# Pediatrics

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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)

[email protected]
 406-439-0715 (mobile) – Texting is best
 406-447-5903 (office – good luck); ask for Jody Inbody

or Lena Phelps
 Missoula outreach 406-327-4279
 Billings Clinic outreach 406-238-5254; ask for Becky,
Jen, or Alli

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