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You are here: Home / Pediatric ortho / Osteochondrosis- Types, Presentation and Treatment

Osteochondrosis- Types, Presentation and Treatment

Dr Arun Pal Singh ·

Last Updated on March 3, 2024

Osteochondrosis is a self-limiting developmental derangement of normal bone growth, primarily involving the centers of ossification in the epiphysis. It usually begins in childhood as a degenerative or necrotic condition. By definition, osteochondrosis is an aseptic ischemic necrosis.

In broad terms, osteochondroses are a group of unrelated lesions that mostly affect immature skeletons [children], and involve either epiphysis or apophysis and bone in the apophyseal region. Epiphyseal ossification centers are primarily affected. It has been suggested to be a type of ischemic necrosis.

As the research on osteochondrosis is gathering more data, a few osteochondroses are labeled as a phenomenon rather than a disease or syndrome.

Most of the osteochondroses are more common in males. However, Freiberg disease and juvenile osteochondritis dissecans of the elbow involving the capitellum (seen often in javelin throwers) is common among females.
It mostly is seen in ages between 10-15 years. The condition is very rare in people younger than 10 years and older than 50.

The condition mostly affects people between 10 and 15 years. They are very rare in people under 10 and over 50 years.

Contents hide
1 Epiphysis, Physis and Apophysis
2 Types of Osteochondrosis
2.1 Location
2.2 Eponym
3 Pathophysiology
4 Clinical Presentation and Diagnosis
5 Lab Investigations
6 Imaging
7 Treatment
8 Prognosis
9 References

Epiphysis, Physis and Apophysis

In an adult skeleton, the bone consists of metaphyses and diaphysis. However, an immature skeleton contains physeal and epiphyseal regions that are present at the ends beyond the metaphyseal region. After the bone has attained its maximum growth potential, the physis, epiphysis, and metaphysis are joined.

Epiphysis

The epiphysis is the end part of the bone and is separated from the metaphysis by the physis or growth plate. The epiphyseal part contributes to the joint formation.

Physis

Physis is also called a growth plate and is a thin cartilage that separates epiphysis from metaphysis.

Apophysis

The apophysis is a secondary ossification center that is located in the non-weight-bearing part of the bone [appears separated from bone] but eventually fuses with it over time It is a site of tendon or ligament attachment. It is also called traction epiphysis.

Physis, Epiphysis and Apophysis

freiberg disease is osteochondrosis of second metatarsal head
Freiberg disease, Image credit: Openi

Types of Osteochondrosis

It divides the osteochondroses into articular, nonarticular, and physeal types.

Articular or Epiphyseal osteochondrosis

This type involves articular regions and could be either primary involvement of the articular and epiphyseal cartilage (Freiberg disease that involves second toe) or secondary involvement of the articular and epiphyseal– (Perthes disease of hip, Kohler disease of foot) In case of secondary involvement, the primary pathology is the ischemic necrosis of the bone.

Nonarticular osteochondrosis

These can occur in any part of the skeleton. These can be at the attachment of tendons (Osgood-Schlatter’s disease of the knee and Monde-Felix disease) or ligamentous attachments like the vertebral ring, and impact sites like Sever disease that is also associated with sports and overuse.

Physeal osteochondrosis

• Long bones – Tibia vara (Blount disease)
• Scheuermann disease

Another type of classification of osteochondrosis is juvenile which occurs in childhood, and adult which occurs in adults.

Another set of terms used about osteochondrosis is osteochondritis deformans or “osteochondritis dissecans depending on the site and its presumed cause.

Osteochondritis deformans affects the primary ossification center in young children (Legg-Calve-Perthes disease, Kohler’s disease, Panner’s disease) and is thought due to vascular causes whereas osteochondritis dissecans affects bone and cartilage of weight-bearing areas in older children such as femoral condyle, talus etc and is thought to be of traumatic origin. But the cause and effect is neither that straightforward nor established as of now.

A List of eponyms of osteochondrosis is given below

Location

Eponym

Foot
Talus Mouchet or Diaz disease
Navicular (Tarsal scaphoid) Kohler’s disease
Calcaneal apophysis Sever disease or phenomenon
Accessory tarsal navicular or os tibiale externum Haglund disease
Second metatarsal Freiberg disease
Fifth metatarsal base Iselin disease
Medial cuneiform Bushcke disease
Spine and Pelvis
Vertebral epiphysis Scheuermann kyphosis
Iliac crest Buchman disease
Symphysis pubis Pierson disease
Ischiopubic junction Van Neck disease or phenomenon
Ischial tuberosity Valtancoli disease
Vertebral body Legg-Calve-Perthes Disease
Lower Limb
Patella Kohler disease
Capital epiphysis of the femur Legg-Calve-Perthes disease
Greater trochanter of the femur Mandl or Buchman disease
Distal tibial epiphysis Lewin disease
Proximal tibial epiphysis Blount disease
Tuberosity of the tibia Osgood-Schlatter disease
Secondary patellar center Sinding-Larsen-Johansson syndrome
Lesser trochanter of the femur Monde-Felix disease
Upper Limb
Lunate Kienboch’s disease
Phalanges Thiemann syndrome
Metacarpal heads Mauclaire disease
Proximal epiphysis of the radius Schaefer disease
Carpal scaphoid Preiser disease
Distal epiphysis of the ulna Burns disease
Medial humeral condyle Froelich disease
Lateral humeral condyle Froelich disease
Capitellum of the humerus Panner disease
Humeral head Hass disease
Clavicle Friedrich disease

Pathophysiology

Most osteochondroses occur shortly after the bony nucleus appears, around the middle of the growth spurt. Physeal and apophyseal osteochondrosis is often caused by injury/trauma in the form of repeated sports injuries or overuse.

For example,physeal osteochondrosis is often found in gymnasts or tennis players in the distal radius.

In the case of apophyses, the growth of bones and the myotendinous units attached may be at a different rate owing to increased traction forces, especially during rapid growth.

However, most of these injuries are reversible early on if the repetitive action causing the injury is stopped.

There is no clear agreement on the cause of epiphyseal osteochondrosis. There are many theories like endocrine, genetic, vascular, and traumatic theories

The initial event whether due to trauma or vascular cause is suggested as ischemic necrosis of the ossification center. This leads to degeneration of the epiphyseal osseous nucleus . The interference with blood supply and failure of the bony centrum to enlarge may lead to this resulting in disordered proliferation of the cartilaginous cells.

Secondary changes like fragmentation, collapse, and sequestrum formation may occur but would vary with the affected region.

Apart from trauma and vascular causes, the following causes have been suggested to play a role

  • Thrombosis/ embolism
  • Trace element deficiency (copper, zinc)
  • Infection
  • Exposure to passive smoking

Clinical Presentation and Diagnosis 

On examination localized swelling, tenderness, and limited movement of a nearby joint may be noted. Lower limb involvement may show gait problems.

Growth disturbance and secondary deformities may occur in the late stages.

The presentation of osteochondrosis depend on the site of involvement and on the stage of progression. Several patients may not have symptoms. Pain localized to the affected site is the usual presentation in the initial stages. The pain might worsen as the condition worsens. For example, pain on kneeling in cases of Osgood-Schlatter disease. Some conditions like Perthes disease may present with a referred pain.

There may or may not be a history of overuse.

The pain may progress as follows

  • Pain after physical activity only
  • Pain on physical activity without affecting function
  • Pain during and after physical activity and affected function
  • Pain even without activity or minimal activity

The pain may not be localized in epiphyseal and physeal osteochondrosis but in cases of apophyseal osteochondrosis, the pain is well localized.
On examination, the following may be seen in some cases

  • Tenderness
  • Swelling over the site
  • Nearby joint movement restriction
  • Limp-in lower limb pathologies

Some conditions may show growth changes and deformity. For example

  • Blount disease- shortening and tibia vara
  • Scheuermann disease -Kyphosis
  • Perthes disease- Shortening and hip changes

Any presence of systemic signs like fever or myalgia in other parts should be noted.

Lab Investigations

Laboratory findings are mostly normal.

However, it is important to rule out other disorders, and following tests would help when suggested.

• Hemogram
• Erythrocyte sedimentation rate (ESR)
• C-reactive protein (CRP) level
• Serum calcium
• Serum phosphate
• Alkaline phosphatase (ALP) levels.

Other lab tests as deemed necessary on an individual basis may be done.

Imaging

X-rays

X-rays in the early stage show an epiphysis of reduced size with increased opacity. The structural irregularities if visible can be seen. As the disease advances, cartilage fissures and fibrillation may occur. Irregular bony trabeculae may be visible. X-rays done in the revascularization phase show osteoporosis, physis deformation, and underlying bone support defects.

The revascularization phase results in osteoporosis, absorption of necrotic tissue, and deformation. Incomplete restoration of the blood supply and poor protection can lead to misshaped epiphysis. Associated changes may be seen in adjoining metaphyseal areas in these cases. Joint arthritis sets in late cases.

A few of the known deformities associated with different osteochondrosis are-

  • Mushroom-shaped femoral head or joint incongruity- Perthes disease
  • Kyphosis – Scheuermann disease
  • Cubitus valgus – Panner disease
  • Madelung deformity in radial epiphysis
  • Genu recurvatum and patella alta in Osgood-Schlatter disease

MRI

MRI can pick up the disease at the asymptomatic stage and before x-ray changes. However, it is required in a few cases especially when differentiation from inflammatory conditions and infection is required.

Bone Scan

Bone scintigraphy is again a sensitive and specific test that can pick up the problem before symptoms. The bone scan can indicate the phase of the disease as well and thus can be used as a prognostic marker.

Treatment

Most of the cases of osteochondrosis are self-limiting. Medical and supportive therapy constitute the mainstay of treatment.

The goal is to obtain a congruous, mobile, and painless joint.•

 

The part is protected from additional trauma and stress. This facilitates ossification and prevention of deformity.  Any loose osteochondral fragments need to be removed.

Surgery is indicated only in cases where conservative therapy has failed or when it would help to reduce late disability. Deformity correction surgeries may be done in late stages if required.

Medical Treatment

  • Rest to joint
  • Ice application
  • Drugs for controlling pain and inflammation  – ibuprofen, diclofenac etc.
  • Traction– provides pain relief, counter spasms and prevents deformity. Needed in selected cases
  • Immobilization –  by plaster or brace
  • Assisted weight bearing when required
  • Physical therapy

Surgical Treatment

Surgical treatment is usually undertaken when conservative methods are not effective. Surgery is also used when it may help restore the reparative process as to improve outcomes over conservative means.

Arthroscopic procedures may be done to facilitate regeneration by microfracture technique or to pin or fix a salvageable fragment. Osteotomy is done to correct the deformity.

Salvage surgeries and reconstructive procedures are done in to improve situations in cases with poor outcomes. These may include arthrodesis, arthroplasty, or bone lengthening procedures where required.

The surgery needs to be individualized.

Prognosis

Osteochondrosis is mostly a self-limiting disorder, the outcome is usually good. However, those uncommon cases who don’t respond to treatment either conservative or surgical are associated with poor prognosis.

References

  • West EY, Jaramillo D. Imaging of osteochondrosis. Pediatr Radiol. 2019 Nov. 49 (12):1610-1616. [Link]
  • Atanda A Jr, Shah SA, O’Brien K. Osteochondrosis: common causes of pain in growing bones. Am Fam Physician. 2011 Feb 1;83(3):285-91.
  • Achar S, Yamanaka J. Apophysitis and Osteochondrosis: Common Causes of Pain in Growing Bones. Am Fam Physician. 2019 May 15;99(10):610-618. [Link]

 

Pediatric ortho This article has been medically reviewed by Dr. Arun Pal Singh, MBBS, MS (Orthopedics)

About Dr Arun Pal Singh

Dr. Arun Pal Singh is a practicing orthopedic surgeon with over 20 years of clinical experience in orthopedic surgery, specializing in trauma care, fracture management, and spine disorders.

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Dr. Arun Pal Singh is an orthopedic surgeon with over 20 years of experience in trauma and spine care. He founded Bone & Spine to simplify medical knowledge for patients and professionals alike. Read More…

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