Osteochondroses are noninflammatory, noninfectious derangements of bony growth at various ossification centers. These derangements occur during the period of greatest developmental activity and affect the epiphyses.

Etiology is unknown, and inheritance is complex. Osteochondroses differ in their anatomic distribution, course, and prognosis; they typically cause pain and have important orthopedic implications. Rare osteochondroses and the involved bones include Freiberg's disease (head of 2nd metatarsal), Panner's disease (capitulum), and Blount disease (proximal tibia). Sever's disease is a more common osteochondrosis.

Infrapatellar Tendinitis

(Jumper's Knee; Sinding-Larsen-Johansson Syndrome)

Infrapatellar tendinitis is an osteochondrosis that is an overuse injury to the patellar tendon at the attachment to the lower pole of the patella.

Knee pain with infrapatellar tendon tenderness in physically active children is caused by an overuse syndrome that usually occurs in figure skaters and basketball or volleyball players. It typically affects children 10 to 13 yr. Pain is the most exaggerated when straightening the knee against force (eg, climbing stairs, jumping, doing knee bends). Etiology is thought to be trauma due to excessive traction by the patellar tendon at its site of origin, leading to microavulsion fractures. History and physical examination are usually sufficient for diagnosis; however, MRI can show the extent of the injury.

Pain is treated with modification of activities, NSAIDs, and physical therapy. Persistent pain may be treated with surgical repair; however, this is usually not necessary.

Köhler's Bone Disease

Köhler's bone disease is osteochondrosis of the tarsal navicular bone.

Köhler's bone disease usually affects children aged 3 to 5 yr (more commonly boys) and is unilateral. The foot becomes swollen and painful; tenderness is maximal over the medial longitudinal arch. Weight bearing and walking increase discomfort, and gait is disturbed. On x-ray, the navicular bone is initially flattened and sclerotic and later becomes fragmented, before reossification. X-rays comparing the affected side with the unaffected side help assess progression.

The course is chronic, but the disease rarely persists ≥ 2 yr. Rest, pain relief, and avoiding excessive weight bearing are required. The condition usually resolves spontaneously with no long-term sequelae. In acute cases, a few weeks of wearing a below-knee walking plaster cast, well molded under the longitudinal arch, may help.

Legg-Calvé-Perthes Disease

Legg-Calvé-Perthes disease is idiopathic aseptic necrosis of the femoral capital epiphysis.

Legg-Calvé-Perthes disease has a maximum incidence at age 5 to 10 yr, is more common among boys, and is usually unilateral. About 10% of cases are familial. Characteristic symptoms are pain in the hip joint and gait disturbance; onset is gradual, and progression is slow. Joint movements are limited, and thigh muscles may become wasted.

Diagnosis

Diagnosis is suspected based on symptoms. Bone scan or MRI should be done to confirm the diagnosis. X-rays initially may not be useful, because they can be normal or show minimal flattening. Later x-rays can show fragmentation of the femoral head, which contains areas of lucency and sclerosis.

In bilateral or familial cases, a skeletal survey to exclude hereditary skeletal disorders, particularly multiple epiphyseal dysplasia, is mandatory because prognosis and optimal management differ. Hypothyroidism, sickle cell anemia, and trauma must also be excluded.

Treatment

Orthopedic treatment includes prolonged bed rest, mobile traction, slings, and abduction plaster casts and splints to contain the femoral head. Some experts advocate subtrochanteric osteotomy with internal fixation and early ambulation. The bisphosphonate alendronate is effective in treating avascular necrosis of the femur in adults. Therefore, bisphosphonates may prove useful in the nonsurgical treatment of Legg-Calvé-Perthes disease.

Without treatment, the course is usually prolonged but self-limited (usually 2 to 3 yr). When the disease eventually becomes quiescent, residual distortion of the femoral head and acetabulum predisposes to secondary degenerative osteoarthritis. With treatment, sequelae are less severe.

Osgood-Schlatter Disease

Osgood-Schlatter disease is osteochondrosis of the tibial tubercle.

Osgood-Schlatter disease occurs between ages 10 yr and 15 yr and is usually unilateral. Although the disease is more common among boys, this status is changing as girls become more active in sports programs. Etiology is thought to be trauma due to excessive traction by the patellar tendon on its immature epiphyseal insertion, leading to microavulsion fractures. Characteristic symptoms are pain, swelling, and tenderness over the tibial tubercle at the patellar tendon insertion. There is no systemic disturbance.

Diagnosis

Diagnosis is by examination. Lateral knee x-rays show fragmentation of the tibial tubercle. However, x-rays are not needed unless pain and swelling extend beyond the area over the tibial tubercle or unless pain is accompanied by redness and warmth. In such cases, x-rays are useful to rule out injuries or acute inflammatory conditions.

Treatment

Resolution is usually spontaneous within weeks or months. Usually, taking analgesics and avoiding excessive exercise, especially deep knee bending, are the only necessary measures. Complete avoidance of sports is unnecessary. Rarely, immobilization in plaster, intralesional injection of hydrocortisone, surgical removal of loose bodies (eg, ossicles, avulsed fragments of bone), drilling, and grafting are required.

Scheuermann's Disease

Scheuermann's disease causes localized changes in vertebral bodies, leading to backache and kyphosis.

Scheuermann's disease manifests in adolescence and is slightly more common among boys. It probably represents a group of diseases with similar symptoms, but etiology and pathogenesis are uncertain. It may result from osteochondritis of the upper and lower cartilaginous vertebral end plates or trauma. Some cases are familial.

Most patients present with a round-shouldered posture and they may have persistent low-grade backache. Some have an appearance similar to people with Marfan syndrome; trunk and limb length are disproportionate. Normal thoracic kyphosis is increased diffusely or locally.

Diagnosis

Some cases are recognized during routine screening for spinal deformity at school. Lateral spinal x-rays confirm the diagnosis by showing anterior wedging of the vertebral bodies, usually in the lower thoracic and upper lumbar regions. Later, the end plates become irregular and sclerotic. Spinal misalignment is predominantly kyphotic but is sometimes partly scoliotic. In atypical cases, generalized skeletal dysplasia must be excluded by x-ray skeletal survey, and spinal TB must be excluded by CT or MRI.

Treatment

The course is mild but long, often lasting several years (although duration varies greatly). Trivial spinal misalignment often persists after the disorder has become quiescent.

Mild, nonprogressive disease can be treated by reducing weight-bearing stress and by avoiding strenuous activity. Occasionally, when kyphosis is more severe, a spinal brace or rest with recumbency on a rigid bed is indicated. Rarely, progressive cases require surgical stabilization and correction of misalignment.

Last full review/revision February 2008 by Frank Pessler, MD, PhD; David D. Sherry, MD