Snap, Crackle, Apophysitis ArAFP 66th Annual Scientific Assembly June 15, 2013 Elton R. Cleveland, DVM, MD. University of Arkansas for Medical Sciences Arkansas Children’s Hospital

Apophysitis Inflamation of the apophysis that is usually caused by overuse or repetitive traction to the physis Usually no bruising or ecchymosis Insidious

Little League Elbow Epiphysitis of medial epicondyle caused by repetitive strain of throwing damage to radiocapitellum osteochondrosis of capitellum increase valgus stress rest, modified activity, limit throws, mechanics

Osgood- Schlatter Boys (12 1/2-13), girls (11 1/2 years) Tensile stresses acting across the junction of the immature patellar tendon and the tibia tubercule Pain, tenderness, swelling - Bilat 56% Rest, ice, activity modification, pain mgmt, hamstring stretches, padding

Osgood-Schlatters Disease

Sinding-Larsen-Johannson Osgood - Schlatter of the inferior pole of the patella

Achilles Tendonitis Frequently recurrent problem tight achilles with recurrent traction rare rupture in young athlete rest, ice, heel cord stretching, strengthening

Sever’s Disease Osgood-Schlatter’s of the heel - Bilat 61% Girls - 8-10y/o, Boys 10-12y/o activity related heel pain X-rays may not be helpful because fragmentation and sclerosis of the calcaneal apophysis is normal calf stretches, heel lifts, strengthen dorsiflexors, activity modification

Pelvic Apophysitis Iliac ASIS AIIS Symphysis Ishial tuberosity Greater Trochanter Lesser Trochanter

Apophysitis vs Apophyseal Avulsion Fractures

Apophysitis Inflamation of the apophysis that is usually caused by overuse or repetitive traction to the physis Usually no bruising or ecchymosis Insidious

Avulsion Fracture Sudden pain with activity Can recall specific activity Most severe with activity Improves with rest +/- Swelling – tenderness with palpation Passive stretch may reproduce pain

Avulsion Fracture Soccer 74 cases Gymnastics 55 cases Rossi, Dragoni

Avulsion Fx – Hip/Pelvis Ishial Tuberosity 54% AIIS 22% ASIS 19% Pubic symphysis 3% Iliac Crest 1 % Rossi, Dragoni

Pelvic Apophysitis – D/D Pelvic Avulsion Fractures Snapping Hip Syndrome Spondylolysis Femoral Neck Stress Fracture Sports Hernia

Imaging Xray CT MRI U/S

Avulsion Fx – Hip/Pelvis ASIS – Sartorius Ishial Tuberosity – Hamstring AIIS- Rectus Femoris – Lesser Trochanter – Iliac Crest – obliques Metzmaker, Pappus

Avulsion Fx – Hip/Pelvis ASIS – Sartorius Ishial Tuberosity – Hamstring AIIS- Rectus Femoris – Lesser Trochanter – Iliac Crest – obliques Metzmaker, Pappus

Avulsion Fx – Hip/Pelvis ASIS – Sartorius Ishial Tuberosity – Hamstring AIIS- Rectus Femoris – Lesser Trochanter – Iliac Crest – obliques Metzmaker, Pappus

Avulsion Fx – Hip/Pelvis ASIS – Sartorius Ishial Tuberosity – Hamstring AIIS- Rectus Femoris – Lesser Trochanter – Iliac Crest – obliques Metzmaker, Pappus

Avulsion Fx – Hip/Pelvis ASIS – Sartorius Ishial Tuberosity – Hamstring AIIS- Rectus Femoris – Lesser Trochanter – Iliac Crest – obliques Metzmaker, Pappus

Surgery ? Consider if >2cm displacement