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Apophyseal Injury

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101. Growth Plate (Physeal) Fractures (Diagnosis)

(Physeal) Fractures Updated: Jul 13, 2017 Author: Steven I Rabin, MD; Chief Editor: Jeffrey D Thomson, MD Share Email Print Feedback Close Sections Sections Growth Plate (Physeal) Fractures Overview Background Growth plate (physeal) fractures may be defined as disruptions in the cartilaginous physis of long bones that may or may not involve epiphyseal or metaphyseal bone. [ ] Injuries to the physes are more likely to occur in an active pediatric population than sprains or ligament injuries are, in part (...) be different in children as compared with adults; percutaneous Kirschner wire (K-wire) fixation may be stable enough, and prevention of iatrogenic injury to the physis is of significant importance. When growth deformity is possible, the treating provider must predict the degree of expected remodeling, and this requires an understanding of the specific fracture. Assessment of bone age using the Greulich-Pyle atlas and charts can give an estimate of remaining growth. Fractures in the metaphysis, closer

2014 eMedicine Surgery

102. Kyphosis (Diagnosis)

of Scheuermann disease is still imprecisely defined. Scheuermann postulated that the condition resulted from avascular necrosis of the apophyseal ring. Other theories include histologic abnormalities at the endplate, osteoporosis, [ ] and mechanical factors that affect spinal growth. [ ] A Danish study demonstrated an important genetic component to the entity. [ ] Postural kyphosis is present when accentuated kyphosis is observed without the characteristic 5° of wedging over three consecutive vertebral (...) , and one had a wound infection. No permanent neurologic injuries occurred. Video-assisted thoracoscopic release followed by posterior arthrodesis has been successful. In one study, deformity correction was 84.8° to 45.3° in patients with thoracic kyphosis associated with Scheuermann disease. [ ] Mean loss of correction was 1.6°, and one hook pulled out. No cases of junctional kyphosis were observed. In a retrospective study, anterior-posterior correction was compared with posterior-only instrumentation

2014 eMedicine Surgery

103. K&ouml (Diagnosis)hler Disease (Diagnosis)

or secondary centers of ossification; almost all of the epiphyses, apophyses, and small bones can be implicated. [ ] In Köhler disease, AVN of the navicular bone occurs. The etiology of these conditions is not well known, but vascular accidents, coagulation anomalies, and heredity have been implicated. [ ] The most common osteochondroses are Kienbock, and Panner diseases. Surgery is not indicated for Köhler disease; treatment is nonoperative (see ). Next: Pathophysiology Vascularization of the navicular (...) ; this clinical entity has been rarely reported in the years since. Dharamsi and Carl reported a case of isolated bilateral Köhler disease of the patella in a male athlete aged approximately 7 years. [ ] Previous Next: Etiology The etiology of Köhler disease, like those of the other osteochondroses, is unknown, but the condition is thought to result from compressive stress-related injury at a critical time of growth. [ ] Vascular insults, retarded bone age, and genetic predilection have also been implicated

2014 eMedicine Surgery

104. Medial Humeral Condyle Fracture (Diagnosis)

of injury for medial epicondyle fractures [ , ] have been proposed for an acute injury. All of them result in a partial or complete separation of the apophyseal fragment from the rest of the humerus. The first mechanism of injury is a direct blow on the posterior medial aspect of the epicondyle that may be associated with fragmentation of the avulsed bone. The second mechanism is a pure avulsion injury produced by the flexor muscles of the forearm (see the image below). This avulsion may occur (...) fractures appear to do worse if the epicondyle is excised than if they are treated nonsurgically. Previous References Rockwood CA, Wilkins KE, Beaty JH. Apophyseal injuries of the distal humerus. Fractures in Children . 3rd ed. Philadelphia: Lippincott-Raven; 1996. 800-19. Behrman MJ, Shelton ML. Fracture of the medial condyle of the humerus in an elderly patient. J Orthop Trauma . 1990. 4(1):98-101. . Bensahel H, Csukonyi Z, Badelon O. Fractures of the medial condyle of the humerus in children. J

2014 eMedicine Surgery

105. Lumbar Spine Fractures and Dislocations (Diagnosis)

acute fractures are or vertebral endplate fractures caused by sudden axial loading, transverse process avulsion by the origin of the psoas muscle, spinous process avulsions, and acute fracture of the pars interarticularis from hyperextension. Vertebral body compression is more common in patients with decreased bone density. [ , ] In adolescents, it is relatively common to find endplate fractures or apophyseal avulsion fractures. All of these injuries generally are stable and heal with immobilization (...) > Lumbar Spine Fractures and Dislocations Updated: Oct 16, 2018 Author: Federico C Vinas, MD; Chief Editor: Jeffrey A Goldstein, MD Share Email Print Feedback Close Sections Sections Lumbar Spine Fractures and Dislocations Overview Background Each year, more than 150,000 persons in North America sustain fractures of the vertebral column. Injuries to the thoracolumbar and lumbar spine constitute most of these fractures. The immediate neurologic damage that accompanies the bony destruction results

2014 eMedicine Surgery

106. Medial Humeral Condyle Fracture (Follow-up)

-term studies and does not appear to be a major issue with these fractures. Previous References Rockwood CA, Wilkins KE, Beaty JH. Apophyseal injuries of the distal humerus. Fractures in Children . 3rd ed. Philadelphia: Lippincott-Raven; 1996. 800-19. Behrman MJ, Shelton ML. Fracture of the medial condyle of the humerus in an elderly patient. J Orthop Trauma . 1990. 4(1):98-101. . Bensahel H, Csukonyi Z, Badelon O. Fractures of the medial condyle of the humerus in children. J Pediatr Orthop . 1986 (...) . . Karlsson MK, Herbertsson P, Nordqvist A, Besjakov J, Josefsson PO, Hasserius R. Comminuted fractures of the radial head. Acta Orthop . 2010 Apr. 81 (2):224-7. . Haxhija EQ, Mayr JM, Grechenig W. [Treatment of medial epicondylar apophyseal avulsion injury in children]. Oper Orthop Traumatol . 2006 Jun. 18(2):120-34. . Hoppenfeld S, Murthy VL. Treatment and Rehabilitation of Fractures . Philadelphia: Lippincott Williams & Wilkins; 2000. Media Gallery Schematic of two types of medial condyle fractures

2014 eMedicine Surgery

107. Growth Plate (Physeal) Fractures (Follow-up)

cause significant genu recurvatum. The image below illustrates a procurvatum deformity of the proximal tibia after repair of a proximal tibia apophyseal avulsion. Growth plate (physeal) fractures. Procurvatum of proximal tibia after open reduction and internal fixation of proximal tibia apophysis injury. If the fracture is nondisplaced or an anatomic stable reduction can be obtained with closed manipulation, treatment consists of an above-knee cast for 4 weeks. Generally, displaced apophyseal (...) =aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTI2MDY2My10cmVhdG1lbnQ= processing > Growth Plate (Physeal) Fractures Treatment & Management Updated: Jul 13, 2017 Author: Steven I Rabin, MD; Chief Editor: Jeffrey D Thomson, MD Share Email Print Feedback Close Sections Sections Growth Plate (Physeal) Fractures Treatment Approach Considerations Salter-Harris (SH) I and SH II growth plate (physeal) injuries usually can be managed adequately with closed manipulative reduction. Upon reduction, these injuries are typically stable, and casting suffices. At times

2014 eMedicine Surgery

108. Tibial Tubercle Fracture (Diagnosis)

. [ , , ] This condition should be distinguished from , a chronic apophysitis of the tibial tuberosity due to recurrent traction injury. Nondisplaced type I injuries can be managed conservatively by cast immobilization in a long leg cast in full-knee extension. All other injuries are best treated by open reduction and internal fixation (ORIF) with cast immobilization for 6-8 weeks. (See .) Next: Anatomy The extensor complex of the thigh exerts its force through the ligamentum patellae on the tibial tuberosity. During (...) its histogenesis, the tibial tuberosity is an anterior extension of the proximal tibial epiphysis separated from the rest of the tibia by the growth plate. As the growth plate closes in late puberty, it is transiently replaced by fibrocartilaginous elements, which predispose it to traction injury as a result of its weaker tensile strength. Previous Next: Pathophysiology The proximal tibia has two ossification centers, the proximal tibial epiphysis and the tibial tuberosity, which are separated

2014 eMedicine Surgery

109. Medial Epicondylitis (Diagnosis)

has also been reported in bowlers, archers, and weight lifters. [ , , , ] Little leaguer's elbow is sometimes considered a variant of medial epicondylitis, but this condition is technically a traction apophysitis of the medial epicondyle, which requires a different treatment course. For patient education resources, see the , as well as . Next: Epidemiology Frequency United States Medial epicondylitis accounts for only 10-20% of all epicondylitis diagnoses [ ] ; the annual incidence is between 3-4 (...) NS, Schickendantz MS. Medial epicondylitis: evaluation and management. J Am Acad Orthop Surg . 2015 Jun. 23 (6):348-55. . Kiel J, Kaiser K. Golfers Elbow. StatPearls [Internet] . 2018 Jan. . . Kohn HS. Prevention and treatment of elbow injuries in golf. Clin Sports Med . 1996 Jan. 15(1):65-83. . Nirschl RP. Prevention and treatment of elbow and shoulder injuries in the tennis player. Clin Sports Med . 1988 Apr. 7(2):289-308. . Nirshal RP. Muscle and tendon trauma: tennis elbow. The Elbow and Its

2014 eMedicine.com

110. Little League Elbow Syndrome (Diagnosis)

year. This increase in participation has been paralleled by an increase in sports-related injuries in the pediatric population. [ , , , , , , , , , , , ] Increased single-sport participation with year-round training, higher intensities at young ages, and longer competitive seasons are contributing factors to the increased injury rates seen in pediatric athletes. [ ] Conditioning and training errors also contribute significantly to the risk and frequency of injury. Although briefly discussed below (...) , injuries to the lateral, posterior, and anterior elbow are separate entities and should not be confused with the medial injuries referred to as little league elbow syndrome. During the throwing motion, valgus stress is placed on the elbow. This valgus stress results in tension on the medial structures (ie, medial epicondyle, medial epicondylar apophysis, medial collateral ligament complex) and compression of the lateral structures (ie, radial head, capitellum). Repeated stress results in overuse injury

2014 eMedicine.com

111. Lumbosacral Spondylolysis (Diagnosis)

):487-99, ix. . Dubousset J. Treatment of spondylolysis and spondylolisthesis in children and adolescents. Clin Orthop Relat Res . 1997 Apr. 337:77-85. . Albanese M, Pizzutillo PD. Family study of spondylolysis and spondylolisthesis. J Pediatr Orthop . 1982. 2(5):496-9. . Stinson JT. Spondylolysis and spondylolisthesis in the athlete. Clin Sports Med . 1993 Jul. 12(3):517-28. . Patel DR, Nelson TL. Sports injuries in adolescents. Med Clin North Am . 2000 Jul. 84(4):983-1007, viii. . Sakai T, Goda Y (...) , Saifuddin A, Wolman RL. The radiological investigation of lumbar spondylolysis. Clin Radiol . 1998 Oct. 53(10):723-8. . Lowe J, Schachner E, Hirschberg E, Shapiro Y, Libson E. Significance of bone scintigraphy in symptomatic spondylolysis. Spine . 1984 Sep. 9(6):653-5. . Bellah RD, Summerville DA, Treves ST, Micheli LJ. Low-back pain in adolescent athletes: detection of stress injury to the pars interarticularis with SPECT. Radiology . 1991 Aug. 180(2):509-12. . . Collier BD, Johnson RP, Carrera GF, et

2014 eMedicine.com

112. Lumbosacral Radiculopathy (Diagnosis)

, and from the opposite side. The sinuvertebral nerve supplies the posterior longitudinal ligament, superficial annulus fibrosus, epidural blood vessels, anterior dura mater, dural sleeve, and posterior vertebral periosteum. The 2 structures capable of transmitting neuronal impulses that result in the experience of pain are the sinuvertebral nerve and the nerve root. The posterior rami of the spinal nerves supply the apophyseal joints above and below the nerve as well as the paraspinous muscles (...) at multiple levels. Herniation of the intervertebral disc can cause impingement of the above neuronal structures, thus causing pain. The presence of disc material in the epidural space is thought to initially result in direct toxic injury to the nerve root by chemical mediation and then exacerbation of the ensuing intraneural and extraneural swelling, which results in venous congestion and conduction block. Notably, the size of the disc herniation has not been found to be related to the severity

2014 eMedicine.com

113. Lumbosacral Facet Syndrome (Diagnosis)

zygos , meaning yoke or bridge, and physis , meaning outgrowth. This “bridging of outgrowths” is most easily seen from a lateral view, where the Z-joint bridges adjoin the vertebrae. The term facet joint is a misnomer because the joint occurs between adjoining zygapophyseal processes, rather than facets, which are the articular cartilage lining small joints in the body (eg, phalanges, costotransverse and costovertebral joints). This joint is also sometimes referred to as the apophyseal joint (...) surgeons or neurosurgeons is not surprising. As the primary cause of work-related injuries, LBP is the most costly of all medical diagnoses when time off from work, long-term disability, and medical and legal expenses are taken into account. [ ] The lumbosacral Z-joint is reported to be the source of pain in 15-40% of patients with chronic LBP. Ray believed that Z-joint–mediated pain is the etiology for most cases of , [ ] whereas other authors have argued that it may contribute to nearly 80% of cases

2014 eMedicine.com

114. Cervical Disc Disease (Diagnosis)

Updated: Mar 21, 2018 Author: Michael B Furman, MD, MS; Chief Editor: Dean H Hommer, MD Share Email Print Feedback Close Sections Sections Cervical Disc Disease Overview Practice Essentials Cervical disc disorders encountered in physiatric practice include (HNP), (DDD), and internal disc disruption (IDD). HNP (seen in the image below) is defined as localized displacement of nucleus, cartilage, fragmented apophyseal bone, or fragmented anular tissue beyond the intervertebral disc space. [ ] Most (...) of the herniation is made up of the annulus fibrosus. DDD involves degenerative annular tears, loss of disc height, and nuclear degradation. IDD describes annular fissuring of the disc without external disc deformation. can result from nerve root injury in the presence of disc herniation or stenosis, most commonly foraminal stenosis, leading to sensory, motor, or reflex abnormalities in the affected nerve root distribution. [ , ] Sagittal magnetic resonance imaging (MRI) scan demonstrating cervical

2014 eMedicine.com

115. Cervical Facet Syndrome (Diagnosis)

, , and , and . Next: Epidemiology Frequency United States Aprill and Bogduk estimated the prevalence of cervical facet joint pain by reviewing the records of patients who had presented with neck pain for at least 6 months secondary to some type of injury. [ ] These patients underwent discography, facet joint nerve blocks, or both at the request of the referring physicians. A total of 318 patients were investigated, and 26% of the patients had at least one symptomatic facet joint. However, only 126 patients (...) , but there was often a painful disc at the same level. This finding is not surprising when one considers how the facet joints and discs are intimately involved in motion of the cervical spine. Cervical facet joint pain is a common sequela of whiplash injury. Barnsley and Lord et al studied the prevalence of chronic cervical facet joint pain after whiplash injury using double-blind, controlled, diagnostic blocks of the facet joints. [ ] The joints were blocked randomly with either a short-acting or long-acting

2014 eMedicine.com

116. Ankylosing Spondylitis and Undifferentiated Spondyloarthropathy (Diagnosis)

) and transforming growth factor-β (TGF-β), are also important in the inflammatory process by leading to fibrosis and ossification at sites of enthesitis. [ , , ] The initial presentation of AS generally relates to the SI joints; involvement of the SI joints is required to establish the diagnosis. SI joint involvement is followed by involvement of the discovertebral, apophyseal, costovertebral, and costotransverse joints and the paravertebral ligaments. Early lesions include subchondral granulation tissue (...) spondylitis. J Rheumatol . 1999 Apr. 26(4):971-4. . Anwar F, Al-Khayer A, Joseph G, Fraser MH, Jigajinni MV, Allan DB. Delayed presentation and diagnosis of cervical spine injuries in long-standing ankylosing spondylitis. Eur Spine J . 2011 Mar. 20(3):403-7. . . Baraliakos X, Hermann KG, Landewé R, Listing J, Golder W, Brandt J, et al. Assessment of acute spinal inflammation in patients with ankylosing spondylitis by magnetic resonance imaging: a comparison between contrast enhanced T1 and short tau

2014 eMedicine.com

117. Ankylosing Spondylitis (Diagnosis)

) and transforming growth factor-β (TGF-β), are also important in the inflammatory process by leading to fibrosis and ossification at sites of enthesitis. [ , , ] The initial presentation of AS generally relates to the SI joints; involvement of the SI joints is required to establish the diagnosis. SI joint involvement is followed by involvement of the discovertebral, apophyseal, costovertebral, and costotransverse joints and the paravertebral ligaments. Early lesions include subchondral granulation tissue (...) spondylitis. J Rheumatol . 1999 Apr. 26(4):971-4. . Anwar F, Al-Khayer A, Joseph G, Fraser MH, Jigajinni MV, Allan DB. Delayed presentation and diagnosis of cervical spine injuries in long-standing ankylosing spondylitis. Eur Spine J . 2011 Mar. 20(3):403-7. . . Baraliakos X, Hermann KG, Landewé R, Listing J, Golder W, Brandt J, et al. Assessment of acute spinal inflammation in patients with ankylosing spondylitis by magnetic resonance imaging: a comparison between contrast enhanced T1 and short tau

2014 eMedicine.com

118. The Approach to the Painful Joint (Treatment)

spine, ask the patient to touch the chin to the chest (flexion) and then look up at the ceiling (extension). For lateral flexion, ask the patient to touch an ear to the shoulder. For lateral rotation, ask the patient to touch the chin to a shoulder. During lateral rotation and flexion, pain that occurs on the ipsilateral side of the neck is bony in origin (eg, from apophyseal joint disease), whereas pain on the contralateral side is muscular or ligamentous in origin. With the thoracic spine (...) polyarthritis include the following: Traumatic osteoarthritis (see ) Hypertrophic pulmonary osteoarthropathy Amyloidosis (see ) Differential diagnoses for regional musculoskeletal pain Shoulder Referred pain may derive from cervical disorders, Pancoast tumor of the lung, subphrenic pathology, or entrapment neuropathies and brachial neuritis (see ). Rotator cuff tendinitis (see ) [ ] is inflammation of the rotator cuff tendons, arising acutely as a result of a recognizable injury (throwing) or insidiously

2014 eMedicine.com

119. Osgood-Schlatter Disease (Treatment)

however both groups reported symptom relief with no adverse outcomes. [ ] Long-term immobilization is typically contraindicated, because it may result in increased knee stiffness in mild cases, thus predisposing the athlete to additional sports-related injuries. However, if a patient is noncompliant, the clinician may recommend immobilization in a knee brace for a minimum of 6 weeks. The brace should be removed daily, but only for stretching and strengthening exercises. Inform the patient to avoid (...) of the extensor mechanism. Open reduction and internal fixation (ORIF) usually is recommended, depending on the size and displacement of the fragment as well as the phase of apophyseal closure. Indications for surgery Occasionally, adults have a large ossicle and an overlying bursa, which may cause pain with kneeling. If so, treatment consists of excision of the bursa, ossicle, and any prominence. [ ] Contraindications for surgery The real question is whether or not surgery is ever indicated in the growing

2014 eMedicine.com

120. Cervical Facet Syndrome (Treatment)

> Cervical Facet Syndrome Treatment & Management Updated: Aug 28, 2018 Author: Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM; Chief Editor: Craig C Young, MD Share Email Print Feedback Close Sections Sections Cervical Facet Syndrome Treatment Acute Phase Rehabilitation Program Physical Therapy Kibler et al defined 3 phases of rehabilitation of soft-tissue injuries. [ ] The goals of the first phase are to reduce pain and inflammation, and increase the pain-free ROM. Ice is indicated during the acute phase (...) for the treatment of chronic cervical facet pain after whiplash injury. [ ] Patients enrolled in the study had been diagnosed with a painful cervical facet joint by responding to different facet joint nerve blocks on 2 separate occasions with Xylocaine and bupivacaine and receiving a longer period of relief with bupivacaine. After allowing time for their usual pain to return, the patients underwent random intra-articular facet joint injections with either bupivacaine or betamethasone. Fluoroscopy was used

2014 eMedicine.com

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