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NQ Foot Ankle Centre

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									Osteochondroses of
     the Foot
      TONY PASCOE
  B.App.Sc. (Pod) Grad.Dip.(Pod) M.A.Pod.A
       OSTEOCHONDROSES
   Group of bone disorders in the
    growing skeleton in which the
    centres of ossification undergo
    aseptic necrosis, followed by bone
    resorption, and then repair

   Primary pathology is a vascular
    deficit in the subchondral region of
    the involved bone
 Osteochondritis
 Osteochondritis   juvenilis
 Aseptic necrosis
 Avascular necrosis
 Infarction
 Osteonecrosis
          More Common
   Sever’s Disease (heel)
   Kohler’s Disease (navicular)
   Iselin’s Disease (5th metatarsal)
   Freiberg’s Disease (2nd metatarsal)

           Less Common
    Diaz or Mouchet’s Disease (talus)
    Buschke’s Disease (cuneiforms)
    Treves’ or Ilfelds’Disease
    (sesamoids)
    Thiemann’s Disease (phalanges)
         Sever’s Disease
      (Osteochondrosis of
      Calcaneal Apophysis)
   First described in 1912 by J.W
    Sever MD in New York Medical
    Journal
   Described as an “inflammation of
    the calcaneal apophysis resulting in
    pain at the posterior heel, mild
    swelling and difficulty walking”
        Sever’s Disease
      PATHOPHYSIOLOGY
• Calcaneal apophysis develops as an
independent centre of ossification in boys
aged 9-10 years and fuses by age 17 (girls
slightly younger age)
• Apophyseal line appears weakened during
rapid growth (puberty) because of
increased fragile cartilage
• Microfractures believed to occur because
of shear stress leading to normal
progression of fracture healing
      Sever’s Disease
    PATHOPHYSIOLOGY
• Radiographic appearance of
resorption, fragmentation and
increased sclerosis leading to
eventual union
• BUT…… Xrays showing
fragmentation of apophysis are NOT
diagnostic, as multiple centres of
ossification may exist in normal
apophysis
Normal apophyseal development in
        a 7 year old child
MRI
          Sever’s Disease
         INCIDENCE

 No exact figures/data
 Higher in boys than girls
 Occurs most frequently between
  ages of 8-15 years
 Peak incidence around 10-11 years
           Sever’s Disease
          AETIOLOGY
 Decreased resistance to shear
  stress at bone-growth plate
  interface
 Research indicates traction
  apophyses have a higher
  composition of fibrocartilage than
  epiphyses subjected to more axial
  load, composed predominantly of
  hyaline cartilage
 Traction from tight Achilles tendon
         Sever’s Disease
    DIFFERENTIAL’S

 Stress fracture
 Tumour
 Tarsal Coalition
 Insertional Achilles Tendinopathy
 Osteomyelitis
         Sever’s Disease
       TREATMENT
 R.I.C.E
 Heel raise
 Triceps surae stretching program
 Correct Footwear
 Foot Orthoses if required
 Complete immobilisation rarely
  required
          Sever’s Disease
    WHEN TO REFER TO
       SURGEON

   NEVER ……….
Unless suspect tumour, coalition or
 infection
   KOHLER’S DISEASE
 AVN of navicular bone occurring
  spontaneously or as a result of
  trauma during ossification process
 Onset at 4yrs (3-5 yrs female, 4-5
  yrs male)
 Less than 1/3 are bilateral
 More common in boys
        Kohler’s Disease
SIGNS AND SYMPTOMS
 Pain at navicular
 Increased perfusion
 Aversion to footwear
 Antalgic gait
 Flattening and narrowing of
  navicular on plain xray
         Kohler’s Disease




  Sclerosis, irregularity and early
collapse of the navicular consistant
 with avascular necrosis (Kohler’s
               disease)
          Kohler’s Disease
PROPOSED PATHOLOGY
Largely speculative, but 3 main theories:
   Mechanical: repetitive, compressive
    forces
   Physiological: ossification
    irregularities are not uncommon and
    more often seen in later developing
    bones
   Co-morbidities: malignancies,
    chemotherapy and radiation can
    cause ossification delays
           Kohler’s Disease
          TREATMENT
   Rest: As a self limiting disease,
    normal function will resume
    within 24 months (avg 18mths)
   Orthoses: reduction in
    compressive force to encourage
    renewed vascularisation
   Immobilisation (BK Cast or CAM
    walker for at least 8 weeks)
     ISELIN’S DISEASE
   Traction apophysitis of tuberosity
    of 5th metatarsal
   Occurs at attachment of peroneus
    brevis
   More common than generally
    appreciated
ISELIN’S DISEASE
ISELIN’S DISEASE
           TIMELINES
   Occurs in older active children or
    young adolescents
   Coincides with appearance of the
    proximal apophysis of tuberosity of
    5th metatarsal
   Apophysis appears in females at
    age 9.7 yrs and males 12.1 years,
    and fuses with shaft of 5th met by
    age 11 yrs in females and 14 years
    in males
          (ISELIN’S DISEASE)
           SYMPTOMS
   Tenderness over a prominent
    proximal 5th metatarsal
   Pain over lateral aspect of foot
    with weightbearing
   More common with lateral
    movement sports which cause
    inversion stress on forefoot
          (ISELIN’S DISEASE)
CLINICAL EXAM FINDINGS
   Larger 5th met tuberosity
   Localised soft tissue swelling and
    mild erythema
   Tender at insertion of peroneus
    brevis
   Pain with resisted eversion,
    plantarflexion and dorsiflexion
       (ISELIN’S DISEASE)
    DIFFERENTIALS

   Avulsion fracture
   Jones fracture
   Os Vesalianum
   Peroneal tendinopathy
     (ISELIN’S DISEASE)
      TREATMENT

   R.I.C.E
   Foot orthoses with lateral
    wedging/posting
   Footwear choices
   Cross training
    FREIBERG’S DISEASE

   First described by Freiberg in
    1914 as an infarction of the 2nd
    metatarsal head
   Can affect the head of any lesser
    metatarsal, 2nd most common
    (70%)
   Onset 11-17 yrs of age (F>M)
           Freiberg’s disease
           AETIOLOGY
   No consensus
   Classed as an osteochondrosis, but
    this does not explain the adult
    onset of the disease??
   Most likely multifactorial cause,
    with initial insult primarily
    vascular or traumatic
    (?biomechanical influence)
           Freiberg’s Disease
CLINICAL PRESENTATION

   Initially asymptomatic, but later
    pain on walking
   Local tenderness and limp
   Limited joint ROM with pain on
    direct palpation of metatarsal head
   Possible periarticular oedema and
    soft tissue swelling
      Freiberg’s Disease
    DIFFERENTIALS

    Stress fracture
    Morton’s neuroma
    Synovitis
    Plantar plate injury
    Gout
     Freiberg’s Disease
X-RAY CLASSIFICATION
    1.Fracture of subchondral
      epiphysis


    2.Flattening of articular surface
      with early collapse of central
      protion of metatarsal

    3.Further flattening and collapse
      of central protion with medial
      and lateral projections
     Freiberg’s Disease
X-RAY CLASSIFICATION

    4.Loose bodies form and lateral
      projections break off



     5.End stage arthrosis
Freiberg’s Disease
  Early Stage 1
Freiberg’s Disease




          Stage 2 - 3
Freiberg’s Disease
     Stage 4
Freiberg’s Disease
     Stage 5
Freiberg’s Disease
Freiberg’s Disease
Freiberg’s Disease
          Freiberg’s Disease
          TREATMENT
   Accommodative padding to
    relieve pressure
   Metatarsal bar/pad
   Orthoses
   BK casting
   Surgical – excision of fragments,
    metatarsal head removal, joint
    implants
    DIAZ OR MOUCHET’S
         DISEASE

   Very rare

   Associated with acute trauma
    with compression of talar dome

   Usually remodels to normal shape
    BUSCHKE’S DISEASE
   Very rare
   Effects each of the cuneiforms
   Pain in region of cuneiforms
   Affected cuneiform has irregular
    outline on xray
    TREVES’ OR ILFELD’S
         DISEASE
   Significant pain on dorsiflexion
    and palpation of sesamoids
   F>M
   Fragmentation of sesamoid on
    xray
   Need to distinguish from
    multipartite sesamoid or fracture
THANK YOU

								
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