Pediatric emergency medicine trisk 3960 3960
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is rare. A worse prognosis is associated with a diagnosis after skeletal maturity, a
larger lesion, and complete separation of the fragment.
Clinical Considerations
Clinical Recognition
Joint pain develops gradually over several months and is worse with activity. Pain
and stiffness typically improves over several hours with rest. Swelling may
occasionally be present with activity.
When a free body is present, patients describe intermittent, abrupt locking of
the joint. Locking in the knee or elbow prevents full extension of the extremity.
This is in contradistinction to buckling, stiffness, or pain with extended range of
motion.
Initial Assessment/H&P
The physical examination of the joint is frequently normal. Occasionally, a small
effusion may be detectable. Lesions in the medial femoral condyle may be
directly palpated and pain elicited when the knee is held in 90 degrees of flexion.
The typical location of a lesion in the talus is not accessible on examination.
Osteochondritis dissecans in the femoral condyle may give rise to an abnormal
gait with external rotation of the affected limb.
Management/Diagnostic Testing
Plain films of the joint should be obtained, and are often diagnostic when
osteochondritis dissecans is suspected ( Fig. 121.12 ). Radiographs reveal a
crescentic-shaped defect within the subchondral bone. The avascular segment of
subchondral bone may have increased density. A radiolucent line may demarcate
the separation from the remainder of the epiphysis. A free body often includes a
portion of dead subchondral bone, which appears as a radiodense object within
the joint space. In addition to the standard anteroposterior (AP) and lateral views
of the knee, tunnel and sunrise views are useful in detecting lesions within the
femoral condyle. Lateral, AP, and mortis views of the ankle are adequate when a
lesion of the talus is suspected, and AP and lateral views of the elbow are
indicated for lesions in the capitellum.
