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Introduction
  • Osteochondrosis or traction apophysitis of tibial tubercle
  • Epidemiology
    • demographics
      • male:female ratio
        • more common in boys
      • age bracket
        • boys 12-15y
        • girls 8-12y
    • location
      • bilateral in 20-30%
    • risk factors
      • jumpers (basketball, volleyball)  or sprinters
  • Pathophysiology
    • stress from extensor mechanism
  • Prognosis  
    • self-limiting but does not resolve until growth has halted
Anatomy
  • Tibial tubercle is a secondary ossification center  
    • age <11y, tubercle is cartilaginous
    • age 11-14y, apophysis forms
    • age 14-18y, apophysis fuses with tibial epiphysis
    • age >18y, epiphysis (and apophysis) is fused to rest of tibia
Presentation
  • Symptoms 
    • pain on anterior aspect of knee
    • exacerbated by kneeling
  • Physical exam
    • inspection
      • enlarged tibial tubercle
      • tenderness over tibial tubercle
    • provocative test
      • pain on resisted knee extension
Imaging
  • Radiographs
    • recommended views
      • lateral radiograph of the knee
    • findings
      • irregularity and fragmentation of the tibial tubercle  
  • MRI
    • indications
      • not essential for diagnosis
      • diagnosis can be made based on history, presence of tender swelling and radiographs alone
    • findings  
      • soft tissue swelling
      • thickening and edema of inferior patellar tendon
      • fragmentation and irregularity of ossification center
Differential
  • Sinding-Larsen-Johansson syndrome    
    • chronic apophysitis or minor avulsion injury of inferior patella pole  
    • occurs in 10-14yr old children, especially children with cerebral palsy
  • Osteochondroma of the proximal tibia  
  • Tibial tubercle fracture  
  • Jumpers knee  
Treatment
  • Nonoperative
    • NSAIDS, rest, ice, activity modification, strapping/sleeves to decrease tension on the apophysitis and quadriceps stretching
      • indications
        • first line of treatment
      • outcomes
        • 90% of patients have complete resolution
    • cast immobilization x 6 weeks
      • indications
        • severe symptoms not responding to simple conservative management above
  • Operative
    • ossicle excision
      • indications 
        • refractory cases (10% of patients) 
        • in skeletally mature patients with persistent symptoms
Complications
  • Complications of cast immobilization
    • quadriceps wasting
 

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