Referat

Osgood-Schlatter Disease

Arrange by: Cahyaning Gusti Agriani G9911112034 Tutor: Dr. Tangkas Sibarani, SpOT, FICS

Orthopaedic and Traumatology Department of Sebelas Maret University Moewardi Hospital / Prof. Dr. R. Soeharso Orthopaedic Hospital Surakarta 2012

LEGALLY SHEET Referat with title Osgood Schlatter Disease is arranged to fulfil the requirement in Orthopaedic and Traumatology Department Sebelas Maret University, Moewardi Hospital/Prof. Dr. R. Soeharso Orthopaedic Hospital Surakarta by: Cahyaning Gusti A. G9911112034 Has been approved by Tutor of Orthopaedic and Traumatology Department in Prof. Dr. R. Soeharso Orthopaedic Hospital Surakarta. Surakarta,
th

September 2012

Tutor

Dr. Tangkas Sibarani, SpOT, FICS

CHAPTER II INTRODUCTION Disease Osgood-Schlatter represents apophysitis of proximal corner of a shinbone (lat. Tibia) or avascular necrosis, which occurs in a time of adolescence, respectively in a time of pronounced growth. It is characterized with appearance of pain inside of tibial protuberance (lat. Tuborerositas tibiae) and probably represents inflammation of the glass of tendon and belonging cartilage plate growth tibia protuberance, and it is caused by physical activity, regarding traction. The magnetic resonance studies showed that in most cases, it is tendinitis of the glass of tendon, and in fewer cases, it comes to fragmentation of the bony part of the attachment of ligaments. It is observed that it frequently appears joined with patella alta syndrome. First time this illness is described in 1903 separately by American surgeon Robert Osgood and Swiss surgeon Carl Schlatter, and by them, it got a name.1 Usually it appears at the age of 10 to 15 years, and etiologic factors can be hormonal, mechanical, inflammatory, and hereditary, mainly in children who deal with sports 20% in a difference with others who do not deal with sports where frequency is 4%. At boys, it occurs mainly in a period from 14 to 15 years, and at girls, it occurs earlier from 10 to 11 years.2 Both knees are affected in nearly 25% of the cases.3 Detailed and correct anamnesis is very important (living conditions, diseases before, family anamnesis, does patient play sports and which, etc.). Next step is approaching to clinical examination. At first, doctor should exclude a possibility of existence of any other injury and/or disease in side of proximal corner of a shinbone and knee. Characteristic sign is a painful sensitive bulge on a top side of a shinbone. It is necessary to test does the pain increase during straining for headed muscle of upper leg or during jumping only on a leg on which is a painful bulge. If stated tests are positive, there is a big possibility that is an Osgood Schlatter disease. Of imaging (RTG) techniques, mainly, it is used native radiography, and with a cause to reject a possibility of existence of the bony tumors

and fractures of a bone. People who have an Osgood-Schlatter disease, they have a characteristic profile X-ray image of a knee. On it is seeable a bulge of attachment of tendon glass on shinbone, with irregular fragmented bone core (fragmented ossification), and swelling of the soft tissues. In some cases, ultrasound scan can be done, but it cannot replace X-ray images, even it gives better information about look of the tendon glass and its attachment. A magnetic resonance (MR) is rarely used for diagnose of an OsgoodSchlatter disease.4

CHAPTER II BIBLIOGRAFI A. OSGOOD SCHLATTER DISEASE

The quadriceps tendon attaches to the patella (knee cap) and then continues down to the top of the tibia as the patellar tendon. When the quadriceps muscle flexes it shortens pulling upward on the tendon, which in turn causes the tendon to pull up on the tibia, causing the lower leg to extend. As with any attachment it is under considerable stress when forcibly extending the knee or supporting the bodyweight during dynamic activities. Repetitive forceful contractions of the quadriceps can cause tiny avulsion fractures at the tendon attachment on the tibia. The bone will attempt to repair itself by adding more calcium to the area to protect and strengthen the attachment. This causes the lump under the knee often associated with Osgood Schlatter's Disease. When an adolescent or young teen goes through a growth spurt the muscles often struggle to keep pace with the growing bones and therefore are often too short

compared with the accompanying bones. This places additional stress on the attachments and happens often with the femur and quadriceps muscle. The femur grows quickly and the quadriceps does not stretch so the muscle is tight until it has a chance to adapt to the new growth. This puts a chronic strain on the quadriceps and patellar tendon. This stress leads to those tiny fractures at the attachment site when the muscle is under stress. These lead to the calcium loading at the site and pain and inflammation result. Osgood-Schlatter Disease is common in boys and girls between the ages of 10-15 years and are highly active in sports. As a child grows, some bones lengthen and mature faster than other bones, muscles and tendons can accommodate. The leg bones for example have been known to grow as long as two inches in a year. The growth of surrounding soft tissue is slower but can adapt without discomfort to the child, if the tissue is not under high levels of stress (such as in impact exercise). Young athletes in basketball, hockey, gymnastics, soccer or any other sport that puts pressure on bent knees are more susceptible to OSD. 5 B. CLINICAL MANIFESTATION

Knee pain without an apparent direct cause or pain in the knee during and after exercise may be a sign of Osgood Schlatter's Disease. Although the symptoms may be similar to other conditions, such as patellar tendonitis, in younger athletes

this condition should be considered. Some of the common signs and symptoms of this disorder include: -Pain below the knee cap, worsens with exercise or when contracting the quadriceps. -Swelling and tenderness below the knee. -A bony prominence may be noted under the knee as the condition advances. -A "grinding" or stretching sensation may be noted at the tendons attachment site. C. RADIOLOGY Plain radiographs Plain radiographs (lateral view of the knee with the leg internally rotated 10 208) show irregularity of apophysis with separation from the tibial tuberosity in early stages of OSD and fragmentation in the later stages. A persistent bony ossicle may be visible in a few cases after fusion of the tibial epiphysis Anterior soft tissue swelling may be the only sign observed very early in the acute phase when avulsion occurs through the cartilaginous portion of the secondary ossification center. In bilaterally condition, plain radiograph is not needed.3

Lateral radiograph of tibial tuberosity showing ununited free ossicle (white arrow)

Magnetic resonance imaging

The early stage did not reveal any MRI evidence of inflammation or avulsed portion of the secondary ossification centre. The progressive stage revealed the presence of partial cartilaginous avulsion from the secondary ossification centre. The terminal stage was characterized by the existence of separated ossicles. The healing stage was defined as osseous healing of the tibial tuberosity without separated ossicles. MRI may assist in diagnosis of an atypical presentation. In future, with more understanding, it may play a role in staging of the disease and prognosticating the clinical course. The role in diagnosis, prognostication, and management is currently limited. 3 D. DIFFERENTIAL DIAGNOSIS SindingLarsenJohansson syndrome Is a traction apophysitis of the inferior patellar pole. The pathology is analogous to OSS except for the involvement of the inferior pole of the patella. Children present between ages 10 and 12 years with complaints of knee pain localized to the inferior patella. Slight separation and elongation or calcification is noted radiographically at the inferior patellar pole on the lateral view of the knee. Hoffas syndrome The infrapatellar fat pad is a richly innervated tissue. Any injury to the fat pad can cause pain. Patients present with complaints of anterior knee pain, and maximal tenderness is noted in the anterior joint line lateral to the patellar tendon. The plain radiographs are usually normal. MRI scans characteristically reveal a low signal on all sequences within the fat pad due to fibrin, hemosiderin and/or calcification. Synovial plica injury Synovial plicas are normal synovial folds within the knee joint. They are remnants from embryological development of the knee. The mediopatellar or infrapatellar plica connects the lower pole of the patella to the intercondylar notch. Trauma and repetitive motion cause thickening, fibrosis and hemorrhage in this plica, giving rise to anterior knee pain. It can be diagnosed by MRI,

which shows a curvilinear high T2 signal intensity within Hoffas fat pad in the line of infrapatellar plica. Tibial tubercle fracture Tibial tubercle fracture usually occurs in boys between the ages of 12 and 17 years. The mechanism of injury is violent contraction of the quadriceps or forceful flexion of the knee when the quadriceps is contracted. Patients present with complaint of pain, local swelling, knee effusion and an inability to actively extend the knee. Lateral radiographs of the tibia in 10208 of internal rotation best reveal the fracture. Watson-Jones classified fractures of the tibial tubercle into three types. In type I, a small distal portion of the tubercle is avulsed. In type II, the secondary center of the tubercle is hinged upward with the apex of the angulation being at the level of the proximal tibial physis. In type III, the fracture line extends through the proximal tibial physis into the knee joint. The presenting history and plain radiographs of the knee differentiate tibial tubercle fracture from OSS. Other differentials to be considered include idiopathic anterior knee pain, tumor and infection. 3 E. THERAPY Operative: Surgery rarely is indicated for Osgood-Schlatter disease; the disorder usually becomes asymptomatic without treatment or with simple conservative measures, such as the restriction of activities or cast immobilization for 3 to 6 weeks. Surgery may be considered if symptoms are persistent and severely disabling. However, after tibial sequestrectomy (removal of the fragments) results were no better than after conservative treatment. Scientist recommended inserting bone pegs into the tibial tuberosity; this procedure is simple and almost always relieves the symptoms. And some other recommended excision of the bony prominence through a longitudinal incision in the patellar tendon. Complications of Osgood-Schlatter disease whether treated surgically or not,

including subluxations of the patella, patella alta, nonunion of the bony fragment to the tibia, and premature fusion of the anterior part of the epiphysis with resulting genu recurvatum. Because of the possibility of genu recurvatum, scientist recommended delaying surgery until the apophysis has fused. We have removed only the ossicle with satisfactory results; we believe the entire tuberosity should be excised only if it is significantly enlarged and the apophysis is closed.6 Non operative: 1. Relative Rest is advisable, though there is currently no evidence to suggest that complete avoidance of activity will hasten recovery. Indeed, stopping all exercise may be somewhat counter-productive as it can lead to secondary loss of fitness and strength generally. 2. R.I.C.E - Rest, Ice, Compression, Elevation. The fundamental principles of soft tissue injury management apply to these conditions and will help reduce pain and local swelling. Icing the front of the knee for 20 minutes roughly every 2-3 hours during acute exacerbations is advisable. 3. Electrotherapy & Ultrasound: These modalities can be effective in managing acute symptoms in the short term, assisting with pain, inflammation, and tissue repair. 4. Anti-inflammatory Medication: either oral tablets or topical creams can be useful in managing symptoms. 5. Strapping & Braces may be used occasionally, particularly in more stubborn or difficult cases. Most of the time they are unnecessary unless there is an issue with a second simultaneous problem such as patello-femoral maltracking or tendinopathy. 6. Manual Therapy & Exercise: Maintaining appropriate strength and flexibility is important.

F. PREVENTION There are some risk factors that put certain players at risk. Those players who articipate in a large amount of sports such as football can be at risk (i.e. 5 or

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more training sessions/ games per week). Players that have tight quadriceps (front thigh muscles) or tight hamstrings (back thigh muscles) can also develop Osgood Schlatters disease. Stretching these muscles can help.

Quadriceps and Hamstring Muscle Stretces

Beside that, preventing Osgood Schlatter's Disease involves avoiding or changing the conditions that lead to it. Knowing that chronic stress on the tendon and attachment causes this disorder, it is important to reduce that stress. Some of the strategies for prevention include:
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Proper warm-up techniques will help prepare the muscles and tendons for the activity and increase the flexibility of the tendon. Warmer tendons are more flexible tendons.

If particular activities cause pain they are probably causing stress on the area. Reducing or avoiding these activities will help prevent the development of this condition. It is important to distinguish between healthy muscle pain and pain of injury. If it is stiffness and pain in the belly of the muscle and goes away in 24 hours it is simply pain from muscle breakdown and recovery, if it does not go away in a day or two, or is focused around a joint or bone attachment it may be the result of an injury.

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Since a lot of the stress placed on the quadriceps and patellar tendons is due to tight quadriceps muscles, stretching these muscles to relieve the tightness and to lengthen the muscle will help alleviate some of the stress. Developing a balance between the hamstrings and quadriceps is also important. If the hamstrings are proportionately weaker than the quadriceps then they will not be able to act as a counter force against the forceful quadriceps contractions, which could put additional stress on the tendon. If the quadriceps muscles are weaker than the hamstrings (very rare) they will be chronically tight from resisting the hamstrings. Strengthening the quadriceps also helps facilitate muscle lengthening and increases flexibility if done properly through a full range of motion.

CHAPTER III CONCLUSION

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1. Osgood Schlatter disease is apophysitis of tubercle Tibia or avascular necrosis, which occurs in a time of adolescence. 2. Clinical manifestation are pain below the knee cap, swelling and tenderness below the knee, a bony prominence may be noted under the knee as the condition advances, and a "grinding" or stretching sensation may be noted at the tendons attachment site. 3. Radiograph of tibia showed irregularity of apophysis with separation from the tibial tuberosity in early stages of OSD and fragmentation in the later stages. 4. Surgical therapy is not needed unless the symptoms appear persistenly 5. Non operative therapy including relative rest, R.I.C.E, electrotherapy & ultrasound, AINS, strapping and braces, and also manual therapy and exercise. 6. Preventing OSD can be done by tightening quadriceps (front thigh muscles) or tight hamstrings (back thigh muscles), do warming up while doing sport, and preventing to do much sport that induces OSD in children.

REFFERENCE

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1. Nowinski, R.J. & Mehlman, C.T. (1998). Hyphenated history Osgood-Schlatter disease. American Orthopedic 27(8), pp. 584585. 2. Kujala, U.M., Kvist, M. & Heinonen, O. (1985). Osgood-Schlatter's disease in adolescent athletes - Retrospective study of incidence and duration. American Journal of Sports Medicine 13(4), pp. 236241. 3. Gholve, P.A., Scher, D.M., Khakharia, S., Widmann, R.F. & Green, DW. (2007). Osgood Schlatter syndrome. Current Opinion in Pediatrics 19(1), pp. 4450. 4. Yashar, A., Loder, R.T. & Hensinger, R.N. (1995). Determination of skeletal age in children with Osgood-Schlatter disease by using radiographs of the knee. Journal Pediatric Orthopedic, 15(3), pp. 298301. 5. Moore K and A Dalley. 1999. Clinically Oriented Anatomy. 4th Edition. Lippincott Williams and Wilkins, Maryland. Pg 514. 6. Canalle, S. Terry and James S. Beaty. 2007. Campbells Operative Orthopaedics. Philadelpia: Elsevier.

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