Apophyseal Injuries

Apophysitis of the Hip

Apophyseal injury involving the anterosuperior and anteroinferior iliac spines, iliac crest, and ischial tuberosity typically occurs in active adolescents. Major abdominal and hip muscles either insert or originate at these sites of bone growth. The condition is most common in distance runners and dancers and is associated with muscle-tendon imbalance and rapid growth (see Chapter 10). Adolescents present with vague, dull pain related to activity located near the hip. Should a single traumatic episode exceed the strength of the physis, an avulsion fracture through the growth plate occurs. Radiographs may be useful for evaluating acute trauma and ruling out other hip pathology. Treatment includes rest from the offending activity followed by a program of stretching and progressive strengthening of the abdominal and hip muscles (Table 7.1). Depending on their size and displacement, acute fractures may be treated with rest or open-reduction internal fixation.

Sinding-Larsen-Johansson Syndrome

Sinding-Larsen-Johansson syndrome is an apophyseal injury to the inferior pole of the patella. The condition is thought to result from multiple episodes of traction-induced microtrauma at an immature, inferior patellar pole, with resultant calcification and ossification at this junction. It is commonly seen in active preteen boys (10-12 years old), who complain of pain over the inferior pole of the patella or at the proximal quadriceps patellar junction that is worsened by running or stair climbing. Point tenderness is noted at the patella-quadriceps or patella-patellar tendon junctions. The remainder of the knee examination is usually normal. Radiographs may be normal or show varying amounts and shapes of calcification or ossification at the patellar junction.

It is important to advise the patient and family that it is a self-limited condition that improves with rest and attainment of skeletal maturity. Activity modification, use of a knee sleeve, ice, massage, and antiinflammatory medication are usually helpful for reducing discomfort.

Table 7.1. Apophyseal Injuries

Age

Differential

Injury

(years)

Site

Presentation

diagnosis

Treatment

Sever's disease

8-13

Posterior calcaneus

Heel pain with activity

Achilles tendinitis, stress fracture

Heel cups, RICE, decrease activity, NSAIDs

Osgood-Schlatter

Boys: 1 0-15

Tibial tuberosity

Anterior knee pain

PFD, OCD, stress

RICE, activity

disease

Girls: 8-13

fracture

modification, NSAIDs

Sindig-Larsen-Johannson

10-13

Inferior pole of

Anterior knee pain

PFD, OCD, stress

RICE, activity

syndrome

patella

fracture

modification NSAIDs

Apophysitis of the

9-13

ASIS, AIIS, iliac

Dull ache around

Muscle strain,

RICE, stretching

hip

crest, ischial tuberosity

the hip

stress fracture

program, NSAIDs

Source: Peck,53 with permission.

NSAIDs = nonsteroidal antiinflammatory drugs; PFD = patellofemoral dysfunction; OCD = osteochondritis dissecans; RICE = rest, ice, compression, and elevation; ASIS = anterosuperior iliac spine; AIIS = anteroinferior iliac spine.

Source: Peck,53 with permission.

NSAIDs = nonsteroidal antiinflammatory drugs; PFD = patellofemoral dysfunction; OCD = osteochondritis dissecans; RICE = rest, ice, compression, and elevation; ASIS = anterosuperior iliac spine; AIIS = anteroinferior iliac spine.

Osgood-Schlatter Disease

Osgood-Schlatter disease, the most common apophyseal disorder, was independently described in 1903.38 The condition is found most commonly in boys age 10 to 15 years and in girls 2 years earlier; it is often bilateral (20-30% of cases). On examination, exquisite tenderness may be noted over the anterior tibial tubercle, with prominence and swelling at that location. Pain worsens during running, jumping, and ascending or descending stairs. Resisted extension of the knee at 90 degrees of flexion causes pain. Radiographs are obtained to exclude the possibility of osteomyelitis and arterial-venous malformations. A discrete separate ossicle is noted at the tibial tubercle in as many as 50% of reported cases.

The patient and family must understand that 12 to 18 months may be required to allow spontaneous resolution by physiologic epiphysiodesis. Treatment with ice, antiinflammatory medication, and an appropriately contoured knee pad relieves symptoms. The level of sporting activity is balanced with tolerance and severity of symptoms. If symptoms progress to disability with activities of daily living, a brief course (7-10 days) of knee immobilization usually resolves the discomfort. Steroid injections into the tibial tubercle should never be done. Rare, persistent cases that fail to respond to a lengthy trial of conservative therapy may resolve with surgical removal of the bony ossicle overlying the tibial tubercle.

Sever's Disease

In 1912 Sever39 described a benign inflammatory condition to the cal-caneal apophysis in active adolescents. The sports most commonly associated with Sever's disease are soccer and running. The disease presents with unilateral or bilateral (60%) posterior heel pain in the 8-to 13-year-old athlete. It is associated with accelerated growth, tight heel cords, and other biomechanical abnormalities. Patients present with tenderness at the insertion of the Achilles tendon on the calcaneus. Radiographs may show partial fragmentation and increased density of the os calcis, thereby ruling out other rare causes of heel pain, such as unicameral bone cyst or a stress fracture. Activity modification, stretching of the gastrocnemius-soleus complex, ankle inverters and everters, and heel cups have all proved helpful. Children may return to sports without limitation 2 to 4 weeks after symptoms resolve.

Osteochondritis Dissecans

Osteochondritis dissecans (OCD) is characterized by separation of a fragment of bone with overlying articular cartilage from the sur rounding normal bone. OCD most commonly affects the medial aspect of the lateral femoral condyle, but is also seen in the talar dome and humeral capitellum (Fig 7.9). OCD can occur in all large joints. The incidence is estimated to be 15 to 30 cases per 100,000 persons. OCD may be more common than is currently known because asymptomatic lesions are discovered only incidentally. Risk factors include repetitive microtrauma as seen in throwing sports or gymnastics. OCD has a familial predisposition. Contralateral joint involvement is noted in 20% to 30% of patients with OCD of the knee.

Without proper management the disease may progress through four stages: stage 1, thickening of the articular cartilage (stable); stage 2, fragment in situ and beginning of demarcation of the articular cartilage (stable); stage 3, partial detachment (unstable); and stage 4, complete detachment of the fragment and formation of a loose body (unstable).40 OCD may be viewed as a stress fracture of the involved subchondral bone and requires differentiation from epiphyseal dysplasia, ossification defects, and acute osteochondral fracture. Symptoms include vague joint pain, catching, restricted range of motion, and pain with activity or range of motion. Plain radiographs reveal most lesions. Radioisotope scanning may be used if onset is acute and x-rays are negative. MRI is the gold standard for staging once the diagnosis is made.

Medial condyle 85%

Classical 69% Extended classical 6% Inferocentral 10%

Classical 69% Extended classical 6% Inferocentral 10%

Lateral condyle 15%

Inferocentral 13%

Anterior 2%

Fig. 7.9. Distribution of osteochondritis dissecans by body location.

Inferocentral 13%

Anterior 2%

Fig. 7.9. Distribution of osteochondritis dissecans by body location.

Conservative treatment, including avoidance of stressful or painful activities and restricted weight bearing for periods ranging from 2 to 6 months may be successful in selected patients. Predictors of good clinical outcomes with conservative management include open joint physis, and small lesions that are stable on MRI.41 Not all lesions heal spontaneously, and surgery may be required to stimulate new bone growth. Most orthopedic surgeons prefer arthroscopic drilling of the lesion from inside the joint.

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