January 2002 Radiological Findings in Osgood-Schlatter s Disease Laura Gottlieb Harvard Medical School Year IV
Agenda Define Osgood-Schlatter s Disease (OSG) Learn Relevant Knee Anatomy Identify X-Ray Findings of OSG Discuss Complications of OSG 2
Osgood Schlatter s = An Osteochondrosis Predilection for immature skeletons Involvement of epiphyseal/apophyseal bone Radiologic picture includes collapse, fragmentation, sclerosis, and frequent reossification The Big Picture Image courtesy of Ferris Hall, MD. BIDMC, Boston, MA. 3
Osgood-Schlatter s Basics: A Non-articulating Osteochondrosis Disorder of patellar ligament s distal attachment at tibial tuberosity Results from chronic stress at site of weak attachment causing repeated microtrauma. Causes temporary or permanent change in chondrogenesis/osteogenesis. Involves no disruption to blood supply but significant soft tissue swelling and pain! 4
Normal Knee Anatomy From Southmayd W, Sports health. Quickfox 1981; 439. From Novelline R, Squire s Fundamental s of Radiology, 5 th ed. Harvard University Press 1997; 60. 5
Apophyseal Growth From Resnick and Niwayama, Diagnosis of Bone and Joint Disorders, 2nd ed. WB Saunders Co, Philadelphia 1988. 5(84): 3314. 6
Normal Adolescent Knee Image courtesy of Ferris Hall, MD. BIDMC, Boston, MA 7
Normal Adolescent Knee Infrapatellar Fat Pad Patellar Ligament Apophysis Image courtesy of Ferris Hall, MD. BIDMC, Boston, MA 8
Adolescents OSG: The Clinical Picture Boys (75%) 10-15yo Girls (25%) 8-12yo Localized pain anterior to tibial tuberosity Pain worsens with activity Up to 50% have bilateral involvement Soft tissue swelling without synovial joint effusion 9
The Case of Adolescent X Presented to Children s Hospital 14 yo male occasional painful swelling over left tibial tuberosity active kid, soccer especially no known trauma to area 10
DDX Unilateral Knee Pain over Tibial Tuberosity infection: osteomyelitis Malignancy or other mass: osteosarcoma, Ewing s sarcoma, osteoid osteoma fracture: complete avulsion of tibial tubercle includes apophysis itself patellar tendonitis = jumper s knee Osgood-Schlatter s disease In this case they ordered an x-ray to r/o the big, the bad, and the ugly. 11
To X-Ray or Not To X-Ray? The Age Old Question Age of patient? Unilateral? Other symptoms? e.g. fever, night sweats Other atypical features? e.g. hx of trauma Experience and type of clinician matters! 12
Adolescent X Films Left knee, lateral film Adolescent X From Children s Hospital Teaching File 4.535. Soft tissue swelling anterior to tibial tuberosity Thickening of patellar ligament Indistinctness of infrapatellar fat pad Bony abnormalities Sclerosis 13
Adolescent X Films Compared to Normal Left knee, lateral film Adolescent X Lateral film, normal From Children s Hospital Teaching File 4.535. Image courtesy of Ferris Hall, MD. BIDMC, Boston, MA. 14
Adolescent X has classic plain film findings of Osgood- Schlatter s Disease. Lets review some other causes for tibial tubercle pain 15
Known Osteomyelitis vs. Adolescent X Osteomyelitis Sclerosis Diffuse involved region Adolescent X Cortical erosion From Children s Hospital Teaching File 6.253 From Children s Hospital Teaching File 4.535. 16
Known Osteosarcoma vs. Adolescent X Diffuse, homogenously increased density of proximal tibia From Children s Hospital Teaching File 4.321. From Children s Hospital Teaching File 4.535. 17
Classic X-Ray Findings in OSG: Some Practice Indistinct patellar ligament and fat pad Fragmentation and sclerosis From Resnick and Niwayama. Diagnosis of Bone and Joint Disorders, 2 nd ed. WB Saunders Co, Philadelphia 1988; 5(84): 3315. 18
Some more practice Bony fragment within ligament Bony fragment From: gait.aidi.udel.edu/res695/homepage/pd_ortho/ educate/clincase/clcsimge/osgod1.jpg From Resnick and Niwayama, Diagnosis of Bone and Joint Disorders, 2 nd ed. WB Saunders Co, Philadelphia 1988; 5(84): 3316. 19
Menu of Tests Used in Osgood-Schlatter s Disease None X-ray: Standard frontal and lateral projections; consider special views --internal rotation views Don t overexpose films! soft tissue density bone density CT and MRI: show changes at insertion of patellar tendon U/S: shows thickening of patellar tendon near insertion (increased echogenicity) 20
CT Images Mild fragmentation of anterior tibial tubercle at insertion site of patellar ligament From uhrad.com/msiarc/msi039.htm. 21
MRI Images T1 Sagittal MR Image Decreased signal in region of tibial tuberosity at insertion of patellar ligament From uhrad.com/msiarc/msi039.htm. 22
Complications of Osgood-Schlatter s Disease Usually resolves when apophysis fuses with tibial tuberosity. May see: Persistent bony fragment/non-union pain--surgery Subluxation of patella from weakened distal insertion point of ligament Patellar ligament tear Scar tissue 23
Avulsion Injuries I Old avulsion injury Sclerosis From Murray and Jacobson. Radiology of Skeletal Disorders. Longman Group NY 1971; 1(1):142. From Resnick and Niwayama. Diagnosis of Bone and Joint Disorders, 2 nd ed. WB Saunders Co, Philadelphia 1988; 5(84): 3315. 24
Avulsion Injuries II Irregular and fragmented tibial tuberosity Abnormally wide apophyseal plate Presentation One year later Prominent tibial tuberosity Bony fragment From Murray and Jacobson. Radiology of Skeletal Disorders. Longman Group Limited NY 1971; 1(1): 143. 25
Subluxation of patella From http://www.medmedia.com/oo1/51.htm 26
Patellar ligament tear Absence of Patellar Ligament Normal Patellar Ligament From http://www.medmedia.com/oo1/238.htm Image courtesy of Ferris Hall, MD. BIDMC, Boston, MA. 27
Related disorder of the Patellar Ligament: Sinding Larsen Johansen Syndrome (SLJS) d/o of proximal patellar ligament where it attaches to patella otherwise the same d/o as OSG! chronic stress leads to microtrauma and change in chondrogenesis/osteogenesis 28
Sinding Larsen Johansen Syndrome II Fragment of lower pole of patella Extraossification area From Resnick and Niwayama. Diagnosis of Bone and Joint Disorders, 2 nd ed. Publisher info! :3326. 29
Treatment of Osgood-Schlatter s Disease Rest and relax no jumping no pushing off no squatting Reality of Adolescence Want teens to comply: give them control 30
Other Treatment Options NSAIDS Wraps--ace bandages, neoprene braces Removable immobilizers, restraints Cast--mid-thigh to mid-calf Quadriceps strengthening Anterior knee strap From www.supports4u.com/osgoodschlatters.htm 31
Conclusions Osgood-Schlatter s Disease is a non-articulating osteochondrosis that occurs in the accelerated growth phase of adolescence when distal attachment of patellar ligament is weakest. Disease usually disappears when apophysis fuses. Treatment depends on severity of symptoms. X-rays are the study of choice and usually reveal: soft tissue swelling: indistinct patellar ligament, blurred fat pad, anterior tissue swelling bony fragmentation focal sclerosis 32
References Children s Hospital Pediatric Radiology Teaching Files. The Children s Hospital, Boston, MA. Murray and Jacobson. Radiology of Skeletal Disorders. Longman Group, NY: 1971. Wenger, Dennis and Mercer Rang. The Art and Practice of Children s Orthopaedics. Raven Press, NY: 1993. Novelline, Robert. Squire s Fundamentals of Radiology, 5 th ed. Harvard University Press: 1997. Resnick and Niwayama. The Diagnosis of Bone and Joint Disorders, 2 nd ed., 5(84). WB Sanders, Philadelphia: 1988. Southmayd, William and Marshall Hoffman. Sports health: The Complete Book of Athletic Injuries. Quick Fox, NY: 1981. Staheli, Lynn. Fundamentals of Pediatric Orthopedics, 2nd ed. Lippincott- Raven, Philadelphia: 1998. Web Resources: www.uhrad.com http://gait.aidi.udel.edu www.medmedia.com/oa2 www.alldoctors.com www.allkids.org/epstein/articles/adolescence.html http://www.medstudents.com.br/orto/orto4.htm 33
Acknowledgements Considerable appreciation is owed to the following people: Michael Stella, MD Daniel Saurborn, MD Ferris Hall, MD Larry Barbaras and Cara Lyn D amour Pamela Lepkowski 34