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RADD 2712 Child AVN Page 1 - Council on Roentgenology TO...

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Unformatted text preview: Council on Roentgenology TO the AMERICAN CHIROPRACTIC ASSOCIATION, Inc. Boentgenological Briefs Compiled by Thomas J. Field, D. C. Roentgenology Resident, National College of Chiropractic EPIPHYSEAL ISCHEMIC NECROSIS Epiphyseal ischemic necrosis is essentially a degeneration and eventual replacement of the osseous center of an epiphysis, due to an interference with its blood supply. The term “osteochon- dritis”is inadequate since no proof of inflammation has been found. The primary epiphyses are involved at an earlier age than the secondary epiphyses. Thus, the primary femoral capital epiphysis is usually affected during the first decade, whereas, the secon- dary epiphyses of the vertebral bodies show involvement during the second decade. Almost any epiphysis can show involvement and can be designated by eponyms such as Freiberg’s disease (second metatarsal head). Scheuermann’s disease (vertebral bodies) and others. Most types of involvement occur more commonly in males with a ratio of about four to one. It should be noted that Osgood Schlatter's disease. which involves the tibial tuberosity, was once considered an epiphyseal ischemic necrosis. Now it is considered to be a traction apophysitis caused by trauma rather than a neurovascular phenomena. An accurate diagnosis of Osgood Schlatter’s disease can be made from the correlation between clinical and radiographic findings and should not be diagnosed strictly from the radiographs. The most important type of epiphyseal ischemic necrosis, from the standpoint of incidence and morbidity, is Legg~Calve-Perthes‘ disease. A discussion of Legg-Calvevperthes“ disease will serve to illustrate the other epiphyseal ischemic necrosis since the morbid physiology of the various epiphyseal ischemic necroses are the same. When the femoral capital epiphysis is involved. the process is called LeggCalve-Perthes’ (Perthes‘) disease or ischemic coxa plana. The resorption and sclerosis seen in Perthes’ disease will not be seen in femoral head dysplasia, as described by Meyer (1964). Femoral head dysplasia may emulate early Legg~Calve«Pertlies’ disease which can be detected by serial radiography. This dyspiasia involves growth in the size of the epiphyseal ossificationcenter which will have a normal appearance in three years without sequelae. Epiphyseal ischemic necrosis is a benign condition that runs a self-limited course with even- tual healing, and occurs bilaterally in 10% of the male involvement. Bilateral occurrence in females is extremely rare and the onset is never simultaneous. Delayed skeletal maturation of 6 months to 3 years is seen in 98% of males with this disease. The peak age incidence is 8 years, but onset may occur between the age of 3 to 12 years. Except in Sickle cell disease. this condition is rarely seen in the Negro population. The onset of symptoms may be insidious or sudden. Pain of varying degrees of severity, limp, and limitation of motion are the cardinal clinical symptoms. Pain may start in the knee area and remain for several weeks to months. The pain is exacerbated by motion and relieved by rest. In- ternal rotation, flexion and abduction are restricted. There may be anterior and posterior tenderness. Eventually, the pain disappears. There are three active stages and one healed stage running a course of two to six year. The first stage lasts two weeks to two months. The very early phase of this ischemic stage may show no radiographic Changes on routine radiographs. Therefore, Perthes’ cannot be totally ruled out and a follow-up study should be considered. This early stage will usually be detected on a radioisotope study, showing a decreased uptake compared to the opposite epiphysis, due to the ischemia. The changes that follow involve, primarily, soft tissue. Lateral displacement of the femoral head, with resultant joint space widening ( Waldenstrom’s Sign ), isthe earliest roentgen sign. This can be determined by measuring from the lateral margin of the pelvic teardrop to the proximal medial femoral metaphysis. The hip is involved in the distance measures greater than 11 mm- If the difference between the two measurements. when evaluating a bilateral study, is greater than 2 ...
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