Osteochondritides (incl. Perthe’s, Osgood-Schlatter) Flashcards
Define Perthe’s disease.
Perthes’ disease is a degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years.
BMJ: It is a self-limiting disease of the femoral head comprising of necrosis, collapse, repair, and re-modelling that presents in the first decade of life
What is the pathophysiology of Perthe’s disease?
It is due to avascular necrosis of the femoral head, specifically the femoral epiphysis. Impaired blood supply to the femoral head causes bone infarction.
It is bilateral in 10% of cases
Who is mostly affected by Perthe’s disease?
<10 yr olds
5x more common in boys
What are the main features of Perthe’s disease?
- hip pain: develops progressively over a few weeks
- limp
- stiffness and reduced range of hip movement
x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening
What investigations are used in the diagnosis of Perthe’s disease?
- plain x-ray
- technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist
Name 2 complications of Perthe’s disease.
- osteoarthritis
- premature fusion of the growth plates
What staging is used for Perthe’s disease?
How do you manage Perthe’s disease?
- To keep the femoral head within the acetabulum: cast, braces
- <6 years: observation
- >6 years : surgical management with moderate results
- Operate on severe deformities
How do you manage acute episodes of Perthe’s disease?
- Conservatively with NSAIDs such as ibuprofen, or paracetamol
- Rest
- Abduction plasters (if necessary)
What is the prognosis with Perthe’s disease?
Most cases will resolve with conservative management. Early diagnosis improves outcomes.
What might you find on examination in Perthe’s disease?
- Antalgic gait in acute episodes
- Trendelenburg’s test may be positive due to gluteal muscle wasting
- Apparent limb shortening
- Reduced range of motion
What are the 4 stages of Perthe’s disease?
- Ischaemia
- Resorption, fragmentation, re-vascularisation, and repair
- Re-ossification and resolution
- Remodelling
A 6-year-old boy presents with pain in the hip it is present on activity and has been worsening over the past few weeks. There is no history of trauma. He was born by normal vaginal delivery at 38 weeks gestation On examination he has an antalgic gait and limitation of active and passive movement of the hip joint in all directions. C-reactive protein is mildly elevated at 10 but the white cell count is normal. What is the most likely diagnosis?
Perthe’s disease - X-ray may show flattening of the femoral head or fragmentation in more advanced cases.
Define Osgood-Schlatter disease.
Paediatric overuse syndrome causing traction apophysitis of the tibial tubercle
What are the risk factor for Osgood-Schlatter disease?
- male
- athletic - sports with repeated forceful knee extension
- adolescent
- history of OSD
Other: proximal/broader tibial attachment of the tibia, increased external tibial torsion, patella alta (high position of patella)
What is the management of OSD?
Bed rest - OSD is self limiting
Other:
- Ice pack or compressive bandage can be applied if swelling
- NSAIDs early
- Physiotherapy after acute epidose to strengthen quadriceps and hamstrings
What is the prognosis of OSD? What complications can occur?
Prognosis: 90% is self-limiting with excellent prognosis.
Complications: Bony overgrowth of the tibial tubercle/persistence of a bony ossicle into adulthood can impinge on the patellar tendon, causing pain and limiting activity. This can be fixed surgically with excision of the ossicle and/or osteoplasty of the tibial tubercle, with excellent long-term outcomes.
What is the aetiology of OSD?
Traumatic theory: micro-avulsion at the insertion of the patellar tendon caused by repeated traction injury
Circulation theory: disturbance in the circulation of the apophysis due to rapid bone growth during adolescence, leading to the inability of the apophysis to withstand traction forces from the patellar tendon.
What is the epidemiology of OSD?
- More common in athletic children
- Occurs at 8-12 years in girls and 12-15 years in boys
- Males > females
- Bilateral in 20-30%
Describe the symptoms of OSD.
- Pain at the tibial tubercle
- Pain worsened by activity (for example, sport)
- Pain relieved by rest, ice, and anti-inflammatory medicines.
What are the findings on examination in OSD?
- Localised swelling
- Localised tenderness
- Localised warmth
- Prominence of the tibial tubercle
- Pain at the tibial tubercle with resisted knee extension.
How is OSD diagnosed?
Clinically
When should you request a plain X ray for OSD?
If the pain is unilateral, severe, or persistent, and if there is any history of trauma.
When should an MRI be requested in OSD?
If malignancy or infection is suspected instead
What is ‘irritable hip’?
Transient synovitis - cause of acute hip pain in children aged 2-12 years often accompanied by viral infection
How does transient synovitis present?
- Acute onset pain in the hip or a limp.
- No pain at rest
- Decreased range of movement including internal rotation
- Pain may be referred to knee
- Mild fever or afebrile
What is a differential diagnosis for irritable hip?
Early septic arthritis of the hip joint - must do joint aspiration and blood cultures if this is suspected
Which condition is irritable hip sometimes associated with?
May precede the development of Perthe’s disease
What is the management of irritable hip?
Bed rest and rarely skin traction
Usually resolves within a few days
Compare and contrast irritable hip with septic arthritis.
