Laura Gottlieb

Gillian Lieberman, MD
Radiological Findings in
Osgood-Schlatters Disease
Laura Gottlieb
Harvard Medical School Year IV
Gillian Lieberman, MD
J anuary 2002
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Laura Gottlieb
Gillian Lieberman, MD
Agenda
Define Osgood-Schlatters Disease (OSG)
Learn Relevant Knee Anatomy
Identify X-Ray Findings of OSG
Discuss Complications of OSG
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Laura Gottlieb
Gillian Lieberman, MD
The Big Picture
Osgood Schlatters =
An Osteochondrosis
Predilection for immature
skeletons
Involvement of
epiphyseal/apophyseal bone
Radiologic picture includes
collapse, fragmentation,
sclerosis, and frequent
reossification
Image courtesy of Ferris Hall, MD.
BIDMC, Boston, MA.
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Laura Gottlieb
Gillian Lieberman, MD
Osgood-Schlatters Basics:
A Non-articulating Osteochondrosis
Disorder of patellar ligaments 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!
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Laura Gottlieb
Gillian Lieberman, MD
Normal Knee Anatomy
From Southmayd W, Sports
health. Quickfox 1981; 439.
From Novelline R, Squires Fundamentals of
Radiology, 5
th
ed. Harvard University Press 1997; 60.
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Laura Gottlieb
Gillian Lieberman, MD
Apophyseal Growth
From Resnick and Niwayama, Diagnosis of Bone and J oint Disorders, 2nd
ed. WB Saunders Co, Philadelphia 1988. 5(84): 3314.
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Laura Gottlieb
Gillian Lieberman, MD
Normal Adolescent Knee
Image courtesy of Ferris Hall, MD. BIDMC, Boston, MA
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Laura Gottlieb
Gillian Lieberman, MD
Normal Adolescent Knee
Patellar Ligament
Infrapatellar Fat Pad
Apophysis
Image courtesy of Ferris Hall, MD. BIDMC, Boston, MA
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Laura Gottlieb
Gillian Lieberman, MD
OSG: The Clinical Picture
Adolescents
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
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Laura Gottlieb
Gillian Lieberman, MD
The Case of Adolescent X
Presented to Childrens Hospital
14 yo male
occasional painful swelling over left tibial
tuberosity
active kid, soccer especially
no known trauma to area
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Laura Gottlieb
Gillian Lieberman, MD
DDX
Unilateral Knee Pain over Tibial Tuberosity
infection: osteomyelitis
Malignancy or other mass: osteosarcoma, Ewings
sarcoma, osteoid osteoma
fracture: complete avulsion of tibial tubercleincludes
apophysis itself
patellar tendonitis = jumpers knee
Osgood-Schlatters disease
In this case they ordered an x-ray to r/o
the big, the bad, and the ugly.
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Laura Gottlieb
Gillian Lieberman, MD
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!
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Laura Gottlieb
Gillian Lieberman, MD
Adolescent X Films
Soft tissue swelling
anterior to tibial
tuberosity
Thickening of patellar
ligament
Indistinctness of
infrapatellar fat pad
Bony abnormalities
Sclerosis
From Childrens Hospital Teaching File 4.535.
Left knee, lateral film
Adolescent X
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Laura Gottlieb
Gillian Lieberman, MD
Adolescent X Films
Compared to Normal
From Childrens Hospital Teaching File 4.535.
Left knee, lateral film
Adolescent X
Lateral film, normal
Image courtesy of Ferris Hall, MD.
BIDMC, Boston, MA.
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Laura Gottlieb
Gillian Lieberman, MD
Adolescent X has classic plain
film findings of Osgood-
Schlatters Disease. Lets review
some other causes for tibial
tubercle pain
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Laura Gottlieb
Gillian Lieberman, MD
Known Osteomyelitis
vs. Adolescent X
From Childrens Hospital Teaching File 6.253 From Childrens Hospital Teaching File 4.535.
Sclerosis
Cortical erosion
Diffuse involved region
Osteomyelitis
Adolescent X
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Laura Gottlieb
Gillian Lieberman, MD
Known Osteosarcoma
vs. Adolescent X
From Childrens Hospital Teaching File 4.535. From Childrens Hospital Teaching File 4.321.
Diffuse, homogenously
increased density of proximal
tibia
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Laura Gottlieb
Gillian Lieberman, MD
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 J oint
Disorders, 2
nd
ed. WB Saunders Co, Philadelphia 1988; 5(84): 3315.
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Laura Gottlieb
Gillian Lieberman, MD
Some more practice
From: gait.aidi.udel.edu/res695/homepage/pd_ortho/
educate/clincase/clcsimge/osgod1.jpg
From Resnick and Niwayama, Diagnosis
of Bone and J oint Disorders, 2
nd
ed. WB
Saunders Co, Philadelphia 1988; 5(84):
3316.
Bony fragment within
ligament
Bony fragment
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Laura Gottlieb
Gillian Lieberman, MD
Menu of Tests Used in
Osgood-Schlatters Disease
None
X-ray: Standard frontal and lateral projections;
consider special views
--internal rotation views
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)
Dont overexpose films!
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Laura Gottlieb
Gillian Lieberman, MD
CT Images
From uhrad.com/msiarc/msi039.htm.
Mild fragmentation of
anterior tibial tubercle at
insertion site of patellar
ligament
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Laura Gottlieb
Gillian Lieberman, MD
MRI Images
Decreased signal in
region of tibial
tuberosity at insertion of
patellar ligament
From uhrad.com/msiarc/msi039.htm.
T1 Sagittal MR Image
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Laura Gottlieb
Gillian Lieberman, MD
Complications of
Osgood-Schlatters 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
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Laura Gottlieb
Gillian Lieberman, MD
Avulsion Injuries I
Old avulsion injury
Sclerosis
From Murray and J acobson. Radiology
of Skeletal Disorders. Longman Group
NY 1971; 1(1):142.
From Resnick and Niwayama. Diagnosis of Bone and
J oint Disorders, 2
nd
ed. WB Saunders Co, Philadelphia
1988; 5(84): 3315.
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Laura Gottlieb
Gillian Lieberman, MD
Avulsion Injuries II
From Murray and J acobson. Radiology of Skeletal Disorders. Longman Group
Limited NY 1971; 1(1): 143.
Presentation One year later
Irregular and
fragmented tibial
tuberosity
Abnormally wide
apophyseal plate
Prominent tibial
tuberosity
Bony
fragment
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Laura Gottlieb
Gillian Lieberman, MD
Subluxation of patella
From http://www.medmedia.com/oo1/51.htm
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Laura Gottlieb
Gillian Lieberman, MD
Patellar ligament tear
Normal Patellar Ligament
Absence of Patellar Ligament
From http://www.medmedia.com/oo1/238.htm
Image courtesy of Ferris Hall, MD.
BIDMC, Boston, MA.
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Laura Gottlieb
Gillian Lieberman, MD
Related disorder of the Patellar Ligament:
Sinding Larsen J ohansen Syndrome
(SLJ S)
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
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Laura Gottlieb
Gillian Lieberman, MD
Sinding Larsen J ohansen Syndrome II
From Resnick and Niwayama. Diagnosis of Bone and J oint Disorders, 2
nd
ed.
Publisher info! :3326.
Extraossification area
Fragment of lower pole of patella
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Laura Gottlieb
Gillian Lieberman, MD
Treatment of Osgood-Schlatters Disease
Rest and relax
no jumping
no pushing off
no squatting
Reality of Adolescence
Want teens to comply: give them control
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Laura Gottlieb
Gillian Lieberman, MD
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/osgood-
schlatters.htm
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Laura Gottlieb
Gillian Lieberman, MD
Conclusions
Osgood-Schlatters 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
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Laura Gottlieb
Gillian Lieberman, MD
References
Childrens Hospital Pediatric Radiology Teaching Files. The Childrens Hospital,
Boston, MA.
Murray and Jacobson. Radiology of Skeletal Disorders. Longman Group, NY:
1971.
Wenger, Dennis and Mercer Rang. The Art and Practice of Childrens
Orthopaedics. Raven Press, NY: 1993.
Novelline, Robert. Squires 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
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Laura Gottlieb
Gillian Lieberman, MD
Acknowledgements
Considerable appreciation is owed to the following
people:
Michael Stella, MD
Daniel Saurborn, MD
Ferris Hall, MD
Gillian Lieberman, MD
Larry Barbaras and Cara Lyn Damour
Pamela Lepkowski