Pediatric emergency medicine trisk 3962 3962
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The management of osteochondritis dissecans depends on the age and skeletal
maturity of the patient, the location of the lesion, and the stage of the lesion.
Conservative therapy consisting of restricted activity and relief of stress on the
involved joint is the first line of treatment in children who have not reached
skeletal maturity and for those diagnosed at an early stage of the disease. Early
diagnosis and rest provides the best chance for recovery. Lesions recognized in
the early stages are more likely to heal with nonoperative management. Full
immobilization in a cast remains controversial. A hasty return to sports may
increase the risk of arthritis or further joint disease. Patients should be followed
closely by an orthopedic surgeon both for resolution of clinical symptoms and
evidence of healing on serial radiographs or MRIs. Most stable lesions occurring
in patients prior to physeal closure go on to heal; however, a few will progress to
separation. Lesions occurring in adults generally do not heal without surgery.
Surgical intervention is generally recommended if lesions fail to improve
clinically or radiographically after 6 months of rest. The presence of an unstable
or free-floating fragment is also considered an indication for surgery. Most
corrective surgical procedures can now be performed arthroscopically. Fine
transarticular or retroarticular drilling through the subchondral fragment into
healthy bone appears to stimulate revascularization and promote healing in stable
lesions. Fragments are replaced whenever possible. Loose fragments and larger
free bodies may be reduced and fixed in place with the use of screws,
bioabsorbable implants, or osteochondral plugs removed from nonarticulating
surfaces in the knee. When free bodies must be removed from the joint space, the
resulting defects may be repaired with the use of a bone graft or through
stimulation of fibrocartilage or scar tissue formation to restore congruity to the
articular surface.
