Case 8: An 11-year-old dancer states she has had random right knee pain and swelling over the past 6 months but does not remember injuring the knee. Sometimes after dancing she gets swelling and pain that dissipates over
3 to 4 days with a decrease in activity. She denies any mechanical symptoms. She has no pain in between episodes. Her examination shows a small effusion of the knee and some minimal tenderness with palpation over the medial femoral condyle.
Osteochondritis dissecans lesions (OCD), an injury to the subchondral bone, can develop in almost any joint but are commonly found in the knee along the posterior portions of the femoral condyles or behind the patella. The most common area is the lateral portion of the posteriormedial femoral condyle. Osteochondral fragments may happen with acute trauma however OCD lesions are more chronic in nature. The exact mechanism is unknown but most believe that repetitive trauma or poor blood flow contributes to these lesions. Unilateral or bilateral, OCD lesions occur in both active and inactive adolescents.
Adolescents typically present with months of intermittent knee swelling and pain that lasts for a few days and then dissipates. If the lesion becomes unstable the adolescent may experience mechanical symptoms including catching or locking of the knee. Examination of the knee may reveal a small effusion with vague knee discomfort, a locked knee, or may be normal. The history of intermittent swelling gives more information than the examination typically provides. Four radiographic views of the knee should be obtained however; a tunnel view is the best view to visualize the posterior condyles and may show the lesion (Fig. 9). MRIs are useful in assessing the stability of the lesion. Skeletally immature adolescents with small stable lesions may heal on their own over time.
Conservative therapy consists of restriction of impact activity and radiographs every 3 months to assess progress. In this author's experience most OCD lesions take a minimum of 6 to 12 months to heal. Skeletally mature adolescents, those with large or unstable lesions, or those with significant pain require surgical evaluation. Many suggest an aggressive surgical approach for most lesions as conservative therapy interferes with lifestyle activity choices during a vulnerable age. Untreated OCD lesions raise the concern for early onset arthritis.
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