Case Files Pediatrics, (LANGE Case Files) 4th Ed.

CASE 53

A previously healthy 12-year-old boy has had right knee pain for 3 weeks. He is athletic, playing basketball and running track, but he denies recent trauma. He describes increased pain when he is running or jumping. He has a normal physical examination except for mild edema and tenderness over his right tibial tubercle.

Image What is the most likely diagnosis?

Image What is the next step in management?

ANSWERS TO CASE 53: Osgood-Schlatter Disease

Summary: A 12-year-old boy presents with knee pain that increases with activity and tenderness and swelling of his tibial tubercle of the affected knee.

• Most likely diagnosis: Osgood-Schlatter disease.

• Next step in management: For most patients rest and ice after activity; in severe cases, knee immobilization.

ANALYSIS

Objectives

1. Know the presentation and treatment of Osgood-Schlatter disease (OSD).

2. Know differential diagnosis of childhood bone pain and extremity swelling.

Considerations

A history is critical to determine whether other signs and symptoms are present in this adolescent who has knee pain and swelling. His lack of constitutional signs and symptoms (fever, joint erythema, fatigue, weight loss, night sweats, bruising, and cough) are clues to the relatively benign nature of this condition. If any of these signs or symptoms is present, evaluation for more serious, potentially life-threatening conditions, such as malignancy, is appropriate.

APPROACH TO:

Osgood-Schlatter Disease

DEFINITION

OSGOOD-SCHLATTER DISEASE (OSD): A condition of painful inflammation of the tibial tubercle.

CLINICAL APPROACH

The knee pain of OSD is caused by inflammation of the tibial tubercle, an extension of the tibial epiphysis or growth plate. Ossification centers begin to form in children between the ages of 9 and 13 years and are completed between the ages of 15 and 17 years. Patients with OSD usually are males who present in late childhood through early adolescence. Repetitive running and jumping motions cause traction and microstress fractures to the developing area, resulting in inflammation, edema, tenderness, and bony changes (see Figure 53-1).

image

Figure 53-1. Osgood-Schlatter disease with the prominence of the tibal tuberosity in addition to ossicles separate from the anterior border of the tubercle. (Reproduced, with permission, from Skinner HB. Current Diagnosis and Treatment in Orthopedics,4th ed. New York, NY: McGraw-Hill; 2006. Figure 11-29.)

The diagnosis of OSD can be made clinically. The patient has no history of trauma, but he complains of knee pain that increases with exercise and trauma. Differential diagnosis of knee pain in adolescents includes a number of conditions. Patellofemoral stress syndrome, also common in athletes, causes chronic, dull, nonlocalizing knee pain. Jumper’s knee (patellar tendonitis) is caused by microscopic patellar tendon injury; most affected patients have chronic, anterior knee pain and tenderness of the inferior portion of the patella. Iliotibial band friction syndrome causes lateral knee pain in runners. Slipped capital femoral epiphysis (SCFE) occurs in heavy adolescents during the growth spurt, leading to a limp and groin or thigh pain; however, hip pain may be referred to the knee. Examination of such patients reveals limited hip flexion, internal rotation, and abduction. Radiographs (anteroposterior and frog-leg views) of the hip reveal widening of the femoral epiphysis and osteopenia. Patients with SCFE are at risk for avascular necrosis of the femoral epiphysis and require orthopedic evaluation. Other diagnoses to be considered in the adolescent with knee pain include trauma, tumor, leukemia, and septic joint.

Treatment of OSD consists of decreased activity. Ice after exercise and nonsteroidal anti-inflammatory drugs may provide some relief. In severe cases, knee immobilization and the use of crutches may be required. A trial of hyperosmolar dextrose injection for recalcitrant Osgood-Schlatter disease has shown some promise in one study. Symptoms may recur until ossification is complete. Long-term prognosis is excellent.

COMPREHENSION QUESTIONS

53.1 A 12-year-old boy complains of right knee pain that is worse after he runs. His pain started 3 weeks after he joined the track team. He has tenderness of the tibial tubercle. Which of the following statements is accurate?

A. A left shoe orthotic device will allow him to continue running and will alleviate the pain.

B. Decreasing his activity should alleviate the pain.

C. Initial therapy consists of immobilization.

D. The most likely cause of his pain is a stress fracture.

E. The most likely diagnosis is slipped capital femoral epiphysis.

53.2 A 13-year-old adolescent male has 1 week of limping and right knee pain. On your growth curve you determine that his weight is greater than the 95th percentile for age. His physical examination is remarkable for mild acanthosis and normal knees. His hip examination demonstrates diminished ability to flex and internally rotate his right femur. Which of the following is the best next step in management?

A. Instruct the patient to rest and apply ice to the affected area.

B. Prescribe daily oral nonsteroidal anti-inflammatory drugs until the pain resolves.

C. Order a magnetic resonance imaging of the knee and hip.

D. Arrange for an orthopedic surgery consultation.

E. Prescribe a short course of oral steroids to decrease inflammation.

53.3 A 14-year-old adolescent female arrives for a routine well-child evaluation. The mother reports that her daughter has previously been well, but she wants you to discuss the importance of sunscreen since she did not use sunscreen at a recent pool party and returned home 3 weeks ago with a sunburn across her cheeks and nose; the adolescent rolls her eyes at her mother. When the mother leaves the room the patient reports that she did use sunscreen but did not feel like arguing with her mother. She states that she has been well, but also notes that she has had 2 months of intermittent right knee pain that does not appear to be related to exercise. Upon further questioning she reports that she has not been feeling well and is increasingly tired. Your physical examination demonstrates the sunburn across the nose but no knee abnormalities and a normal gait. Which of the following is the most appropriate next step in management?

A. Prescribe ibuprofen and recommend daily sunscreen use.

B. Obtain radiographs of the knee.

C. Obtain further history with regard to fever, weight loss, rashes, and arthritis.

D. Recommend a knee immobilizer.

E. Arrange for an emergent orthopedic consultation for evaluation of possible SCFE.

53.4 A 15-year-old adolescent male presents with right knee pain; he cannot bear weight on the affected joint. The knee is tender, edematous, warm, erythematous, and has significantly diminished range of motion. Which of the following is the best next step in his evaluation?

A. Obtain more history, including sexual history.

B. Prescribe a course of systemic steroids.

C. Administer intra-articular steroids to decrease inflammation.

D. Prescribe anti-inflammatory drugs.

E. Arrange for an outpatient orthopedic surgery consultation.

ANSWERS

53.1 B. This boy’s history is consistent with OSD. Initial therapy includes ice after exertion and rest.

53.2 D. The most likely diagnosis is SCFE. The patient is put on bed rest, and orthopedic surgery consultation is required.

53.3 C. This patient has complaints of joint pain and malaise, and she had a malar facial rash consistent with that of systemic lupus erythematosus (SLE). The next step is to obtain more history of other signs and symptoms of autoimmune disease, medication use (drug-induced SLE), and travel history (tick exposure for Lyme disease).

53.4 A. This patient has signs and symptoms of a septic joint. Neisseria gonorrhoeae is a major cause of septic arthritis in sexually active adolescents and young adults. If septic arthritis is suspected, immediate orthopedic evaluation and intravenous antibiotics are warranted.


CLINICAL PEARLS

Image Osgood-Schlatter disease is found exclusively in young adolescents prior to closure of the growth plate.

Image Edema and tenderness of the tibial tuberosity are classic features of Osgood-Schlatter disease.

Image Slipped capital femoral epiphysis can cause limping and is most common in overweight adolescents.


REFERENCES

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Sponseller PD. Bone, joint, and muscle problems. In: McMillan JA, Feigin RD, DeAngelis CD, Jones MD, eds. Oski’s Pediatrics: Principles and Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:2474, 2479.

Topol GA, Podesta LA, Reeves KD, Raya MF, Fullerton BD, Yeh HW. Hyperosmolar dextrose injection for recalcitrant Osgood-Schlatter disease. Pediatrics. 2011 Nov; 128(5):e1121-8. Epub 2011 Oct 3.

Wells L, Sehgal K. The knee. In: Kliegman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RE, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: WB Saunders; 2011:2351-2355.