, reactive
sclerosis, intervertebral disc space narrowing, anterior vertebral wedging, and kyphosis
B. Lumbar spine. Observe the cartilaginous nodes (arrowheads) creating surface irregularity, lucent areas, and reactive sclerosis. An anterior discal displacement (arrow) has produced an irregular anterosuperior corner of a vertebral body, the limbus vertebra.
SINDING-LARSEN-JOHANSSON DISEASE most common in 10-14 years of age tenderness and soft tissue swelling over the lower
pole of the patella associated with fragmentation of the inferior portion
of the patella with spastic paralysis (which is consistent with traction phenomenon)
“jumper’s knee” radiographically: small bone fragments adjacent to
the distal surface of the patella with overlying soft tissue swelling
natural duration of the disease – approx. 3 to 12 mos
SINDING-LARSEN-JOHANSSON DISEASE In this patient with spastic paralysis, observe
fragmentation of the lower pole of the patella (arrow) related to abnormal stress
SEVER’S DISEASE disorder due to variation in ossification irregularity of the secondary calcaneal ossification fragmentation and sclerosis of the secondary
ossification center of the calcaneus normal consequence of proper weight-bearing
SEVER’S DISEASE An example of sclerosis of the secondary calcaneal
ossification center Normal consequence of weight-bearing