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Chapter 71 MARIA THERESA M. NAVARRO, MD. Department of Medical Imaging Quirino Memorial Medical Center
GENERAL 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)
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: soft tissue swelling on the lateral side of the joint smallness of the femoral ossification nucleus lateral displacement of the femoral ossification nucleus fissuring and fracture of the femoral ossific nucleus (radiographs on frog-leg position) flattening and sclerosis of the femoral ossific nucleus intraepiphyseal gas
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 metaphyseal “cysts” – characteristic widening and shortening of the femoral neck
LEGG-CALVE-PERTHES DISEASE: METAPHYSEAL ABNORMALITIES B. 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. C. In another child, note the broad and short femoral neck containing multiple radiolucent lesions. Most of the epiphyseal ossification center is destroyed.
GRADES OF FEMORAL INVOLVEMENT IN LEGG-CALVEPERTHES DISEASE (CATTERALL CLASSIFICATION) I Site of epiphyseal involvement Sequestrum Crescent sign Collapse Metaphyseal abnormalities anterior part No No No No II anterior part Yes anterior Yes
almost whole epiphysis
IV whole epiphysis Yes
anterior and posteriorly
anterior and extends posteriorly
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 Initial radiograph reveals minimal increased radiodensity of the head of the 3rd metatarsal bone (arrow) 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 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 Magnification radiograph demonstrates patchy increased density of the lunate without alterations in the shape of the bone Collapse of a sclerotic lunate bone
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 DISEASE Lateral radiograph reveals the small fragmented and slightly dense tarsal navicular bone. The interosseous spaces of the tarsus are not disturbed. Wafer-like radiodense tarsal navicular bone is identified in a different child. Again, the neigboring joint spaces are not diminished in width
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
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.
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, 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 severe altered alignment occurs in the proximal portion of the tibia, not between the femur and tibia, as seen in physiologic bowing
Infantile Type – 1st few years of life tibia is in varus position owing to angulation of the metaphysis tibial shaft is adducted without intrinsic curvature depressed medial tibial metaphysis with an osseous excrescence or spur
(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 (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
(4 to 6 years) The cartilage-filled depression in the metaphyseal beak deepens. The medial part of the bone epiphysis remains wedgeshaped and is less distinct. Small calcific foci may be evident beneath the medial border (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
(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. (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 Stage II, at age 4 years Stage IV, at 8 ½ years
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 wedging medial tibial growth plate is diminished in height
INFANTILE VERSUS ADOLESCENT TIBIA VARA
INFANTILE Age of Onset Distribution 1-3 years Bilateral : 50-75% Obesity, absent pain, tenderness, prominent derformity, slight leg shortening Trauma, growth arrest or dysplasia ADOLESCENT 8-15 years Unilateral : 90% Normal body weight, pain and tenderness, mild deformity, moderate, severe leg shortening Trauma Growth arrest
Clinical Findings: Etiology or Pathogenesis
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)
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 DISEASE Thoracic spine. Findings include irregularity of vertebral contour, reactive sclerosis, intervertebral disc space narrowing, anterior vertebral wedging, and kyphosis 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.
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
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
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