What is your diagnosis?

Patient has a lesion of the distal epiphysis, located in the right lateral condyle. This diagnosis ended up being Osteochondritis Dissecans (OCD). 

• Pearl: Given the x-ray findings, you should consider the following differential In a young otherwise healthy individual: 

1. Osteochondritis Dissecans - benign

2. Chondroblastoma - benign

3. Clear cell chondroblastoma - malignant (aggressive)

4. Subchondral cyst - benign

5. Giant cell tumor - benign (aggressive locally)

6. Enchondroma - benign

7. Osteoblastoma - benign

8. Ewing Sarcoma - malignant (less likely as this is not well circumscribed)

9. Osteogenic Sarcoma - malignant (less likely as this is not well circumscribed)

What is your management in the ED?

Discuss with the patient and parents the possibilities for this lesion as well as the plan for pain management. Arrange close outpatient follow up and MRI, if possible.

• Pearl: MRI does not need to be done emergently as most of these lesions are benign.

What is your disposition?

Follow up with PCP to obtain further workup - starting with likely MRI.

Do you consult orthopaedics emergently?

No. However most of these patients will end up seeing orthopaedics once outpatient imaging is obtained.

What is the management of this?

OCD lesion management is based on the stability of the lesion. The stability is based off of the DeSmitt Criteria: 

• high-intensity signal beneath the OCD lesion

• well-defined focal defect in the overlying articular cartilage

• fracture of the overlying articular cartilage

• subchondral cysts

If all four are present this indicates a very unstable lesion. Operative treatment is typically recommended for unstable lesions and skeletally mature individuals. This consists of a wide variety of interventions based on the individual's lesion. Non-operative management is typically reserved for those who do not meet these criteria and consists of activity modifications and immobilization.