Musculoskeletal - Bone - Vascular

Question 1

Legg-Calve-Perths Disease

Answer 1

• Avascular osteonecrosis of the capital femoral epiphysis

AKA - Coxa plana

Question 2

Legg-Calve-Perths Disease - Epidemiology

Answer 2

• Approxmately 1 in 1200 childrenyounger than 15 years is affected
• Males 5;1
• Typically between the ages of 4 to 8-12 years
• Bilateral involvement (successive rather than simultaneous) is seen in 10% of cases

Question 3

Legg-Calve-Perths Disease - Presentation

Answer 3

• Hip joint pain or referred to knee
• Limping
• Can also present as a “painless limp”
• Limitation of motion
• Possibly microtrauma leads to vascular compromise and osteonecrosis

Question 4

Legg-Calve-Perths Disease - Diagnostic Testing

Answer 4

• Radiographic studies
• Plain films: AP and Lauenstein (frog-lateral) position
• Arthroscopy to evaluate the condition of the joint if necessary
• Bone scan can identify process very early
• Grading
• Grade 1:
• 1/3 of epiphysis
• cystic appearance
• Epiphyseal height maintained
• Viable tongue of epiphysis
• Grade 2
• rarified bone
• Avascular segment
• ‘V’ segment
• Gage’s sign
• metaphyseal rarefaction
• Grade 3
• Avascular segment - most of epiphysis
• viable bone posterior and anterior
• Metaphyseal changes
• Grade 4
• Total epiphyseal involvement
• Diffuse metasphyseal changes
• No posterior viable bone
• Epiphyseal consolidation

Question 5

Legg-Calve-Perths Disease - Treatment

Answer 5

• Self-limiting disease
• Object is to preserve:
• normal femoral head contour
• congruous hip joint
• normal length of femoral neck
• Containment of femoral head
• Maintain range of motion of hip joint
• Use of containment orthosis surgery
• Containment
• best rest
• traction
• ischial weight bearing brace
• snyder sling
• abduction/internal rotation brace
• petrie cases
• toronto brace
• scottish rites brace

Question 6

Legg-Calve-Perths Disease - Management with complications

Answer 6

• Predisposition to osteoarthritis of the hip

Question 7

Legg-Calve-Perths Disease - Prevention and Health promotion issues

Answer 7

• Psychosocial issues concerning leg deformity

Question 8

Osteochondritis Dissicans

Answer 8

• Osteochondritis involves the degeneration of aseptic necrosis of a portion of a bone or a growth center in a bone followed by reossification. The origin appears to involve chronic, repetitive trauma, or microtrauma.
• Osteochondritis dissicans is a form of osteochondrosis which commonly involves the femoral condyle in the knee, but may involve other joints as well.

Question 9

Osteochondritis Dissicans - History

Answer 9

• Overall prevalence of OCD is unknown, but prevalence in specific joints has been reported:
• femoral condyles: 6 per 10,000 men and 3 per 10,000 women younger than 50 years.
• ankles: 0.002 per 1000, regardless of age/sex
• Elbows: 4.1% for OCD
• OCD occurs more commonly in the convex surface than in the concave surface of a joint
• Overall, the knee is most frequently involved in OCD; lateral aspect of medial femoral condyle.
• Since the advent of cross-sectional imaging (CT and MRI), OCD of the talus has been diagnosed more frequently and in future series may represent the most frequent site of OCD.
• Chronic trauma could be the prime cause of this disease

Question 10

Osteochondritis Dissicans - Presentation

Answer 10

• Gradual onset of vague pain from the affected joint
• Catching and locking phenomena with the joint
• Possibly joint effusion

Question 11

Osteochondritis Dissicans - Diagnostic Testing

Answer 11

• Radiographic studies
• AP, Lateral and Tunnel views required
• MRI to investigate the integrity of the cartilage

Question 12

Osteochondritis Dissicans - Treatment

Answer 12

• With children younger than 11, observation
• With children over 13 can require arthroscopic surgery to remove the loose body, replacement and internal fixation, or drilling into the lesion to stimulate revascularization

Question 13

Osteochondritis Dissicans - Management with complications

Answer 13

• Avascular bone fragment can become detached from the articular surface and go lose in the joint space necessitating surgery
• Defective articular surface can lead to degenerative joint disease

Question 14

Osgood-Schlatter Disease

Answer 14

• Osteochondrosis involves the degeneration or aseptic necrosis of a growth center in a bone followed by reossification. The origin appears to involve chronic, repetitive trauma or microtrauma.
• Osgood-Schlatter disease or juvenile osteochondrosis of teh tibial tuberosity is one of several forms of the osteochondrosis.
• It involves fragmentation of the tibial tubercle around the inferior attachment of the patella tendon. It most likely represents a traction apophysitis of the tibial tubercle growth plate.

AKA - Tibial osteochondrosis, Apophysitis, Tibial tuberosity apophysitis, Apophysitis tibialis adolescentium

Question 15

Osteochondritis Dissicans - History

Answer 15

• Osgood-Schlatter disease is the most common form of osteochondrosis and represents up to 10% of sports clinic’s diagnosis
• Most common in males 3:1
• Benign in course

Question 16

Osteochondritis Dissicans - Presentation

Answer 16

• Severe tenderness over the tibial tuberosity
• Physical exam reveals swelling and tenderness over the tibial tubercle
• Increased prominent of the tibial tubercle

Question 17

Osteochondritis Dissicans - DIagnostic Testing

Answer 17

• Radiographic studies

* Lateral radiograph

Question 18

Osteochondritis Dissicans - Treatment

Answer 18

• Rest
• Restriction
• Isometric exercises

Question 19

Osteonecrosis

Answer 19

• Vascular infarction leading to the cellular death of bone tissue

AKA - Avascular necrosis; Bone infarction

Question 20

Osteonecrosis - History

Answer 20

• Relatively common process, it can happen to any bone but is most common in the hip and knee.
• Avascular necrosis of the femoral head has an incidence of 15,000 new cases per year in the US and prevalence of 300,000 to 600,000 cases exist.
• Avascular necrosis of the femoral head occurs in sporatic and familial cases
• Analysis of the familial cases reveals the defect to involve a mutation in the gene for Type II Collagen (COL2A1)
• Factors that can result in osteonecrosis include:
• embolization of arteries
• vasculitis
• abnormal accumulation of cells
• elevated interosseous pressure
• inhibition of angiogenesis
• mechanical stress
• radiation exposure
• drugs such as corticosteroids
• idiopathic
• Infarction of subchondral bone in a joint leads to compression of the dead bone and a flattening of the affected region of the joint surface; the overlying cartilage can remain viable due to nutrient supply from the synovial fluids
• New bone is laid down on the scaffolding of the old bone, termed “creeping substitution” as the bone attempts repair
• In subchondral locations the dead bone is prone to collapse resulting in sloughing of the cartilage and distortion of the joint surface

Question 21

Osteonecrosis - Presentation

Answer 21

• Insidious onset of a dull, achy, throbbing pain in the general area of the bone involved
• Mild changes are usually seen on imaging with the onset of pain

Question 22

Osteonecrosis - Diagnostic Testing

Answer 22

• Radiographic studies
• plain films
• MRI imaging (gold standard)

Question 23

Osteonecrosis - Treatment

Answer 23

• Precollapse
• aim is to perserve the shape of the bone and joint surfaces
• surgical coring or transplantation
• Postcollapse
• replacement arthroscopy

Question 24

Osteonecrosis - Management with complications

Answer 24

• Osteonecrosis can contribute to the early development of osteoarthritis in affected joints