By Dr PRAMOD GOVINDRAJ
• A typical long bone, ossifies in three parts; the
two ends and one shaft.
• The ends ossify from secondary centers of
ossification while the shaft ossifies from
primary center of ossification
• In a young bone in which the process of
ossification is not complete
• Epiphyseal plate of cartilage
• The ends and the tips of a long bone that
ossify from secondary centers are known as
epiphyses. Growth of the epiphysis arises from
two areas: (1) the vascular reserve zone car-
tilage, which is responsible for growth of the
epiphysis toward the joint, and (2) the
epiphyseal plate, which is responsible for
growth in bone length
TYPES OF EPIPHYSIS
• Pressure epiphyses: articular & take part in joint formation. These
epiphyses are the weight transmitting epiphyses. Ex -head of the
humerus, lower end of the radius etc.
• Traction epiphyses: provide attachment to tendons of muscles. The
traction epiphyses ossify later than the pressure epiphyses.
Examples of these epiphyses are tubercles of humerus and
trochanters of femur
• Atavistic epiphyses: are phylogenetically independent but they
become fused in man. Examples are coracoid process of scapula
• Aberrant epiphyses: these epiphyses are not always present.
Examples are epiphyses at the head of the first metacarpal bone
and at the base of other metacarpal bones.
• The terms osteochondrosis or epiphysitis is a
self limiting developmental dearrangement of
normal bone growth primarily involving
centres of ossification in the epiphysis
• It is an aseptic ischemic necrosis
• The disorder may be localized to a single
epiphysis or occasionally may involve two or
more epiphyses simultaneously or
• Predilection of immature skeleton
• Involvement of epiphysis
• Radiographic picture dominated by
fragmentation ,collapse, sclerosis and
reossification of osseous centres
• BURROW’S CLASSIFICATION into pressure
and atavistic types
• Articular osteochondroses:
– Calvé-Legg-Perthes Disease (hip/femur)
– Köhler's Bone Disease (ankle navicular bone)
– Freiberg's Disease (2nd metatarsal head)
– Panner's Disease (capitulum of humerus)
• Non-articular osteochondroses:
– Osgood-Schlatter Disease (tibial tuberosity)
– Sever's Disease (calcaneus)
– Sinding-Larsen and Johansson Syndrome (inferior tip of patella)
• Epiphyseal osteochrondroses:
– Scheuermann's Disease (vertebral bodies)
Legg Calve Perthes Disease
(LCPD) is the name given to
idiopathic osteonecrosis of the
capital femoral epiphysis in a
Blood supply to femoral head
• Upto 4 years
1. Retinacular vessels mainly lateral epiphyseal
3. Artery of ligamentum teres
Blood supply to femoral head
• By 4 yrs
Epiphyseal plate forms a barrier to metaphyseal
1. After 7 yrs arteries of lig teres become more
prominent and anastomose with the lateral
Between 4&7 yrs blood supply is dependent on
retinacular vessels only
• Male : Female = 4-5:1
• 2.5:1 in India
• Age of onset earlier in females.
• Age –
Range – 2-13 years.
Most common 4-8 years.
Average – 6 years.
• Bilateral in 10-12 %
• Incidence more in Caucasians as compared to Negroid,
• Etiology not known.
• Coagulation disorders.
• Altered arterial status of femoral head.
• Abnormal venous drainage.
• Abnormal growth and development.
• Hyperactivity or attention deficit disorder.
• Genetic component.
• Environmental influences.
• As a sequelae to synovitis.
• Waldenstrom staged the pathological
process of the disease as
1. Initial or ischaemic stage
2. Resorption or fragmentation stage
3. Reparative stage
4. Remodelling stage
Stage of Avascular Necrosis
A part ( anterior) or whole of capital
femoral epiphysis is necrosed.
On X-ray –
– The ossific nucleus looks smaller
– Classically of Perthes’, looks
– The articular cartilage remains
viable & becomes thicker than
– increased joint space.
Stage of REVASCULARIZATION / FRAGMENTATION
• Ingrowths of highly vascular & cellular connective tissue.
• Necrotic trabecular debris is resorbed & replaced by vascular
fibrous tissue the alternating areas of sclerosis and
fibrosis appear on X- ray as fragmentation of epiphysis.
• New immature bone laid on intact
necrosed trabeculae by creeping
substitution further increases
the density of ossific nucleus on
Stage of Ossification / Healing
New bone starts forming and epiphyseal
density increases in the lucent portions of
the femoral head.
• Remodeling / Residual stage
This is the stage of remodeling and there is no
additional change in the density of the femoral
Depending on the severity of the disease the
residual shape of the head may be spherical
(replacement by biologically plastic
• Femoral head is
• Subluxation and deformity
• Classic portrait of the child with Legg-Calvé-
Perthes disease—small, often thin, extremely
active, constantly running and jumping, and
limping after strenuous physical activities
• Often insidious onset of a painless limp,
excaberated by activity.
• C/O pain in groin, thigh, knee
• Few relate trauma hx
• Can have an acute onset
• Tredelenburg with antalgic
• Trendelenburg test often
• Muscular atrophy of
• Limb length discrepency
• Decreased ROM, especially
abduction and internal
rotation: initially due to
Imaging – Radiographic Feature
• Widening of the joint space and minor subluxation
• Fragmentation and focal resorption
• Loss of height
• Metaphyseal cyst formation
• Widening of the femoral neck & head (Coxa Magna)
• Lateral uncovering of the femoral head
• Sagging rope sign
• Acetabular remodelling
Sclerosis of epiphysis & widening of
joint space in the early stages
Fragmentation of the femoral capital
• As the disease progresses, a
subchondral # may occur in the
anterolateral aspect of the
femoral capital epiphysis.
• Is an early radiographic feature
best seen on the frog-lateral
• This produces a crescentic
radiolucency known as the
crescent, Salter’s or Caffey’s
Metaphyseal cyst formation within the
Stages of radiological changes in
Perthe's disease: cont…
Flattened femoral head
Irregular articular surface
‘Sagging Rope Sign’
• This a curvilinear sclerotic
line running horizontally
across the femoral neck.
• It is confirmed by 3D CT
• It is a finding in AP
radiograph in a mature
hip with Perthes’ disease.
• Technetium 99 bone scan -
Helpful in delineating the
extent of avascular changes
before they are evident on
– The sensitivity of
radionuclide scanning in the
diagnosis of LPD is 98%, and
the specificity is 95%.
• Avascular areas show cold
• Effusion, especially if persistent
• Synovial thickening
• Cartilaginous thickening
• Atrophy of the ipsilateral quadriceps muscle
• Flattening, fragmentation, irregularity of the
• New bone formation
• Revascularisation with contrast enhanced power
• Staging determined by
using plain radiographic
findings is upgraded in 30%
• Not as sensitive as nuclear
medicine or MRI.
• CT may be used for follow-
up imaging in patients with
• Shows configuration of the femoral head and
its relation with the acetabulum.
• Not routinely used .
• It allows more precise
localization of involvement
• MRI is preferred for
evaluating the position, form,
and size of the femoral head
and surrounding soft tissues.
• MRI is as sensitive as isotopic
Morphological classifications of the
extent of the lesion
• Classification according to Catterall (Common)
• Classification according to Salter &
• Classification according to Herring
• Legg, who identified two types of femoral
heads—a “cap” and a “mushroom.”
• Goff also identified three types of femoral
heads—spherical, cap, and irregular—that
correlated with disease outcome.
Classification of extent of lesion - (Acc to
I Only anterolateral quadrant affected
II Anterior third or half of the femoral head
Up to 3/4 of the femoral head affected,
only the most dorsal section is intact
IV Whole femoral head affected
Grade – I
• Only anterolateral quadrant affected
Grade - II
• Anterior third or half of the femoral head
Grade – III
• Up to 3/4 of the femoral head affected,
• only the most dorsal section is intact
• Rarefaction in the
lateral part of the
epiphysis and subjacent
Classification of End Results
• The Mose classification system is based on fitting
the contour of the healed femoral head to a
template of concentric circles.
• In good outcomes, the shape of the femoral
head deviates no more than 1 mm from a given
circle on both AP and frog-leg lateral radiographs.
• If the shape falls within 2 mm, it is considered a
• If the deviation is greater than 2 mm, it is a poor
• Class I – Shape of the femoral head was
• Class II – Loss of head height but within 2 mm
to a concentric circle on AP and frog
• Class III – Deviates more than 2 mm and
acetabulum contour matches
the head contour
• Class IV – Head Flattened, Flattened area
<1cm. Acetabulum contour matches
the head contour
• Class V – Collapse of femoral head, Acetabular
contour does not change
• Class I & II – Spherically congruent.
• Class III & IV – Congruous Incongruity
• Class V – Incongruous incongruity
• Goals of treatment
– Achieve and maintain ROM
– Relieve weight bearing
– Containment of the femoral epiphysis within the
confines of the acetabulum
– Prevent secondary degenerative arthritis of the
• Caterall group 1 and
group 2 ( < 7 years)
• Herring group 1 & Treatment
group 2 (< 6 years)
Treatment is divided into 3 phases
• Initial Phase – restore & maintain mobility
• Active Phase – Containment and maintainance
of full mobility.
• Reconstructive phase – correct residual
Treatment ( Initial Phase )
• Physiotherapy – active and passive range of
motion exercises to restore motion
• Traction – B/L skin traction and gradually
abducting over 1-2 weeks till full abduction
Treatment ( Active Phase )
• Consists of containment of the femoral head
within the acetabulum. This can be achieved
• Non Ambulatory weight releiving
1. Abduction broomstick plaster cast
2. Hip spica cast
• Ambulatory Both limbs included
1. Petrie Abduction cast
2. Toronto orthosis
3. Newington orthosis
4. Birmingham brace
5. Atlanta Scotish Rite Brace
• Orthotic treatment is discontinued when the disease
enters the reparative phase and healing is established.
• The radiographic evidence of healing are
1. Appearance of irregular ossification in the femoral head.
2 . Increased density of femoral head should disappear.
3 . Medial segment of femoral head should increase in size
4 . Metaphyseal rarefaction involving the lateral cortex of the
metaphysis should ossify.
5 . There should be intact lateral column.
• If non-op tx cannot maintain containment
• Surgically ideal pt:
– Catterral II-III
– Good ROM
– In collapsing phase
• varusderotation osteotomy :-
– INDICATIONS- patients with a spherical femoral head,
– little or no acetabular dysplasia (center-edge angle of at least
15 to 20 degrees),
– lateral overloading, and
– a valgus neck-shaft angle of more than 135 degrees.
varus angulation that may not correct with growth (especially in a
further shortening of an already shortened extremity,
the possibility of a gluteus lurch produced by decreasing the leng
of the lever arm of the gluteal musculature,
the possibility of nonunion of the osteotomy,
requirement of a second operation to remove the internal fixatio
• Anterolateral coverage of the femoral head,
• lengthening of the extremity (possibly shortened by the
avascular process), and
• avoidance of a second operation for plate removal
• DISADVANTAGES-1)inability sometimes to
obtain proper containment of the femoral head,
especially in older children;
• 2)an increase in acetabular and hip joint
pressure that may cause further avascular
changes in the femoral head;
• 3)an increase in leg length on the operated side
compared with the normal side that may cause a
relative adduction of the hip and uncover the
• Valgus extension osteotomy
indication -hinge abduction of hip
indication – malformed femoral head
• Chiari osteotomy
indication – malformed femoral head with lateral
• Trochanteric advancement or Greater trochanteric
indication – premature capital femoral physeal arrest
• Shelf augmentation procedure
indication – coxa magna & lack of acetabular
• Osteochondritis of the second metatarsal head.
But may also involve 1st 3rd and 4th metatarsal
• Usually occurs following trauma.
• A misshapen metatarsal head frequently is an
incidental radiographic finding, and careful
questioning of the patient often reveals a
period during adolescence when pain was
noted in the forefoot.
• The second toe is the longest and the second
ray the least mobile, excessive pressure on the
metatarsal head on weight bearing cause
loss of blood supply to subchondral bone,
collapse of this cancellous bone, and cartilage
• Synovitis accompanies the process, and if it is
prolonged and severe, limitation of motion,
especially in extension, results.
• With this loss of extension of the
metatarsophalangeal joint, weight bearing
causes abnormal stress to be applied to the
metatarsal shaft, which becomes widened
from bicortical thickening.
-Pain around the involved metatarsophalangeal
joint primarily on weight bearing, local
tenderness around the metatarsophalangeal
joint, and limitation of motion.
-If a synovitis is present, swelling becomes
Irregular ossification of the primary ossification center of the
metatarsal head,widening of the metatarsal shaft,and osteochondral
• Modification of activities, semirigid orthoses,
and metatarsal bars.
• A short leg walking cast with a toe extension
may be needed if other non operative
• Occasionally, crutches are needed to rest the
painful foot completely.
• If conservative management fails, surgical treatments
include (1) Resection of the metatarsal head
• (2) Elevation of the depressed fragment of the
metatarsal head and bone grafting of the defect
• (3) Resection of the base of the proximal phalanx with
syndactylization of the second and third toes
• (4) Dorsal closing wedge osteotomy of the metatarsal
• (5) Joint débridement and metatarsal head remodeling
• Osteochondritis of tarsal navicular
• The aetiology of Köhler's disease is unknown.
Theories have included vascular trauma and
• It commonly affects children aged 3 to 5 years
old, but is seen any time between age 2 and 10
• It is more common in boys; however, girls with
this condition are often younger than boys with
• Children present with a unilateral antalgic gait (a
limp, avoiding putting weight on painful
• Local tenderness of the medial aspect of the foot,
over the navicular bone
• The child is able to walk by taking the majority of
their weight on the lateral aspect of the foot.
Frequently, there is swelling and redness of the
• Plain X-ray -The navicular bone is initially
flattened and sclerotic. Later it becomes
fragmented and then re-ossifies.
• The lateral view shows a flat tarsal
• The space between the talus and the
cuneiforms is preserved.
Rest ,avoiding excessive weight bearing
,analgesia & immobilisation in a short leg cast
moulded under the longitudinal arch for at least
6 weeks is recommended.
If pain persists after a 6-week period of casting,
a new cast must be applied for 6 supplementary
• The course is chronic, but rarely lasts longer
than 2 year
• Arthrodesis is the only operation of value, and
the midtarsal joints (talonavicular and
calcaneocuboid) can be arthrodesed.
• Here arthrodesis is difficult to secure; metallic
internal fixation and inlay grafts of autogenous
cancellous bone are helpful.
• OSTEOCHONDRITIS OF CAPITELLUM
• Panner's disease affects the dominant elbow
of children, mainly boys, between the ages of
five and 10.
• Interference in blood supply to growing
epiphysis, which results in resorption & eventual
repair & and replacement of the ossification
• In patients under 20 years of age, capitellum is
only supplied by end arteries entering
• - inciting causes:
- chronic repetitive trauma, congenital
and hereditary factors, embolism (fat), and
• Intermittent pain and stiffness in the affected
elbow that lasts for several months
Symptoms are relieved by rest and aggravated by
• local tenderness over capitellum, limited extension is
typical, lacking 20 to 30 deg of full extension
• There may be slight loss of pronation and supination
• An irregular surface on the capitellum. The
entire growth plate may appear fragmented
and transparent. The capitellum may appear
flattened out, which means that the bone has
• The MRI can give a better view of bone
irregularities. The MRI can also detect
• Children may need to stop sports activities for a
short time. This reduces the pain and
• NSAIDS to help reduce pain and swelling. Physical
therapy such as heat, ice, and ultrasound may be
used to ease pain and swelling.
• In severe cases, when regular treatment is not
effective, doctors may recommend that the child
wear a long-arm splint or cast for three to four
• Osgood–Schlatter disease or syndrome (OSD)
is an irritation of the patellar ligament at
the tibial tuberosity
Osgood Schlatters disease is a very common cause of
knee pain in children and young athletes.
It occurs during the period of rapid growth, due to a
combined high level of sporting activity who play
soccer, basketball, and volleyball, and who participate
It occurs more frequently in boys than in girls, with
reports of a male-to-female ratio ranging from 3:1 to as
high as 7:1. 
Following an adolescent growth spurt, repeated stress
from contraction of the quadriceps is transmitted through
the patellar tendon to the immature tibial tuberosity.
This can cause multiple sub-acute avulsion fractures along
with inflammation of the tendon, leading to excess bone
growth in the tuberosity and producing a visible lump
which can be very painful when hit.
Activities such as kneeling may irritate the tendon further.
What Makes OSD Worse?
o walking up or down stairs
o forceful contractions of the quadriceps muscle
o jumping (basketball, volleyball)
o repetitive hard landings
Anything that puts excessive stress on the insertion of the
Symptomso Main symptom - painful swelling over a bump on the
tibia on one or both sides
o Pain: mild and intermittent initially.
o Later stages- the pain is severe and continuous
o Pain usually resolve with treatment but may recur for
12–24 months before complete resolution at skeletal
maturity, when the tibial epiphysis fuses.
Palpation: The area is tender to pressure, and swelling
ranges from mild to very severe.
o Regular stretching, both before and after exercise and
athletics, can help prevent injury
o NSAIDS for pain relief &rest (3 days) and decreasing
activity (1-2 weeks)
o Ice - over the painful area, 2 to 3 times a day, 20 to 30
minutes at a time,
o Bracing, Orthopedic casting
o Infra patellar strap – 6 to 8 weeks
• Surgery may be considered if
symptoms are persistent and severely
disabling & include -Excision of intra-
• Inflammation of the calcaneal apophysis
which occurs in children and adolescents due
to repeated 'microtrauma' at the site of the
attachment of the Achilles tendon to the
apophysis of the heel, often result of sporting
• The line of ossification in the calcaneal
apophysis is thought to develop
microfractures due to recurrent stresses on
the heel, combined with the growth spurt of
puberty. It is caused by decreased resistance
to shear stress at the bone-growth plate
• Heel pain, usually in young physically active individuals,
which is gradual in onset, and worse on exercise,
especially running or jumping relieved by rest. Often
• Tenderness on palpation of the heel - particularly on
deep palpation at the Achilles tendon insertion.
• Pain on dorsiflexion of the ankle - particularly when
doing active toe raises; forced dorsiflexion of the ankle
is also uncomfortable.
• Swelling of the heel - usually mild.
• Calcaneal enlargement - in long-standing cases
• X-ray of the heel may show increased sclerosis
and fragmentation of the calcaneal apophysis
– but these features are nonspecific and it
may be normal
• CT or MRI scan may be useful to exclude
osteomyelitis or fusion of the small bones of
• Physiotherapy and exercises
• Soft orthotics or heel cups.
• Advice on suitable athletic footwear. In severe
cases: temporarily limiting activity such as
running and jumping.
• Ice and non-steroidal anti-inflammatory drugs
(NSAIDs), which can reduce pain
• In very severe cases, a short period of
immobilisation (eg 2-3 weeks in a case in mild
- osteochondrosis of the inferior pole of the
- presents as anterior knee pain in the active
- usually resolves with skeletal maturation
• The mechanism in Sinding-Larsen Johansson
disease is thought to be persistent traction at
the cartilaginous junction of the patella and
the patellar ligament/tendon
It is essentially a chronic stress injury with
overuse of the patella-patellar tendon junction
• Knee X-ray: can show calcification or
ossification at the junction between the
patella and the patella ligament
• Physiotherapy is the mainstay of treatment,
including quadriceps strengthening exercises
• Avascular Necrosis of Lunate
• First Described by Robert Kienbock in 1910; as
“traumatic softening” of Lunate bone
• Aetiology = unknown, but several cause have been
• Vascular compromise from repetitive trauma causes
microfracture & excessive stress on microscopic
architecture (sports injury)
• Ulnar minus variant:- Individual having ulnar minus
variance are at increased risk. Short Ulna
increases shear force across the lunate Causes
• There may be history of trauma with wrist in severe
The lesion presents with
1. Dorsal wrist pain:- Pain may be produced in lunate
region by axial strike/injury at distal end of middle
3. Decreased Grip strength
4. Decreased range of motion; particularly in extension.
In later stage movement may be painful
• X-ray at first show no abnormality but
• Bone scan may reveals increased activity
• Later x-ray may show either mottled or diffuse
density of bone – to – osteoarthritic changes
• MRI Most reliable way of detecting the early
Casting of wrist for several wks ; for early
stages of disease ( St I or II, before sclerosis,
fragmentation or collapse)
But- Unacceptable & Ineffective
• Surgery is only definitive treatment
Early Disease Stage I & II
• Unloading the Lunate*
• 1. Ulnar lengthening
• Transverse osteotomy at distal ulna
Distraction Cortical iliac graft Tightening
of plate screw
Early Disease Stage I & II
2. Radial Shortening
– Negative ulnar variance
– Lunate compression fracture without fragmentation or
Transverse osteotomy 3”
proximal to distal
shortening of radius by 2
fixing the bone with
• Vascularized grafts include the distal radius
based on the pronator quadratus, the pisiform
as a pedicle graft, and various other grafts
from the distal radius, second metacarpal, and
• These procedures also are effective in
relieving pain and improving function in
approximately 90% of patients
In stage III
1. Ulnar lengthening
2. Silicon prosthesis
- silicon synovitis
- foreign body cyst
3. Interacarpal fusion
4. Lunate excision
5. Arthrodesis Tri scaphe
In stage IV
• Proximal carpal row resection
• Wrist arthrodesis
• Traction epiphysitis of the base of the fifth
metatarsal occurring in young adolescents at
the time of appearance of the proximal
epiphysis of the fifth metatarsal
• This bone is located within the cartilaginous
flare onto which the peroneus brevis inserts
• Tenderness over a prominent proximal fifth
• Weight bearing produces pain over the lateral
aspect of the foot.
• The affected area over the tuberosity is larger on
the involved side, with soft-tissue edema and
• The area is tender to palpation at the insertion of
the peroneus brevis, and resisted eversion and
extreme plantar flexion and dorsiflexion of the
foot elicit pain.
• Oblique radiographs- enlargement and
fragmentation of the epiphysis and widening
of the cartilaginous-osseous junction.
• Technetium-99m bone scanning-incresed
• For mild symptoms, limitation of sports
activity, application of ice, and administration
• For severe symptoms, cast immobilization
may be required. Internal fixation of the
epiphysis is not indicated.
• It is essentially osteochondrosis of the
• It affects the thoracic or thoracolumbar spine
causing increased kyphosis, poor posture and
possible backache. It is the most common
cause of structural kyphosis in adolescents.
• A defect in the secondary ossification centres
of the vertebral bodies. A few vertebral bodies
may be involved or the whole thoracolumbar
• Hereditary factors are thought to play a part
• Taller height, as well as an association with
increased levels of growth hormone, have also
• Mechanical factors and trauma
• Usually presents in children aged 13-16 years
• Occurs more commonly in boys.
• Poor posture with increased kyphosis (usually
noticed by parents).
• Pain is a more common presentation if the
disease affects the lumbar spine. Pain is usually
dull aching worse on activity and relieves on rest
• Neurological symptoms may rarely be the
• Cardiorespiratory symptoms can also rarely occur.
• It is normal to have a degree of kyphosis. Any degree of
kyphosis of more than 40° is considered abnormal
• Kyphotic deformity may be progressive.
• Upper thoracic kyphosis is best seen in the forward
flexed position; lower thoracic kyphosis may be seen at
the thoracolumbar junction.
• There is reduced flexibility of the spine.
• There may be tenderness above and below the apex of
• Scoliosis may also be present
• Neurological signs are rare.
• Wedge-shaped vertebral bodies
• Rigid kyphosis
• Narrow intervertebral disc spaces with
• Prominent irregularities of the vertebral
• Vertebral plates that are poorly formed and
that develop multiple herniations of the
nucleus pulposus known as Schmorl nodes
• Mild, nonprogressive disease can be treated
by reducing weight-bearing ,stress and
avoiding strenuous activity
• For severe kyphosis , recommendations
include casting, a spinal brace, or rest and
recumbency on a rigid bed. Orthotic Mx
usually requires 12-24 months of treatment.
• Non-steroidal anti-inflammatory drugs may be
used for pain relief
• Surgery ,if there is neurological deficit,
uncontrolled pain, unacceptable cosmetic
appearance or documented progression
• Cord decompression for neurological deficit
• Spinal fusion techniques for kyphosis
correction and pain control.
• Chronic back pain.
• Progressive and permanent deformity.
• Neurological deficit.
• Cardiorespiratory problems.