Calves vertebral Calves vertebral compressincompressin(vertebra (vertebra

plana;vertebral plana;vertebral osteochondritis)osteochondritis)

• Whereas in scheuermann’s disease it Whereas in scheuermann’s disease it is the vertebralis the vertebral ring epiphyses that ring epiphyses that are affected,calve’s disease affects are affected,calve’s disease affects the central bony nucleus of a the central bony nucleus of a vertebral body .it is generally vertebral body .it is generally confined to a single vertebra.it isconfined to a single vertebra.it is uncommon.uncommon.

**pathologypathologyFrom its radiological features and benign From its radiological features and benign course , calve’s disease was regarded as an course , calve’s disease was regarded as an osteochondritis.Histological studies have osteochondritis.Histological studies have shown that the majority of cases are in fact shown that the majority of cases are in fact caused by an eosinophilic granuloma in a caused by an eosinophilic granuloma in a typical case the bony nucleus of one of the typical case the bony nucleus of one of the vertebral body , usually in thoracic vertebral body , usually in thoracic region,become soft and is condensed into a thin region,become soft and is condensed into a thin wafer.later ,this may re-develop to a more wafer.later ,this may re-develop to a more normal size thought it is doubtfull if it is ever normal size thought it is doubtfull if it is ever restored to full hight. The intervertebral disc restored to full hight. The intervertebral disc above and below are intact & unaffectedabove and below are intact & unaffected..

**clinical featuresclinical features::The affection occurs in children of 2-10 The affection occurs in children of 2-10 years of age.The complaint is of years of age.The complaint is of pain ,usually in the thoracioc region of the pain ,usually in the thoracioc region of the

spinespine . .

On examinationOn examination::There may be slight localised There may be slight localised kyphosis .Percussion of the spinal column kyphosis .Percussion of the spinal column reveals deep tenderness in the affected reveals deep tenderness in the affected region . Movement of the spine as a whole region . Movement of the spine as a whole are impaired little ,if at allare impaired little ,if at all..

• Radiographic features:Radiographic features:• Raidiographs show the Raidiographs show the

characteristic extreme flattening of characteristic extreme flattening of the affected vertebral body,which the affected vertebral body,which appears greatly increased in density appears greatly increased in density

**TreatmentTreatment::Calve’s disease is non progressive, Calve’s disease is non progressive, and in practice treatment is required and in practice treatment is required only for as long as the symptoms only for as long as the symptoms last. If pain is severe the child last. If pain is severe the child should be kept recumbent in bed, should be kept recumbent in bed, but in most case he may safely but in most case he may safely resume an active life without resume an active life without external support within a few weeksexternal support within a few weeks..

Osteochondritis dissecans Osteochondritis dissecans of the elbowof the elbow

(general descriptions of (general descriptions of osteochondritis of osteochondritis of

dissecans)dissecans)

• After the knee, the elbow is the most After the knee, the elbow is the most frequent site of osteochondritis frequent site of osteochondritis dissecans. The disorder is dissecans. The disorder is charecterised by necrosis of part of charecterised by necrosis of part of the articular cartilage & of the the articular cartilage & of the underline bone,with eventual underline bone,with eventual seperation of the fragment to form seperation of the fragment to form an intra articular loose bodyan intra articular loose body

• CauseCause• The precise cause is The precise cause is

unknown.impairment of blood unknown.impairment of blood supply to the affected segment of supply to the affected segment of bone & cartilage by thrombosis of bone & cartilage by thrombosis of an end artery has been suggested. an end artery has been suggested. injury probably plays a part. injury probably plays a part.

• PathologyPathology• The part of the elbow affected is nearly always the The part of the elbow affected is nearly always the

capitulum of the humerus.the necrotic segment of capitulum of the humerus.the necrotic segment of articular surface varies in size; commonly its surface articular surface varies in size; commonly its surface area is about a centimetre in diameter & its depth area is about a centimetre in diameter & its depth less than half a centimetre. A line of demarcation less than half a centimetre. A line of demarcation forms between the avascular segment & the forms between the avascular segment & the surrounding normal bone and cartilage,and after an surrounding normal bone and cartilage,and after an interval of months the avascular segment separates interval of months the avascular segment separates as a loose body(some time two or three),leaving a as a loose body(some time two or three),leaving a shallow cavity in the articular surface which is shallow cavity in the articular surface which is ultimately filled with fibrous tissue.the damage to ultimately filled with fibrous tissue.the damage to the joint surface predisposes to the later the joint surface predisposes to the later development of osteoarthritis.development of osteoarthritis.

• Clinical features:Clinical features:• In the early stage ,before the fragment has In the early stage ,before the fragment has

seperated,the symptoms are those of mild seperated,the symptoms are those of mild mechanical irritation of the joint-namely, mechanical irritation of the joint-namely, aching after use and intermittent swelling aching after use and intermittent swelling (from fluid effusion).(from fluid effusion).

• On examinationOn examination• At this stage there is often an effusion of At this stage there is often an effusion of

clear fluid into the joint,and there is slight clear fluid into the joint,and there is slight limitation of flexion or extension.limitation of flexion or extension.

• When a loose body has separate,the When a loose body has separate,the main features are recurrent sudden main features are recurrent sudden painfull locking of the elbow & painfull locking of the elbow & subsequent effusion of fluidsubsequent effusion of fluid

• ImagingImaging• Plain radiographs in the early stages Plain radiographs in the early stages

show an area of irregularity on the show an area of irregularity on the affected subchondral bone,usually of the affected subchondral bone,usually of the capitulum. Later a shallow cavity,whose capitulum. Later a shallow cavity,whose margins are demarcated clearly from margins are demarcated clearly from the bone within it.eventually the bony the bone within it.eventually the bony fragment separated from the cavity and fragment separated from the cavity and lies free within the joint,usually in the lies free within the joint,usually in the lateral compartment,lateral compartment,

• MR scanning in the earlier stages of MR scanning in the earlier stages of the disease may be valuable in the disease may be valuable in determining the possibilty of determining the possibilty of operative treatment prior to operative treatment prior to separation of the bony fragment.separation of the bony fragment.

• Treatment:Treatment:• If the fragment is small,operation is If the fragment is small,operation is

delayed until the fragment of bone and delayed until the fragment of bone and cartilage is ripe for separation or has cartilage is ripe for separation or has actually separated. The fragment is then actually separated. The fragment is then removed. If the fragment is large and is removed. If the fragment is large and is identified prior to separation it may be identified prior to separation it may be fixed in place with a fine screw or pin fixed in place with a fine screw or pin until fixation to the underling bone until fixation to the underling bone occurs.occurs.

KIENBOCK’S DISEASEKIENBOCK’S DISEASE(Osteochondritis of the (Osteochondritis of the

lunate bone)lunate bone)• Kienbock’s disease is an uncommon Kienbock’s disease is an uncommon

affection of the lunate bone affection of the lunate bone characterised by temporary characterised by temporary softening,fragmentation,and liability softening,fragmentation,and liability to deformation .it tends to to deformation .it tends to predispose to the later development predispose to the later development of osteochondritis of the wrist.of osteochondritis of the wrist.

• CauseCause• The precise cause is unknown. A disterbance The precise cause is unknown. A disterbance

of blood supply ,possibly from thrombosis of of blood supply ,possibly from thrombosis of a nutrient vessel,is believed to be the a nutrient vessel,is believed to be the essential factor,but how it comes about is not essential factor,but how it comes about is not clea.Repeated injury(for example,using the clea.Repeated injury(for example,using the front of the wrist to drive a chisel in front of the wrist to drive a chisel in carpentry,or operating a pneumatic road carpentry,or operating a pneumatic road drill) has sometimes been noted in the case drill) has sometimes been noted in the case history,but a causative connection is not fully history,but a causative connection is not fully established.established.

• Pathology:Pathology:• In its behaviour the disease resembles In its behaviour the disease resembles

osteochondritis of developing epiphysial osteochondritis of developing epiphysial centres in children,such as Perthes’ centres in children,such as Perthes’ disease:in effect it is a form of avascular disease:in effect it is a form of avascular necrosis(osteonecrosis). The bone becomes necrosis(osteonecrosis). The bone becomes granular in texture, small dense fragments granular in texture, small dense fragments being interspersed with softened areas.in this being interspersed with softened areas.in this state the bone eventually crumbles, and state the bone eventually crumbles, and under the pressure imposed by muscle action under the pressure imposed by muscle action and use use of the wrist it gradually becomes and use use of the wrist it gradually becomes compressed into a thin saucer shaped mass .compressed into a thin saucer shaped mass .

• The overlying cartilage dies. After The overlying cartilage dies. After about two years the bone texture is about two years the bone texture is restored to normal ,but the bone restored to normal ,but the bone remains deformed and lacks a remains deformed and lacks a smooth cartilaginous covering .the smooth cartilaginous covering .the bone behaves like a piece of grit in a bone behaves like a piece of grit in a bearing and leads gradually to the bearing and leads gradually to the development of osteochondritis of development of osteochondritis of the wrist.the wrist.

• Clinical features:Clinical features:• There is pain in the wrist ,most There is pain in the wrist ,most

marked at the centre of the joint marked at the centre of the joint over the lunate area.the pain is over the lunate area.the pain is worse during active use of the wrist . worse during active use of the wrist . Because of the pain ,the strength of Because of the pain ,the strength of grip is impaired.grip is impaired.

• On examination:On examination:• There is discomfort on pressure over There is discomfort on pressure over

the lunate bone . An important sign the lunate bone . An important sign is that movements of the wrist are is that movements of the wrist are substantially restricted and cause substantially restricted and cause pain if forced.pain if forced.

• Radiographs:Radiographs:• Are diagnositic.in the early stages the lunate Are diagnositic.in the early stages the lunate

bone appears slightly more dense than the bone appears slightly more dense than the surrounding bones,and if its depth is compred surrounding bones,and if its depth is compred with that of the lunate bone of the other wrist with that of the lunate bone of the other wrist it is seen to be redused,though only slightly it is seen to be redused,though only slightly at first.later,the bone has a fragmented at first.later,the bone has a fragmented appearance ,small areas of increased density appearance ,small areas of increased density being scattered through it,and the flattening being scattered through it,and the flattening of the bone becomes obvious. Later still signs of the bone becomes obvious. Later still signs of osteoarthritis of the wrist are evidentof osteoarthritis of the wrist are evident

• Treatment:Treatment:• Treatment is often rather unsatisfactory. Treatment is often rather unsatisfactory.

It must depend upon the duration of the It must depend upon the duration of the symptoms and the degree of damage to symptoms and the degree of damage to the wrist. In the earliest stage,when the wrist. In the earliest stage,when radiographic changes are only just radiographic changes are only just perceptible,there is probably a place for perceptible,there is probably a place for protecting the wrist in plaster for two or protecting the wrist in plaster for two or three months in the hope that the three months in the hope that the condition will resolve through condition will resolve through revascularisation of the bone.revascularisation of the bone.

• But once the disease is cleary established But once the disease is cleary established surgical treatment is recommended.if the wrist surgical treatment is recommended.if the wrist is free from arthritis it is probably best to is free from arthritis it is probably best to excise the lunate bone and replace it with a excise the lunate bone and replace it with a metal prosthesis.this probably gives better metal prosthesis.this probably gives better results than excision alone,without results than excision alone,without replacement but the long-term results are replacement but the long-term results are nevertheless uncertain.in the late cases ,if nevertheless uncertain.in the late cases ,if severe osteoarthritis is already present,excision severe osteoarthritis is already present,excision of the lunate bone is of no avail. Treatment of the lunate bone is of no avail. Treatment should then be the same as for osteoarthritis of should then be the same as for osteoarthritis of the wrist.the wrist.