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

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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

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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

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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

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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

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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

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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

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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

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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

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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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