My Orthopedic Surgery

Contents -Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Future And Controversies Pictures Bibliography
Blount disease is an uncommon growth disorder characterized by disordered ossification of the medial aspect of the proximal tibial physis, epiphysis, and metaphysis. This progressive deformity is manifested by varus angulation and internal rotation of the tibia in the proximal metaphyseal region immediately below the knee. The natural history of this disease leads to irreversible pathologic changes, especially at the medial portion of the proximal tibial epiphysis because of growth disturbances of the subjacent physis

Contents - Introduction Differentials Radiograph CT Scan MRI Ultrasound Nuclear Medicine Angiography Intervention Pictures Bibliography
A brief overview of normal age-related angulation changes in the knee joint helps improve understanding the disease process. A pronounced varus angulation is seen in newborns and in children younger than 1 year. Varus angulation is believed to be secondary to in utero molding of the lower extremities, and this gradually resolves after children start walking. Varus angulation is usually corrected by the time children reach an approximate age of 18-24 months or after approximately 6 months of walking. From that time on, during the second and the third years, pronounced valgus angulation changes occur. The valgus position is partially corrected in the following years, reaching the adult pattern of mild valgus of the knees by age of 6-7 years. Thus, any varus angulation at the knee joint seen in individuals older than 2 years is abnormal; this finding is the basis for diagnosing tibia vara, or Blount disease.

Blount's disease aka/or Proximal tibial osteochondrosis may cause or feature Symptoms and Signs Genu varum Leg pain

Blount’s disease is a developmental deformity of the proximal tibial epiphysis that results in bowing of the lower extremities. It is divided into two forms: infantile and late-onset, which are determined based upon the age of onset and associated conditions. The deformity is thought to be a result of disturbed endochondral ossification secondary to abnormal pressure and force on the medial aspect of the proximal tibial epiphysis. Diagnosis is made by a combination of clinical presentation and plain film radiographic findings.

Freiberg's Disease Case Presentation: HISTORY: 15 + 4 year old female with left foot pain near the fourth toe for one year. She had no antecedent trauma. She described her pain as a constant, dull ache which had been getting progressively worse. PHYSICAL EXAM: She complained of exquisite tenderness with flexion and extension of her left fourth toe. She had tenderness to palpation over the dorsum of the fourth metatarsal phalangeal joint. She was unable to toe walk without inverting her foot to releive pressure from the fourth metatarsal head.

KÖHLER'S DISEASE OF THE TARSAL NAVICULAR Case Presentation -a 3 year old girl who presented to the Orthopaedic Clinic with a complaint of left foot pain exacerbated by bearing weight. Four weeks prior to this visit, the patient's 4 year old sister had jumped onto her left foot during play resulting in pain and an antalgic gait. She had no pain in the left foot prior to this episode. She was evaluated at an outside emergency room where radiographs were remarkable only for radiodensity and collapse of the tarsal navicular.

Osgood-Schlatter Disease
* Originally described simultaneously by Osgood and Schlatter in 1903
* Lesion affects adolescent apophysis of proximal tibia (particularly in young athletes)
* More commonly affects boys than girls (3:1)
* Boys are older at presentation (correlates with ossification dates)
* Bilateral 25-50%
* Controversy regarding etiology, natural history, and treatment.

Blount's Disease, The Alfred I. duPont Institute.

* Etiology thought to be traction apophysitis secondary to repetitive microtrauma with partial avulsion, inflammation and new bone formation at the ligament insertion.
* Must differentiate from malignancy, infection, fracture, tendonitis and Sindling-Larsen- Johansson Disease.
* Should be referred to a "condition" not a "disease."
* Affects children between 10 and 14 years old, more commonly males 3:1, and is present bilaterally in 25 - 50% of cases.
* Diagnosis is based on clinical signs and symptoms. These include pain, heat, tenderness and local swelling with prominence at the tibial tuberosity.
* Ossification of the tibial tubercle begins distally between 7-9 years of age and progresses proximally.

Illustrations of the surgical procedure

Another manifestation of juvenile traction osteochondritis? Batten J, Menelaus MB. J Bone Joint Surg Br. 1985 Mar;67(2):249-51
Six boys with fragmentation of the proximal pole of the patella are reported; the condition was bilateral in one. Four of the six presented with symptoms of Osgood-Schlatter's disease or Larsen-Johansson disease of the same or of the contralateral knee, but they had no symptoms or signs relating to the proximal pole of the patella; one also had features suggesting minimal chondromalacia patellae. Two boys had no objective abnormality in either knee. It is suggested that the fragmentation may be a further form of traction osteochondritis of the attachments of the quadriceps mechanism. Attention is drawn to its characteristic radiographic appearance, its association with other forms of juvenile traction osteochondritis (which are commonly symptomatic), and to its occurrence in boys aged 10 or 11 years.

Freiberg infraction

Synonyms and related keywords: infraction of the metatarsal head, osteochondrosis of the metatarsal heads, avascular necrosis of the metatarsal head, eggshell fracture, peculiar metatarsal disease, Koehler second disease, Panner disease of the metatarsals, osteochondritis deformans metatarso-juvenilis, malacopathia, subchondral bone fatigue fracture of the metatarsal head, dorsal trabecular stress injury of the metatarsal head
Contents - Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Future And Controversies Pictures Bibliography
Freiberg first described the painful collapse of the articular surface of the second metatarsal head. He described 6 cases of young women presenting with a painful limp and discomfort localized to the second metatarsal. All 6 patients had similar radiographic findings with collapse of the articular surface of the second metatarsal head. In 3 patients, intra-articular loose bodies also were seen.

Xray illustration and discussion Freiberg-Kohler's disease is the only bone necrosis that is more often seen in girls than in boys.
II: partially detached osteochondral lesion
III: completely detached, non-displaced fragment
IV: detached and displaced fragment
There are 4 stages:
1. Initial stage with cartilaginous edema and joint effusion. The X-ray is still unnoticeable, in MRI bone marrow edema.
2. Condensation-density of bone structures in hypermineralization of necrotic bony trabecula. In the X-ray it is already seen, in MRI double-line sign.
3. Fragmentation with deformity of joint structures. Up until this stage, 2 or 3 years since begin of disease may have passed.
4. Repair with replacement of necrotic tissue with the new bone substance. Requirement: Revascularisation

Freiberg's disease
aka/or Kohler second disease
aka/or Second metatarsal osteochondrosis
aka/or Freiberg infraction
Links to resources on this condition