PEDIATRIC KNEE
INJURIES
Big Sky Sports Medicine Conference 2013
Kerry Hale Ford, MD
Financial Disclosures
Legal consulting for Stryker
Pediatric Knee Injuries
Overuse injuries
OCD’s and osteochondral
fractures
Meniscus tears
Anterior cruciate ligament
injuries
Patellar Instability
Fractures about the knee
Anatomy
Growth plate
Varying
degrees of “openness”
Assess growth potential remaining for that child
Length and angular deformity
Reconstruction
What damage are you going to do?
ACL reconstruction in a 10 yo compared to a 16yo
Tibial tubercle osteotomy vs soft-tissue recon for patellar
instability
Anatomy
Apophysis
Tensile forces from
musculotendinous
junction
Apophysitis rather than
tendonitis
Sever’s disease
Articular Cartilage
More susceptible to
shear stress
OCD, chondral fractures
Anatomy
Tendon and ligament
insertion
Insert into fibrous and
fibrocartilaginous periosteal and
perichrondrial regions of the
metaphysis
Progressive rather than abrupt
gradations of moduli of elasticity
Ligaments and tendons are stronger
than these attachments
ACL avulsions
Tibial tubercle avulsions
“ligament instability” maybe a
growth plate injury
Sharpey’s fibers develop with
skeletal maturation
Anatomy
Mismatches between bone and soft tissue
growth
Longitudinal bone growth more rapid than soft tissue
growth
Increase in muscle-tendon unit tightness and a loss of
flexibility
APOPHYSEAL INJURIES
Apophyseal Conditions
Osgood-Schlatter , Sinding-Larsen-Johannson
10 – 15 years of age
Incidence
15% boys, 10% girls
Kujala et al Am J Sports Med 1985
Treatment
Rule out other causes
Reassurance, rest ( activity modification), stretching, antiinflammatory
No steroid injections. No surgery
Apophyseal injuries
Osgood – schlatters
SindingLarsenJohannson
Tendinosis
Tenosynovitis more
common
Achilles
Patella
Popliteus
OSTEOCHONDRITIS DISSECANS
Osteochondritis Dissecans
Osteochondritis Dissecans
Major etiology is
likely repetitive
microtrauma
Necrosis of
subchondral bone –
healed by creeping
substitution
Fracture of overlying
cartilage can expose
bone to synovial fluid
Osteochondritis Dissecans –
Physical Findings
Vague pain with activity
Effusion
Unstable lesions will have mechanical
symptoms
Point tenderness over lesion area
Osteochondritis Dissecans - Diagnosis
Xray – AP, lateral, PA
flexion, and sunrise
views (contralateral
views?)
MRI gold standard
Osteochondritis Dissecans - Treatment
4 groups: skeletally immature vs skeletally
mature, stable versus unstable lesions
Nonsurgical:
cast, brace, restrict activity
Period of rest prior to other treatments
When/who to treat???
AAOS guidelines – consensus statements for groups
including the skeletally immature and mature with
symptomatic unstable or displaced lesions
May 2011, Vol 19, No 5
Osteochondritis Dissecans - Treatment
Skeletally Immature Patients
Asymptomatic
– Observe, educate parents
Symptomatic – period of rest, discuss surgery
Skeletally Mature Patients
Asymptomatic
– role for drilling?
Symptomatic - surgery
Osteochondritis Dissecans - Treatment
Options include microfracture,
antegrade/retrograde drilling for stable lesions,
ORIF +/- bone grafting for unstable lesions
Osteochondritis Dessicans: AAOS
Practice Guidelines
Osteochondral Fractures
Fractures occur
through the zone of
provisional
calcification
Nutcracker
injuries,
patellar
dislocations
Chondral Lesion - Treatment
Fix them – suture, bioabsorbable versus stainless Herbert screws
OAT, ACI for the sports guys
Osteochondral Lesions - Treatment
Trend toward stainless screw fixation
Take screw out at second procedure
Brace, NWB for 4-6 weeks, early ROM, CPM
MENISCUS TEARS
Meniscus Tears
Becoming increasingly common as
pediatric population participates in
athletics at earlier ages
Anatomy
Meniscus
Vascular
Clark C JBJS Am 1983
Kaplan E JBJS Am 1957
Discoid
Meniscus Tears – Work-Up
Twisting injury
Medial meniscus more common than lateral
Pain, effusion, mechanical symptoms
Joint line tenderness
McMurray’s, Apley’s, duck walk
Xrays, MRI
Meniscus Tears
Natural History
80 -90% symptomatic
in 5-8 years
Manzione M Am J Sports
Med 1983
Medlar R Am J Sports
Med 1980
Repair
80 -90% success
Cassidy R Am J Sports
Med 1981
Scott G JBJS Am 1986
Meniscal Tears - Treatment
Aggressively treat red-red, red-white zone tears
All-inside vs inside-out vs outside-in
Nice videos on Vumedi
Post-op: WBAT, limit flexion in brace
ANTERIOR CRUCIATE LIGAMENT INJURIES
ACL injuries
ACL injuries
8 yo
14 yo
ACL injuries
Dramatic rise in incidence
Female soccer players, football players (both about
14/100,000)
Shift towards operative management earlier than
historically
ACL injuries – Work-Up
Twisting injury, “funny” fall
Hemarthrosis over 50% of time, laxity with
Lachman’s and anterior drawer testing
Xrays, MRI
ACL injuries
PATELLAR INSTABILITY
Patellar Instability
2-3% of acute knee
injuries in kids
Females, sports,
personal or family
history of instability
Patellar Instability - Treatment
First-time dislocators – 62%
success with non-op mgmt
Immature with
trochlear dysplasia
only a 31% success rate
Patellar Instability
1 – crossing sign
2 - supratrochlear
spur
3 – double contour
Patella Instability
Patellofemoral disorders 10% of all sports injuries
DeHaven K Am J Sports Med 1986
Acute Patellar Dislocation
Look for osteochondral injury (Starship series)
Nat. History: Redislocation
11-14 yo 60%
19-28 yo 30%
Cash J Am J Sports Med 1988
Identify high risk patients
De Jour Sign
Patellar Instability – Nonop treatment
Good PT; cast vs
brace; closed-chain
exercises, VMO
focused; gluteal
strengthening
Patellar Instability – Operative Treatment
MPFL recon now gold
standard of surgical treatment
MPFL provides at least 50% of
medial restraint of lateral translation
Many, many described methods of
reconstruction; Single bundle
gracilis, patellar and femoral tunnels,
tension in 60 degrees of flexion; Bob
Burk Vumedi video
FRACTURES ABOUT THE KNEE
Fractures about the Knee
Two groups:
Physeal
– concern for
growth arrest and NV
complications
Distal femur, proximal
tibia, tibial
tubercle/tuberosity
Extra-physeal
–
concern for joint
stiffness and function
Patellar sleeve, tibial
eminence fractures
Fractures about the Knee
Distal femur/Proximal Tibia – analogous to knee
dislocation in adults (NV compromise possible)
Higher-energy injuries (trampoline, MVC) in
pre-adolescents
Typically anteriorly displaced in the femur
Typically posteriorly displaced in the tibia
Lower-energy injuries in adolescents (football,
basketball)
Fractures about the Knee
Treatment for physeal
fractures:
non-displaced –
immobilization
Displaced – anatomic
ORIF for intra-articular
SH III/IV; varus/valgus
realignment for extraarticular fractures
Undulating physes at
high risk for injury,
need vigilant follow-up
until skeletal maturity
Fractures about the Knee
Tibial tubercle avulsion fractures
Similar
to juvenile Tillaux regarding differential
closure of the physis
Remember fracture can propagate through the
physis into the joint
Displaced fractures need ORIF to avoid extensor lag
Beware of compartment syndrome
Tibial Tubercle Avulsion Fractures
Fractures about the Knee
Tibial spine fractures – classic story is fall from a
bike ages 8-14
Present with hemarthrosis, pain, knee flexed,
inability to bear weight
Meyers/McKeever classification I-IV
Type
I – LLC
Type II – aspirate joint, reduce and LLC
Type III/IV – ORIF (take your pick of techniques…)
Avoid transphyseal fixation except in kids near skeletal
maturity
Fractures about the Knee
Patellar sleeve fractures
Hemarthrosis, difficult
active knee extension
Xrays show a small fleck of
bone usually off inferior
pole of patella
MRI is helpful
Non-displaced – LLC
Displaced ORIF (tension
band)
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