Chronic Apophyseal Injury

Overview

Etiology

The apophysis, a secondary ossification center Secondary ossification center Development of the Limbs, may be susceptible to repetitive or acute physical loading, which may lead to injury.

• The apophysis, or traction epiphysis Epiphysis The head of a long bone that is separated from the shaft by the epiphyseal plate until bone growth stops. At that time, the plate disappears and the head and shaft are united. Bones: Structure and Types, is a secondary ossification center Secondary ossification center Development of the Limbs. 
• Most secondary ossification Ossification The process of bone formation. Histogenesis of bone including ossification. Bones: Development and Ossification centers fuse by one’s late teens; exceptions include the ischial apophysis and iliac crest, which may not close until the early 20s.
• The apophysis is the weakest part of the musculotendinous junction; bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types growth and general inflexibility contribute to increased tension at the apophysis.
• The apophysis, or traction epiphysis Epiphysis The head of a long bone that is separated from the shaft by the epiphyseal plate until bone growth stops. At that time, the plate disappears and the head and shaft are united. Bones: Structure and Types, is the site of tendon or ligament attachment.
• Apophysitis Apophysitis Osgood-Schlatter Disease occurs from a traction injury to the apophysis.
• The apophysis is subjected to tensile forces; apophyseal injury occurs when the apophysis is unable to meet the demands of physical activity.
• Risk factors:
  • Age: occur during periods of growth
  • Training errors
  • Poorly fitting equipment
  • Muscle weakness and imbalance
  • Repetitive shear forces

Epidemiology

Injuries related to sports and activities in school-age children are the common presentation:

• Typically presents to primary care physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship (PCPs) and orthopedic physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship
• Apophysitis Apophysitis Osgood-Schlatter Disease accounts for a significant percentage of these visits.

Pathophysiology

• Apophyses Apophyses Apophyseal Avulsion Fracture contain fibrocartilage Fibrocartilage A type of cartilage whose matrix contains large bundles of collagen type I. Fibrocartilage is typically found in the intervertebral disk; pubic symphysis; tibial menisci; and articular discs in synovial joints. Cartilage: Histology instead of columnar cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology.
• Occurs secondary to an overuse injury Overuse Injury Osgood-Schlatter Disease with repetitive strain of the apophysis (a secondary ossification center Secondary ossification center Development of the Limbs)
• Age-related inflexibility and rapid bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types growth appear to contribute to the apophysis becoming susceptible to repeated forces.

Clinical Presentation

The majority of traction apophysitis Apophysitis Osgood-Schlatter Disease presents with localized swelling Swelling Inflammation and pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways at the site of the apophysis that worsens with resisted motion or muscle activation of the associated muscle–tendon complex.

Apophyseal disorders of the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy

There are specific apophyseal disorders of the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy with associated muscles. These disorders can present secondary to repetitive trauma, direct trauma Direct Trauma Toddler’s Fractures, or acute avulsion:

• Iliac crest apophysitis Apophysitis Osgood-Schlatter Disease: insertion of external and internal abdominal oblique muscles
• Anterior superior iliac spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy: sartorius Sartorius Thigh: Anatomy muscle (proximal tendon attachment)
• Anterior inferior iliac spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy: rectus femoris Rectus femoris Thigh: Anatomy (proximal tendon attachment)
• Greater trochanter: gluteus medius Gluteus medius Gluteal Region: Anatomy and gluteus minimus Gluteus minimus Gluteal Region: Anatomy muscle tendons attachment
• Lesser trochanter: iliopsoas tendon attachment
• Ischial tuberosity: proximal hamstring muscles attachment
• Pubic symphysis Pubic Symphysis A slightly movable cartilaginous joint which occurs between the pubic bones. Vagina, Vulva, and Pelvic Floor: Anatomy: adductor muscles
• The most commonly affected pelvic apophyses Apophyses Apophyseal Avulsion Fracture are the anterior superior iliac spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy and anterior inferior iliac spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy—sometimes referred to as “sprinter’s fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures.”

Diagnosis

• The diagnosis of apophysis-related disorders is based on the history and physical exam.
• Physical exam findings:
  • Point tenderness
  • Swelling Swelling Inflammation and pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways at the apophysis
  • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways with resisted activation of the associated muscle group
• Radiography:
  • Radiographs are often inconclusive in apophyseal disorders.
  • Often not indicated; may be ordered to exclude other disorders or lack of clinical improvement
  • Other possible indications for radiographic studies:
    • Evaluate for apophyseal avulsion fracture Avulsion fracture Tearing away of the cortical bone fragment at the location of a strong ligament or tendon attachment. The bone fragment detachment site often occurs near a soft site (e.g., growth plate) at the base where ligaments; tendons; or joint capsules attach. Overview of Bone Fractures
    • Stress fractures
    • Infection 
    • Malignancy Malignancy Hemothorax
  • Ultrasound: An office-based ultrasound may show widened apophysis or fragmentation and support diagnosis.

Management, Prevention, and Prognosis

Management

• 1st-line treatment involves modifying activities as tolerated, relative rest, and starting a stretching and strengthening program.
• Education: self-limited problem that generally resolves with modifying activity and ultimately with closure of the apophysis

Prevention

• Reduce early sports specialization.
• Reduce overtraining.

Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas

• Self-limiting Self-Limiting Meningitis in Children disorder that usually resolves with modification of activity and PT and eventually with closure of the apophyseal centers
• Most patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship do well with conservative therapy.
• Only a very small minority will require surgery.

Differential Diagnosis

• Osteochondrosis: less common than apophysitis Apophysitis Osgood-Schlatter Disease, osteochondrosis is due to temporary disruption of blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure at the bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types– cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology complex of the growing bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types. Osteochondrosis is a rare disease with an uncertain etiology, and it is usually a transient disorder that resolves spontaneously but requires vigilance to avoid long-term morbidity Morbidity The proportion of patients with a particular disease during a given year per given unit of population. Measures of Health Status.
  • Examples include:
    • Freiberg disease: avascular necrosis Avascular Necrosis Hip Fractures of the 2nd metatarsal head
    • Legg-Calvé-Perthes disease Legg-Calvé-Perthes Disease Legg-Calvé-Perthes disease (LCPD) is characterized by idiopathic avascular necrosis of the femoral head. The disease presents as a limp with an insidious onset and associated hip pain. Legg-Calvé-Perthes disease primarily affects school-age children and has a male predominance. Legg-Calvé-Perthes Disease: avascular necrosis Avascular Necrosis Hip Fractures of the femoral head
    • Köhler disease: avascular necrosis Avascular Necrosis Hip Fractures of the navicular Navicular Foot: Anatomy bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types of the foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy
    • Scheuermann disease: osteochondrosis of the secondary ossification Ossification The process of bone formation. Histogenesis of bone including ossification. Bones: Development and Ossification centers of the vertebral bodies; may develop kyphotic deformity Deformity Examination of the Upper Limbs
    • Panner disease: osteochondrosis of the capitellum of the elbow
• Apophyseal avulsion fracture Avulsion fracture Tearing away of the cortical bone fragment at the location of a strong ligament or tendon attachment. The bone fragment detachment site often occurs near a soft site (e.g., growth plate) at the base where ligaments; tendons; or joint capsules attach. Overview of Bone Fractures: an apophyseal avulsion fracture Avulsion fracture Tearing away of the cortical bone fragment at the location of a strong ligament or tendon attachment. The bone fragment detachment site often occurs near a soft site (e.g., growth plate) at the base where ligaments; tendons; or joint capsules attach. Overview of Bone Fractures is an acute injury in which a portion of the apophysis is avulsed, usually secondary to explosive movements or eccentric muscular contractions. Symptoms include severe pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, swelling Swelling Inflammation, point tenderness, and ecchymosis Ecchymosis Extravasation of blood into the skin, resulting in a nonelevated, rounded or irregular, blue or purplish patch, larger than a petechia. Orbital Fractures. The majority of apophyseal avulsion fractures are treated conservatively, but some may require surgery if the avulsed fragment is large or significantly displaced (although there is a lack of consensus, > 2 cm displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms is often recommended for surgical intervention).