E

Necrosis Avascular

Enfermedad de Osgood Schlatter

Definicin

Fenmeno de traccin resultante de contraccin repetitiva del cudriceps a travs del tendn rotuliano en su insercin en el tubrculo tibial inmaduro.

Causa principal de dolor de rodilla: 8 a 15 aos

Autolimitante

Etiologa / Factores de Riesgo

Contraccin repetida que causa avulsiones parciales o micro avulsiones del tejido condrofibroso del tubrculo tibial anterior

Deporte:

Atletismo, gimnasia, futbol, etc.

Edad: 8 a 15

Sexo masculino (3:1)

Crecimiento seo rpido

Saltos repetitivos (deporte)

The proximal area of the patellar tendon insertion separates, resulting in elevation of the tibial tubercle. During the reparative phase of this stress fracture, new bone is laid down in the avulsion space, which may result in a deviated and prominent tibial tubercle. When an individual with an injured tibial tubercle continues to participate in sports, more and more microavulsions develop, and the reparative process may result in a markedly pronounced prominence of the tubercle, with longer-term cosmetic and functional implications. A separated fragment may develop at the patellar tendon insertion and may lead to chronic, nonunion-type pain.

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Epidemiologia

Incidencia:

5% de adolescentes NO ACTIVOS

20% de adolescentes Atletas

25 a 50% de los casos son bilaterales

Clinica

Evolucin prolongada

Tumoracin subcutnea en la regin del tubrculo tibial

Dolorosa a la palpacin

Dolor de Rodilla

Exacerba con actividad fsica

Bajar y subir escaleras

Arrodillarse

Inflamacin moderada

Mas aumento de sensibilidad por debajo de la patella.

Other physical examination findings may include the following:

Proximal tibial swelling and tenderness

Enlargement or prominence of the tibial tubercle

Reproducible and aggravated pain by direct pressure and jumping (quadriceps contraction)

Pain with resisted knee extension (quadriceps contraction)

Full range of motion of the knee

Hamstring tightness

No effusion or meniscal signs

Negative Lachman test (no knee instability)

Normal neurovascular examination

No abnormal findings in the hip and ankle joints

Tenderness to palpation over the proximal tibial tuberosity at the site of patellar insertion may be present. A firm mass may be palpable.

Erythema of the tibial tuberosity may be present.

Some patients may have quadriceps atrophy.

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Diagnostico

Radiografa lateral de rodilla

knee in slight internal rotation of 10-20.

However, plain films are helpful for ruling out other etiologies, such as neoplasm, acute tibial apophyseal fracture, and infection. In addition, radiographs may indicate:

Superficial ossicle in the patellar tendon

Irregular ossification of the proximal tibial tuberosity

Calcification within the patellar tendon

Thickening of the patellar tendon

Soft-tissue edema proximal to the tibial tuberosity

In severe cases, radiographs may reveal radiodense fragments or ossicles separated from the tibial tuberosity.

Occasionally, the radiographs may reveal irregularity, fragmentation (seen below), or increased density of the ossification of the tibial tubercle. This pattern may be a normal variant in asymptomatic children.

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Tratamiento

Conservador: hielo por 20 mins cada 2-4 horas

Analgsico + AINE

Disminucin de activades exacerbantes

Inmovilizador de rodilla

No se recomiendan esteroides

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Pronostico

Excelente

10% pueden persistir sntomas hasta la adultez.

Falta de apego al tratamiento

OSD usually resolves by the time the patient is aged 18 years, when the tibial tubercle apophysis ossifies.

In some cases, however, discomfort may persist for 2-3 years until the tibial growth plate closes.

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Enfermedad de Kienbck

Necrosis avascular del hueso semilunar

Etiologa desconocida

Secundario a osteonecrosis

Frecuente en adultos (varones) de 20 a 40 aos de edad

Cargas repetitivas en mueca

who is either a manual laborer or one who participates in recreational activities that repetitively load the wrist.

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Clinica

Dolor de mueca (dorsal)

Disminucion de arco de movimiento

Pobre agarre

Inflamacion y sensibilidad de la articulacion radiocubital inferior

Masculino de 20 a

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Diagnostico

Radiografia

Tratamiento

Inmobilizacion

AINE

Quirurgico

Excision de semilunar con o sin reemplazo

Procedimientos para nivelar la articulacion

Fusion intercarpal

revasvularizacion

Etapas

I: radiografa normal

II: Aumento de radiodensidad del semilunar con posible decremento de la altura radial del mismo hueso

Stage I - Normal radiograph

Stage II - Increased radiodensity of lunate with possible decrease of lunate height on radial side only

During the first stage of the disease, the symptoms are similar to those of a wrist sprain. Although the blood supply to the lunate has been disrupted, x-rays may still appear normal or suggest a possible fracture. An MRI scan can better detect blood flow and is helpful in making the diagnosis in this early stage.

An x-ray of a patient's wrist during Stage I shows no deterioration of the lunate bone.

The lunate bone begins to harden due to the lack of blood supply during Stage 2. This hardening process is called sclerosis. In addition, the lunate will appear brighter or whiter in areas on x-rays, which indicates that the bone is dying. To better assess the condition of the lunate, your doctor may also order either MRI scans or computed tomography (CT) scans.

The most common symptoms during this stage are wrist pain, swelling, and tenderness.

(Left)This illustration shows that the lunate has hardened with more than one fracture line.(Right)The lunate is brighter than the surrounding bones, which indicates that the bone is dying.

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III: Colapso del semilunar

A: sin rotacin escafoidea

B: rotacin escafoidea

IV: cambios degenerativos alrededor del semilunar

Stage IIIa - Lunate collapse, no scaphoid rotation

Stage IIIb - Lunate collapse, fixed scaphoid rotation

Stage IV - Degenerative changes around the lunate

3: the dead lunate bone begins to collapse and break into pieces. As the bone begins to break apart, the surrounding bones may begin to shift position.

During this stage, patients typically experience increasing pain, weakness in gripping, and limited wrist motion.

Both the illustration and x-ray image show that the lunate has begun to collapse and several bones in the wrist have shifted out of position.

4: the surfaces of the bones surrounding the lunate also deteriorate, and the wrist may become arthritic.

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Enfermedad de Sever

Necrosis avascular de calcaneo

Inflamacion apofisiaria de calcaneo

Etiologa: trauma repetitivo

Mas frecuente en varores de 10 a 12 aos

Deportistas

La aposifisis de calcaneo se solidifica en kids de 9 a 10 anhos (empieza) y se termina a los 17, en ninhas poco antes.

Se cree que ocurren microfracturas por estres repetido

Clinica: dolor progresivo de talon, con exacervacion a la actividad fisica.

A la dorsiflexion forzada de tobillo hay molestia

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Diagnostico

Clinico

Diagnostico: clinico, se usa la placa para descartar otras anomalias

MRI para descartar osteomielitis

Radiographic findings include increased sclerosis and fragmentation of the calcaneal apophysis NO ESPECIFICOS

primary value in this setting is for exclusion of other causes of heel pain. This point should be clearly explained to patients and parents.

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Tratamiento

Reducir actividad fisica

Ejercicios de calentamiento adecuados

AINE

Ibuprofeno

Naproxeno

Enfermedad de Kohler

Necrosis avascular del hueso navicular

5 a 10 aos de edad. Mas frecuente en varores

Marcha antialgica, sensibilidad en la parte media del pie

Incidente vascular o trauma.

The navicula is the last tarsal bone to ossify in children. This bone might be compressed between the already ossified talus and the cuneiforms when the child becomes heavier. Compression involves the vessels in central spongy bone, leading to ischemia, which then causes clinical symptoms. Thereafter, the perichondral ring of vessels sends the blood supply, allowing rapid revascularization and formation of new bone. The radial arrangement of the vessels of this bone is of great importance in explaining why the prognosis of this lesion is always excellent.

Cargar peso lateralmente.

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Diagnostico

Clnico

increased radiodensity of the navicular with a flattened appearance to the ossific nucleus

Radiography is indicated (see the first image below). The lateral view shows a flat tarsal scaphoid (see the second image below). The space between the talus and the cuneiforms is not decreased. Frequently, there is an irregular ossification of the tarsal navicular bone or radiologic changes that resemble Khler disease, but the diagnosis must not be made in the absence of clinical signs.

If pain persists 6 months after casting, magnetic resonance imaging (MRI) or computed tomography (CT) is necessary to exclude a tarsal coalition

Furthermore they revealed increased density and callus formation in the proximal 1st through 4th metatarsals. This was consistent with multiple non-displaced fractures of the proximal metatarsals secondary to trauma

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Tratamiento

Uso de frula por debajo de rodilla

En ligero varo

weightbearing below-the-knee cast is recommended

in moderate varus (10-15)

In this position, the navicula is relaxed from posterior tibialis strain.

Arch supports can be prescribed after the cast period and used for an average of 6 months. In mild cases, soft arch supports may be the only treatment necessary.

Dolor debe desaparecer en 3 meses, la ferula puede ser 6 semanas, sino, otra por 6 semanas. Si persiste buscar coalicion tarsal o un navicular accesorio.

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