Paediatrics: Osteochondroses

Osteochondroses

A spectrum of conditions primarily affecting the epiphyses , but may also involve cartilage and bone. Despite the term ‘osteochondritis’, the con-dition is not always due to inflammation and may be due to trauma or over-usage, vascular irregularities, or may be a normal variation. The af-fected devascularized bony region undergoes spontaneous healing with revascularization, resorption, and re-ossification. Symptoms are usually worse with activity and relieved with rest. It is usually a self-limiting con-dition with clinical outcomes ranging from normal to serious disability. Investigations include radiographs of the affected region, which may dem-onstrate fragmentation/collapsed sclerotic bone. An MRI scan will confirm the diagnosis. The conditions can be classified anatomically.

‘Physeal’ (growth plate) osteochondroses

Often require treatment.

•   Madelung deformity (distal radius): defect in the volar and ulna side of the distal radial physis resulting in a shortened tilted distal radius and a prominent ulna. Occurs in teenage girls and features include pain, decreased range of movement, and abnormal wrist joint. Treated with analgesia and surgery.

•   Scheuermann’s disease (vertebra)

•   Blount disease: tibial physis.

Articular osteochondroses

Great potential for disability.

•   Freiberg disease: infarction of the second metatarsal head or epiphysis in teenagers (females > males), presenting with pain on running and dancing. Joint tenderness with decreased range of movement, and pain on tip-toe standing. Managed with change of activities, analgesia, orthotics, intra-articular corticosteroids+/– surgery.

•   Perthes’ disease

•   Panner’s disease (osteonecrosis of the capitellum): children <10yrs. No history trauma. Mild flexion contracture diffuse synovitis. X-ray shows irregular areas with sclerosis. MRI/CT/USS may aid diagnosis. Treatment NSAIDs, splint, occasionally arthroscopy. Prognosis good.

•   Osteochondritis of capitellum: occurs in older children. May be due to overloading of the elbow (e.g. overhand throwing/batting) with accentuation of any valgus deformity. Clinical findings include mechanical block +/– flexion contracture, general lateral elbow pain, and swelling. AP X-ray with elbow flexed 45° may demonstrate irregular joint surface. CT/MRI/USS have also been used. Treatment: rest with avoidance of exacerbating factors; anti-inflammatories; arthroscopic removal of loose bodies, drilling, or fixation of unstable lesions.

Radial head: similar to osteochondritis capitellum, except the radial head is affected. Child is prone to developing overgrowth and joint incongruity.

Non-articular osteochondroses

At tendon attachments

• Osgood–Schlatter’s disease (tibial tubercle traction apophysitis): failure of the tibia tubercle apophysis due to repetitive traction stress from the extensor mechanism in boys (aged 12–14yrs) > girls (aged 10–12yrs). Usually a self-limiting condition with complete resolution through physiological healing (physeal closure) of tibia tubercle within 12–24mths. Presents with painful swelling over a prominent tibial tubercle (usually unilateral), associated with running/jumping. An irregular fragmented tibial tubercle may be seen on X-ray. Treatment includes non-operative (activity modification, rest +/– ice +/– knee brace), physiotherapy (isometric hamstring and quadriceps exercises), medication (NSAIDs), and operative (occasionally excision of separate ossicles may improve symptoms after skeletal maturity).

• Sinding–Larsen–Johansson syndrome: related condition arising at distal end of the patella.

At ligament attachments

Adam’s disease (medial epicondyle)

Repetitive injury to the elbow following throwing/serving sports (e.g. rac-quet sports). Results in medial epicondylar fragmentation or avulsion and delayed closure of the growth plate. May have ulnar nerve involvement and point tenderness over the medial epicondyle.

Treated with rest/change of activities, splintage, analgesia (NSAIDs). Gradual return to activities once symptoms have settled. May need sur-gery to excise loose bodies.

At impact sites

• Kohler’s disease: infarction of the navicular bone presenting as medial midfoot pain and a limp in young children (males > females) especially with load-bearing sports. Treated with rest from load-bearing sport, in soles/casts. If symptoms are severe, child may need to be non-weight-bearing with gradual return to activities depending on symptoms.

Sever’s disease: calcaneal apophysitis. Caused by repeated microfracture (with subsequent inflammation and healing) of the fibrocartilaginous insertion of the tendo-Achilles to the calcaneum during the pubertal growth spurt. Symptoms vary depending on the level of activity and it improves with skeletal maturation. There may be a bony prominence at the tendon insertion due to overgrowth during healing response. Treatment symptomatic NSAIDs, heel cord stretching.