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Transcript of Refrat Agri -Tks
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
1
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
2
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
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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 Osgood–Schlatter disease.4
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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
5
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:
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-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
7
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
Sinding–Larsen–Johansson 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.
Hoffa’s 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
8
by MRI, which shows a curvilinear high T2 signal intensity within Hoffa’s 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 10–208 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
9
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
10
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
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:
- 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
11
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.
- 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
12
CONCLUSION
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. 584–585.
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. 236–241.
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.
44–50.
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. 298–301.
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. Campbell’s Operative
Orthopaedics. Philadelpia: Elsevier.
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