Scheuermann's Panner's and Thiemann's Disease - Simon Coleridge 4/2/2002

Scheuermann’s Kyphosis

Definition: Thoracolumbar kyphosis of the spine developing before puberty, becomes prominent during adolescent growth spurt, it can be progressive and become symptomatic.

Characterised by vertebral wedging and subsequent growth disturbance of vertebral end plate.Described in 1921 by Scheuermann.

Incidence: M=F   0.4% to 8% of general pop

Aetiology: Initially thought to be AVN of the vertebral ring apophyses. This has never been proven. Maybe genetic with autosomal dominant pattern. Often misdiagnosed as postural kyphosis.

Presentation: Around puberty with Kyphosis and back pain aggrevated by sitting, standing and physical exercise. Pain decreases with skeletal maturity. Forward bending exaggerates the kyphosis in scheuermann’s disease whereas eliminates kyphosis in postural kyphosis.

Radiographs: Irregular vertebral end plates; Schmorl’s nodes, decreased disc space, all localised to anterior rim, giving the appearance of anterior wedging of the vertebral body.

Diagnosis: Hyperkyphosis >40º and wedging of at least 5º in 3 consecutive vertebra.

Natural History: Murray PM. The Natural History and Long Term F/U of SK. JBJS(A)1993;75:236-48.   Less than 60º outcome is benign. Greater than 60º may lead to biomechanical problems which maybe progressive.

Management: nonoperative, exercises, and infrequent f/u. 50-75º in skeletally immature, bracing may help. >75º surgery if pain significant. This involves an anterior release and grafting, plus posterior fusion!!

Reference: Read M.Ali. Scheuermann’s Kyphosis. Current Opinion in Orthopaedics 1999;11:70-5.

Panner’s Disease

Definition: Osteonecrosis of the capitellum. Described by Panner in 1927 in 2 boys aged 9 and 11 years. Both had minor injuries.

Incidence: Rare.

Aetiology: In 1955 Laurent and Lindstrom reviewed 21 cases in boys between 4 and 10 years, they emphasized there was an absence of a clear history of trauma in most cases. Adams in 1965 provided a more accurate description of capitellar osteonecrosis in Little League base ball pitchers, “thrower’s elbow”.

A suggested aetiology is repeated lateral stress on the humeral epiphysis associated with poor vascularization.

Presentation: Clinical problems and deformities are rare in the initial stages. Those who present late have experienced arrested growth and collapse of the capitellum resulting in osteonecrosis, accompanied by radial head overgrowth due to the associated hyperaemic response in the repair phase. Thus resulting in loss of joint congruity and eventually secondary OA.

Radiographs: Xrays in the acute phase are consistent with those of osteonecrosis elsewhere, e.g. Perthes, Freiberg ’s and Osgood-Schlatters. Irregular mineralisation, fragmentation, poorly defined cortical margins with or without collapse.

Management: Conservative versus debridement and radial head resection at a later date.

Reference: Daniel WW. Panner’s Disease. Arthritis and Rheumatism. 1989;32:341-2.

Thiemann’s Disease

Definition: Juvenile aseptic necrosis of the phalangeal epiphysis, an uncommon cause of joint swelling.

Incidence: Rare. Onset before the age of 25 years. Peak age 13-15 years.

Aetiology: Reported as hereditary( autosomal dominant) and in isolated cases.

Presentation: Painless swelling of the PIPJ and DIPJ of fingers and occasionally toes.

Radiographs: The xray findings are found in the proximal epiphyses of the phalanges: flattening, cupshaped, broadening, irregular opacities and fragmentation. Plus premature ossification of the physis.

Lab Tests: ESR normal; FBC normal, Complement and Ig normal. ANF maybe weakly positve but RF normal.

Management: conservative and aspirin.