Avulsion vs apophyseal distortion

[Martin Blaus]

Hi Stephen. Always a pleasure watching your lectures, with the unique skill of education and entertainment. This lecture had a whole set of nice points and clarifications. Thanks for those.

Now to my question: Since you lifted the issues with scanning younger patients; pediatrics is a different topic, and sometimes I scan adolecent and youngsters still in their growthphase. The apophyseal cleft is always a little bit of a challenge to assess, given that it has a normal appearance that could possibly be interpreted as an avulsion. The clinical picture and history certainly gives clues, but have you seen cases where ther is a apophyseal distortion due to tendinous strain on the growth-area and caused injuries. Is it something to be considered? I have only come across one suspicious changes where a apophyseal affection is suspected (sever’s disease) – and of course the classical Osgood Schlatter, but It would be interesting to hear your perspective on this in other parts of the growing body. I know people talking about ”hip cold” some kind of hipjoint-affection (growthrelated?)in very young ages (5-10 y), but never seen any signs when scanning.

ALl the best from Sweden
/Martin Blaus

[Stephen Bird]

Hi Martin,

Yes, peediatric MSK examinations are another whole topic!

“Hip cold” is a transient synovitis of the hip that we see following a viral infection. It normally settles spontaneously in a short period of time. I am sure I would have included an example of transient synovitis in the fundamentals of the hip presentation. What I look for is a convex iliofemoral ligament, synovitis, joint effusion and sometimes Doppler signal in the capsule. When you see this it is unfortunately not diagnostic of a transient synovitis as a septic hip joint effusion can look exactly the same!
So you need to take into consideration the clinical presentation and if there is any other signs of sepsis an aspiration and culture must be rapidly performed. Looking at the ultrasound characteristics of the fluid does mot help. I have seen it looking a little cloudy on ultrasound and it comes out as pure, clean synovial fluid and I have seen it looking crystal clear on the ultrasound and it comes out as frank puss. So clinical is always king and aspiration should be performed if there is any clinical uncertainty.
As for tendon traction pain “apophyseal traction pain” there may be ultrasound evidence on some occasions and on others nothing to see sonographically.
I don’t find ultrasound particularly useful with Severs or Osgood schlatters and really feel like it is a clinical diagnosis and the management is obvious.
Around the pelvis I sometimes have more luck, especially in teenage boys. They can get apophyseal traction injuries where they widen the apophysis at the ASIS from sartorius traction of the AIIS from rectus femoris.
I have also seen several cases of medial elbow humeral epicondyle apophysis widening in baseball pitchers during my work in Taiwan.
So it is worth looking for it.
Scan where the patient has the point tenderness and compare to the opposite side to see if there is a difference.

Very commonly there is localised pain over a tendon origin and it looks exactly the same as the other side with no obvious sonographic injury. In these cases I am sure it is apophyseal traction causing the pain and rest will settle the symptoms, however the injury is not bad enough to show any evidence on the ultrasound.

I guess the value of the ultrasound it to ascertain there is no major disruption of the apophysis.

I am sure I show some examples of this in the MSK pathology principles lesson.

Steve.

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