Author: Alex Tomesch, MD
Peer-reviewer: Mark Hopkins, MD
Editor: Katie Dolbec, MD
15 year old female presents to the emergency department for right knee pain. Pain is worst with jumping and landing, but is present to a minor extent at rest. You get x-rays and they show this.
Figure 1: Weight bearing x-ray of bilateral knees, provided by the author
What is your diagnosis?
What is your management in the ED?
What is your disposition?
Do you consult orthopaedics emergently?
What is the management of this?
See Answers Below -
What is your diagnosis?
Patient has a lesion of the distal epiphysis, located in the right lateral condyle. This diagnosis ended up being Osteochondritis Dissecans (OCD).
PEARL: Given the x-ray findings, you should consider the following differential In a young otherwise healthy individual:
Osteochondritis Dissecans - benign
Chondroblastoma - benign
Clear cell chondroblastoma - malignant (aggressive)
Subchondral cyst - benign
Giant cell tumor - benign (aggressive locally)
Enchondroma - benign
Osteoblastoma - benign
Ewing Sarcoma - malignant (less likely as this is not well circumscribed)
Osteogenic Sarcoma - malignant (less likely as this is not well circumscribed)
What is your management in the ED?
Discuss with the patient and parents the possibilities for this lesion as well as the plan for pain management. Arrange close outpatient follow up and MRI, if possible.
PEARL: MRI does not need to be done emergently as most of these lesions are benign.
What is your disposition?
Follow up with PCP to obtain further workup - starting with likely MRI.
Do you consult orthopaedics emergently?
No. However most of these patients will end up seeing orthopaedics once outpatient imaging is obtained.
What is the management of this?
OCD lesion management is based on the stability of the lesion. The stability is based off of the DeSmitt Criteria:
high-intensity signal beneath the OCD lesion
well-defined focal defect in the overlying articular cartilage
fracture of the overlying articular cartilage
subchondral cysts
If all four are present this indicates a very unstable lesion. Operative treatment is typically recommended for unstable lesions and skeletally mature individuals. This consists of a wide variety of interventions based on the individual's lesion. Non-operative management is typically reserved for those who do not meet these criteria and consists of activity modifications and immobilization.
References:
Quatman CE, Quatman-Yates CC, Schmitt LC, Paterno MV. The clinical utility and diagnostic performance of MRI for identification and classification of knee osteochondritis dissecans. J Bone Joint Surg Am. 2012;94(11):1036-1044. doi:10.2106/JBJS.K.00275
Bauer KL, Polousky JD. Management of Osteochondritis Dissecans Lesions of the Knee, Elbow and Ankle. Clin Sports Med. 2017;36(3):469-487. doi:10.1016/j.csm.2017.02.005
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